Every finding on record at Desert Canyon Post Acute, LLC

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity by failing to ensure the resident's oxygen concentrator was inventoried in the Resident's Clothing and Possessions. This deficient practice had the potential to result in loss, misplacement, and replacement challenges. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 6/3/2026 with diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and atrial fibrillation (an irregular and often very rapid heart rhythm). During a review of Resident 1's History and Physical (H&P), dated 6/14/2026, the H&P indicated the resident has the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/19/2026, the MDS indicated the resident makes self-understood and has the ability to understand others. The MDS indicated the resident was dependent on staff in rolling left and right while in bed, sitting to lying, and lying to sitting on the side of the bed and respiratory treatments including oxygen therapy were not performed. During a review of Resident 1's Care Plan (CP) focused on Congestive Heart Failure (CHF), created on 6/22/2026, the CP indicated the resident with goals of reduced risk adverse consequences from signs and symptoms of fluid and electrolyte imbalance with interventions which included Oxygen therapy as ordered. During a concurrent observation and interview on 6/30/2026 at 9:23 a.m., inside Resident 1's room, Resident 1 was observed lying in bed, awake. Resident 1 stated he has heart issues and sometimes when he overexerts himself, he gets short of breath, and he puts on his oxygen. Resident 1 stated he has an oxygen concentrator that he brought from home. Resident 1 stated he asked if it was okay for him to bring it in, but he has been using his oxygen concentrator for a long time at home. Resident 1 stated right now he does not need it, so he does not have it on. Resident 1 stated when he needs it, he lowers his bed to get closer to the oxygen concentrator, puts on the nasal cannula tubing and turns on the concentrator and adjusts the concentration as he needs it. Resident 1 stated he would call for help with his concentrator when it is too far for him to reach, besides that he puts it on and turns it on by himself. The oxygen concentrator was observed turned off at Resident 1's right side of bed with nasal cannula tubing connected. During a concurrent interview and record review on 6/30/2026 at 12:44 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's physician orders, Weights and Vitals Summary, nursing progress notes from 6/3/2026 to 6/30/2026, and Resident's Clothing and Possessions, dated 6/3/2026 were reviewed. LVN 1 stated there was no order for oxygen therapy administration and no monitoring. LVN 1 stated there should be an order and monitoring when the resident is receiving oxygen including vital signs. The Weights and Vitals Summary indicated the following:6/6/2026 at 8:21 a.m. 96 percent (% - one per hundred) oxygen via nasal cannula (NC)6/7/2026 at 1:29 a.m. 96% oxygen via NC6/18/2026 at 10:18 p.m. 97% oxygen via NC6/19/2026 at 8:44 p.m. 97% oxygen via NCLVN 1 stated when its documented oxygen given via NC means the oxygen was administered. LVN 1 stated there was no mention about the resident's oxygen concentrator. LVN 1 stated it would either be documented in the progress notes or on the Resident's Clothing and Possessions, but there was no mention. During a concurrent observation and interview on 6/30/2026 at 12:51 p.m. with LVN 1, inside Resident 1's room, LVN 1 stated Resident 1 has an oxygen concentrator with nasal cannula tubing attached. Resident 1 stated he brought this from home and was delivered sometime last week. Resident 1 stated when he came back from the hospital no one had come to update his personal belongings to include his oxygen concentrator. Resident 1 stated he does not recall the exact date. LVN 1 stated it was mentioned to her that the resident asked if it was okay to bring in his oxygen concentrator from home awhile back. LVN 1 stated this is the one that was delivered here. LVN 1 stated she does not know when this was brought in. During an interview on 6/30/2026 at 2:10 p.m. with the Director of Nursing (DON), the DON stated she reviewed all the nursing notes and Resident 1's inventory and there was no mention of the resident's oxygen concentrator. The DON stated the Resident's Clothing and Possessions form should be updated on the same day of admission or after admission. The DON stated usually it's updated by the receptionist, who monitors what comes into the building. The DON stated the visitor informs the receptionist about adding items on to the resident's inventory. The DON stated that for the oxygen concentrator it would go through either the desk nurse or charge nurse. The DON stated it is to ensure that if the residents were to be discharged , they would go home with the same belongings and respect their rights for their property. The DON stated that when the resident's items are not inventoried and becomes missing, they would not be replaced by the facility for the resident. The DON stated the residents' rights would not be followed. The DON stated updating the resident's personal belongings inventory is also protection from misappropriation of property. During a review of the facility's policy and procedure (P&P) titled, Respect and Dignity to Have Personal Property, last reviewed and approved on 10/23/2025, the P&P indicated that the Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits . 4. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished . 7. In the event the resident is physically or cognitively unable to mark their personal inventory items, and he or she does not have authorized resident representative, facility personnel may assist with inventorying personal items

Based on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for one of two sampled residents (Resident 1) reviewed for respiratory care, by failing to ensure there were physician orders for oxygen administration, documentation of when oxygen was administered, and monitored while in use. These deficient practices had the potential to place residents at risk for respiratory complications such as signs and symptoms of tracheal irritation, difficulty breathing, or slow, shallow rate of breathing of oxygen and toxicity (too much oxygen). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 6/3/2026 with diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and atrial fibrillation (an irregular and often very rapid heart rhythm). During a review of Resident 1's History and Physical (H&P), dated 6/14/2026, the H&P indicated the resident has the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/19/2026, the MDS indicated the resident makes self-understood and has the ability to understand others. The MDS indicated the resident was dependent on staff in rolling left and right while in bed, sitting to lying, and lying to sitting on the side of the bed and respiratory treatments including oxygen therapy were not performed. During a review of Resident 1's Care Plan (CP) focused on Congestive Heart Failure (CHF), created on 6/22/2026, the CP indicated the resident's goals included a reduced risk for adverse consequences from signs and symptoms of fluid and electrolyte imbalance with interventions which included Oxygen therapy as ordered. During a concurrent observation and interview on 6/30/2026 9:23 a.m., inside Resident 1's room, Resident 1 lying in bed, awake. Resident 1 stated he has heart issues and sometimes when he overexerts himself, he gets short of breath, and he puts on his oxygen. Resident 1 stated he has an oxygen concentrator that he brought from home. Resident 1 stated he asked if it was okay for him to bring it in, but he has been using his oxygen concentrator for a long time at home. Resident 1 stated right now he does not need it, so he does not have it on. Resident 1 stated when he needs it, he lowers his bed to get closer to the oxygen concentrator, puts on the nasal cannula tubing and turns on the concentrator and adjusts the concentration as he needs it. Resident 1 stated he would call for help with his concentrator when it is too far for him to reach besides that he puts it on and turns it on by himself. The oxygen concentrator was observed to be turned off at Resident 1's right side of the bed with nasal cannula tubing connected. During a concurrent interview and record review on 6/30/2026 at 12:44 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's physician orders, Weights and Vitals Summary, and nursing progress notes from 6/3/2026 to 6/30/2026 were reviewed. LVN 1 stated there was no order for oxygen therapy administration and no monitoring. LVN 1 stated there should be an order and monitoring when the resident is receiving oxygen including vital signs. The Weights and Vitals Summary indicated the following:6/6/2026 at 8:21 a.m. 96 percent (% - one per hundred) oxygen via nasal cannula (NC).6/7/2026 at 1:29 a.m. 96% oxygen via NC.6/18/2026 at 10:18 p.m. 97% oxygen via NC.6/19/2026 at 8:44 p.m. 97% oxygen via NC.LVN 1 stated when it's documented that oxygen was given via NC, it means the oxygen was administered. During a concurrent observation and interview on 6/30/2026 at 12:51 p.m. with LVN 1, inside Resident 1's room, LVN 1 stated Resident 1 has an oxygen concentrator with nasal cannula tubing attached. Resident 1 stated he brought this from home and it was delivered sometime last week. LVN 1 stated the purpose of the order is to ensure it was approved by the physician. LVN 1 stated the doctor should have been notified before it was administered. LVN 1 stated there should be an order to make sure it is the right treatment for the resident. LVN 1 stated the resident could receive the wrong treatment. During an interview on 6/30/2026 at 1:28 p.m. with the Director of Nursing (DON), the DON stated before oxygen therapy initiation there needs to be an order and when a resident has a change in condition or asking for oxygen, the resident is to be assessed to determine if it's really needed. The DON stated that when it was assessed that the resident has a low oxygen saturation, then the nurse should initiate a change in condition assessment. The DON stated it is important to obtain oxygen orders and further monitoring orders because the resident has the potential to not received the oxygen that is needed and would not be monitored. The DON stated that when the resident is not assessed, administering oxygen without an order, and not monitoring vital signs and signs or symptoms of respiratory distress, it could potentially affect the resident's respiratory status and cause the resident to not get the appropriate oxygen needed. During a concurrent interview and record review on 6/30/2026 at 2:28 p.m. with the DON, the facility's policy and procedures (P&P) titled, Oxygen Therapy, was reviewed. The DON stated when the resident adjusts the oxygen concentration by himself, he could have too much oxygen. The DON stated their P&P indicated Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: a. signs and symptoms of cyanosis . b. Signs or symptoms of hypoxia . c. Signs or symptoms of oxygen toxicity (i.e. tracheal irritation, difficulty breathing, or slow, shallow rate of breathing). The DON stated it is important that the resident is assessed and monitored when receiving oxygen therapy. During a review of the facility's P&P titled, Oxygen Therapy, last reviewed and approved 10/23/2025, the P&P indicated that the purpose of this P&P is to provide guidelines to the administration of oxygen. The P&P indicated the guidelines:1. Residents receiving oxygen therapy will have a physician order including a. Device. b. Flow Rate or FiO2. c. Frequency/Duration. d. Target Oxygen Saturation. e. Titration Parameters (if applicable). f. Indication. g. Start Date & Time. h. Reassessment or Stop Parameters i. Reassess in X hours/days. j. Discontinue when stable. k. Physician providing order. l. Title and signature of staff receiving order . 9. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: a. signs and symptoms of cyanosis . b. Signs or symptoms of hypoxia . c. Signs or symptoms of oxygen toxicity (i.e. tracheal irritation, difficulty breathing, or slow, shallow rate of breathing). d. Vital signs. e. Lung sounds. f. Oxygen Saturation . h. Other laboratory results (hemoglobin, hematocrit, and complete blood count), if applicable . 11. Record the following information in the medical record as applicable: a. The date and time that the procedure was performed. b. The rate of oxygen flow, route, and rationale. c. The frequency and duration of the treatment. d. The reason for p.r.n. administration. e. Resident adverse reactions to treatment as applicable; and f. The signature and title of the person recording the data. 12. Only Registered Nurses and Respiratory Therapist or Respiratory Care Practitioners may initiate or titrate oxygen.

Based on interview and record review, the facility failed to provide the requested medical records to the responsible party of one of three sampled residents (Resident 1). The facility received the request to release Resident 1's medical records on 4/23/2026. The facility provided the requested medical records on 5/11/2026, 16 days after the date the requested medical records were supposed to be released. This deficient practice violated Resident 1's rights to secure medical records.Findings: During a review of Resident 1's undated admission Record, the admission Record indicated on the facility admitted the resident on 11/29/2016 with diagnoses including epilepsy (a brain condition that causes a person to have repeated, unprovoked seizures [a sudden, uncontrolled burst of abnormal electrical activity in the brain]), type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), and chronic obstructive pulmonary disease (COPD - a progressive, long-term lung condition that damages the airways and air sacs, making it hard to breathe). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/4/2024, the MDS indicated Resident 1's cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. During a review of Resident 1's Authorization for the Release of Medical Information, dated 2/25/2026, the Authorization for the Release of Medical Information indicated that Resident 1's Responsible Party (RP) 1 authorized the facility to release all health information, business office files, billing records, and writings pertaining to Resident 1's medical history and treatment received to RP 2. During a review of the facility-provided email transmission, dated 4/23/2026, the email transmission indicated the facility received RP 2's request for Resident 1's medical records via electronic fax (eFax). During a review of the facility-provided email transmission, dated 5/11/2026, the email transmission indicated RP 2's medical records requests were sent as an attachment to the email. During a concurrent interview and record review on 5/18/2026 at 10:57 a.m. with the Medical Records Director (MRD), RP 2's email transmissions and the facility's policy and procedure (PnP) titled Right to Access Personal Medical Records, dated 10/23/2025 were reviewed. The MRD stated she received the eFax indicating RP 2's request for Resident 1's medical records on 4/23/2026. The MRD stated she emailed RP 2 on 5/6/2026, 11 days after the requested medical records were supposed to be released, indicating the requested medical records would be available at the end of that week. The MRD stated RP 2's medical records request was sent as an attachment to the email on 5/11/2026. The MRD stated the facility's PnP indicated discharged residents or their authorized representatives may request and receive a copy of the medical record within 15 days. During a concurrent interview and record review on 5/18/2026 at 4:29 p.m. with the Administrator (ADM), the State Operation Manual (SOM), dated 4/25/2025, was reviewed. The ADM acknowledged and stated the SOM indicated the facility must allow the resident to obtain a copy of the records or any portions thereof upon request and two working days advance notice to the facility. The ADM stated the requested medical records should be available to the requestor within two days. The ADM stated the facility failed to provide Resident 1's representative with the right to access the requested medical records.

Based on observation, interview, and record review, the facility failed to honor the resident's right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for two of five sampled residents (Residents 46 and 85) reviewed under environment facility task by failing to ensure the hot water in the residents` bathroom sink was between 105 to 120 degrees Fahrenheit (F, a temperature scale commonly used in the United States to measure how hot or cold it is). The deficient practice had violated the resident's right to a safe, clean, comfortable and homelike environment that resulted to residents being unable to bathe comfortably. Findings: 1. During a review of Resident 46's admission Record (AR), the AR indicated the facility admitted the resident on 9/18/2025, and readmitted the resident on 12/25/2025, with diagnoses including anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), anemia (a condition where the body does not have enough healthy red blood cells), and history of falling. During a review of Resident 46's History and Physical (H&P), dated 9/19/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 46's Minimum Data Set (MDS, a resident assessment tool), dated 12/21/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental processes-such as thinking, memory, learning, and decision-making-are functioning normally without any significant impairment or decline). During an interview on 2/23/2026 at 9:31 a.m., with Resident 46, Resident 46 stated that the water in the bathroom is cold and it is very uncomfortable for them to take a bath, because the water does not get warm enough and it takes time to warm up. Resident 46 stated this has been going on for a while now and the facility is aware of the issue. During a concurrent observation and interview on 2/23/2026 at 9:35 a.m., with the Maintenance Director (MD), inside Resident 46's bathroom, the hot water temperature at the bathroom sink was measured. The bathroom sink faucet ran for five (5) minutes and started to warm up. The water temperature was measured with the MD using a thermometer and registered at 81 degrees F. The MD stated it was caused by the building setup, and hot water gets pulled to the laundry room when they use the washers. The MD stated he (MD) is aware of the issue, and he cannot do anything about it. The MD stated the water temperature should be maintained between 105 to 120 degrees F to ensure residents have a comfortable hot water temperature for bathing. During an interview conducted at the Resident Council meeting (RCM, make recommendations to facility administrators to improve the quality of daily living and care in the facility and to promote and protect residents' rights) on 2/24/2026 at 2 p.m., five (5) out of five (5) residents who attended confirmed that the hot water temperature in the facility was not warm enough and it is very uncomfortable for them to do their ADLs such as bathing since the water was cold for bathing. The Resident Council attendees stated the facility is aware of the concerns for months now. During a review of the facility-provided Resident Council Meeting Minutes, dated 12/30/2025, the RCM indicated under the maintenance section that hot water was lacking in the majority of residents rooms. During an interview on 2/25/2026 at 3:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the hot water temperature in Resident 46's bathroom sink should be within 105 to 120 degrees F for residents to take a bath comfortably. The ADON stated she will escalate the issue to the governing body chair (GBC- the leader of a group of individuals with the authority to set policies, direct, and oversee an organization). During an interview on 2/26/2026 at 11:50 a.m., with the GBC, the GBC stated the hot water in the facility should be within 105 to 120 degrees F to promote comfort to residents to perform their ADLs. The GBC stated the issue should be fixed regardless of the issue of the age of the building and the hot water getting pulled to the washers when they are doing laundry. The GBC stated he (GBC) will instruct the MD to fix them right away as it affects the resident's ADLs and they are failing to provide a homelike environment to the resident. During an interview on 2/26/2026 at 12:10 p.m., with the Head Maintenance (HD), the HD stated they found the issues with the hot water temperature in the facility and all they needed to do was to shut a valve off and now the water temperature in Resident 46's room is in between 105 to 120 degrees F. During a review of the facility's recent policy and procedure (P&P) titled, Homelike Environment, last reviewed on 10/23/2025, the P&P indicated the facility strives to provide a personalized, homelike environment which recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. During a review of the facility's recent P&P titled, Maintenance Services- Water Temperature, last reviewed on 10/23/2025, the P&P indicated to control water temperature in resident-use fixtures to prevent scalding and ensure resident comfort while meeting regulatory standards. Policy - Water temperatures at resident-use fixtures shall be maintained between 105 degrees F and 120 degrees F in accordance with state and federal regulatory requirements. - Temperature variances shall be documented and corrected promptly to maintain compliance. 2. During a review of Resident 85's AR, the AR indicated the facility admitted the resident on 6/16/2025, and readmitted the resident on 6/21/2025, with diagnoses including hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet the body's needs), depression (a serious, long-lasting mental health condition-not just a temporary sad mood-characterized by a persistent feeling of sadness, emptiness, and loss of interest in daily life), and overactive bladder (OAB, a common condition causing a sudden, uncontrollable need to urinate, often resulting in frequent trips (8+ times/day) and waking up at night). During a review of Resident 85's H&P dated 6/22/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 85's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. During an interview on 2/23/2026 at 10:55 a.m., with Resident 85, Resident 85 stated the water in the bathroom is cold and it is very uncomfortable for them to take a bath because it does not get warm enough and the water takes time to warm up. Resident 85 stated it had been going on for a while now and the facility is aware of the issue and he reported them to the diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent observation and interview on 2/23/2026, at 9:35 a.m., with the MD, inside Resident 85's bathroom, measured the water temperature at the bathroom sink. The bathroom sink faucet was ran for five (5) minutes and started to warm up. The water temperature was measured with the MD using a thermometer and registered at 81 degrees F. The MD stated it was caused by the building setup, and hot water gets pulled to the laundry room when they use the washers. The MD stated he (MD) is aware of the issue, and he (MD) cannot do anything about it. The MD stated the water temperature should be maintained between 105 to 120 degrees F to ensure residents have a comfortable hot water temperature for bathing. During an interview conducted at the Resident Council meeting on 2/24/2026 at 2 p.m., five (5) out of five (5) residents who attended confirmed that the hot water temperature in the facility was not warm enough and it is very uncomfortable for them to do their ADLs such as bathing since the water was cold for bathing. The Resident Council attendees stated the facility is aware of the concerns for months now. During a review of the facility-provided Resident Council Meeting Minutes, dated 12/30/2025, the RCM indicated under the maintenance section that hot water was lacking in the majority of residents rooms. During an interview on 2/25/2026 at 3;30 p.m., with the ADON, the ADON stated the hot water temperature on Resident 85's bathroom sink should be within 105 to 120 degrees for residents to take a bath comfortably. The ADON stated she will escalate the issue to the GBC. During an interview on 2/26/2026 at 11:50 a.m., with the GBC, the GBC stated hot water in the facility should be within 105 to 120 degrees F to promote comfort to residents to perform their ADLs. The GBC stated the issue should be fixed regardless of the issue of the age of the building and the hot water getting pulled to the washers when they are doing laundry. The GBC stated he (GBC) will instruct the MD to fix them right away as it affects the resident's ADLs and they are failing to provide a homelike environment to the resident. During an interview on 2/26/2026 at 12:10 p.m. with the HD, the HD stated they found the issues with the hot water temperature in the facility and all they needed to do was to shut a valve off and now the water temperature in Resident 46's room is in between 105 to 120 degrees F. During a review of the facility's recent P&P titled, Homelike Environment, last reviewed on 10/23/2025, the P&P indicated the facility strives to provide a personalized, homelike environment which recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. During a review of the facility's recent P&P titled, Maintenance Services- Water Temperature, last reviewed on 10/23/2025, the P&P indicated to control water temperature in resident-use fixtures to prevent scalding and ensure resident comfort while meeting regulatory standards. Policy - Water temperatures at resident-use fixtures shall be maintained between 105 degrees F and 120 degrees F in accordance with state and federal regulatory requirements. - Temperature variances shall be documented and corrected promptly to maintain compliance.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for five of five sampled residents (Residents 63, 41, 3, 76, and 56) reviewed for physical restraints by failing to ensure: 1. Resident 63's physician's order for Bilateral Bolsters ([often called roll-control bolsters or bed wedges] are long, firm, cushioned pads placed on both sides of a resident's body while they are in bed) had appropriate indication as a restraint and was not tucked under the sheets. 2. Resident 41's physician's order for low air loss mattress (LALM, a medical bed system designed to prevent and treat bedsores) w/bolster had an appropriate indication and was not tucked under the sheets. 3. Resident 3's use of pommel wedge cushion (a specialized, often foam or gel-filled, wheelchair accessory with a tapered shape and a front center protrusion) had a physician order, restraint assessment, and informed consent prior to use. 4. Resident 76's physical restraint assessment was completed prior to application of bilateral bolsters, the physician's order had an appropriate indication for use, and the bilateral bolters were not tucked under the fitted sheet. 5. Resident 56's physical restraint assessment was completed prior to application of bilateral bolsters and the physician's order had an appropriate indication for use. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from the resident climbing up on the bolsters and falling on a higher ground causing injuries such as fractures (a broken or cracked bone). Findings: 1. During a review of Resident 63's admission Record (AR), the AR indicated the facility admitted the resident on 2/5/2024, with diagnoses including muscle weakness, dementia (a progressive state of decline in mental abilities), and altered mental status. During a review of Resident 63's Minimum Data Set (MDS - a resident assessment tool), dated 12/16/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a significant, advanced decline in mental abilities—such as memory, reasoning, and language—that makes it impossible to live independently). The MDS indicated the resident was dependent to needing setup assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 63's Order Summary Report (OSR), dated 6/11/2025, the OSR indicated an order for bilateral bolsters to bed to define parameters of bed. During a review of Resident 63's Fall Risk Evaluation (FRE), dated 12/17/2025, the FRE indicated the resident was high risk for falls. During a review of Resident 63's Informed Consent (IC)- Devices & Physical Restraints, dated 6/11/2025, the IC indicated restraint type of bilateral bolsters with a target behavior of sliding off the bed for fall risk. During a review of Resident 63's Devices/Physical Restraint Assessment/Re-evaluation, dated 2/18/2026, the Assessment indicated the resident had medical symptoms of climbing out of bed, confusion, and sliding or leaning. The physician order indicated bilateral landing mat, bilateral bolsters. During a review of Resident 63's Care Plan (CP) Report regarding the resident being at risk for falls related to gait (the specific pattern or manner in which a person or animal walks or runs)/balance problems, ., last revised on 2/13/2026, the CP indicated an intervention of bilateral bolsters to bed to define parameters of bed. During a concurrent observation and interview on 2/23/2026, at 10:21 a.m., with Certified Nursing Assistant (CNA) 9, inside Resident 63's room, observed Resident 63 with bilateral bolsters tucked under the sheet. CNA 9 stated the bolster was applied to prevent the resident from getting out of bed and fall. CNA 9 stated tucking the bolster under the sheet will prevent the resident from removing them and it will be hard for the resident to get out of the bed. During a concurrent interview and record review on 2/25/2026 at 3:30 p.m. with the Assistant Director of Nursing (ADON), Resident 63's Medical Diagnoses, OSR, FRE, IC, Restraint Assessment, and CP were reviewed. The ADON stated the physician's order and consent does not match. The ADON stated the physician's order and the IC should match to ensure the consent is obtained for what it is being intended for. The ADON stated the order is just to define the parameter of the bed but the behavior and medical indication was not indicated. The ADON stated if the bolster is just for repositioning it should not be tucked under the sheet because it becomes a restraint. The ADON stated the use of the bilateral bolsters for the resident is to prevent the resident from getting out of the bed to prevent a fall, which is a restraint. 2. During a review of Resident 41's AR, the AR indicated the facility admitted the resident on 4/5/2021, and readmitted the resident on 7/2/2025, with diagnoses including muscle weakness, difficulty in walking, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 41's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities—thinking, memory, reasoning, and judgment—are functioning normally and without significant impairment or decline). The MDS indicated the resident was dependent to needing setup assistance on mobility and ADLs. During a review of Resident 41's OSR, dated 7/14/2025, the OSR indicated an order for low air loss mattress with bolsters every shift for skin maintenance. During a review of Resident 41's FRE, dated 1/2/2026, the FRE indicated the resident was high risk for falls. During a review of Resident 41's CP Report regarding the resident being at risk for falls related to gait /balance problems, . muscle weakness, and history of falls, last revised on 11/3/2025, the CP indicated an intervention of low air loss mattress with bolsters. During an interview on 2/23/2026, at 9:22 a.m., with Resident 41, Resident 41 stated she was on a LALM w/ bolsters because she is high risk for falls. During a concurrent observation and interview on 2/23/2026 at 9:26 a.m. with the Minimum Data Set Coordinator (MDSC), inside Resident 41's room, observed Resident 41 had LALM w/ bolsters tucked under the sheets. The MDSC stated the resident had LALM w/ bolsters tucked under the sheets because the resident was high risk for falls. The MDSC stated tucking the bolsters under the sheet will make it harder for the resident to remove them. During a concurrent interview and record review on 2/25/2026 at 3:30 p.m. with the ADON, Resident 41's Diagnoses, OSR, FRE, Restraint Assessment, IC, and CP were reviewed. The ADON stated there is an order for low air loss mattress with bolsters every shift for skin maintenance, however, there was no informed consent, restraint assessment, and a care plan on its use. The ADON stated they are using the LALM w/bolster for fall prevention as reflected on the care plan. The ADON stated the use of the LALM w/bolster was a restraint. The ADON stated it was important to have a physician's order for the restraint, informed consent, restraint assessment, and a care plan on the use of LALM w/ bolster for its safe use and to honor the resident's right to agree or disagree with the proposed treatment after explaining the risk and benefits of its use. During a review of the facility-provided Bolster (B) 1 Information, undated, the Information indicated the roll-control bolsters are not substitutes for bed side rails. If you plan to use the Roll-Control Bolsters and leave one or both side rails in the lowered position, it is the responsibility of the facility and its qualified healthcare professionals to evaluate the resident to determine if that resident should be permitted to leave the bed at his/her discretion. Roll-Control Bolsters are not as effective as side rails for preventing a resident from rolling off or leaving the bed. 3. During a review of Resident 3's AR, the AR indicated that the facility admitted the resident on 12/21/2025 with diagnoses including dementia, anxiety disorder (a condition characterized by persistent and excessive worries that interfere with daily activities), and chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing). During a review of Resident 3's H&P, dated 12/22/2025, the H&P indicated that the resident has the capacity to make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated the resident had severe impaired cognitive function. The MDS indicated that the resident required substantial/maximal assistance with mobility including roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. During an observation on 2/23/2026 at 9:29 a.m., in Resident 3's room, Resident 3 sat up in wheelchair with a pommel wedge cushion. During an observation on 2/23/2026 at 3:09 p.m., in the main activity/dining room, Resident 3 sat up in wheelchair with a pommel wedge cushion, asleep. During an observation on 2/24/2026 at 8:48 a.m., in Resident 3's room, Resident 3 sat up in wheelchair with a pommel wedge cushion. During a concurrent observation and interview on 2/26/2026 at 8:27 a.m. with Licensed Vocational Nurse (LVN) 4, inside Resident 3's room, LVN 4 confirmed and stated Resident 3 sat on a wheelchair with a pommel wedge cushion. During a concurrent interview and record review on 2/25/2026 at 8:28 a.m. with LVN 4, Resident 3's physician orders, informed consents, and restraint assessments were reviewed. LVN 4 stated there was no order, restraint assessment, and informed consent done prior to the use of the pommel wedge cushion. LVN 4 stated it should have been completed to ensure that the device is appropriate for the resident. LVN 4 stated without an order, assessment, and informed consent the resident can potentially fall and injure herself. LVN 4 stated the resident has a responsible party and should have been informed of the risk and benefits of the use of the wedge cushion because it is a restraint. During an interview on 2/26/2026 at 12:39 p.m. with the ADON, the ADON stated that the pommel wedge cushion is a restraint and is applied to fall risk residents. The ADON stated the resident should be assessed if the resident is a candidate. The ADON stated the facility should inform the responsible party/family and ask the MD for an order if the responsible party/family want the pommel wedge cushion for the resident. The ADON stated that the care plan should be developed. The ADON stated that the restraint assessment is done to see if the resident really needs the pommel cushion because the resident's movement could be restrained and not be able to move freely, which can make the resident agitated and can possibly fall because of the agitation. The ADON stated that when the informed consent is not obtained from the responsible party, then the responsible party would not be able to know the care plan and the staff may be doing interventions that is not part of the resident's care plan. The ADON stated it is the residents' right to be informed and not informing them would violate their rights. During a review of the facility provided Manufacturer Instruction (MI) 1 titled, [MI 1] Wedge Foam Pommel Cushions, dated year 2007, the MI 1 indicated that the MI 1's Wedge Foam Pommel Cushions are designed to keep hip and knees in alignment, while minimizing patient forward sliding. Can be used to help prevent hip dislocation following surgery and allow patients to exercise their knees and lower legs. 4. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted the resident on 11/29/2022 with diagnoses including dementia, major depressive disorder, and generalized muscle weakness. During a review of Resident 76's H&P, dated 7/18/2025, the H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76 had severely impaired cognition was sometimes able to understand others and make her needs known. The MDS further indicated Resident 76 required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene and substantial/maximal assistance to totally dependent on staff with all other ADLs. During a review of Resident 76's OSR dated 2/26/2026, the OSR indicated the following physician's orders: - 4/23/2025: May use an alternating pressure pump (APP – a therapeutic, inflating mattress overlay designed to prevent and treat bed sores [pressure ulcers] in bedridden individuals) from Hospice Provide (HP) 1. - 10/14/2025: Bilateral bolster as per family request. During a review of Resident 76's fall risk evaluations, dated 9/4/2025, 12/1/2025, and 2/22/2026, the fall risk evaluations indicated the resident was at a high risk for falls. During a review of Resident 76's CP on risk for falls, initiated on 12/6/2026 and last revised on 11/4/2025, the CP indicated bilateral bolsters to the bed to facilitate resident's awareness of the edge of the mattress for repositioning as one of the interventions to minimize Resident 76's risk of injury from fall. During a review of Resident 76's device/physical restraint assessment form, dated 11/17/2025, the device/physical restraint assessment form indicated bilateral bolster to define the parameters of bed and for proper positioning. During an observation on 2/23/2026 at 11:22 a.m., inside Resident 76's room, observed Resident 76 not in bed but observed an APP mattress with bilateral bolsters with the straps looped around the side rails. During a follow up concurrent observation and interview on 2/25/2026 at 8:39 a.m., inside Resident 76's room, with CNA 6, observed Resident 76 up on the Geri chair (also known as a geriatric chair, a specialized, comfortable, and mobile reclining chair with wheels, designed for elderly individuals or residents with limited mobility). CNA 6 stated he just made Resident 76's bed, and the bilateral bolsters are usually placed under the fitted sheet bilateral bolsters to prevent the bolsters from sliding out of the bed and to prevent the resident from sliding out as well and fall. During a concurrent interview and record review on 2/26/2026 at 9:05 a.m. with the ADON, Resident 76's diagnoses, physician's orders, fall risk evaluations, device/physical restraint assessment form, informed consent, and CP were reviewed. The ADON stated Resident 76 had a physician's order for bilateral bolsters per family request, however the order did not specify the indication for the use of the bolsters, and there was no device/physical restraint assessment completed prior to the application of the bolsters. The ADON stated the facility is using the bilateral bolsters for the resident to be aware of the edges of the bed to minimize risk of injury from falls as reflected on the care plan. The ADON stated the bolsters should not have been tucked under the fitted as it was restricting Resident 76's freedom of movement and can be considered a restraint. The ADON stated that if the use of bilateral bolsters was to minimize the risk of injury from falls, a device/physical restraint assessment should have been complete prior to application of the bolsters and that the physician's order was complete with the indication for the use to ensure the use of the device was appropriate and safe. 5. During a review of Resident 56's admission Record, the admission Record indicated the facility admitted the resident on 3/25/2025, with diagnoses including dementia, history of falling, and generalized muscle weakness. During a review of Resident 56's H&P, dated 2/28/2025, the H&P did not indicate Resident 56's capacity to understand and make decisions. During a review of Resident 56's MDS, dated [DATE], the MDS indicated Resident 56 had severely impaired cognition and rarely understands others and make her needs known. The MDS indicated Resident 56 required setup or clean-up assistance with eating; partial/moderate assistance to substantial/maximal assistance with all other ADLs. During a review of Resident 56's OSR, dated 2/26/2026, the OSR indicated a physician's order dated 4/11/2025 for LALM with bolsters. During a review of Resident 56's fall risk evaluation, dated 2/10/2025, the fall risk evaluation indicated the resident was at a high risk for falls. During a review of Resident 56's CP on use of LALM with bolsters for safety, initiated on 4/23/2025, the CP indicated monitor/document/report to the physician as needed changes regarding the effectiveness of the device, less restrictive device, if appropriate; any negative of adverse effects noted including decline in mood, change in behavior, decrease in ADL performance, decline in cognitive ability or communication contracture formation, skin breakdown, signs and symptoms of delirium, falls/accidents/injuries, agitation and weakness as one of the interventions so Resident 56 will remain free of complications related to the device use. During a review of Resident 56's device/physical restraint assessment form, dated 4/23/2025, the device/physical restraint assessment form did not indicate the use of LALM with bolsters. During a concurrent observation and interview on 2/23/2026 at 11:24 a.m., inside Resident 56's room, with CNA 10, CNA 10 stated Resident 56 was in the small dining room, but the resident's LALM has bolsters inside on both sides and closed with a zipper. CNA 10 stated Resident 56 cannot remove the bolsters freely as it zippered inside the LALM. CNA 10 stated that Resident 56 just fell recently and had the tendency to slide on the bed, so the bolsters protect the resident from sliding off the bed and fall. During an interview on 2/24/2026 at 8:30 a.m. with LVN 5, LVN 5 stated that the LALM with bolsters were ordered for residents who were at a high risk for falls. LVN 5 stated that due to the height of the LALM, the residents had the tendency to slide off the mattress. LVN 5 stated the bolsters are for the residents' safety to prevent falls. During an interview on 2/24/2026 at 9:30 a.m. with the ADON, the ADON stated the facility is using the bilateral bolsters for the residents to be aware of the edges of the bed and for safety to minimize risk of injury from falls. The ADON stated that due to the height of the LALM, the residents have the tendency to slide and can fall. During a follow-up concurrent interview and record review on 2/26/2026 at 9:15 a.m. with the ADON, Resident 56's diagnoses, physician's order, fall risk evaluations, device/physical restraint assessments, and CP were reviewed. The ADON stated Resident 56 had a physician's order for LALM with bolsters, however, the order did not specify the indication for the use of the bolsters, there was no device/physical restraint assessment completed prior to the application of the bolsters. The ADON stated the facility is using the bilateral bolsters for Resident 56 to be aware of the edges of the bed and for safety to minimize the risk of injury from falls, the bolsters were restricting Resident 56 to move freely. The ADON stated if the bolsters were inside the LALM and zippered, Resident 56 would not be able to remove the device and can be considered a restraint if there was no device use/physical restraint assessment completed prior to use and that the physician's order should be complete with the indication for the use to ensure the use of the device was appropriate and safe. During a review of the facility's recent policy and procedure (P&P) titled, Nursing Service - Restraints, last reviewed on 10/23/2025, the P&P indicated the Facility shall adhere to California Code of Regulations, Title 22, Section 72319 regarding the use of restraints. Restraints shall only be used when permitted by law, under physician order, and never for punishment, staff convenience, or as substitute for a care. All subsections (a) through (j) of this regulation are included herein. Definitions Restraint: Any physical or mechanical device or chemical agent that restricts the patient's freedom of movement or access to their body. - Restraints shall only be used upon the written order of a physician or other person lawfully authorized to give such an order, which specifies the duration and circumstances under which the restraints are to be used. - Restraints shall not be used for punishment, for the convenience of staff, or as a substitute for more effective patient care. During a review of the facility's recent P&P titled, Patient Rights - Informed Consent Requirements, last reviewed on 10/23/2025, the P&P indicated the facility shall comply with California Code of Regulations, Title 22, Section 72528, which requires that informed consent be obtained prior to the administration of psychotherapeutic drugs, medical treatment, or procedures that carry significant risk. Informed consent shall be obtained voluntarily from the resident or their authorized representative after disclosure of relevant information. During a review of the facility's P&P titled, Respect and Dignity – Physical Restraints, last reviewed on 10/23/2025, the P&P indicated, the facility does not use physical restraint imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The P&P further indicated: - Physical restraints: any manual method or physical or mechanical devices, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. - Removes easily: the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff considering the resident's physical condition and ability to accomplish objective. - Convenience: any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. - Freedom of movement: any change in place or position of the body or anby pat of the body that the person is physically able to control. - The following practices shall be considered a physical restraint including but not limited to tucking in a sheet tightly so that the resident cannot get out of bed or fastening fabric or clothing so that a resident's freedom of movement is restricted. - Physical restraints may increase the risk decline in physical functioning, respiratory complications and accidents such as falls, strangulation, or entrapment. - Psychosocial impact related to the use of physical restraints may include feelings of imprisonments or restriction of freedom of movement - The licensed nurse shall obtain a physician's order for the use and specific type of restraint. - The interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) shall complete a physical restraint assessment to identify the potential risks associated with the restraint use, specifically to the resident. - The facility does not implement the use of a restraint at the resident or resident representative request in the absence of an evaluation and identification of a medical symptom that must be treated and includes the practitioner in the review and discussion.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of eight sampled residents (Residents 63, 77, 41, and 21) reviewed for accidents by failing to ensure: 1. Resident 63 did not have a furniture or equipment on top of the floor mat (specially designed mats provide cushioning and support to patients who are at risk of falling, helping to prevent serious injuries). 2. Resident 77 did not have medications or biologicals (medicines derived from living organisms-such as humans, animals, or microorganisms-rather than being created from chemicals) left at the bedside. 3. Resident 41 did not have frayed wires (a condition where electrical cables become worn or damaged, exposing the internal wires) on the resident's call light button. 4. Resident 21 did not push a trolley (a small vehicle with wheels that can be pushed or pulled along and is used for carrying things) used by the maintenance department without supervision along the hallway. These deficient practices increase the risk of accidents such as electrocution (the injury or killing of someone by electric shock), falls with injuries, and ingested poisoning on residents. Findings: 1. During a review of Resident 63's admission Record (AR- front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 2/5/2024, with diagnoses including muscle weakness, dementia (a progressive state of decline in mental abilities), and altered mental status. During a review of Resident 63's Minimum Data Set (MDS, a resident assessment tool), dated 12/16/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a state where a person's ability to think, reason, remember, and communicate has declined to a point where they can no longer live independently and require full-time care). The MDS indicated the resident was dependent to needing set-up assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 63's Order Summary Report (OSR), dated 5/25/2025, the OSR indicated an order for landing mat on both sides every shift. During a review of Resident 63's Fall Risk Evaluation (FRE), dated 12/17/2025, the FRE indicated the resident was at high risk for falls. During a review of Resident 63's Care Plan (CP) Report regarding the resident use of devices/bilateral bolsters (are firm, cylindrical pillows or foam cushions placed on both sides of a resident in bed) and bilateral landing mats/floor mats., last revised on 4/29/2025, the CP indicated an intervention the resident needs a safe environment with adequate glare-free light; floors that are even and free from spills or clutter, call light within reach, and personal items within reach. During a concurrent observation and interview on 2/23/2026 at 10:21 a.m., with Certified Nursing Assistant (CNA) 11, inside Resident 63's room, observed Resident 63 had bilateral floor mats and there were a side table and a wheelchair on top of the floor mat on the right side. CNA 11 stated there should be no objects or equipment on top of the floor mats as it defeats the purpose of its use. CNA 11 stated that when the resident falls, they will land on the hard objects or equipment on top of the floor mat causing injuries such as a broken bone. During an interview on 2/25/2026 at 3:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the floor mat of Resident 63 should not have any equipment or furniture on top of them because it defeats the purpose of using a floor mat. The ADON stated the floor mat serves as a soft-landing area for residents to fall to. The ADON stated if there is an object on top of the floor mat, the resident could fall on them and it can cause bruises, bumps, or even fracture (break in bone) to the resident. During a review of the facility's recent policy and procedure (P&P) titled, Other Environmental Conditions, last reviewed on 10/23/2025, the P&P indicated the facility should provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Guidelines: 2. The functions of the maintenance personnel include but are not limited to: g. Maintaining the paging system in good working order. j. Others that may become necessary or appropriate. During a review of the facility's recent P&P titled, Accident Physical Plant Hazards, last reviewed on 10/23/2025, the P&P indicated the facility ensures the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. During a review of the facility's recent P&P titled, Fall Management Program, last reviewed on 10/23/2025, the P&P indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible. Definitions Avoidable Accident: An accident which occurred because the facility failed to: - Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or - Implement interventions, including adequate supervision and assistive devices; consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident. During a review of the facility-provided Landing Mat (LM) 1 Owner's Manual (OM), printed date 2016, the OM indicated the Direct Choice Bedside Mat may be placed next to a resident's bed to help reduce the impact of a fall should a resident fall from the bed. Storage When product is stored: 4. Do not place objects on the product during storage. 2. During a review of Resident 77's AR, the AR indicated the facility admitted the resident on 2/10/2026, with diagnoses including dementia, depression (a serious, long-lasting mood disorder—more than just temporary sadness—characterized by a persistent feeling of hopelessness, emptiness, or loss of interest in activities), and cerebral infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). During a review of Resident 77's History and Physical (H&P), dated 2/14/2026, the H&P indicated the resident was well nourished and not in acute distress. The H&P indicated the resident's cranial nerves (a set of 12 nerves that send electrical signals between your brain and different parts of your head, face, neck and torso) two through seven are gross motor intact (specifically indicates no obvious signs of paralysis, severe weakness, or severe droop in the face, eyes, or tongue). During a review of Resident 77's Order Summary Report (OSR), dated 2/26/2026, the OSR did not indicate an order for vitamin A&D ointment (is a thick, petroleum-based skin protectant designed to soothe, moisturize, and heal irritated or damaged skin). During a review of Resident 77's Self-Administration of Medication Assessment ([NAME]), dated 2/10/2026, the [NAME] indicated the resident did not express desire to self-administer medications and mentally the resident is not able to administer own medications. During a review of Resident 77's CP Report regarding the resident being at risk for falls related to confusion., last revised on 2/23/2026, the CP indicated an intervention to promote a safe environment. During a concurrent observation and interview on 2/23/2026 at 12:29 p.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 77's room, observed Resident 77 had an opened A&D ointment at the resident's side table. LVN 1 stated there should be no medications or biologicals left at the resident's side table because if used wrongly the resident can develop skin issues and when ingested can be harmful to the resident and other confused resident as well. During an interview on 2/25/2026 at 3:30 p.m., with the ADON, the ADON stated Resident 77 should not have any medications or biologicals left at the bedside as it can be accidentally ingested by the resident or other confused residents in the facility and cause poisoning. During a review of the facility's recent P&P titled, Labeling of Biologicals and Storage of Biologicals, last reviewed on 10/23/2025, the P&P indicated the facility, in coordination with the licensed pharmacist, provides accurate labeling to facilitate precaution and safe administration of medications, and safe and secure storage. Storage of Drugs and Biologicals 4. The facility has procedures for the control and safe storage of medications for those residents who can self-administer medications. Access to Medications 6. During a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart. During a review of the facility's recent P&P titled, Resident Self-Administer Medications, last reviewed on 10/23/2025, the P&P indicated the interdisciplinary team supports the right of each resident to self-administer medications when this practice is clinically appropriate. During a review of the facility-provided Vitamin A and D- vitamin a and d ointment, undated, the information indicated warnings of: External Use Only. When using this product.: Avoid contact with eyes. Do not apply over deep or punctured wounds, infections or lacerations. If Condition Worsens or Does not improve within 7 days stop use and consult a physician. Keep out of reach of children. In event of accidental ingestion contact a Poison Control Center right away. 3. During a review of Resident 41's AR, the AR indicated the facility admitted the resident on 4/5/2021, and readmitted the resident on 7/2/2025, with diagnoses including psychosis (a mental health symptom—not a specific illness—where a person loses touch with reality, causing them to struggle with what is real and what is not) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 41's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). During a review of Resident 41's CP Report regarding the resident being at risk for falls related to psychosis and depression., last revised on 11/3/2025, the CP indicated an intervention to promote a safe environment. During a concurrent observation and interview on 2/23/2026 at 9:20 a.m., with Maintenance Director (MD), inside Resident 41's room, observed Resident 41's call light button cable had frayed/exposed wires near the call button console. The MD stated the call light is a low voltage electricity carrier, he (MD) will replace the call light button immediately. During a concurrent observation and interview on 2/23/2026 at 9:29 a.m., with the Minimum Data Set Coordinator (MDSC), inside Resident 41's room, observed Resident 41's call light button with frayed/ exposed electrical wires near the call light button console. The MDSC stated there should be no exposed electrical wires on the resident's call light button because it can cause accidents such as electrocution. During an interview on 2/25/2026 at 3:30 p.m., with the ADON, the ADON stated there should be no exposed/frayed wires on Resident 41's call light because it can cause electrocution on the resident. The ADON stated the staff should report all hazards that they see at the resident's bedside to prevent accidents to residents. During a review of the facility's recent P&P titled, Other Environmental Conditions, last reviewed on 10/23/2025, the P&P indicated the facility should provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Guidelines: 2. The functions of the maintenance personnel include but are not limited to: g. Maintaining the paging system in good working order. j. Others that may become necessary or appropriate. During a review of the facility's recent P&P titled, Accident Physical Plant Hazards, last reviewed on 10/23/2025, the P&P indicated the facility ensures the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. During a review of the facility's recent P&P titled, Fall Management Program, last reviewed on 10/23/2025, the P&P indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible. Definitions Avoidable Accident: An accident which occurred because the facility failed to: - Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or - Implement interventions, including adequate supervision and assistive devices; consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident. During a review of the facility-provided Call Light (CL) 1 Installation & Operating Instructions ([NAME]), undated, the [NAME] indicated to read the following instructions concerning system equipment and determine installation methods before proceeding and to check wires. Connections Checkout re-check all connections to equipment. If all wires and connections are satisfactory, connect the primary coil of the SS106 Transformer to a source of 117 VAC 60 Hz (30 VA max). 4. During a review of Resident 21's AR, the AR indicated the facility admitted Resident 21 on 9/15/2025, with diagnoses including cerebral infarction (also known as stroke, loss of blood flow to a part of the brain), difficulty in walking, and aphasia (a disorder that makes it difficult to speak). During a review of Resident 21's History and Physical (H&P) dated 9/21/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and able to make his needs known. The MDS further indicated Resident 21 required setup or clean-up assistance with eating, oral hygiene, and rolling left and right; supervision or touching assistance with toileting, sit to lying, lying to sitting, and walking ten (10 ) feet (ft – a unit of distance); partial or moderate assistance from staff with all other activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 21's fall risk evaluation forms dated 9/15/2025, and 12/18/2025, the fall risk evaluation forms indicated that Resident 21 was not at a high risk for falls. During a review of Resident 21's care plan (CP) on risk for falls initiated on 9/16/2025 and last revised on 12.12.2025, the CP indicated maintain a clear pathway free of obstacles, promote a safe environment, provide visual prompts to ask for help, and provide activities that minimize the potential for falls while providing diversion and distraction as a few of the interventions to minimize risk of injury from falls. During an observation on 2/24/2026 at 2:03 p.m., observed Resident 21 walking on the hallway with a slight limp (a mild unevenness in gait) past the maintenance department office pushing a trolley. Observed Certified Nursing Assistant (CNA) 3, who was standing by the door outside Room (RM) 1, spoke with Resident 21 and CNA 3 continued going inside RM [ROOM NUMBER]. During an interview with CNA 3 on 2/24/2026 at 2:04 p.m., CNA 3 stated she (CNA 3) told Resident 21 not to push the trolley as it was not safe to do so. CNA 3 stated Resident 21 was not supposed to be pushing the trolley as he (Resident 21) was a little unsteady while walking. CNA 3 stated she (CNA 3) was not attending to a resident at the time of observation and that she (CNA 3) should have stopped what she (CNA 3) was doing and taken the trolley away from Resident 21. CNA 3 stated if Resident 21 continued to walk in the hallway with the trolley, Resident 21 can slip or trip and fall causing injury such as broken bone. During an interview on 2/24/2026 at 2:08 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 21 was normally ambulatory but walks with a slight limp and can be unsteady on his feet. The ADON stated that all residents are supposed to be supervised regardless of their ambulatory status. The ADON stated if residents push any equipment unsupervised, they can potentially fall and get injured. The ADON stated CNA 3 should have stopped what she (CNA 3) was doing if she (CNA 3) was not attending to another resident and taken the trolley from Resident 21 while the resident was walking in the hallway pushing the trolley as it placed the resident at risk to trip and fall and get injured from the fall. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, last reviewed on 10/23/2025, the P&P indicated the facility ensures to provide an environment that is free from accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accidents. The P&P further indicated: - Avoidable accident: an accident which occurred because the facility failed to: - Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision. - Evaluate and analyze the hazards and risks and eliminate them. - Implement interventions, including adequate supervision and assistive devices, consistent with as resident's needs, goals, care plan and current professional standards of practice; and/or eliminate the risk, if possible, and if not, reduce the risk of an accident. - Environment: any environment or area in the facility that is frequented by or accessible to residents, including but not limited to the resident's rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. - Hazards: elements of the resident environment that have the potential to cause injury or illness. Hazards over which the facility has control; hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury of illness.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites for one of one sampled resident (Resident 6). 2. Rotate subcutaneous enoxaparin (an injectable prescription medicine that acts as a powerful blood thinner [anticoagulant]) administration sites for one of three sampled residents (Resident 94) observed during Medication Pass Facility Task. The deficient practices had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: 1. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted the resident on 8/26/2021, and readmitted the resident on 5/9/2024, with diagnoses including type two diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure), and encephalopathy (any disease, damage, or malfunction that causes the brain to stop working properly). During a review of Resident 6's History and Physical (H&P), dated 11/2/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 1/25/2026, the MDS indicated the resident usually had the ability to make self-understood and understand others and had intact cognition (a person's brain is functioning normally, without any significant decline or impairment in their mental abilities). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a type of medicine used to lower high blood sugar (glucose) levels, primarily in people with type two diabetes). During a review of Resident 6's Order Summary Report (OSR), dated 2/12/2026, the OSR indicated an order for Insulin Lispro Subcutaneous Solution Cartridge 100 unit per milliliter (unit/ml, in insulin refers to the concentration or strength of the medication-essentially, how much insulin is packed into every one milliliter of liquid) (Insulin Lispro). Inject as per sliding scale (a flexible, customized plan that tells you how much rapid-acting insulin to take before meals or at bedtime based on your current blood sugar reading): if 0 - 179 = 0; 180 - 200 = 2 units; 201 - 230 = 4 units; 231 - 260 = 6 units; 261 - 290 = 8 units CALL MD for blood sugar (BS) less than (<) 70 OR greater than (>) 350; 291 - 320 = 10 units; 321 - 350 = 12 units. Give 12 u and call MD for BS >350, subcutaneously before meals and at bedtime for DM Notify MD below 70 hold insulin or above 350, subcutaneously before meals and at bedtime for DM 2 If resident can eat or drink give fruit juice or glucose 15 grams (g, a unit of weight). If resident can't eat or drink. Give intramuscular (IM, means delivering medication directly into a muscle, typically via injection, allowing for faster absorption into the bloodstream compared to fat-layer injections) glucagon 1 milligram (mg, a unit of weight). Rotate site. During a review of Resident 6's Care Plan (CP) Report titled, On insulin (insulin glargine, insulin lispro) therapy related to DM, last revised on 3/20/2025, the CP indicated an intervention of insulin administration as ordered. During a review of Resident 6's Location of Administration Report (LAR) from 2/12026 thru 2/28/2026, the LAR indicated insulin Lispro subcutaneous solution cartridge 100 unit/ ml was given on: 2/4/2026 at 06:58 a.m. on the Arm - Upper arm (rear) (left) 2/4/2026 at 11:55 a.m. on the Arm - Upper arm (rear) (left) 2/17/2026 at 5:39 a.m. on the Arm - forearm (left) 2/18/2026 at 5:53 a.m. on the Arm - forearm (left) 2/20/2026 at 8:44 p.m. on the Arm - left 2/22/2026 at 5:45 a.m. on the Arm - left During a concurrent interview and record review on 2/25/2026 at 3:30 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 6's Medical Diagnoses, H&P, MDS, OSR, CP, and LAR. The ADON stated there were multiple instances that the licensed staff did not rotate the insulin administration of the resident as reflected in the LAR. The ADON stated there was an order to rotate the administration sites of insulin the physician's order. The ADON stated the insulin is a significant medication and the licensed staff did not follow the physician's order by not rotating them constituting a medication error. The ADON stated the failure of the licensed staff to rotate the sites of injection of insulin can lead to lipodystrophy. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 10/23/2025, the P&P indicated the facility develops protocol to provide guidelines for the safe administration of insulin. Procedure 16. Select an injection site. 17. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. 18. Injection sites should be rotated to reduce the risk of damaging the skin tissue. During a review of the facility's recent P&P titled, Medication Errors, last reviewed on 10/23/2025, the P&P indicated the facility ensures that its residents are free of any significant medication errors; and that its medication error rates are not 5 percent or greater. Definitions Medication Error: The observed or identified preparation or administration of medications or biologicals which are not in accordance with: a. the prescriber's order. b. Manufacturer's specifications regarding the preparation and administration of the medication or biological; or c. Accepted professional standards and principles which apply to professionals providing services. d. Accepted professional standards and principles include various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. During a review of the facility-provided Highlights of Prescribing Information (HPI) on Admelog (insulin lispro) injection, for subcutaneous or intravenous use, with initial U.S. approval on 2017, the HPI indicated rotate injection sites to reduce of lipodystrophy and localized cutaneous amyloidosis. 2. During a review of Resident 94's AR, the AR indicated the facility admitted the resident on 2/16/2026, with a diagnosis of displaced fracture (a broken bone in which the pieces on either side of the break have moved out of their normal, straight alignment) of greater trochanter of right femur (the large, bony bump on the outer side of your upper right thigh, just below the hip joint), subsequent encounter for closed fracture (a broken bone that does not break or pierce through the skin) with routine healing. During a review of Resident 94's H&P, dated 2/17/2026, the H&P indicated the resident had the capacity to make decisions. During a review Resident 94's OSR, dated 2/16/2026, the OSR indicated an order for enoxaparin sodium solution 40 mg/0.4 ml. Inject 40 milligram subcutaneously one time a day for post hemi-arthropathy (a partial joint replacement surgery, most commonly performed on the hip, where only one half of the joint-the ball (femoral head)-is replaced with a prosthetic, while the original socket is left intact) prophylaxis (ppx, any action, treatment, or measure taken beforehand to prevent diseases or infections before they occur) rotate sites. During a review of Resident 94's LAR from 2/1/2026 to 2/28/2026, the LAR indicated enoxaparin sodium solution 40 mg/0.4 ml was administered subcutaneously on: 2/24/2026 at 9:10 a.m. at the Arm-right 2/25/2026 at 8:29 a.m. at the Arm-right During a review of Resident 94's CP Report titled, Black box warning for use of Lovenox for deep vein thrombosis (DVT, is a serious medical condition that occurs when a blood clot forms in a deep vein) prophylaxis, last revised on 2/17/2026, the CP indicated a goal of the resident will not experience side effects/interactions with the use of Lovenox (Enoxaparin Sodium). During a concurrent observation, interview, and record review on 2/25/2026, at 8:11 a.m., with Licensed Vocational Nurse (LVN) 1, observed LVN 1 preparing administration of Enoxaparin Sodium sq to Resident 94. LVN 1 checked the medication compared the dosage against the Medication Administration Record (MAR) in Point Click Care (PCC, an electronic healthcare record) and prepared the supplies for administration. LVN 1 knocked at the door of Resident 94, sanitized hands with antiseptic solution. LVN 1 checked the resident using two identifiers, asked for resident's name and birthdate comparing them on Resident 94's arm band. LVN 1 sanitized the right arm shoulder of Resident 94 with alcohol wipes. LVN 1 administered the enoxaparin sodium solution 40 mg/0.4 ml subcutaneously at the right shoulder of Resident 94. LVN 1 activated the safety latch of the enoxaparin sodium solution 40 mg/0.4 injection and discarded the syringe with needle in sharps container. LVN 1 washed hands and proceeded to document the administration site. Asked LVN 1 where the last administration site of the enoxaparin was on Resident 94. LVN 1 opened the PCC and checked the history and found out the last site was on the right arm too. LVN 1 stated he should have checked the PCC for last administration site of the enoxaparin sq to prevent repetition of sites. LVN 1 stated there was an order to rotate sites and he did not follow the physician's order which is a medication error. LVN 1 stated not rotating sites of injection for enoxaparin could cause excessive bruising or calluses which will affect the medication absorption. During an interview on 2/25/2026, at 3:30 p.m., with the ADON, the ADON stated Resident 94's enoxaparin sq administration should have been rotated to prevent excessive bruising to the resident. The ADON stated the enoxaparin sodium sq is a significant medication and the licensed staff did not follow the physician's order to rotate the insulin administration site which constitutes a medication error. The ADON stated they should always check for history of last site of administration of sq medications that needed to be rotated in the PCC before administering them to the residents. During a review of the facility's recent P&P titled, Medication and Treatment Orders, last reviewed on 10/23/2025, the P&P indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. During a review of the facility-provided HPI on the use of Lovenox (enoxaparin sodium) injection, for subcutaneous and intravenous use, with initial U.S. approval in 1993, the HPI indicated under subcutaneous injection technique: - Alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall.

The facility failed to ensure sufficient kitchen staff had the appropriate skills and competencies to carry out the functions of the food and nutrition service when the Dietary Supervisor (DS), [NAME] 1, [NAME] 2, and [NAME] 3 did not demonstrate knowledge of and / or competency for following International Dysphagia Diet Standardization Initiative (IDDSI - a standardized framework used to classify food textures and liquid thickness for people with dysphagia) testing (methods to confirm the flow or textural characteristics of a particular food or liquid) of mechanically altered diets on 2/23/2026 for one of four residents (Resident 25) on puree diet (a texture modified diet that consists of smooth, pudding-like consistencies that are easy to swallow). This deficient practice resulted in Resident 25's lunch plate on 2/23/2026 containing broccoli that wept (release of moisture, forming liquid on the surface) potentially resulting in the resident choking (when food gets stuck in your airway, blocking the flow of the air to your lungs) on the food. Findings: During a review of Resident 25's admission Record (AR - front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 11/6/2025 with diagnoses including dysphagia, chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 25 had the ability to understand others and had the ability to make herself understood. The MDS further indicated Resident 25 required supervision or touching assistance with eating and oral hygiene, and substantial/maximal assistance to total assistance dressing and personal hygiene, and was dependent on staff for toileting and bathing. The MDS further indicated Resident25 was on mechanically altered (requires change in texture of food) and therapeutic diet. During a review of Resident 25's Order Summary Report, dated 2/26/2026, the Order Summary Report indicated a physician's order dated 2/23/2026 for consistent carbohydrate (CCHO - a nutritional approach that involves eating a similar, measured amount of carbohydrates at each meal to maintain stable blood sugar levels) no added salt (NAS - eliminating the use of salt during cooking and at the table) diet pureed texture, mildly thick consistency, fortify diet (practice of adding vitamins and minerals to commonly consumed foods during processing to increase the nutritional value). During a review of the facility's Diet Spreadsheet - Spring/Summer 2025, the Diet Spreadsheet indicated the following menu for lunch on 2/23/2026 for Pureed (PU4) / (texture): - Pureed Penne with mushroom sauce 1 and one half (1/2 - a unit of measurement) cups - Pureed seasoned fresh broccoli florets, number twelve (12) scoop - Pureed garlic bread (PU4) - number 12 scoop - Pureed key lime pie - number 12 scoop - Choice of beverage During a kitchen tray line (specialized, assembly-line food service system) observation on 2/23/2026 at 12:02 p.m., observed [NAME] 1 plating the resident lunch meals. Observed Resident 25's tray prepared with the plate covered, and sitting on the tray line. Just prior to being placed in the meal cart, the surveyor asked to see the plate. Resident 25's plate cover was removed and observed puree broccoli, puree pasta, and puree bread. Observed a green tinted, water like liquid surrounding the broccoli. [NAME] 1 stated the broccoli was separating and should not have water, but it did. [NAME] 1 stated he needed to stir the broccoli more. Observed cook 1 stirred the broccoli and replated Resident 25's meal. Observed [NAME] 1 did not perform IDDSI standardized testing on the prepared puree foods during tray line. [NAME] 1 stated the process for making pureed broccoli was to measure the cooked broccoli and puree in the blender, then add water or a commercial thickener (food additive designed to increase the thickness of liquids and food items) to make sure it was not lumpy and was an applesauce like texture. [NAME] 1 stated [NAME] 3 prepared the puree broccoli. [NAME] 3 then stated she prepared the broccoli by placing an unmeasured amount of cooked broccoli from the regular recipe in the blender with an unmeasured amount of cooking water. The Dietary Supervisor (DS) stated there is a recipe for puree broccoli. The Surveyor asked to see the recipe and observed the DS walk to the recipe binder. The DS stated the puree broccoli recipe was not with the printed recipes and the DS would now print the recipe. The DS, [NAME] 1, [NAME] 2, and [NAME] 3 stated they were not familiar with the term IDDSI spoon tilt test (method used to determine the stickiness of puree foods and the ability of the food to hold its shape and easily fall off a spoon when tilted). During a follow-up concurrent interview and record review on 2/23/2026 at 1:42 p.m. with [NAME] 1, [NAME] 3, and the DS, [NAME] 1 reviewed the recipe titled, Pureed Seasoned Fresh Broccoli Florets, dated 2026. [NAME] 1 stated the recipe indicated to place the broccoli from the regular recipe into a blender and blend until smooth and if the consistency needed thinning, then gradually add water or if it needs thickening then add commercial thickener. [NAME] 1 stated the recipe indicated to perform appropriate IDDSI testing to ensure texture standards are met. [NAME] 1 stated he did not know the term IDDSI testing, but puree should be smooth and not separate with liquid. The DS and [NAME] 2 stated they did not know the term IDDSI testing. During an interview on 2/23/2026 at 1:59 p.m. with the DS, the DS stated the facility implemented Menu and Recipe System (MS) 1 about a year prior that includes IDDSI. The DS stated he completed an on-line training at that time. The DS stated he did not provide an in-service for kitchen staff when MS 1 was implemented. The DS stated the kitchen staff have never been given in-services on IDDSI or IDDSI testing or had competency evaluations for IDDSI testing of mechanically altered diets. The DS stated the DS works with the Registered Dietician (RD) and RD has never provided and in-service or completed a competency evaluation for the DS on IDDSI. During an interview on 2/24/2026 at 3:58 p.m. with the Speech-Language Pathologist (SLP), the SLP stated IDDSI is a diet level system for modified diets for residents that are at risk of choking and possible aspiration (accidentally inhaling food or liquid into the lower airway) from food or liquids that are too thin or too thick. The SLP stated puree is level 4 and like a pudding texture. The SLP stated the kitchen staff should have a diet manual for testing of puree texture. The SLP stated the IDDSI testing for puree is to visually make sure there are no lumps, to use the spoon tilt test, or to use the fork drip test (puree food should not drip or continuously flow through the tines of the fork). During a concurrent interview and record review on 2/24/2026 at 4:32 p.m. with the DS, the MS 1 Diet Manual (MS1DM), last revised 9/26/2025, was reviewed. The DS stated the MS1DM is a kitchen resource for any questions regarding the MS 1 diets, menu, and recipes. The DS stated he assembled the MS1DM but did not thoroughly read it. The DS stated the MS1DM indicates the IDDSI framework uses standardized testing methods for evaluation of modified food and liquid consistencies. The DS stated the MS1DM indicates level 4 puree foods must pass the IDDSI Appearance Test (no lumps), Fork Drip Test, and Spoon Tilt Test. The DS stated on 2/23/2026 during the lunch service the kitchen staff did not perform IDDSI testing on the puree broccoli and it resulted in broccoli being watery that could potentially cause liquid going to the lungs, coughing, and aspiration when served to residents. The RD stated he was responsible for making sure the kitchen staff was competent. The DS stated he did not provide an in-service to kitchen staff or evaluate the staff for competency with IDDSI standards and testing. During an interview on 2/25/2026 at 2:11 p.m. with the RD, the RD stated that the proper consistency for a pureed diet is that it slides off the spoon, maintains its shape and form, not sticky, and not watery. The RD further stated the cook should follow the recipe and the recipe has instructions on what to do. The RD stated the cook should test the consistency of the pureed diet during tray line and adjust as needed using water or thickener depending on the consistency. The RD stated the pureed diet served should have been the correct consistency for the residents to be able to swallow the food without any choking which may lead to aspiration pneumonia (a lung infection caused by inhaling something other than air into the lungs such as food, liquid, saliva or stomach contents). The RD stated the facility staff should have known how to test the puree broccoli based on IDDSI testing. The RD stated the kitchen staff did not display competence when Resident 25's puree broccoli wept and the staff did not perform puree testing on the trayline. The RD stated she did not provide an in-service regarding IDDSI and she did not perform a competency evaluation for the DS. The RD stated she was not sure who was responsible for ensuring the DS was evaluated for competencies. During a concurrent interview and record review on 2/26/2026 at 9:58 a.m. with the Assistant Director of Nursing (ADON), a photograph of Resident 25's lunch tray contents, dated 2/23/2026, was reviewed. The ADON stated that the liquid was separating from the puree broccoli. The ADON stated liquid should not separate from the broccoli because it was the wrong consistency to serve to residents. The ADON stated on 2/23/2026 during the lunch service when the DS, [NAME] 1, [NAME] 2, and [NAME] 3 did not follow puree recipes, did not perform IDDSI testing, and prepared broccoli that wept. The ADON stated they did not demonstrate competency with IDDSI standards used in the MS 1 system potentially resulting in Resident 25 choking and aspirating when the puree broccoli wept. During an interview on 2/26/2026 at 10 a.m. with the DS, the DS stated when IDDSI was first starting to be implemented in the facility, about four years ago, he (DS) learned about IDDSI on the old computer menu system. The DS stated his competency on IDDSI was never evaluated. The DS stated the implementation of IDDSI should have been more organized to ensure all the kitchen staff were knowledgeable regarding IDDSI levels and testing. During an interview on 2/26/2026 at 12:13 p.m. with the ADON, the ADON stated she had worked in the facility for about five years and didn't really know the diet levels and IDDSI terminology. The ADON stated it was really the responsibility of the Administrator (ADM) to ensure the DS was provided with competency evaluations regarding IDDSI standards and implementation. During a concurrent interview and record review on 2/26/2026 at 12:22 p.m. with the Governing Body Chair (GBC), the Facility Assessment and policy and procedures regarding administrator duties were reviewed. The GBC stated if the DS does not know the terminology and procedures of the Diet Manual then it is a problem. The GBC stated it is the responsibility of the ADM to ensure that the DS is competent. The GBC stated if the DS did not demonstrate competence and stated he was never provided a competency evaluation then it ultimately falls on the ADM. The GBC stated the facility assessment indicates the dietary staff should have competence to provide care to residents on mechanically altered diets that require specialized aspiration and choking prevention. The GBC stated there was no documentation that the ADM provided competency evaluations for the DS. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet, last reviewed on 10/23/2025, the P&P indicated, The facility ensures residents receive and consume food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) to support the resident's treatment, plan of care, in accordance with his or her goals and preferences. During a review of the facility's P&P titled, Staffing Food and Nutritional Services, last reviewed on 10/23/2025, the P&P indicated, The facility ensures there are sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. The facility should employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. When the qualified dietitian or other clinically qualified nutrition professional is not employed full time, the facility shall designate a person to serve as the director of food and nutrition services. Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. The Registered Dietitian/designated person(s) shall: . Participate in developing and evaluating regular and therapeutic diets, including texture of foods and liquids, to meet the specialized needs of residents. Develop and implement the person-centered education programs involving food and nutrition services for all facility staff. A qualified dietitian or other clinically qualified nutrition professional may delegate activities to the director of food and nutrition services. During a review of the facility's P&P titled, Administrators Duties and Responsibilities, last reviewed on 10/23/2025, the P&P indicated, The facility has a qualified administrator who leads the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility has policies and procedures for screening and training employees. During a review of the Facility Assessment, last reviewed on 10/23/2025, the Facility Assessment indicated, Our Facility Assessment serves as a basis for Staff Members to understand decisions made with regard to staffing and other resources necessary to carry out our Facility's functions and competently care for our residents. Our Facility Assessment evaluates our resident population and identifies the resources needed to provide the necessary person-centered care and services our residents require. SECTION 3- STAFFING RESOURCES & STAFF COMPETENCY. Utilizing our resident population assessment data, we have identified categories of resident care needs and the specific staff needed to care for these residents, as shown in the chart below. Category of Resident Care Needs. Dietary Services . Specific Staff Needed . Registered Dietician, Dietary Supervisor, Cooks, Dietary Aides. Based on our resident profile assessment, we have determined the type of competencies needed by our staff to care for our unique population as shown in the chart below. Our Facility constantly evaluates staff training needs based on our resident population to ensure we are appropriately caring for our residents. Our Facility does not admit residents who we cannot appropriately provide care for. Level and Type of Support per Resident Population. Residents on Mechanically Altered and Special Diets. Staff Training Needed. Individualized Dietary Requirements, Specialized Choking and Aspiration Prevention, Consistencies . Competencies Needed . Dietary Competencies, Safe Swallowing . Our Facility evaluates our process to ensure staff are competent and are accurately practicing identified competencies both during day-to-day and emergency operations through/by conducting thorough training upon hire as well as skills competency tests that are conducted at least annually or as needed. During a review of the facility provided Job Description for Cook, dated 10/2016, the Job Description indicated, Job Title: Cook. Reports to. Dietary Manager. Prepares and cooks for the regular and modified diets for the resident population. Reviews menus prior to preparation of food. Prepares meals in accordance with planned menus, standardized recipes and production sheets. Prepares food for therapeutic diets in accordance with planned menus. Prepares meals in accordance with planned menus, standardized recipes and production sheets. Prepares food for therapeutic diets in accordance with planned menus. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. During a review of the facility provided Job Description for Dietary Manager, dated 10/2016, the Job Description indicated, Job Title: Dietary Manager. Reports to. Administrator. Responsible for supervision of both the kitchen and dining room staff in. serving food Completes evaluations on dietary staff. Ensures food is handled in accordance with applicable standards.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs for: 1. One (1) of four (4) residents (Resident 25) on puree diet (a texture modified diet that consists of smooth, pudding-like consistencies that are easy to swallow) when the resident`s lunch plate did not contain broccoli that wept (release of moisture, forming liquid on the surface) because International Dysphagia Diet Standardization Initiative (IDDSI, a standardized framework used to classify food textures and liquid thickness for people with dysphagia) testing (methods to confirm the flow or textural characteristics of a particular food or liquid) was not performed to ensure appropriate texture standards for residents with dysphagia (difficulty swallowing). 2. One (1) of one (1) resident (Resident 7) on Minced and Moist diet (MM5 - consists of soft, moist, and cohesive food with small, 4 millimeter [mm - a unit of measurement] lumps that are easily mashed with the tongue or fork, no separate liquids should be present, and requires minimal chewing) was served pureed garlic bread and penne pasta with mushroom sauce that was not runny and did not hold its shape during dining observation. 3. One (1) of one (1) resident (Resident 42) on soft bite sized (SB6- soft, tender foods that are appropriate for oral processing skills with no more than 15 millimeters [mm, a unit of length], for adults) diet was given pasta with mushroom sauce that was finely chopped and minced. These deficient practices had potential to cause the residents to not be able to eat their food and/or choke (when food gets stuck in your airway, blocking the flow of the air to your lungs) on the food. Findings: a. During a review of Resident 25's admission Record (AR, front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted the resident on 11/6/2025, with diagnoses including dysphagia, chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), and chronic obstructive pulmonary disease (COPD, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 25's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 25 had the ability to understand others and had the ability to make herself understood. The MDS further indicated Resident 25 required supervision or touching assistance with eating and oral hygiene, and substantial/maximal assistance to total assistance dressing and personal hygiene and was dependent on staff for toileting and bathing. The MDS further indicated Resident 25 was on mechanically altered (requires change in texture of food or) and therapeutic diet. During a review of Resident 25's Order Summary Report dated 2/26/2026, the Order Summary Report indicated a physician's order dated 2/23/2026 for consistent carbohydrate (CCHO – a nutritional approach that involves eating a similar, measured amount of carbohydrates at each meal to maintain stable blood sugar levels) no added salt (NAS - eliminating the use of salt during cooking and at the table) diet pureed texture, mildly thick consistency, fortify diet (practice of adding vitamins and minerals to commonly consumed foods during processing to increase the nutritional value). During a review of the facility's Diet Spreadsheet – Spring/Summer 2025, the Diet Spreadsheet indicated the following menu for lunch on 2/23/2026 for Pureed (PU4) / (texture): - Pureed Penne with mushroom sauce one and one half (1/2 – a unit of measurement) cups - Pureed seasoned fresh broccoli florets, number twelve (12) scoop - Pureed garlic bread (PU4) – number 12 scoop - Pureed key lime pie - number 12 scoop - Choice of beverage During a kitchen tray line (specialized, assembly-line food service system) observation on 2/23/2026 at 12:02 p.m., observed [NAME] 1 plating the resident lunch meals. Observed Resident 25's tray prepared with the plate covered, and sitting on the tray line. Just prior to being placed in the meal cart, the surveyor asked to see the plate. Resident 25's plate cover was removed and observed puree broccoli, puree pasta, and puree bread. Observed a green tinted, water like liquid surrounding the broccoli. [NAME] 1 stated the broccoli was separating and should not have water, but it did. [NAME] 1 stated he (Cook 1) needed to stir the broccoli more. Observed [NAME] 1 stirred the broccoli and replated Resident 25's meal. Observed [NAME] 1 did not perform IDDSI standardized testing on the prepared puree foods during tray line. [NAME] 1 stated the process for making pureed broccoli was to measure the cooked broccoli and puree in the blender, then add water or a commercial thickener (food additive designed to increase the thickness of liquids and food items) to make sure it was not lumpy and was an applesauce like texture. [NAME] 1 stated [NAME] 3 prepared the puree broccoli. [NAME] 3 then stated she (Cook 3) prepared the broccoli by placing an unmeasured amount of cooked broccoli from the regular recipe in the blender with an unmeasured amount of cooking water. The Dietary Supervisor (DS) stated there is a recipe for puree broccoli. The Surveyor asked to see the recipe and observed the DS walk to the recipe binder. The DS stated the puree broccoli recipe was not with the printed recipes and the DS would now print recipe. The DS, [NAME] 1, [NAME] 2, and [NAME] 3 stated they were not familiar with the term IDDSI spoon tilt test (method used to determine the stickiness of puree foods and the ability of the food to hold its shape and easily fall off a spoon when tilted). During a follow-up interview and record review on 2/23/2026 at 1:42 p.m. with [NAME] 1, [NAME] 3, and the DS, [NAME] 1 reviewed the recipe titled, Pureed Seasoned Fresh Broccoli Florets, dated 2026. [NAME] 1 stated the recipe indicated to place the broccoli from the regular recipe into a blender and blend until smooth and if the consistency needed thinning, then gradually add water or if it needs thickening then add commercial thickener. [NAME] 1 stated the recipe indicated to perform appropriate IDDSI testing to ensure texture standards are met. [NAME] 1 stated he (Cook 1) did not know the term IDDSI testing, but puree should be smooth and not separate with liquid. The DS and [NAME] 2 stated they did not know the term IDDSI testing. During an interview on 2/23/2026 at 1:59 p.m. with the DS, the DS stated the facility implemented Menu and Recipe System (MS) 1 about a year prior that includes IDDSI. The DS stated he (DS) completed an on-line training at that time. The DS stated he did not provide an in-service for kitchen staff when MS 1 was implemented. During an interview and record review on 2/24/2026 at 3:58 p.m. with the Speech-Language Pathologist (SLP), the SLP stated IDDSI is a diet level system for modified diets for residents that are at risk of choking and possible aspiration (accidentally inhaling food or liquid into the lower airway) from food or liquids that are too thin or too thick. The SLP stated puree is level 4 and like a pudding texture. The SLP stated the IDDSI testing for puree is to visually make sure there are no lumps, to use the spoon tilt test, or to use the fork drip test (puree food should not drip or continuously flow through the tines of the fork). The SLP stated the kitchen staff should have a diet manual for testing of puree texture. During an interview and record review on 2/24/2026 at 4:32 p.m. with the DS, the DS reviewed the MS 1 Diet Manual (MS1DM), last revised 9/26/2025, and stated the MS1DM is a kitchen resource for any questions regarding the MS 1 diets, menu, and recipes. The DS stated he (DS) assembled the MS1DM but did not thoroughly read it. The DS stated the MS1DM indicates the IDDSI framework uses standardized testing methods for evaluation of modified food and liquid consistencies. The DS stated the MS1DM indicates level 4 puree foods must pass the IDDSI Appearance Test (no lumps), Fork Drip Test, and Spoon Tilt Test. The DS stated on 2/23/2026 during the lunch service the kitchen staff did not perform IDDSI testing on the puree broccoli and it resulted in broccoli being watery that could potentially cause liquid going to the lungs, coughing, and aspiration when served to residents. During an interview on 2/25/2026 at 2:11 p.m., with the RD, the RD stated that the proper consistency for a pureed diet is that it slides off the spoon, maintains its shape and form, not sticky, and not watery. The RD further stated the cook should follow the recipe and the recipe has instructions on what to do. The RD stated the cook should test the consistency of the pureed diet during tray line and adjust as needed using water or thickener depending on the consistency. The RD stated the pureed diet served should have been the correct consistency for the residents to be able to swallow the food without any choking which may lead to aspiration pneumonia (a lung infection caused by inhaling something other than air into the lungs such as food, liquid, saliva or stomach contents). The RD stated the facility staff should have known how to test the puree broccoli based on IDDSI testing. The RD stated the kitchen staff did not display competency when Resident 25's puree broccoli wept and the staff did not perform puree testing on the trayline. During a concurrent interview and record review on 2/26/2026 at 9:58 a.m. with the Assistant Director of Nursing (ADON), the ADON reviewed the photograph of Resident 25's lunch tray contents dated 2/23/2026 and Policy and Procedures (P&P) regarding therapeutic diets. The ADON stated that the liquid was separating from the puree broccoli. The ADON stated liquid should not separate from the broccoli because it was the wrong consistency to serve to residents. The ADON stated on 2/23/2026 during the lunch service when the DS, [NAME] 1, [NAME] 2, and [NAME] 3 did not follow puree recipes , did not perform IDDSI testing, and prepared broccoli that wept they did not demonstrate competency with IDDSI standards used in the MS 1 system potentially resulting in Resident 25 choking and aspirating when the puree broccoli wept. The ADON stated the P&P was not followed. During a review of the facility's P&P titled, Therapeutic Diet, last reviewed on 10/23/2025, the P&P indicated, The facility ensures residents receive and consume food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) to support the resident's treatment, plan of care, in accordance with his or her goals and preferences. Mechanically altered diet: a diet in which the texture of a diet is altered. When the texture is modified, the type of texture modification must be specific and part of the physician's or delegated RD order During a review of the facility's policy and procedure (P&P) titled, Dietetic Service – Diet Manual, last reviewed on 10/23/2025, the P&P indicated, The facility shall maintain a current diet manual approved by the dietitian and medical staff. The manual shall be readily available to attending physicians, nursing, and dietetic staff. Intent.To provide staff and physicians with authoritative, standardized dietary guidelines for planning and implementing patient diets. Diet Manual: A current reference manual containing nutritional standards and therapeutic diet descriptions, approved annually. The manual must include descriptions of therapeutic diets and serve as a guide for prescribing and serving patient diets. Procedures / Standards . Staff use the manual for guidance in prescribing and serving diets. During a review of the MS1DM document titled, Common Ground between National Dysphagia Diet (NDD) and IDDSI, dated 2025, the MS1DM document indicated, The National Dysphagia Diet (NDD) of 2002 was replaced with the International Dysphagia Diet Standardization Initiative (IDDSI) Framework. This document explores the development of the IDDSI framework and the identification of diet levels. IDDSI is the only professionally recognized and supported diet framework as of October 2021. IDDSI framework consists of 8 more clearly defined levels (0-7) of drinks through foods. Drinks and foods are tested using IDDSI Testing Methods. Testing Methods such as the Spoon Tilt Test to ensure safety of a pureed food product. During a review of the MS1DM document titled, IDDSI Texture-Modified Diets, dated 2025, the MS1DM document indicated, texture-modified diets are prepared and served by the physician or community speech language pathologist when a resident has difficulty chewing and/or swallowing. The residents' acceptance and tolerance of the diet determine the extent of texture modification and meals need to be modified to suit individual resident preferences. Use the IDDSI testing methods to evaluate the final consistency.Testing Info. Level 4 – Pureed PU 4. sits in a mound or pile above the fork, does not dollop or drip continuously through a fork. Holds its shape on a spoon, falls off easily if the spoon is tilted or lightly flicked, must not be firm or sticky, should be smooth with no lumps, no chewing ability needed, and can be eaten with a spoon. During a review of the MS1DM document titled, Pureed (PU4), dated 2025, the MS1DM document indicated, This modification is designed for people who have severe chewing and/or swallowing problems. Properly pureed foods eliminate the chewing phase. Pureed diet menus follow the foods on the regular menu as closely as possible and differ primarily in consistency. Puree all foods to a smooth, lump-free, Extremely Thick (EX4) consistency (not firm or sticky). Use an appropriate recipe. This diet is also appropriate for Dysphagia Pureed (Level 1). Use of commercial thickeners (used according to the resident's tolerance) when preparing pureed foods is recommended. Always refer to the recipe and spreadsheet for directions . Foods on this level must pass the IDDSI Appearance Test, Fork Drip Test and Spoon Tilt Test. Food is smooth, with no lumps. Food sits in a mound on a fork, does not drip continuously through the tines of a fork, holds its shape on a spoon, slides off spoon easily (not sticky). Pureed food must pass both tests! During a review of the facility's P&P titled, Staffing Food and Nutritional Services, last reviewed on 10/23/2025, the P&P indicated, The facility ensures there are sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. The facility should employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. When the qualified dietitian or other clinically qualified nutrition professional is not employed full time, the facility shall designate a person to serve as the director of food and nutrition services. Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. The Registered Dietitian/designated person(s) shall: . Participate in developing and evaluating regular and therapeutic diets, including texture of foods and liquids, to meet the specialized needs of residents. Develop and implement the person-centered education programs involving food and nutrition services for all facility staff. A qualified dietitian or other clinically qualified nutrition professional may delegate activities to the director of food and nutrition services. During a review of the facility provided Job Description for Cook, dated 10/2016, the Job Description indicated, Job Title: Cook. Reports to. Dietary Manager. Prepares and cooks for the regular and modified diets for the resident population. Reviews menus prior to preparation of food. Prepares meals in accordance with planned menus, standardized recipes and production sheets. Prepares food for therapeutic diets in accordance with planned menus. Prepares meals in accordance with planned menus, standardized recipes and production sheets. Prepares food for therapeutic diets in accordance with planned menus. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. During a review of the facility provided Job Description for Dietary Manager, dated 10/2016, the Job Description indicated, Job Title: Dietary Manager. Reports to. Administrator. Responsible for supervision of both the kitchen and dining room staff in. serving food Completes evaluations on dietary staff. Ensures food is handled in accordance with applicable standards. b. During a review of Resident 7's admission Record, the admission Record indicated the facility originally admitted the resident on 1/20/2023, and readmitted in the facility on 11/4/2025, with diagnoses including dysphagia, adult failure to thrive (a condition in older adults marked by physical and mental decline such as loss of appetite and weight loss), generalized muscle weakness). During a review of Resident 7's History and Physical (H&P) dated 11/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 7 required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, and substantial/maximal assistance to total assistance with all other activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS further indicated Resident had a diagnosis of dysphagia and was on mechanically altered and therapeutic diet. During a review of Resident 7's Order Summary Report dated 2/26/2026, the Order Summary Report indicated a physician's order dated 2/13/2026 for consistent carbohydrate NAS diet Minced and Moist texture, moderately thick consistency, fortify diet. During an observation on 2/23/2026 at 12:40 p.m. with Certified Nursing Assistant (CNA) 8, observed Resident 7 eating lunch in the small dining room. CNA 8 stated Resident 7's meal ticket indicated CCHO Minced and Moist (MM5) texture moderately thick honey liquid fortify diet and Resident 7 was served with pureed bread, pureed pasta, and finely chopped broccoli. CNA 8 stated the pureed bread and pasta were runny and did not hold their shape. CNA 8 stated the liquid was separating from the broccoli. CNA stated if the food is too runny and thin, it placed Resident 7 at risk for choking. During a concurrent interview and record review on 2/25/2026 at 2:11 p.m., photograph of Resident 7's lunch tray and meal ticket for 2/23/2026 was reviewed with the RD. The RD stated the meal ticket indicated that Resident 7's diet was CCHO Minced and Moist (MM5) texture moderately thick honey liquid fortify diet and the resident was served pureed pasta and bread that is too thin and did not hold its shape and that the liquid was separating from the finely chopped broccoli. The RD stated that the proper consistency for a pureed diet is that it slides off the spoon, maintains its shape and form, not sticky, and not watery. The RD further stated the cook should follow the recipe and the recipe has instructions on what to do. The RD stated the cook should test the consistency of the pureed diet during tray line and adjust as needed using water or thickener depending on the consistency. The RD stated the pureed diet served should have been the correct consistency for the residents to be able to swallow the food without any choking which may lead to aspiration pneumonia (a lung infection caused by inhaling something other than air into the lungs such as food, liquid, saliva or stomach contents). During a concurrent interview and record review on 2/26/2026 at 9:29 a.m., Resident 7's Order Summary Report, medical diagnosis, and photograph of Resident 7's lunch tray contents and meal ticket dated 2/23/2026 were reviewed with the ADON. The ADON stated that Resident 7 had a diagnosis of dysphagia. The ADON stated the meal ticket indicated that Resident 7's diet was CCHO Minced and Moist (MM5) texture moderately thick honey liquid fortify diet and that the resident was served pureed pasta and bread that is too thin and did not hold its shape and that the liquid was separating from the finely chopped broccoli. The ADON stated that the pureed diet served to Resident 7 should have been more formed and not too thin as it placed Resident 7 at risk for choking and aspiration as the resident had a diagnosis of dysphagia. During a review of the facility's Diet Spreadsheet – Spring/Summer 2025, dated 2025, the Diet Spreadsheet indicated the following menu for lunch for Minced and Moist (MM5) texture: - Penne with mushroom sauce 1 and one half (1/2 – a unit of measurement) cups - Minced seasoned fresh broccoli florets with thick broth number eight (8) scoop with thick broth - Pureed garlic bread (PU4) – number 12 scoop - Pureed key lime pie - number 12 scoop - Choice of beverage During a review of the facility provided document titled, Diet Descriptions, dated 2025, the Diet Descriptions indicated the following: 3. Texture-Modified Diets and Thickened liquids – texture-modified diets are prepared and served by the physician or community speech language pathologist when a resident has difficulty chewing and/or swallowing. Texture-modified diets and thickened liquid consistencies are based on the International Dysphagia Standardization Initiative (IDDSI, a framework made up of levels and describes food textures and drink thickness) framework. Texture modifications and thickened liquid consistencies include the following: - Minced and Moist (MM5); also appropriate for dysphagia mechanically altered (level 2) – used in the dietary management of dysphagia with food texture described as s soft, tender, moist foods with no separate thin liquids. Food should be no greater than 4 mm by 15 mm pieces. All foods from pureed (PU4) are acceptable at this level. - Pureed (PU4); also appropriate for dysphagia pureed (level 1) – follows the regular diet menu items whenever possible with the modification of pureeing the food items. During a review of the facility provided document titled, IDDSI Texture-Modified Diets, dated 2025, the IDDSI Texture-Modified Diets document indicated that texture-modified diets are prepared and served by the physician or community speech language pathologist when a resident has difficulty chewing and/or swallowing. The residents' acceptance and tolerance of the diet determine the extent of texture modification and meals need to be modified to suit individual resident preferences. The document further indicated: - Use the IDDSI testing methods to evaluate the final consistency. - Level 5 – Minced and Moist MM5 testing information indicated 4 mm lump size for adults, hold its shape on a spoon, falls off easily if the spoon is tilted or lightly flicked, and must not be firm or sticky. Further information stated the food should be very soft, and had small moist lumps, minimal chewing ability needed. - Level 4 – Pureed PU 4 testing information indicated the food should sit in a mound or pile above the fork, does not dollop or drip continuously through a fork, holds its shape on a spoon, falls off easily if the spoon is tilted or lightly flicked, must not be firm or sticky, should be smooth with no lumps, no chewing ability needed, and can be eaten with a spoon. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet, last reviewed on 10/23/2025, the P&P indicated that the facility ensures residents receive and consume food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) to support the resident's treatment, plan of care, in accordance with his or her goals and preferences. The P&P further indicated: - Mechanically altered diet: a diet in which the texture of a diet is altered. When the texture is modified, the type of texture modification must be specific and part of the physician's or delegated RD order. During a review of the facility's P&P titled, Standardized Recipes, last reviewed on 10/23/2025, the P&P indicated that food products prepared and served by the dietary department will utilize standardized recipes. The P&P further indicated: - Standardized recipes will have adjustments or separate recipes for therapeutic and consistency modifications. - Recipes will have diet modifications noted. During a review of the facility's P&P titled, Menus, last reviewed 10/23/2025, the P&P indicated that the facility ensures menus ae developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. The P&P further indicated: - Residents receive food in the amount, type, consistency, and frequency to maintain normal body weight and acceptable nutritional values. - Menus meet basic nutritional needs by providing meals based on individual nutritional assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue. c. During a review of Resident 42's admission Record, the admission Record indicated the facility admitted the resident on 10/30/2025, with diagnoses including dysphagia, dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 42's History and Physical (H&P) dated 11/2/2025, the H&P indicated Resident 42 did not have the capacity to understand and make decisions. During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and make his needs known. The MDS further indicated Resident 42 required supervision or touching assistance with rolling to left and right and sit to lying; partial/moderate assistance with eating and lying to sitting; partial/moderate assistance with oral hygiene, and substantial/maximal assistance to total assistance with all other activities of daily living. The MDS further indicated Resident had a diagnosis of dysphagia and was on mechanically altered and therapeutic diet. During a review of Resident 42's Order Summary Report dated 2/26/2026, the Order Summary Report indicated a physician's order dated 2/22/2026 for no added salt diet soft and bite sized (SB6- soft, tender foods that are appropriate for oral processing skills with no more than 15 millimeters [mm, a unit of measurement], for adults)thin liquids consistency, fortify diet. During a concurrent observation and interview on 2/23/2025 at 12:46 p.m. inside Resident 42's room with CNA 6 and CNA 7, CNA 6 stated Resident 42's meal ticket indicated NAS soft and bite sized (SB6) thin liquids consistency, fortify diet. CNA 7 stated the pasta noodles served to Resident 42 were soft but were not bite sized. CNA 6 and CNA 7 both stated that they just cut the noodles in small bite sized pieces before giving it to the resident but were unable to tell the approximate measurement for bite-sized food. CNA 6 stated that he (CNA 6) will send the tray back to the kitchen and request a replacement with bite-sized pasta. CNA 7 stated that the lunch tray served to the resident should have been the correct one. CNA 7 stated that if Resident 42 ate the big pieces of pasta on the plate, the resident can end up choking. During a concurrent interview and record review on 2/25/2026 at 2:11 p.m., a photograph of Resident 42's lunch tray and meal ticket for 2/23/2026 was reviewed with the RD, the RD stated the meal ticket indicated that Resident 42's diet was NAS soft and bite sized (SB6) thin liquids consistency, fortify diet and the resident was served pasta and the noodles were not bite-sized pieces. The RD stated that the proper consistency for a soft and bite-sized diet is at least 1/2 of an inch for the pasta pieces and should not be bigger than that. The RD further stated the cook should follow the recipe and the recipe has instructions on what to do. The RD stated the cook should prepare the soft and bite-sized according to the recipe and should have been chopped in bite-sized pieces. The RD stated the soft and bite-sized diet served to Resident 42 should have been the correct consistency for the resident to be able to swallow the food without any choking which may lead to aspiration pneumonia (a lung infection caused by inhaling something other than air into the lungs such as food, liquid, saliva or stomach contents). During a concurrent interview and record review on 2/26/2026 at 9:29 a.m., Resident 42's Order Summary Report, medical diagnosis, and photograph of Resident 42's lunch tray contents and meal ticket dated 2/23/2026 were reviewed with the Assistant Director of Nursing (ADON). The ADON stated that Resident 42 had a diagnosis of dysphagia. The ADON stated the meal ticket indicated that Resident 42's diet was NAS soft and bite sized (SB6) thin liquids consistency, fortify diet and that the resident was served pasta noodles that were not bite-sized pieces. The ADON stated that most of the pasta noodles served to Resident 42 on the plate were at least 1 inch in length which is not a bite-sized length. The ADON stated that the soft and bite-sized pasta served to Resident 42 should have been cut by the cook in bite-sized pieces as it placed Resident 42 at risk for choking and aspiration if consumed as the resident had a diagnosis of dysphagia. During a review of the facility's Diet Spreadsheet – Spring/Summer 2025, dated 2025, the Diet Spreadsheet indicated the following menu for lunch for soft and bite-sized (SB6) texture: - Chopped penne with mushroom sauce 1 1/2 cups - Bite-sized seasoned fresh broccoli florets (SB6) number 8 scoop - Pureed garlic bread (PU4) number 12 scoop - Pureed key lime pie (PU 4) number 12 scoop - Choice of beverage 1 cup During a review of the facility provided doc

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen reviewed during the Kitchen task by failing to: 1. Ensure used towels were stored in sanitation buckets or dirty towel bins and not left unattended in the sink, at the trayline (a specialized, assembly-line food service system), and in the dirty dish washing area. 2. Ensure food items in the Dry Food Storage Area were labeled with the date per facility policy and procedure (P&P). 3. Ensure perishable fruits and vegetables were stored in the refrigerator and according to facility P&P. 4. Ensure frozen items in the Ice Cream Freezer were labeled with the contents and date. 5. Ensure food items in the Dry Can Storage Area were properly covered with tight sealed lids. 6. Ensure expired foods in the Dry Can Storage Area were discarded and not readily available to be served. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (the process by which bacteria, chemicals, or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs) in 87 of 89 medically compromised residents who received food and drinks from the kitchen. Findings: a. During an Initial Kitchen Tour on 2/23/2026 at 7:53 a.m., with the Dietary Supervisor (DS), observed the Food Preparation Area, the Dishwashing Area, and Trayline Area. The DS stated the facility uses white towels to clean and sanitize the kitchen. The DS stated all towels should only be stored in red sanitizer buckets when in use or dirty towel bins after use. The DS stated no towels should be left out on kitchen surfaces to prevent cross contamination from one surface to another while staff is performing tasks in the kitchen. Observed the following: 1.A damp white towel was placed in the kitchen prep sink. The DS stated the towel was dirty and should not be left in the sink. The DS stated the staff should have placed the used towel in the dirty towel area and they did not. 2.A soiled, white towel was placed under a plate of parsley on the tray line. The DS stated towels should not be left under a plate of food on the trayline to prevent cross contamination from the towel to the food. 3.A damp, soiled towel was left on top of dirty dishes in the dirty dish area. The DS stated the used towel should not have been left in the dirty dish area, but staff left it there. During an interview on 2/25/2026 at 2:11 p.m. with the Registered Dietician (RD), the RD stated kitchen towels are kept in the sanitation solution buckets and then used only one time and then placed in the dirty towel bin. The RD stated the kitchen towels should not be left on kitchen surfaces to ensure staff does not grab and re-use dirty towels. The RD stated she (RD) has previously corrected the practice of leaving used towels on kitchen surfaces and has provided in-services to staff. The RD stated when dirty towels were left out in the kitchen there was the potential to spread bacteria in the kitchen resulting in cross contamination and food poisoning in residents. During a review of the facility P&P titled, Safe Food Preparation, last reviewed 10/23/2025, the P&P indicated, POLICY. The facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. PURPOSE: To provide guidelines for the safe preparation of meals. DEFINITIONS: The following definitions are provided to clarify terms related to professional standards for food service safety, sanitary conditions, and the prevention of foodborne illness. Foodborne illness refers to illness caused by the ingestion of contaminated food or beverages. Cross-Contamination. 2. Cross-contamination can occur when harmful substances. i.e . chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges. cloth towels. or utensils that are not adequately cleaned. 3. Examples of ways to reduce cross-contamination include. but are not limited to:. b. Between uses, store towels/cloths used for wiping surfaces during the kitchen's daily operation in containers filled with sanitizing solution at the appropriate concentration per manufacturer's specifications. b. During an Initial Kitchen Tour on 2/23/2026 at 7:53 a.m., with the DS, observed the Dry Food Storage Area, Ice Cream Freezer, and Dry Can Storage Area. The DS stated the facility uses the First-In, First-Out method (FIFO, an inventory management and food safety system where the oldest stock [first in] is used before newer stock [last in]) and labels and dates all food with the food item, date of arrival, and open date to ensure staff knows what they are serving and to ensure no expired or old food is served to residents. The DS stated food is used or discarded by a date determined by the Product Shelf-Life guidelines and the expiration date on packaging. The DS stated when items are removed from the original packaging, they are labeled with the food item and date. Observed the following: 1. In the Ice Cream Freezer, observed a clear plastic bag containing two frozen pizzas. The DS stated the frozen pizzas were removed from the original container and were not labeled with the contents or the date. The DS stated all frozen foods should be labeled and have the date removed from the original box or an expiration date to track quality and freshness of the food, but the kitchen staff did not label the frozen pizzas. 2. In the Dry Can Storage Area observed a clear plastic bin containing dry cereal. Observed the lid to the bin was not secured and cereal was exposed. The DS stated bins containing cereal should be properly covered with tight sealed lids, but it was not. The DS stated it was important to keep food covered to preserve the quality of the food and ensure nothing got inside that may contaminate the food and result in illness in residents. 3. In the Dry Can Storage Area observed a package of English Muffins labeled with a best if used by date of 2/11/2026. The DS stated the muffins should have been discarded and not available to be served, but they were not. The DS stated expired food items should not be served to residents to ensure quality and prevent food borne illness. 4. In the Dry Food Storage Area, observed there was no thermometer in the room. Observed a box containing sprouting potatoes. The DS stated the box was not labeled with the date and the potatoes were growing roots. The DS stated he (DS) was not sure when the potatoes arrived in the facility because the box was not labeled with a date. The DS stated kitchen staff should have labeled the box of potatoes but did not. The DS stated he (DS) would discard the potatoes. 5. The DS stated the Dry Food Storage Area was used to store food that does not need to be refrigerated and / or food that will be used within a day. The DS stated there was no thermometer in the Dry Food Storage Area and there were no temperature monitoring logs maintained. In the Dry Food Storage Area: - Observed on the shelf a box of cabbage dated 2/23/2026. The DS stated the cabbage was mislabeled because it was delivered on 2/21/2026. The DS stated cabbage was stored in the Dry Food Storage area and can be stored outside the refrigerator for up to five days. - Observed on the shelf a box of green bell peppers. The DS stated some of the bell peppers were wilting. The DS stated bell peppers were stored in the Dry Food Storage area and did not require refrigeration. - Observed on the shelf a box of cantaloupes labeled 2/21/2026. The DS stated cantaloupes were stored in the Dry Food Storage area and did not require refrigeration. - Observed on the shelf a box of cucumbers labeled 2/19/2026. The DS stated cucumbers were stored in the Dry Food Storage area and did not require refrigeration. - Observed on the shelf a box containing honey dew melons labeled 2/19/2026. The DS stated honey dew melons were stored in the Dry Food Storage area and did not require refrigeration. During a follow-up concurrent interview and record review on 2/24/2026 at 2:23 p.m. with the DS, the DS reviewed the facility P&P regarding food storage. The DS stated the Dry Food Storage Area did not have a thermometer and was not monitored for temperature. The DS stated the P&P indicates all vegetables and fruits, except potatoes, onions, and bananas should be stored at 41 degrees Fahrenheit ( F, a measurement of temperature) in the refrigerator. The DS stated all the vegetables and fruit in the Dry Food Storage Area, except the potatoes, onions, and bananas, should have been stored in the refrigerator to keep them fresh and to prevent spoiling, but they were not. The DS stated when spoiled food is served to residents it could result in harm to the residents. During an interview on 2/25/2026 at 2:11 p.m. with the RD, the RD stated fruits and vegetables should be stored per the P&P. The RD stated when fruits and vegetables are not stored per the facility P&P there is the potential that the food would not maintain the nutrients for residents or there could be bacteria growth resulting in resident illness. The RD stated all foods in the freezer need to be labeled with the contents and dated. The RD stated it was important to label the contents because some residents have allergies and it was important to know the exact ingredients of the food. The RD stated the frozen pizza should have been labeled, but it was not. The RD stated lids should be secured on the food bins to ensure the food does not become stale or contaminated. The RD stated she (RD) has noticed and reported to the DS that the lids were not secured on the food bins in the facility kitchen in the past. The RD stated the cereal bin lid should have been secured, but it was not. The RD stated expired English muffins and sprouting potatoes should have been discarded, but they were not. The RD stated expired food should not be available to be served to residents because it could potentially result in food born illness. During a review of the facility P&P titled, Food Storage, last reviewed 10/23/2025, the P&P indicated, Purpose. To establish guidelines for storing, thawing, and preparing food. Procedure. Foods should be stored in their original containers if designed for freezing. Foods to be frozen should be store in airtight containers. Label and date all food items. Fresh Fruits Storage Guidelines. Store at a temperature of 41 For less, except bananas, which should be stored at 60 F to 70 F. Fresh Vegetable Storage Guidelines. Fresh vegetables should be checked and sorted for ripeness.Store at a temperature of 41 F or less, except potatoes and onions, which should be stored in a cool and dry place at 60 F to 70 F. Fresh vegetables should be ordered and delivered frequently to ensure freshness. Dry Storage Guidelines . The area should be well lit and ventilated with a temperature of 50 F to 70 F. Any opened products should be placed in storage containers with tight fitting lids. Label and date storage products. During a review of the facility P&P titled, Food Receiving and Storage, last reviewed 10/23/2025, the P&P indicated, PURPOSE STATEMENT.When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. DRY FOOD STORAGE GUIDELINES.1. Dry storage may be in a room or area designated for the storage of dry goods, such as single service items, canned goods, and packaged or containerized bulk food that is not Potentially Hazardous Foods. 4. Dry foods and goods should be handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. It is recommended that foods stored in bins (e.g., flour or sugar) be removed from their original packaging. Desirable practices include managing the receipt and storage of dry food, removing foods not safe for consumption, keeping dry food products in closed containers, and rotating supplies. REFRIGERATED STORAGE GUIDELINES. Potentially hazardous foods shall be maintained at or below 41 degrees F, unless otherwise specified by law. 3. Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microorganisms. Inadequate temperature control during refrigeration can promote bacterial growth. Adequate circulation of air around refrigerated products is essential to maintain appropriate food temperatures. During a review of the facility provided guidelines document titled, Product Shelf Life, undated, the guidelines indicated, TV dinners purchased frozen. frozen for three to four months. Commercial muffins. pantry stored three to seven days. Vegetables. refrigerator three to five days. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less.

Based on interview and record review, the facility failed to maintain documentation and demonstrate evidence of ongoing Quality Assurance and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) program by: 1. Failing to provide documentation of the written QAPI plan (guides the nursing home's quality efforts and serves as the main document to support implementation of QAPI). 2. Failing to provide documentation of data collection and analysis at regular intervals to include falls, which was identified by the facility as a problem issue in the facility. These deficient practices had the potential for systemic failures to go uncorrected and no improvement to the facility's delivery of care for all residents. Findings: During the Entrance Conference conducted on 2/23/2026 at 8:09 a.m. with the Assistant Director of Nursing (ADON), the ADON was provided the Entrance Conference Worksheet (information needed from the facility, including the QAPI Plan). During a concurrent interview and record review on 2/26/2026 at 3:11 p.m. with the ADON, the Entrance Conference Worksheet and survey binder (binder used to collect and organize requested documents from the Entrance Conference Worksheet) were reviewed. The ADON stated the QAPI Plan that was in the survey binder was not the correct one and was dated 1/26/2023. The ADON stated she does not have access to the current QAPI Plan. The ADON stated the Administrator (ADM) is unable to be reached and the Director of Nursing (DON) is not available. The ADON stated the QAPI Plan is to identify the problem care areas of the facility for them to discuss and fix it. The ADON stated the QAPI plan is a written plan, and it contains data, logs, in-services, meeting minutes and analyzed during the QAPI meeting by the DON. The ADON stated by not having a QAPI plan, the facility would not have a goal and would not know when to meet and would not know what quality care areas to improve. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance Performance Improvement (QAPI), last reviewed 10/23/2025, the P&P indicated the purpose of the P&P is 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. PROCEDURE 1. The facility maintains documentation and demonstrates evidence of its ongoing QAPI program. 3. The facility shall present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request. 5. The facility QAPI plan is a written plan containing the process that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. 6. The QAPI plan describes in detail the scope the QAA committee's responsibilities and activities, and the process addressing how the committee will conduct the activities necessary to identify and correct quality deficiencies. 7. The QAPI plan described how the facility will ensure care and services delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress toward correction or improvement is achieved and sustained. 8. The facility QAPI plan described the process for identifying and correcting quality deficiencies, including but not limited to: - Tracking and measuring performance. - Establishing goals and thresholds for performance measurement. - Identifying and prioritizing quality deficiencies. - Systematically analyzing underlying causes of systemic quality deficiencies. - Developing and implementing corrective action or performance improvement activities; and - Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (a disease that is spread from one person to another through a variety of ways that include: contact with blood and bodily fluids; breathing in an airborne virus; or by being bitten by an insect), and infections by failing to ensure: 1. Resident 41's call light (a button, cord, or remote device in a hospital or nursing home room that allows a patient or resident to electronically alert nurses or staff that they need assistance) that was inside the trash can was sanitized before handing it off to the resident for use observed during random screening of residents. 2. Resident 37's call light that was on the floor was sanitized before handing them off to the resident for use during random screening of residents. 3. Certified Nursing Assistant (CNA) 10 was wearing a gown while providing activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) care to the resident who was on enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) for one (1) out of three (3) sampled residents (Resident 4) reviewed under infection control. The deficient practices had the potential to cause cross-contamination (a mechanical device used by caregivers to safely move people with limited mobility from one place to another) of infection among residents and staff. Findings: 1. During a review of Resident 41's admission Record (AR), the AR indicated the facility admitted the resident on 4/5/2021, and readmitted the resident on 7/2/2025, with diagnoses including muscle weakness, difficulty walking, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 1/19/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities—such as memory, thinking, reasoning, and learning—are working normally, without any significant decline, impairment, or loss of function). The MDS indicated the resident was dependent to needing set-up assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 41's Order Summary Report (OSR), dated 7/21/2025, the OSR indicated an order of EBP due to left heel peripheral vascular disease (PVD, a slow, progressive circulation disorder caused by narrowed, blocked, or damaged blood vessels (arteries or veins) outside the heart and brain, most commonly affecting the legs and feet) ulcer every shift. During a review of Resident 41's Care Plan (CP) Report titled, Enhanced barrier precaution related to left heel PVD ulcer, last revised on 7/21/2025, the CP indicated an intervention of environmental cleaning on resident's room, equipment and devices. During a concurrent observation and interview on 2/23/2026 at 9:26 a.m., with the Minimum Data Set Coordinator (MDSC), inside Resident 41's room, observed Resident 41's call light button dangling inside the trash can. The MDSC stated the call light button should not be dangling inside the trash can as it will contaminate the call light. The MDSC stated she (MDSC) should have sanitized the call light button before handing them off to the resident to prevent cross-contamination of infection to the resident. During a concurrent interview and record review on 2/25/2026 at 3:30 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 41's OSR and CP. The ADON stated Resident 41 was on an enhanced barrier precaution due to the residents OPVD and the care plan indicated to clean the environment of the resident including the equipment and devices. The ADON stated the MDSC should have sanitized the call light button that was inside the trash before handing it to the resident to prevent the spread of infection, especially if the resident had an open wound. During a review of the facility's recent policy and procedure (P&P) titled, Infection and Prevention and Control, last reviewed on 10/23/2025, the P&P indicated the facility has an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. During a review of Resident 37's AR, the AR indicated the facility admitted the resident on 9/18/2025, and readmitted the resident on 10/5/2025, with diagnoses including cellulitis (a skin infection that causes swelling and redness) of the left and right lower limb, local infection of the skin and subcutaneous tissue (the deepest layer of the skin, located just beneath the dermis), and depression (a common, serious mood disorder characterized by persistent feelings of sadness, emptiness, or loss of interest in activities for at least two weeks). During a review of Resident 37's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was dependent to needing set-up assistance on mobility and activities of daily living (ADLs). During a concurrent observation and interview on 2/23/2026 at 10:09 a.m., with Certified Nursing Assistant (CNA) 4, inside Resident 37's room, observed Resident 37's Call light was resting on the floor at the right side of the bed. CNA 4 stated the call light should always be within the reach of the resident so they can call for help when needed. CNA 4 picked the call light from the floor and handed it to Resident 37 without wiping the call light button with an antiseptic wipe. CNA 4 stated she (CNA 4) should have wiped the call light button with an antiseptic wipe prior to handing it to the resident to prevent the spread of infection among staff and resident. During a concurrent interview and record review on 2/25/2026 at 3:30 p.m., with the ADON, reviewed Resident 37's Medical Diagnoses and MDS. The ADON stated the call light of Resident 37 should not be resting on the floor as it will be hard for the resident to reach them and will not be able to call for help when needed and it can be a source of infection to the resident since the floor is contaminated. The ADON also stated CNA 4 should have wiped the call light button with an antiseptic wipe prior to handing the call light button of the resident to prevent the spread of infection to the resident. During a review of the facility's recent P&P titled, Infection and Prevention and Control, last reviewed on 10/23/2025, the P&P indicated the facility has an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 3. During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted the resident on 8/26/2018 and readmitted in the facility on 2/9/2022 with diagnoses including gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 4's History and Physical (H&P) dated 11/19/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) was sometimes able to understand others and make his needs known. The MDS further indicated Resident 4 was on GT feeding and totally dependent on staff with all ADLs. During a review of Resident 4's Order Summary Report dated 2/26/2026, the Order Summary Report indicated the following physician's orders: - 11/7/2024: GT: cleanse with normal saline (NS – a saltwater solution), pat dry, cover with split sponge dressing, secure with tape. - 11/17/2025: Enteral feed order: every shift Tube Feeding (TF) 1; set pump at 73 milliliters (ml – a unit of measurement) per hour for 20 hours to provide 1460 ml per 2190 kilocalories (Kcal – a unit of measurement). Start infusion at 2 p.m. and continue for 20 hours or until total volume is complete. - 12/23/2025: EBP due to GT and ulcer on the right third toe. During a review of Resident 4's care plan (CP) on EBP initiated on 5/1/2024, and last revised on 1/16/2026, the CP indicated health teaching to resident, family members and staff about importance of EBP including proper hand hygiene and wearing of personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) as one of the interventions to minimize risk and complications of infection. During a concurrent observation and interview on 2/23/2026 at 11:10 a.m. inside Resident 4's room with CNA 10, observed Resident 4 lying in bed, alert, and verbally responsive. Observed outside the room by the doorway a sign for EBP and a personal protective equipment (PPE- wearable gear and clothing designed to protect individuals from safety hazards, injuries, or infectious diseases) caddie (a portable storage). Observed CNA 10 used hand sanitizer prior to putting on gloves but did not put on a gown. CNA 10 stated she (CNA 10) will start providing ADL care to Resident 4. During a follow up observation and concurrent interview and review of EBP signage on 2/23/2026 at 11:35 a.m. outside Resident 4's room by the doorway, with CNA 10, observed CNA 10 only wearing gloves and stated she (CNA 10) just finished providing ADL care to Resident 4. CNA 10 stated there was a signage posted by Resident 4's doorway for EBP. CNA 10 stated the EBP signage indicated the staff have to observe proper hand hygiene and put on gloves and gown during high contact resident activities. CNA 10 stated she (CNA 10) did not observe the EBP by not putting on gown while providing care to Resident 4. CNA 10 stated Resident has a GT, and she (CNA 10) should have put on a gown while providing ADL care to Resident 4 as it placed Resident 4 at risk for acquiring infection and the infection can spread to other staff and residents. CNA 10 stated they get in-services and reminders regarding observing EBP during high contact activities, but she (CNA 10) forgot to put on gown before providing care to Resident 4. During an interview on 2/25/2026 at 9:37 a.m. outside Resident 4's room with the Assistant Director of Nursing (ADON), the ADON stated Resident 4 has a GT and there was a signage posted by the doorway for EBP to perform proper hand hygiene using hand sanitizer, then put on gown and gloves. The ADON stated that PPE caddies are inside the room by the doorway or a PPE cart outside the room by the doorway if there is no caddie inside the room. The ADON stated the staff are supposed to perform proper hand hygiene, put on gown and gloves prior to providing care to residents with wounds and indwelling medical devices (instruments placed inside the body either temporarily or permanently to assist with diagnostic, monitoring, or therapeutic functions) such as GT. The ADON stated that CNA 10 should have put on a gown while providing care to Resident 4 as it placed Resident 4 at risk of acquiring infection and the infection can potentially spread to other residents and staff. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, last reviewed on 10/23/2025, the P&P indicated the facility established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P further indicated: - EBP are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with and MDRO. - An indwelling medical device examples include central lines (a long flexible tube inserted into a vein in the neck, chest, arm or groin, up to the large vein near the heart for the patient to receive medications, fluids or additional blood), urinary catheters (a hollow tube inserted into the bladder to drain or collect urine), feeding tubes, and tracheostomies (a surgical opening in the neck into the trachea [also known as windpipe] to facilitate the passage of air and removal of secretions). - The staff will implement EBP for residents who are indicated when performing the following high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care (any skin opening requiring a dressing). - The facility alerts staff when EBP is necessary and for which residents require the use of EBP prior to staff providing high-contact care activities.

Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the residents for two of four sampled residents (Residents 41 and 37) reviewed under environment task. The deficient practice had the potential for residents unable to summon health care worker for help as needed. Findings: 1. During a review of Resident 41's admission Record (AR), the AR indicated the facility admitted the resident on 4/5/2021, and readmitted the resident on 7/2/2025, with diagnoses including muscle weakness, difficulty walking, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 1/19/2026, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident was dependent to needing set-up assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 41's Fall Risk Evaluation (FRE), dated 1/2/2026, the FRE indicated the resident was at high risk for falls. During a review of Resident 41's Care Plan (CP) Report regarding the resident being at risk for fall related to gait (the specific pattern or manner in which a person or animal walks or runs)/balance problems, peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs) . muscle weakness, and history of falls, last revised on 11/3/2025, the CP indicated an intervention to keep the call light within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 2/23/2026 at 9:26 a.m., with the Minimum Data Set Coordinator (MDSC), inside Resident 41's room, observed Resident 41's call light button dangling inside the trash can. The MDSC stated the call light button should not be dangling inside the trash can as it will make it hard for the resident to reach the call light button to call for help when needed. The MDSC stated the resident can also fall while reaching for the call light and sustain an injury. During a concurrent interview and record review on 2/25/2026 at 3:30 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 41's FRE and CP. The ADON stated the resident was at high risk for falls as indicated on the 1/2/2026 FRE. The ADON stated the call light of Resident 41 should not be dangling on the trash can as it will be hard for the resident to reach them and will not be able to call for help when needed. The ADON also stated the resident can slide down from the bed while reaching for the call light in the trash can and fall sustaining an injury. The ADON stated it is everyone's responsibility in the facility to keep the call light within the reach of the resident. During a review of the facility's recent policy and procedure (P&P) titled, Resident Call System, last reviewed on 10/23/2025, the P&P indicated the facility is adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from the resident's bedside, floor, or toileting facilities. Procedure: 8. Resident call system shall be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 11. The Environmental Services Department completes routine audits and maintenance to ensure all portions of the system are functioning, including but not limited to . 2. During a review of Resident 37's AR, the AR indicated the facility admitted the resident on 9/18/2025, and readmitted the resident on 10/5/2025, with diagnoses including muscle weakness, difficulty in walking, and depression (a serious, long-lasting mental health condition-not just a temporary sad mood-characterized by persistent sadness, hopelessness, and a loss of interest in daily life for at least two weeks). During a review of Resident 37's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was dependent to needing set-up assistance on mobility and ADLs. During a review of Resident 37's FRE, dated 1/2/2026, the FRE indicated the resident was not at risk for falls. During a review of Resident 37's CP Report regarding the resident being at risk for falls related to limited mobility. muscle weakness, last revised on 9/26/2025, the CP indicated an intervention to anticipate and meet the resident's needs and call light is within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 2/23/2026, at 10:09 a.m. with Certified Nursing Assistant (CNA) 4, inside Resident 37's room, observed Resident 37's call light was resting on the floor at the right side of the bed. CNA 4 stated the call light should always be within the reach of the resident so they can call for help when needed. CNA 4 stated their failure to keep the call light within reach will prevent the resident from asking for help when needed and can fall. During a concurrent interview and record review on 2/25/2026 at 3:30 p.m., with the ADON, reviewed Resident 37's FRE and CP. The ADON stated the resident was not high risk for falls as indicated on the 1/2/2026 FRE. The licensed staff placed the resident on fall risk per nursing judgement. The ADON stated the call light of Resident 37 should not be resting on the floor as it will be hard for the resident to reach them and will not be able to call for help when needed. The ADON also stated the resident can slide down from the bed while reaching for the call light in the trash can and fall sustaining an injury. The ADON stated it is everyone's responsibility in the facility to keep the call light within the reach of the resident. During a review of the facility's recent P&P titled, Resident Call System, last reviewed on 10/23/2025, the P&P indicated the facility is adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from the resident's bedside, floor, or toileting facilities. Procedure: 8. Resident call system shall be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 11. The Environmental Services Department completes routine audits and maintenance to ensure all portions of the system are functioning, including but not limited to .

Based on interview and record review, the facility failed to ensure residents rights to request, refuse, and / or discontinue treatment for one of two sampled residents (Resident 2) reviewed under the Advance Directives (AD - a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) care area by failing to ensure medical records were updated with a current copy of the resident's Durable Power of Attorney (DPOA or POA, a type of AD). This deficient practice had the potential to violate the resident's right to have their wishes honored regarding health care decisions. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted the resident on [DATE] with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere with daily living), epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). The AR further indicated Friend 1 was Resident 2's POA. During a review of Resident 2's Minimum Data Set (MDS - resident assessment tool), dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated that the resident required partial / moderate assistance from staff for toileting, bathing, dressing, personal and oral hygiene and mobility. During a review of Resident 2's History and Physical (H&P), dated [DATE], the H&P indicated the resident had the capacity to make decisions. During a review of Resident 2's Care Plan (CP) titled, Resident / responsible party (RP) / surrogate decision maker has chosen full code status (a medical directive indicating that in the event of cardiac or respiratory arrest, healthcare teams will use all available measures to revive the resident), full treatment, initiated [DATE], the CP indicated a goal to honor and remain full code unless rescinded by resident / RP / surrogate decision maker. The CP indicated an intervention that included to review code status / advance care directives per resident / RP request and as needed. During a review of Resident 2's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), dated [DATE] and signed by Resident 2, the POLST indicated the resident did not have an AD. During a review of Resident 2's Psychosocial Assessment / Social History / Discharge Planning (PASHDP) form, dated [DATE], the PASHDP form indicated Resident 2 had completed an AD. The PASHDP indicated the type of AD completed was a POA. During a concurrent interview and record review on [DATE] at 8:55 a.m., with Registered Nurse (RN) 1, Resident 2's AR was review and RN 1 stated the AR indicated the resident had a POA. RN 1 stated Resident 2's electronic health record (EHR) did not have any documented evidence of Resident 2's POA documentation. RN 1 stated the Social Services (SS) department keeps the residents' POA documentation. During a concurrent interview and record review on [DATE] at 8:57 a.m., with the Social Services Coordinator (SSC), Resident 2's EHR was review and the SSC stated when a resident indicates that they have a POA, the POA documentation should be uploaded into the EHR. The SSC stated Friend 1 had not provided Resident 2's POA documents, so the POA was not in the EHR. The SSC stated there was no documented evidence that the facility had followed up or requested to obtain Resident 2's POA document, but there should be. The SSC stated when a POA document is not followed up on and provided, there is no way to verify that a resident actually has a POA or what the exact role of the POA would be if the resident was not able to make their wishes known. During an interview on [DATE] at 9:08 a.m. with Friend 1, Friend 1 stated he was Resident 2's POA. Friend 1 stated the POA documents were already provided to the facility, and the facility should have them. Friend 1 stated he (Friend 1) was never contacted by the facility to provide another copy of the POA documents. During a concurrent interview and record review on [DATE] at 11:39 a.m. with the Assistant Director of Nursing (ADON), facility's policy and procedure (P&P) regarding AD was reviewed. The ADON stated the POA document is a type of AD that communicates a resident's wishes when they are no longer able to do so. The ADON stated the SS department follows up to ensure a copy of the resident's POA is obtained and placed in the resident's chart. The ADON stated there are different kinds of POAs and it is important that the facility is aware of the POA responsibilities to ensure the POA is appropriately included in the resident's plan of care. The ADON stated that when Resident 2's POA was not followed up on and placed in the resident's EHR, there was a potential that staff would not follow the resident's desires with the POA. The ADON stated the facility P&P was not followed. During a review of the facility P&P titled, Advance Directives, last reviewed [DATE], the P&P indicated, POLICY STATEMENT.Residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. DEFINITIONS.Advance Care Planning: A process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals cannot make their own healthcare decisions.Advance Directive: A written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Health Care Decision-Making Capacity: Possessing the ability (as defined by State law) to make decisions regarding health care and related treatment choice. GUIDELINES. 3. The facility honors residents' choices for care and does not treat the resident against his or her wishes. 4. If a resident is unable to make a health care decision, a decision by the resident's legal representative to forgo treatment may, subject to State requirements, be equally binding on the facility. 13. The ability of a dying person to control decisions about medical care and daily routines has been identified as one of the key elements of quality care at the end of life. 17. Advance care planning is an integral aspect of the facility's comprehensive care planning process and assures re-evaluation of the resident's desires on a routine basis and when there is a significant change in the resident's condition. 18. The medical record has documentation indicating whether the resident has an advance directive.19. The facility will request a copy of the resident's advance directive, if applicable, at the time when the resident states they have formulated an advance directive and periodically during care conferences when the resident or their representative have not provided a copy to the facility for inclusion in the medical record. 20. The facility is required to establish, maintain, and implement written policies and procedures regarding the residents' right to formulate an advance directive, refuse medical or surgical treatment. 21. In addition, the facility management is responsible for ensuring that staff follow those policies and procedures.

Based on interview and record review, the facility failed to document a significant change of condition (COC, is the formal written record of any significant, non-temporary change in a resident's physical, mental, or emotional health [e.g., sudden confusion, falls, weight loss]) on a resident's physical condition that had deteriorated for one of one sampled resident (Resident 5) by failing to inform the resident's representative/family member when the resident fell at the facility on 10/31/2025. This deficient practice had violated the resident's responsible party's right to be informed of the resident's accident and the facility's intervention to mitigate the situation. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted the resident on 2/2/2024, and readmitted the resident on 11/11/2025, with diagnoses including metabolic encephalopathy (a broad term for temporary or permanent brain dysfunction caused by chemical imbalances in the body, rather than direct physical injury), cerebral infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5's History and Physical (H&P), dated 11/12/2025, the H&P indicated the resident was transferred to general acute care hospital (GACH) for worsening confusion and fall. The H&P also indicated the resident had the capacity to make decisions. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 11/18/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a noticeable decline in memory, thinking, or language skills that is greater than normal aging, yet not severe enough to interfere with daily independence). The MDS indicated the resident was dependent to needing supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 5's Fall Risk Evaluation (FRE), dated 9/24/2025, the FRE indicated the resident was at high risk for falls. During a review of Resident 5's Change of Condition (COC) form, dated 10/3/2025, the COC indicated Resident 5 had a witnessed fall at around 8 p.m. Certified Nursing Assistant (CNA) 5 lowered down Resident 5 while sliding off from the bed. Registered Nurse (RN) assessed the resident and found sitting on the floor, denied any pain. RN stated the resident's range of motion (ROM, the full distance and direction a joint (like the knee, shoulder, or elbow) can move, measured in degrees or by its ability to bend and straighten) was within normal limits, vital signs (reflect essential body functions, including your heartbeat rate, breathing rate, temperature, and blood pressure) was baseline, and no injuries noted, and the resident denied any pain. RN and CNA 5 assisted the resident to bed and notified PMD and will continue to monitor the resident. The COC form indicated that the Family/Health Care Agent Notified Name was recorded as Self-monitoring. During a review of Resident 5's Care Plan (CP) Report titled, Initial goal based on admission, last revised on 1/29/2026, the CP indicated an intervention of interdisciplinary team (IDT, the group of professionals from different specialties who come together to plan, coordinate, and review the care of a resident) to continue to identify resident goals and support and IDT, Resident Representative and physician involvement to support initial goals. During an interview on 2/23/2026 at 12:40 p.m., with Resident Representative (RR) 1, on the phone, RR 1 stated she (RP 1) was upset because she (RP 1) was not notified when Resident 5 fell in the facility on 10/31/2025 at around 8 p.m. RP 1 stated after Resident 5`s fall, the resident was transferred to a GACH for altered mentation suspecting urinary tract infection (UTI, an infection in the bladder/urinary tract) on 11/1/2025, and they later found out that the resident had a broken hip in the hospital. During an interview on 2/24/2026, at 11:42 a.m. with CNA 5, on the phone, CNA 5 stated she (CNA 5) was the CNA assisting Resident 5 when she (Resident 5) fell on [DATE] at around 8 p.m. CNA 5 stated she (CNA 5) was trying to scoot the resident up in bed by herself and the resident stood up and tried to scoot herself up. CNA 5 stated Resident 5 cannot bear her weight and started to descend on the floor; the bed was close to the resident and the resident slid on the bed with her trying to lessen the impact of the fall. CNA 5 stated she (CNA 5) was holding Resident 5`s arm while she (CNA 5) tried to lower the resident to the floor. CNA 5 stated the resident did not complaint of any pain after the fall and she (CNA 5) informed RN 2 regarding the resident's fall. CNA 5 cannot remember if the resident representative was informed of the resident's fall. During an interview on 10/26/2025 at 10:52 a.m., with RN 2, RN 2 stated she (RN 2) was the RN supervisor that night (10/31/2025) at around 8 p.m. RN 2 stated she (RN 2) got a report from CNA 5 that Resident 5 fell while being assisted by CNA 5 in bed. RN 2 stated she (RN 2) immediately went to the resident`s room and assessed the resident. RN 2 stated the resident did not complain of pain or tenderness in any part of the body and had no indication of the resident having a fracture (break in bone) of limbs. RN 2 stated she (RN 2) cannot remember calling the family member about the fall and she (RN 2) knew the RR 1 is very involved in the care of the resident. RN 2 stated she (RN 2) should have informed RR 1 of the resident's accidents as it is their policy to inform family members or resident reps when they have accidents in the facility. RN 2 stated their failure to report the incident to RR 1 resulted in the family getting upset and worried about the resident. During a review of the facility's recent policy and procedure (P&P) titled, Notification of Changes, last reviewed on 10/23/2025, the P&P indicated the facility informs the resident, the resident's physician, and the resident's representative when there is an accident resulting in injury, changes involving life threatening conditions, adverse treatment consequences or transfer or discharge the resident. Guidelines: 1. The facility shall immediately or as soon as practicable inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is: b. A significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures for one (1) of five (5) sampled resident (Resident 12) reviewed for unnecessary medications by failing to ensure there was a physician's order for the behavior manifestations monitoring, adverse side effects (unwanted or dangerous medication-related side effects) monitoring, and non-pharmacological approach attempted for the use of clonazepam (also known as Klonopin, a medication used to treat panic attacks and control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] by slowing down the overexcited brain). This deficient practice had the potential for Resident 12 to experience the adverse effects related to psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 10/15/2025, with diagnoses including cerebral infarction (also known as stroke, loss of blood flow to a part of the brain), epilepsy (a long-term condition that causes repeated seizures [burst of uncontrolled electrical activity within brain cells] due to abnormal electrical signals produced by damaged brain cells), and generalized muscle weakness. During a review of Resident 12's History and Physical (H&P) dated 10/29/2025, the H&P indicated Resident 12 had the capacity to make decisions. During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 1/30/2026, the MDS assessment indicated Resident 12 was able to understand others and make his needs known and had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 12 required setup or clean-up assistance with eating and oral hygiene; supervision or touching assistance with rolling to left and right; partial/moderate assistance with toileting, personal hygiene, upper body dressing, and sit to lying; substantial/maximal assistance with lower body dressing and lying to sitting; and total assistance from staff with all other activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS further indicated that Resident 12 received antianxiety medication (A drug used to treat symptoms of anxiety, such as feelings of fear, uneasiness, and muscle tightness, that may occur as a reaction to stress). During a review of Resident 12's Order Summary Report dated 2/26/2026, the Order Summary Report indicated a physician's order dated 1/12/2026 for clonazepam oral tablet one milligram (mg - a unit of measurement) give one tablet by mouth three (3) times a day for anxiety manifested by restlessness. The Order Summary Report did not physician's order to monitor episodes of anxiety manifested by restlessness, monitor for adverse side effects, and non-pharmacological interventions attempted every shift for the use of clonazepam. During a review of Resident 12's informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), the informed consent indicated Resident 12's responsible party gave a consent via telephone call for the resident to receive clonazepam for anxiety manifested by restlessness. During a review of Resident 12's care plan (CP) on use of clonazepam for behaviors of restlessness initiated on 1/31/2025 and last revised on 2/4/2026, the CP indicated to give anti-anxiety medication as ordered. The care plan interventions were to review the medication use for gradual dose reduction (the systematic, stepwise tapering of a medication's dosage to determine if the patient's symptoms can be managed on a lower dose or if the drug can be discontinued entirely) , monitor and document side effects and effectiveness, and use [NAME]-pharmacological approaches. The CP indicated that Resident 12 will not experience any side effects from the medication use. During a concurrent interview and record review on 2/26/2026 at 8:41 a.m., Resident 12's physician's order, informed consents, summary of episodes of anxiety, and care plans were reviewed with the Assistant Director of Nursing (ADON). The ADON stated Resident 12 had a physician's order for the use clonazepam dated 1/12/2026 and had a CP in place for the use of the medication for anxiety manifested by restlessness. The ADON there was no physician's order to monitor Resident 12 for behavior manifestations of anxiety manifested by restlessness. The ADON stated there was no physician's order to monitor the adverse side effects for the use of clonazepam, and there was no physician's order for non-pharmacological interventions/approaches implemented during every shift. The ADON stated that when a psychotropic medication is ordered for a resident, there should be a physician's order to monitor the behavior manifestation, adverse side effects, and non-pharmacological approaches every shift. The ADON stated there should have been a physician's order for the monitoring for episodes of restlessness every shift, monitoring for adverse side effects every shift, and non-pharmacological approaches attempted every shift for Resident 12's use of clonazepam so the physician, pharmacist, and the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) would be able to know if the medication use was effective, if Resident 12 was tolerating the use of clonazepam without any adverse side effects, and if the non-pharmacological approaches were effective to address Resident 12's behavior of restlessness. The ADON stated if there was no monitoring in place, Resident 12 could have developed adverse side effects or the medication not being effective that the nurses were not aware of which could result in a delay in notification of the physician and cause delay in providing the care Resident 12 needed. During a review of the facility's policy and procedure (P&P) titled, Unnecessary Drugs, last reviewed on 10/23/2025, the P&P indicated that each resident's drug regimen shall be free from unnecessary drugs. The P&P further indicated the facility ensures that each resident 's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental. Physical, and psychosocial well-being. - Unnecessary drugs include but may not be limited to medications used: a. In excessive dose (including duplicate therapy); or b. For excessive duration; or c. Without adequate monitoring; or d. Without adequate indication for its use; or e. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or f. Any combinations of aforementioned reasons. - Monitoring and Adverse Consequences: 1. The facility is responsible for the resident's medication management including but not limited to: a. Recognition or identification of the problem/need. b. Assessment, c. Diagnosis/cause identification, d. Management/treatment, e. Monitoring, and f. Revising interventions. 2. The IDT are responsible for documenting medication management steps including monitoring and documenting the resident's response to any treatment such as lab results, vital signs, progress notes, behavior flow sheets, medication administration records, and the consultant pharmacist's drug regimen review. During a review of the facility's P&P titled, Nursing Service - Restraints, last reviewed on 10/23/2025, the P&P indicated that restraints shall only be used when permitted by law, under physician's order, and never for punishment, staff convenience, or as a substitute for care. - Definitions: - Chemical Restraint: a drug used to control behavior or restrict freedom of movement, not a standard treatment for a patient's condition. - Use of chemical restraints: 1. The specific behavior or manifestation for which the drug is given must be documented on the health record. 2. The care plan must define the data to be collected to evaluate the effectiveness of the drug and adverse reactions.

Based on interview and record review, the facility failed to follow its policy and procedure regarding transfers and discharge by failing to ensure that necessary medical information was communicated to the receiving hospital for one (1) of one (1) sampled resident (Resident 90) reviewed for hospitalization. This deficient practice placed Resident 90 at risk for a delay in the continuity of care and receiving the services and treatment the resident needed. Findings: During a review of Resident 90's admission Record, the admission Record indicated the facility admitted the resident on 1/14/2026, with diagnoses including sepsis (a life-threatening blood infection), acute respiratory failure (a condition that occurs when the lungs cannot release oxygen into the blood resulting to shortness of breath, confusion, drowsiness, and bluish discoloration of the lips, skin, or extremities), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 90's Minimum Data Set (MDS, a resident assessment tool), dated 1/30/2026, the MDS indicated Resident 90 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) was unable to understand others and make his needs known. The MDS further indicated Resident 90 was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 90's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Change of Condition (COC) form dated 1/21/2026, the SBAR COC form indicated that Resident 90 had abnormal laboratory result for blood urea nitrogen (BUN - a blood test that measures how much urea [a waste product of protein breakdown] and determines how well the kidneys are working; normal level is 7 to 30 milligrams per deciliter [mg/dl - a unit of measurement]) of 202 mg/dl. The SBAR COC further indicated that the physician was notified with an order to transfer Resident 90 to the emergency room via non-emergent transportation. The SBAR COC form indicated that the responsible party was made aware on 1/21/2026 at 10 p.m. During a review of Resident 90's Health Status Notes dated 1/21/2026 at 11:39 p.m., 1/22/2026 at 4:48 a.m., and 1/22/2026 at 11:42 a.m., the Health Status Notes indicated: - 1/21/2026 at 11:39 p.m.: Nurse Practitioner (NP) ordered to transfer Resident 90 via non-emergency transportation to the hospital due to elevated BUN and that the medical transportation company will pick up Resident 90 at 3 a.m. The health status notes further indicated that handoff report was given to oncoming shift. - 1/22/2026 4:48 a.m.: Resident 90 left the facility via gurney at 4:35 a.m. for evaluation of abnormal lab oratory results, elevated BUN and left a message for the responsible party. - 1/22/2026 11:42 a.m. Resident 90 was sent to emergency room and left the facility at 4:35 a.m. Responsible party was made aware. During a concurrent interview and record review on 2/25/2026 at 7:01 a.m., Resident 90's SBAR COC form dated 1/21/2026, and Health status Notes dated 1/21/2026 at 11:39 p.m., 1/22/2026 at 4:48 a.m., and 1/22/2026 at 11:42 a.m. were reviewed with the Assistant Director of Nursing (ADON). The ADON stated that Resident 90's SBAR COC dated 1/21/2026 at 11:39 p.m. indicated that the NP was made aware of Resident 90's abnormal BUN with an order to send the resident to the hospital via non-emergency transportation. The ADON stated that Resident 90's Health Status Notes indicated that the resident left the facility at 4:35 a.m. on 1/22/2026. However, there was no documentation that the facility nurse provided the hospital with the necessary medical information upon transferring Resident 90. The ADON stated that the facility practice when transferring residents to the hospital via non-emergent transportation is that the resident will be sent out with the admission Record and the current physician's orders. The ADON stated then licensed staff will give a telephone report to the receiving hospital and document in the electronic health record under the Health Status Notes. The ADON stated the licensed nurse who transferred Resident 90 should have called the hospital to provide the necessary medical information when Resident 90 was transferred and documented in the Health Status Notes. The ADON stated the importance of giving the proper handoff report to the receiving facility or hospital is for the members of the healthcare team taking care of Resident 90 would be aware of what was going on with the resident for continuity of care and if it was not done, it placed Resident 90 at risk for a delay in receiving the care and services the resident needed in the hospital. During a review of the facility's policy and procedure (P&P) titled, Transfers and Discharge, last reviewed on 10/23/2025, the P&P indicated that the facility transfers or discharges residents in a safe manner. The P&P further indicated that the facility documents the resident's transfer or discharge in the medical record and communicates appropriate information to the receiving healthcare institution or provider when a resident is transferred from the facility.

Based on interview and record review, the facility failed to ensure the PASRR was completed accurately for one of four sampled residents (Resident 10) reviewed under Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) when Resident 10 was admitted with a serious mental illness and was taking a psychotropic medication (medication that alters brain chemistry to manage mental health conditions by affecting mood, thoughts, behavior, or perception). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 10. Findings: During a review of Resident 10's admission Record (AR), the AR indicated that the facility admitted the resident on 2/11/2025 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition characterized by persistent and excessive worries that interfere with daily activities), post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 10's History and Physical (H&P), dated 2/15/2025, the H&P indicated the resident has the capacity to make decisions. During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 2/18/2025, the MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated the resident with active diagnoses including anxiety disorder, depression, and PTSD. The MDS indicated the resident was taking an antidepressant medication since admission to the facility. During a review of Resident 10's Order Summary Report (OSR), dated 2/11/2025, the OSR indicated escitalopram oxalate (medication used to treat major depressive disorder) tablet 10 milligrams (mg - a unit of measurement), Give one tablet by mouth one time a day for depression manifested by persistent feeling of worthlessness. During a review of Resident 10's PASARR Level I Screening, dated 2/13/2025, the PASARR indicated that the resident does not have a diagnosed serious mental illness and has not been prescribed psychotropic medications for serious mental illness. During a concurrent interview and record review on 2/26/2026 at 10:22 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 10's PASARR Level I Screening, admitting diagnoses, and physician orders were reviewed. LVN 4 stated the resident had admitting diagnoses including anxiety disorder, major depressive disorder, and PTSD and was taking escitalopram. LVN 4 stated the PASARR Level I Screening was not completed accurately. LVN 4 stated there was no correction or second PASARR Level I Screening submitted after 2/13/2025. During an interview on 2/26/2026 at 1:40 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she was made aware about Resident 10's PASARR not being completed accurately. The ADON stated it should be accurately completed to ensure the outcome is correct and the resident is evaluated and receives specialized services if required. The ADON stated that when the PASARR is not completed accurately the resident could experience delay in care and treatment. During a review of the facility's policy and procedure (P&P) titled, Preadmission Screening and Resident Review (PASRR), dated 10/23/2025, the P&P indicated that the PASRR requires that: 1. All applicants to a Medicaid-certified nursing facility are evaluated for a serious mental disorder and/or intellectual disability. 2. Are offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); . Guidelines 1. The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders. 2. The initial screening is referred to as Level I identification of individuals with Mental Disorder (MD) or Intellectual Disability (ID) and is completed prior to admission to a nursing facility. 3. The purpose of the Level I pre-admission screening is to identify individuals who may have or may have MD/ID or a related condition, who would then require PASARR Level II evaluation and determination prior to admission to the facility. 6. Failure to pre-screen residents prior to admission to the facility may result in failure to identify residents who have or may have MD, ID, or a related condition. 7. At the time of admission, the facility will review the admission documentation to identify the presence of the PASARR Level I and Level II recommendations as applicable.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of 21 sampled residents (Resident 5) reviewed for accidents by failing to develop and implement a care plan when the resident fell on [DATE]. This deficient practice had the potential to result in a delay of nursing care and medical interventions for the residents. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted the resident on 2/2/2024, and readmitted the resident on 11/11/2025, with diagnoses including metabolic encephalopathy (a broad term for temporary or permanent brain dysfunction caused by chemical imbalances in the body, rather than direct physical injury), cerebral infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 5's History and Physical (H&P), dated 11/12/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 5's Minimum Data Set (MDs, a resident assessment tool), dated 11/18/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderately impaired cognition (a stage of thinking decline that is more severe than mild memory loss but not yet full-blown dementia). The MDS indicated the resident was dependent to needing supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 5's Fall Risk Evaluation (FRE), dated 9/24/2025, the FRE indicated the resident was at high risk for falls. During a review of Resident 5's Change of Condition (COC), dated 10/3/10225, the COC indicated Resident 5 had a witnessed fall at around 8 p.m. Certified Nursing Assistant (CNA) 5 lowered down Resident 5 while sliding off from the bed. Registered Nurse (RN) 2 assessed the resident and found sitting on the floor, denied any pain. RN stated the resident's range of motion (ROM, the full distance and direction a joint (like a knee or shoulder) can move, often measured in degrees) was within normal limits, vital signs (reflect essential body functions, including your heartbeat rate, breathing rate, temperature, and blood pressure) was baseline, and no injuries noted, and the resident denied any pain. RN 2 and CNA 5 assisted the resident to bed and notified Primary Medical Doctor (PMD) and will continue to monitor the resident. The COC form indicated that the Family/Health Care Agent Notified Name was recorded as Self-monitoring. During a concurrent interview and record review on 2/25/2026 at 3:30 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 5's Medical Disgnosis, COC, and CP. The ADON stated the COC indicated the resident had an accident on 10/31/2025, and she (ADON) was not able to see an actual care plan for the resident`s fall. The ADON stated the licensed staff should have developed and implemented a care plan on the resident's actual fall on 10/31/2025, to ensure the resident got all the care needed and prevent delays of care. During a review of the facility's recent policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, last reviewed on 10/23/2025, the P&P indicated the facility develops a person-centered comprehensive care plan that is culturally competent and trauma-informed, developed and implemented to meet each resident's 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 provide necessary services to maintain good grooming and personal hygiene for two of two sampled residents (Resident 13 and 19) by failing to: 1. Ensure Resident 13's nails were trimmed per family requests and plan of care. 2. Ensure Resident 19's right hand fingernails were cleaned as dirt and dead skin had accumulated under the free edge of the nails from the resident scratching himself. These deficient practices had the potential to result in resident infections caused by abrasions from long fingernails and uncleaned free edge fingernails. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated the facility admitted the resident on 3/24/2015, with diagnoses including vascular dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere with daily living), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 13's Minimum Data Set (MDS – resident assessment tool) dated 1/29/2026, the MDS indicated the resident was rarely / never able to understand others or to make herself understood. The MDS further indicated that the resident was completely dependent on staff for eating, toileting, bathing, dressing, personal and oral hygiene and mobility. During a review of Resident 13's Care Plan (CP) titled, (Resident 13) has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, dementia, initiated 6/29/2021 and last reviewed 1/30/2026, the CP indicated interventions that included to communicate with the family regarding the resident's needs. During a review of Resident 13's CP titled, (Resident 13) has an activity of daily living (ADL) self-care performance deficit related to Alzheimer's dementia, limited range of motion, ., initiated 4/8/2021, and last reviewed 1/30/2026, the CP indicated interventions to be provided by Certified Nursing Assistants (CNA) and licensed nurses (LN) that included to check nail length and trim and clean on bath day and as necessary. During a concurrent observation and interview on 2/23/2026 at 11:45 a.m., with the Assistant Director of Staff Development (ADSD) and CNA 2, observed the ADSD at Resident 13's bedside holding fingernail clippers and trimming the resident's fingernails. Resident 13 did not verbally respond. Observed Resident 13's left hand with two trimmed nails and three remaining. Observed the untrimmed nails were white colored, overgrown to approximately one inch in length past the tip of the finger and curling inward. The ADSD stated she (ADSD) was making rounds and noticed the resident's fingernails were long. The ADSD stated she (ADSD) had never seen a resident's fingernails grown out that long. The ADSD stated the LN or CNA is responsible to trim a resident's fingernails and Resident 13's nails were not trimmed. CNA 2 entered the room and stated that she (CNA 2) had not cared for Resident 13 in over a week and did not notice the Resident's fingernails were long. During an interview on 2/23/2026 at 4:19 p.m., with Family Member (FM) 1, FM 1 stated Resident 13's fingernail length is an ongoing issue that (FM 1) discusses with the facility staff every time he (FM1) speaks with them. FM 1 stated he (FM1) would like the nail issue addressed. FM 1 stated Resident 13's nails are long and her hands are atrophied (weakened due to disease or lack of use) and the nails press into the palm of the resident's hands. During an interview on 2/25/2026 at 7:39 a.m. with CNA 1, CNA 1 stated she (CNA 1) was caring for Resident 13. CNA 1 stated she (CNA 1) has never cut Resident 13's fingernails because the resident has diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and CNAs do not cut the nails of residents with DM. CNA 1 stated a couple of weeks prior, CNA 1 reported to the LN that the resident's fingernails were very long. CNA 1 stated CNA 1 could not remember which LN she (CNA 1) reported to. CNA 1 stated Resident 13's nails should not have been so long because it was dangerous and the resident could scratch herself. CNA 1 stated resident fingernails should be kept trimmed and the LN did not follow up. During an interview on 2/25/2026 at 7:57 a.m. with the Director of Staff Development (DSD), the DSD stated Resident 13 did not have DM and the CNAs are responsible for cutting Resident 13's fingernails. The DSD stated Resident 13's fingernails did not grow over night, and the CNAs should have been trimming her fingernails and they were not. The DSD stated when Resident 13's nails were not clipped there was the potential that the resident could cut herself. The DSD stated a cut in Resident 13 could result in an infection in the resident. During an interview and record review on 2/26/2026 at 9:08 a.m. with the Assistant Director of Nursing (ADON), the ADON reviewed the facility policy and procedure (P&P) regarding ADLs. The ADON stated the facility is responsible for cutting resident fingernails and Resident 13's nails should not have been kept long unless the family wanted them that way. The ADON stated long nails can potentially cause a skin issue resulting in infection in Resident 13. The ADON stated the facility P&P was not followed. During a review of the facility P&P titled, Activities of Daily Living Maintain Abilities, last reviewed 10/23/2025, the P&P indicated, POLICY STATEMENT. The facility provides each resident with care and services to maintain activities of daily living. INTENT. To ensure facility staff provide necessary care and services, based on the resident's comprehensive assessment, to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. GUIDELINES. 1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility provides care and services needed to assist the resident' to maintain or improve his or her ability to carry out activities of daily living, including: a. Hygiene -bathing, dressing, grooming, and oral care. b. During a review of Resident 19's admission Record (AR), the AR indicated that the facility originally admitted the resident on 10/22/2020, and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anemia (a condition where the body does not have enough healthy red blood cells), and hypertension (HTN-high blood pressure). During a review of Resident 19's MDS dated [DATE], the MDS indicated the resident had clear speech, able make self-understood and had the ability to understand others. The MDS indicated the resident was dependent on staff with toileting hygiene and personal hygiene and with mobility including sit to lying, lying to sitting, chair/bed-to-chair transfer and tub/shower transfers. During a review of Resident 19's Care Plan titled, ADL: [Resident 19] requires assistance in. personal hygiene, revised 12/19/2025, the CP indicated the resident with goals of increased ADL participation and minimizing functional decline which included interventions assist with maintaining good personal hygiene every shift and as needed. During an observation on 2/23/2026 at 10 a.m., inside Resident 19's room, Resident 19 was observed lying in bed awake. The free edges of the right –hand fingernails were noted to have accumulated dirt that was black in color. During a concurrent observation and interview on 2/24/2026 at 8:49 a.m. with CNA 13, inside Resident 19's room, CNA 13 delivered Resident 19's breakfast meal tray. Resident 19 was about to eat breakfast. CNA 13 stated underneath the resident's fingernails, along the free edges, there was dirt that was black in color. CNA 13 stated the dirt is from the resident scratching himself and when he (Resident 19) wheels himself on a wheelchair he (Resident 19) uses his right hand. CNA 13 stated the resident's left hand is contracted (when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) and the resident is not able to move it. CNA 13 stated she will clean the resident's hands now before he eats. During an interview on 2/26/2026 at 1:30 p.m. with the ADON, the ADON stated residents are provided with nail care per resident request. The ADON stated the CNAs should check the resident's fingernails before the resident eats and offer to clean it. The ADON stated when the resident's fingernails are not clean the resident could use his dirty hands and eat it. The ADON stated the resident could have an infection and experience abdominal pain, nausea, vomiting, and diarrhea from eating with unclean hands. During a review of the facility's P&P titled, Activities of Daily Living Maintain Abilities, last reviewed 10/23/2025, the P&P indicated, POLICY STATEMENT. The facility provides each resident with care and services to maintain activities of daily living. INTENT. To ensure facility staff provide necessary care and services, based on the resident's comprehensive assessment, to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. GUIDELINES. 1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility provides care and services needed to assist the resident' to maintain or improve his or her ability to carry out activities of daily living, including: a. Hygiene -bathing, dressing, grooming, and oral care.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology) by another resident for one of ten sampled residents (Resident 1). On 7/17/2024 at 5:15 a.m., Resident 2 poured lemon juice on Resident 1's face while Resident 1 was sleeping. This deficient practice resulted in Resident 1 feeling defenseless, hopeless, and verbalized not being able to sleep. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 11/13/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/22/2024, indicated the resident's cognitive (problems with a person's ability to think, learn, remember, use judgement, and make decisions) skills was intact. The MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on roll left to right. The MDS indicated Resident 1 was dependent on facility staff on chair/bed to chair transfers. The MDS indicated Resident 1's sit to stand ability was not attempted because of the resident's medical condition or safety concerns. A review of Resident 1's Fall Risk Evaluation, dated 5/23/2024, indicated the resident had a total score of 12. A total score above 10 represented high risk for falls. A review of Resident 1's psychiatric (related to the study of mental illness) evaluation, dated 6/18/2024, indicated the resident had a diagnosis that included major depressive disorder. The Medications section indicated Resident 1 had doxepin (a medication used to treat depression and anxiety) 6 milligrams (mg - unit of measurement) at bedtime for depression and difficulty falling asleep and trazadone (a medication used for treating major depressive disorder) 150 mg at bedtime for depression and inability to fall asleep. A review of Resident 1's COC Form, dated 7/17/2024, indicated that on 7/17/2024 at 5:15 a.m., Resident 1 received physical aggression from Resident 2. The COC indicated Resident 2 poured lemon juice on Resident 1's face that resulted to an eye irritation. A review of Resident 2's Admission Record indicated the facility admitted the resident on 7/16/2024 with diagnoses including encephalopathy (damage or disease that affects the brain), schizophrenia (mental disorder in which people interpret reality abnormally), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 2's History and Physical (H&P), dated 7/19/2024, indicated the resident had the capacity to make decisions. A review of Resident 2's Progress Notes, dated 7/22/2024, indicated the resident went out on pass (a request by the resident to leave the facility for a period and then come back to continue treatment or stay after clinical assessment). Resident did not return to the facility. During an interview on 7/30/2024 at 12:54 p.m., Resident 1 stated the Admission Director (AD) was informed that Resident 1 was uncomfortable with Resident 2 as the roommate. Resident 1 stated that a bottle of lemon juice was on top of the Resident 1's table. Resident 1 stated on 7/17/2024 early morning, Resident 2 poured the lemon juice on Resident 1's face and chest which went to Resident 1's eyes. Resident 1 stated the lemon juice prevented the resident's eyes to open. Resident 1 pulled the bedside table in front of Resident 2 to prevent the resident from hitting Resident 1. Resident 1 stated that he was not able to fight back because he required assistance on standing up or moving. Resident 1 stated he felt defenseless and was not able to sleep for three days even with his regular sleeping medications. Resident 1 stated that he did not feel safe in the facility and had requested to be discharged sooner. During an interview and concurrent record review on 7/31/2024 at 9:53 a.m., Resident 1's Progress Notes, dated 7/18/2024 at 3:58 p.m., were reviewed with the Social Service Director (SSD) indicated SSD met with Resident 1 and performed a psychosocial wellbeing (the state of mental, emotional, and social health of an individual) visits as follow up on the altercation that happened on 7/17/2024. The Progress Notes indicated Resident 1 stated Mentally, I just don't feel okay. He, referring to Resident 2, really caught me off guard and I couldn't sleep last night. The SSD Progress Notes indicated Resident 1 felt hopeless and defenseless. The SSD stated Resident 1 refused a psychologist (a person that specializes in helping treat people's cognitive, emotional, and social process and behaviors) and psychiatrist (a medical doctor that specializes in the field of psychiatry [field of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders]) evaluation. The SSD was not able to provide documented evidence that Resident 1 refused the psychologist and psychiatrist evaluations. The SSD stated that Resident 1's inability to sleep after the altercation with Resident 2 was not reported to the nursing staff. The SSD stated that the altercation had a negative effect on Resident 1's care. The SSD stated that if the effects of the resident-to-resident altercation were reported, the nursing staff had the opportunity to provide necessary interventions for Resident 1. During an interview and concurrent record review on 7/31/2024 at 10:34 a.m., Resident 1's Physician Orders were reviewed with the Assistant Director of Nursing (ADON) indicated a psychiatry and psychology evaluation was ordered on 7/24/2024, seven days after Resident 1 and Resident 2's physical altercation. The ADON was not able to provide documented evidence that Resident 1 was offered and refused a psychiatry and psychology evaluation. Resident 1's SSD Progress Notes, dated 7/18/2024 at 3:58 p.m., was reviewed with the ADON indicated SSD documented Resident 1 felt hopeless, defenseless and the inability to sleep. The ADON stated the SSD should report to the licensed nurses the negative impact of the resident-to-resident altercation on Resident 1 that resulted to the resident's feeling of hopelessness, defenseless and inability to sleep. The ADON stated the act of pouring juice on another person was considered a physical abuse because there was contact. The ADON stated Resident 1 had the potential for an increased anxiety and depression. During a follow up interview on 7/31/2024 at 12:44 p.m., the ADON stated the effect of lack of sleep on residents included easily irritated, more emotionally sensitive, grumpy, slow decision-making ability, and slow performance. The ADON stated the facility failed to address the resident-to-resident altercation effect on Resident 1. During an interview on 7/31/2024 at 2:51 p.m. Attending Physician 2 (MD 2) stated people that lack sleep for a couple of days may develop behavior changes such as feeling irritated, not happy, frustrated, or behaviors that required the need for medication or medication adjustment. A review of the facility's policy and procedure titled, Abuse Prohibition and Prevention Program, dated 10/26/2023, indicated the purpose to provide staff guidelines to ensure protection for the health, welfare, and rights of each resident residing in the facility and to ensure the facility was doing all that is within its control to prevent occurrence of abuse. The Prevention section of the policy indicated the facility strived to provide an environment which prohibits and prevents abuse, neglect, and exploitation of residents through identification, correction, and intervention in situations in which abuse, neglect, and/or misappropriation of resident property was more likely to occur. The Protection section of the policy indicated the facility will provide protection of residents from harm during an investigation including but not limited to . c. interventions to calm the situation and support the involved residents. A review of the facility's policy and procedure titled, Resident Rights, dated 10/26/2023, indicated residents in long term care facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The policy indicated employees shall treat residents with kindness, dignity, and respect.

Based on interview and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries forone of ten sampled residents (Resident 3), who was identified as a high fall risk. The facility failed to: 1. Ensure Resident 3 was provided visual supervision while sitting on a Geri-chair (a padded reclining chair that was designed to help older adults with limited mobility) in the hallway. 2. Review and revise Resident 3's care plan interventions that were person-centered and were individualized based on the resident's risks, physical, and mental condition. 3. Implement the facility's policies and procedure on Fall Management Program and Free of Accident Hazards / Supervision / Devices. As a result, on 7/14/2024 at 7:45 p.m., Resident 3 fell out of the Geri-chair in the hallway and sustained a right femur fracture (a break in the thighbone), acute (severe or sudden onset) nondisplaced fracture (the bone cracks or breaks but retains its proper alignment) of the right inferior and superior pubic ramus (pelvic bones), and an acute mildly comminuted (a bone that is broken in at least two pieces) and mildly displaced fracture (the ends of the bone had come out of alignment) of the left inferior pubic ramus. Findings: A review of Resident 3's Admission Record indicated the facility admitted the resident on 4/12/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), muscle weakness, and essential hypertension. A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/16/2024, indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills was moderately impaired. The MDS indicated Resident 3 required moderate assistance (helper lifts, holds, or supports trunk or limbs but provides less than half the effort) roll left and right. The MDS indicated Resident 3's assessment on lying to sitting, sit to stand, and chair/bed-to-chair transfer were not attempted because of the resident's medical condition or safety concerns. A review of Resident 3's Fall Risk Evaluation, dated 4/18/2024, indicated the resident had a total score of ten. A score of ten or greater represented high risk for falls. The fall risk evaluation indicated a prevention protocol should be initiated immediately and documented on the care plan and reviewed at least quarterly and with COC. A review of Resident 3's Change of Condition (COC) Form, dated 6/22/2024, indicated the resident had an unwitnessed fall. Resident 1 was seen lying on the floor and sustained a skin tear on the right elbow. The COC indicated Resident 3 was agitated and wanted to throw self off the bed. The COC indicated the family was notified and consents were acquired for pad alarm (a device placed under a high fall risk resident on the bed or on a chair to alert the caregivers), extra mattress on the floor, and to put the resident's bed against the wall. The COC indicated Ativan 0.5 milligrams (mg - unit of measurement) twice a day, as needed was ordered. A review of Resident 3's Fall Risk Evaluation, dated 6/22/2024, indicated the resident had a total score of 12. A score of ten or greater represented high risk for falls. The fall risk evaluation indicated a prevention protocol should be initiated immediately and documented on the care plan and reviewed at least quarterly and with COC. A review of Resident 3's Physician Orders, dated 6/22/2024, indicated an order for a pad alarm on bed. A review of Resident 3's Physician Orders, dated 6/22/2024, indicated an order for lorazepam (a medication used to manage anxiety disorders) 0.5 milligrams (mg - unit of measurement) for verbalization of feeling nervous. A review of Resident 3's Care Plan on actual fall, dated 6/22/2024, indicated the resident had a fall secondary to poor balance. The Care Plan interventions included bed against the wall, mattress on the floor, encourage Resident 3 to use bell to call for assistance, and to keep the call light (a device used to call for assistance from the facility staff) within reach at all times. The Care Plan interventions did not include Resident 3's pad alarm. A review of Resident 3's COC Form, dated 7/14/2024, indicated the resident was found on the floor beside Resident 3's chair. The COC indicated Resident 3 sustained a small bump on the head without bleeding and Emergency Medical Services (EMS) were notified. Resident 3 was transferred to General Acute Care Hospital 1 (GACH 1) for further evaluation. A review of Resident 3's Post Fall Evaluation/Interdisciplinary Team (IDT) Review, dated 7/14/2024, indicated the resident was observed on the floor at 7:45 p.m., beside the resident's Geri-chair. The IDT Review indicated Resident 3 sustained a bump on the head. The IDT Review indicated Resident 3 had hallucination of being killed. A review of Resident 3's GACH 1 History and Physical (H&P) Reports, dated 7/14/2024 at 9:03 p.m., indicated the resident was admitted to the emergency department due to a fall. The Physical Exam section indicated Resident 3 had a deformity of the right leg consistent with fracture. The Assessment / Plan section indicated Resident 3 sustained a fall, blunt head injury (caused by an external force strong enough to move the brain within the skull), and hematoma (an area of blood that collects outside of the larger blood vessels caused of the face). A review of Resident 3's GACH 1 Discharge Instructions, dated 7/16/2024, indicated the resident's diagnoses included fall, blunt head trauma, and hematoma of the face. The Imaging section indicated a computed tomography (CT - a diagnostic imaging procedure that used a combination of x-ray [the use of electromagnetic energy beams to produce images of internal tissues, bones, and organs] and computer technology to produce images of the inside of the body) scan of the brain/head without contrast (a dye or other substance that helps show abnormal areas inside the body) was done at 8:42 p.m. on 7/14/2024. The CT scan impression indicated Resident 3 had mild to moderate bi-frontoparietal scalp (both forehead and upper back wall of the head bones) hematoma or contusion (an injury that resulted from a direct blow or impact in which the skin is not broken) at the vertex (top of the head). The CT scan of the pelvis without contrast indicated Resident 3 had a right femur fracture, acute nondisplaced fracture of the right inferior and superior pubic ramus, and an acute mildly comminuted and mildly displaced fracture of the left inferior pubic ramus. During an interview and concurrent record review on 7/30/2024 at 11:42 a.m., Registered Nurse 1 (RN 1) stated that Resident 3 was agitated and anxious. RN 1 stated that Resident 3 was unable to walk and had a high risk for falls. Resident 3's Care Plan on risk for falls, initiated on 4/13/2023 and last revised on 2/9/2024, was reviewed with RN 1 and indicated the resident was at risk for falls secondary to gait and balance problems and muscle weakness. The Care Plan had a goal to minimize risk of injury from falls. The Care Plan Interventions included to educate the resident /family/caregivers about safety reminders and what to do if a fall occurs. During a telephone interview on 7/31/2024 at 6:10 p.m., CNA 4 stated she went on her lunch break and informed LVN 2 and CNA 6 that Resident 3 was on a Geri-chair in the hallway across from the resident's room. During a telephone interview on 7/31/2024 at 6:22 p.m., LVN 2 stated CNA 4 went on a lunch break and informed her that Resident 3 was on a Geri-chair in the hallway. LVN 2 stated CNA 6 informed her that she was going to return a food tray to the kitchen. LVN 2 stated she was at nurse station 2 and could not see Resident 3 from the nurse station. CNA 6 returned to the hallway and found Resident 3 on the floor. LVN 2 was made aware and saw Resident 3 lying facing the left side on the floor beside the Geri-chair. LVN 2 stated that Resident 3 complained of pain on the head. LVN 2 stated that EMS was called, and Resident 3 was brought to GACH 1. During an interview on 8/1/2024 at 10:40 a.m., CNA 6 stated she went to the kitchen to return a resident's food tray and informed LVN 2, who weas at nurse station 2, that Resident 3 was on a Geri-chair in the hallway. CNA 6 stated she returned to the hallway and found Resident 3 on the floor with the resident's hand on the head. CNA 6 stated Resident 6 was on a Geri-chair in the hallway for closer supervision because of the resident's daily attempt to jump out of the bed. CNA 6 stated Resident 3's fall could be prevented if there was someone visually watching the resident. CNA 6 stated Resident 3 was on a Geri-chair without a pad alarm or a mattress on the floor. During an interview on 8/1/2024 at 12:44 p.m., the Assistant Director of Nursing (ADON) stated Resident 3 was a fall risk, had impulsive behavior, and attempted to get out of bed. The ADON stated Resident 3 was placed on a Geri-chair in the hallway for more visual monitoring. The ADON stated the pad alarm and mattress were not provided for Resident 3 while on the Geri-chair. Resident 3's Care Plan on risk for falls, dated 6/22/2024, was reviewed with the ADON indicated the resident did not have the pad alarm and Geri-chair as part of the Care Plan interventions. The ADON stated that care plans should be individualized to meet the resident's need. The ADON stated the facility failed to include the use of Geri-chair, pad alarm, and visual monitoring in Resident 3's Care Plan interventions. Resident 3's facility provided GACH 1 records were reviewed with the ADON and indicated the resident sustained an acute right hip fracture and left pubic fracture. The ADON stated the facility failed to ensure Resident 3 was monitored and visually supervised to prevent resident falls. A review of the facility's policy and procedure titled, Fall Management Program, dated 11/2017 and last reviewed on 10/26/2024, indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls and to provide an environment which remains as free from accident hazards as possible. The policy defined fall as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force. The policy indicated the facility nursing staff and/or the interdisciplinary team shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall and/or to reduce the risk for significant injury related to falling. A review of the facility's policy and procedure titled, Free of Accident Hazards / Supervision / Devices, dated 3/2018 and last reviewed on 10/26/2023, indicated the intent to provide guidelines for facility staff to manage residents at risk for avoidable accidents. The System Approach section indicated implementation of individualized, resident centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment. A review of the facility's policy and procedure titled, Develop - Implement Comprehensive Care Plans, dated 2/2018 and last reviewed on 10/26/2023, indicated the facility develops a person-centered comprehensive care plans that are culturally competent and trauma-informed, developed, and implemented to meet the preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. The policy indicated the facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining their highest practicable quality of life.

Based on interview and record review, the facility failed to provide nursing services that meet professional standards of practice for one of two sampled resident (Resident 1). On 3/1/2023, at 11 a.m., when Certified Nursing Assistants 1 and 2 (CNAs 1 and 2) informed Licensed Vocational Nurse 1 (LVN 1) Resident 1 slipped out of the lift machine (designed to lift and transfer patients from one place to another and may be operated using a power source or manually) sling (or sling lift, consists of a soft fabric tool that wrap around a patient's body and it is hooked to the lift machine; sling lifts come in various sizes, materials, and weight capacities). CNAs 1 and CNA 2 reported CNA 2 was able to catch Resident 1 before hitting the floor. LVN 1 failed to: 1. Immediately notify a Registered Nurse (RN) to perform a head to toes assessment of Resident 1 for any injuries. 2. Notify Resident 1's attending physician and the responsible party of the resident's witnessed fall incident. 3. Initiate an investigation of Resident 1's incident to identify causes of the fall and prevent further incidents. Interview potential witnesses including Resident 1's roommate. 4. Initiate a Change of Condition form to document findings and ensure continued monitoring of Resident 1's condition for 72 hours as per facility's policy. This deficient practice resulted in delayed medical care and Resident 1's deterioration of condition and subsequent transfer to General Acute Care Hospital 1 (GACH 1) the following day after the fall (3/2/2023), where the resident was identified with a right hip fracture (broken bone). On 3/5/2023, Resident 1 underwent a surgery to repair the broken bone. Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident, a [AGE] years-old male, on 10/5/2020 with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), repeated falls, benign prostatic hyperplasia (BPH, enlarged prostate [gland in the male reproductive system] that may cause problems associated with urination). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/23/2023, indicated the resident had memory problems, could understand others, and make herself understood. Resident 1 required extensive assistance with bed mobility and was totally dependent on staff with transfers with two or more-person physical assist. The MDS indicated the resident was not steady and could only stabilize with staff assistance during surface-to-surface transfer (between bed and chair). Resident 1's weight was 127 pounds. A review of Resident 1's nursing Progress Notes, indicated there was no documentation dated 3/1/2023 about the resident's incident of slipping out the lift machine. A review of Resident 1' s SBAR (Situation, Background, Assessment, and Recommendation, a tool to aid in facilitating and strengthening communication between health care staff) Communication form, documented by LVN 1 on 3/2/2023, indicated receiving a report on 3/1/2023, that Resident 1 slipped out of the sling during transfer. CNA 2 caught Resident 1 before hitting the floor. Upon assessment the resident had redness to the right side on the scalp. Resident 1 had no complains of pain. The SBAR indicated LVN 1 notified the resident's caregiver and the attending physician on 3/2/2023 at 11 a.m. The physician ordered an x-ray of the skull. The x-ray result was negative for a fracture. No other injuries were identified. Resident 1 would be monitored for any delayed sign of injuries. A review of Resident 1' s SBAR Communication form, dated 3/3/2023, indicated at 1:32 p.m., the resident had oxygen desaturation (low oxygen in the blood), the oxygen saturation reading was 86% (normal above 95%) and was mumbling. Resident 1 was speaking but not in his baseline. Given oxygen at 2 liters per minute (2 L/min) via nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). Emergency Medical Services (EMS, paramedics) were called, and Resident 1 was transferred to GACH 1. A review of Resident 1's GACH 1 History and Physical Reports dated 3/4/2023, indicated the patient was noted to have pain upon transfer onto the gurney. An extensive work-up was initiated in the emergency room and the patient was noted to have a right hip fracture. A review of Resident 1's GACH 1 Computed Tomography (CT, a diagnostic test that produces images of the inside of the body), dated 3/3/2023, indicated the resident with suspected right femoral (thigh bone) neck fracture. A review of Resident 1 GACH 1 Discharge Instructions, dated 3/7/2023, indicated Resident 1 underwent a hemiarthroplasty (partial hip replacement, leaving the socket intact and replacing only the thigh side of the bone) of the right hip on 3/5/2023. Resident 1 was transferred back to the facility on [DATE]. During an interview on 3/24/2023 at 10:29 a.m., CNA 1 stated she was the assigned CNA to Resident 1 on 3/1/2023 when the fall incident happened. CNA 1 stated after she assisted Resident 1 with a shower, she and CNA 2 were transferring Resident 1 back to bed. CNA 1 stated she was the one managing the lift machine and CNA 2 assisted her with the transfer. CNA 1 stated during the transfer one of the sling hooks came loose from the lift machine and the resident slipped out of the sling. and CNA 2 caught the resident and was able to put the resident back to bed. CNA 1 stated she saw the resident hit his head of the bed's foot board. CNA 1 stated the resident had been itchy and was wiggling in the air and one of the slings got unhooked. On 3/24/2023 at 1:13 p.m., during a concurrent observation and interview, CNA 1 brought a sling and stated that slings came in one size with four hooks. On 3/24/2023 at 1:22 p.m., during a concurrent observation and interview CNA 1 and CNA 2 did a demonstration of the transfer of Resident 1 in the Rehab Room using a dummy, a sling, and a lift machine. CNA 2 stated the slings size go from small, medium, large, and extra-large. CNA 2 stated small would be used for Resident 1 but an extra-large was used. On 3/24/2023 at 11:15 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 3/1/2023 CNAs 1 and 2 informed him slipped from the sling but one of them caught the resident preventing him from hitting the floor. LVN 1 stated he checked the resident and asked him if he had any pain and did not see anything on the resident's head. LVN 1 stated the resident did not hit the floor and if the resident had hit the floor, he would have notified the resident's attending physician and the responsible party. LVN 1 stated he did not talk to his supervisor until the next day. LVN 1 stated he did not document a change in condition for the resident because the resident did not fall and hit the floor. During an interview on 3/24/2023 at 2:22 p.m., the Assistant Director of Nursing (ADON) stated on 3/2/2023 during the standup meeting (consists of nursing going over the 24-hour report, incidents, follow ups, etc.) she learned about Resident 1's incident. ADON stated LVN 1 should have done a change of condition assessment and monitoring right away on 3/1/2023 and should have notified the resident's attending physician and responsible party right away. On 3/24/2023 at 2:39 p.m., during a concurrent observation and interview, the Director of Staff Development (DSD) stated the size of the sling used depends on the positioning of the resident. The DSD stated the red, blue, green, and black go small, medium, large, extra-large. The DSD stated this is determined by making sure the sling fits snug to the resident. On 3/24/2023 at 3:11 p.m., during an interview, the DON stated the CNAs are trained for the proper use of the sling for patient safety. A review of the facility's policy and procedure titled, Total Mechanical Lift, reviewed on 4/22/2022, indicated nursing staff will be trained to use the mechanical lift. The procedure indicated to hook the loops on the side of u-sling to sling bar and attach each corner of the sling to the correct hook on the sling bar. A review of the facility's policy and procedure titled, Change of Condition Notification, reviewed on 4/22/2022, indicated that the facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative when the resident endures a significant change in condition caused by, but not limited to an injury/accident. The procedure indicated the attending physician will be notified timely with a resident's change in condition The procedure further indicated that the licensed nurse would notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure its residents were free from accident hazards for one of two sampled residents (Resident 1). On 3/1/2023 at 11 a.m., Certified Nursing Assistant 1 (CNA 1) with CNA 2 were transferring Resident 1 from the shower chair to bed using a lift machine (designed to lift and transfer patients from one place to another and may be operated using a power source or manually; lift machines use a lifting sling [soft fabric tool that wrap around a patient's body] hooked to the lift; sling lifts come in various sizes, materials, and weight capacities). CNA 1 used the wrong size of sling (an extra-large when Resident 1 was small) and Resident 1 slipped down and out of the sling. CNA 2 reported to Licensed Vocational Nurse 1 (LVN 1) she was able to catch the resident before hitting the floor. Licensed Vocational Nurse 1 did not identify Resident 1's right hip pain or right hip mobility problem and did not report the incident to a Registered Nurse (RN) to accurately assess the resident for possible injuries. As a result, on 3/2/2023, when Resident 1 was being transferred to General Acute Care Hospital 1 (GACH 1) due to low oxygenation, the resident was noted with right hip pain when placing him on the gurney. Resident 1 was identified with a right hip fracture (break of a bone) and on 3/5/2023, underwent surgery to repair the fracture. Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident, a [AGE] years-old male, on 10/5/2020 with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), repeated falls, benign prostatic hyperplasia (BPH, enlarged prostate [gland in the male reproductive system] that may cause problems associated with urination). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 2/23/2023, indicated the resident had memory problems, could understand others, and make herself understood. Resident 1 required extensive assistance with bed mobility and was totally dependent on staff with transfers with two or more-person physical assist. The MDS indicated the resident was not steady and could only stabilize with staff assistance during surface-to-surface transfer (between bed and chair). Resident 1's weight was 127 pounds. A review of Resident 1's nursing Progress Notes, indicated there was no documentation dated 3/1/2023 about the resident's incident of slipping out the lift machine. A review of Resident 1' s SBAR (Situation, Background, Assessment, and Recommendation, a tool to aid in facilitating and strengthening communication between health care staff) Communication form, documented by LVN 1 on 3/2/2023, indicated receiving a report on 3/1/2023, that Resident 1 slipped out of the sling during transfer. CNA 2 caught Resident 1 before hitting the floor. Upon assessment the resident had redness to the right side on the scalp. Resident 1 had no complains of pain. The SBAR indicated LVN 1 notified the resident's caregiver and the attending physician on 3/2/2023 at 11 a.m. The physician ordered an x-ray of the skull. The x-ray result was negative for a fracture. No other injuries were identified. Resident 1 would be monitored for any delayed sign of injuries. A review of Resident 1' s SBAR Communication form, dated 3/3/2023, indicated at 1:32 p.m., the resident had oxygen desaturation (low oxygen in the blood), the oxygen saturation reading was 86% (normal above 95%) and was mumbling. Resident 1 was speaking but not in his baseline. Given oxygen at 2 liters per minute (2 L/min) via nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). Emergency Medical Services (EMS, paramedics) were called, and Resident 1 was transferred to GACH 1. A review of Resident 1's GACH 1 History and Physical Reports dated 3/4/2023, indicated the patient was noted to have pain upon transfer onto the gurney. An extensive work-up was initiated in the emergency room and the patient was noted to have a right hip fracture. A review of Resident 1's GACH 1 Computed Tomography (CT, a diagnostic test that produces images of the inside of the body), dated 3/3/2023, indicated the resident with suspected right femoral (thigh bone) neck fracture. A review of Resident 1 GACH 1 Discharge Instructions, dated 3/7/2023, indicated Resident 1 underwent a hemiarthroplasty (partial hip replacement, leaving the socket intact and replacing only the thigh side of the bone) of the right hip on 3/5/2023. Resident 1 was transferred back to the facility on [DATE]. During an interview on 3/24/2023 at 10:29 a.m., CNA 1 stated she was the assigned CNA to Resident 1 on 3/1/2023 when the fall incident happened. CNA 1 stated after she assisted Resident 1 with a shower, she and CNA 2 were transferring Resident 1 back to bed. CNA 1 stated she was the one managing the lift machine and CNA 2 assisted her with the transfer. CNA 1 stated during the transfer one of the sling hooks came loose from the lift machine and the resident slipped out of the sling. and CNA 2 caught the resident and was able to put the resident back to bed. CNA 1 stated she saw the resident hit his head of the bed's foot board. CNA 1 stated the resident had been itchy and was wiggling in the air and one of the slings got unhooked. On 3/24/2023 at 1:13 p.m., during a concurrent observation and interview, CNA 1 brought a sling and stated that slings came in one size with four hooks. On 3/24/2023 at 1:22 p.m., during a concurrent observation and interview CNA 1 and CNA 2 did a demonstration of the transfer of Resident 1 in the Rehab Room using a dummy, a sling, and a lift machine. CNA 2 stated the slings size go from small, medium, large, and extra-large. CNA 2 stated small would be used for Resident 1 but an extra-large was used. On 3/24/2023 at 11:15 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 3/1/2023 CNAs 1 and 2 informed him slipped from the sling but one of them caught the resident preventing him from hitting the floor. LVN 1 stated he checked the resident and asked him if he had any pain and did not see anything on the resident's head. LVN 1 stated the resident did not hit the floor and if the resident had hit the floor, he would have notified the resident's attending physician and the responsible party. LVN 1 stated he did not talk to his supervisor until the next day. LVN 1 stated he did not document a change in condition for the resident because the resident did not fall and hit the floor. During an interview on 3/24/2023 at 2:22 p.m., the Assistant Director of Nursing (ADON) stated on 3/2/2023 during the standup meeting (consists of nursing going over the 24-hour report, incidents, follow ups, etc.) she learned about Resident 1's incident. ADON stated LVN 1 should have done a change of condition assessment and monitoring right away on 3/1/2023 and should have notified the resident's attending physician and responsible party right away. On 3/24/2023 at 2:39 p.m., during a concurrent observation and interview, the Director of Staff Development (DSD) stated the size of the sling used depends on the positioning of the resident. The DSD stated the red, blue, green, and black go small, medium, large, extra-large. The DSD stated this is determined by making sure the sling fits snug to the resident. On 3/24/2023 at 3:11 p.m., during an interview, the DON stated the CNAs are trained for the proper use of the sling for patient safety. A review of the facility's policy and procedure titled, Total Mechanical Lift, reviewed on 4/22/2022, indicated nursing staff will be trained to use the mechanical lift. The procedure indicated to hook the loops on the side of u-sling to sling bar and attach each corner of the sling to the correct hook on the sling bar. A review of the facility's policy and procedure titled, Change of Condition Notification, reviewed on 4/22/2022, indicated that the facility will promptly inform the resident, consult with the resident's attending physician, and notify the resident's legal representative when the resident endures a significant change in condition caused by, but not limited to an injury/accident. The procedure indicated the attending physician will be notified timely with a resident's change in condition The procedure further indicated that the licensed nurse would notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible.

Based on interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who was assessed at risk for falls (move downward, typically rapidly and freely without control, from a higher to a lower level), was kept free from accident and hazards by failing to: 1. Ensure Resident 1 was provided with one to one supervision (one specific person will be assigned to remain at the resident's side to ensure safety) as recommended to prevent 10 unwitnessed falls from 2/6/2021 to 4/9/2021. 2. Develop a resident-centered care plan with interventions and approaches addressing Resident 1's continued episodes of falls. 3. Reevaluate the nursing interventions and revise the plan of care when the interdisciplinary team (IDT - a team representing different disciplines working together to provide the greatest benefit for the resident) meeting was conducted to monitor the effectiveness of the current fall interventions and evaluate the need for modification. 4. Provide bowel and bladder program training (B&B program - a training to manage incidences of incontinence [inability to control urine or feces] effectively with a combination of exercises, techniques, and lifestyle changes) when Resident 1 was identified as a candidate. These deficient practices resulted in Resident 1 falling a total of 10 instances from 2/6/2021 to 4/9/2021. On 4/9/2021, while attempting to use the bathroom, Resident 1 had an unwitnessed fall sustaining a left [CONDITION(S)] (broken bone) requiring hospitalization to undergo an open reduction internal fixation (ORIF - a surgery to fix severely broken bones) on the left hip. Findings: 1. A review of Resident 1's Admission Record indicated the resident was originally admitted on [DATE] with [CONDITION(S)] (a disease of the heart muscle that makes it harder to pump blood to the rest of the body), cognitive communication deficit (difficulty with any aspect of communication affected by disruption of thought process), and seizures (a burst of uncontrolled electrical activity between brain cells). A review of the History and Physical examination dated 12/15/2020 indicated Resident 1 had the capacity to make needs known but was unable to make her own medical decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/12/2021 indicated Resident 1's cognitive (ability to think, understand and reason) skills for daily decision-making were moderately impaired. The MDS further indicated that Resident 1 required limited assistance (one-person physical assist needed) for bed mobility and transfers; and extensive assistance (two persons physical assist) for dressing, toilet use and personal hygiene. A record review of Resident 1's Fall Risk assessment dated [DATE] indicated that Resident 1 was assessed as a high risk for falls and was identified as having balance problems, unsteady gait and lower extremity weakness. Further review of the Fall Risk Assessment indicated Resident 1 has poor decision-making skills, poor safety awareness and memory deficit. A record review of Resident 1's Situation Background Assessment Recommendation (SBAR - provides a framework for communication between members of the health care team about a resident's condition) dated 2/6/2021 to 4/9/2021 indicated the following: 1. On 2/6/2021 at 1:51 p.m., Resident 1 had an unwitnessed incident of fall. The SBAR notes indicated to consider placing Resident 1 on a one to one supervision. 2. On 2/6/2021 at 5:45 p.m., Resident 1 with an incident of fall. The SBAR notes indicated Resident 1 continues to get out of bed unassisted. 3. On 2/27/2021 at 7:24 a.m., Resident 1 had an unwitnessed incident of fall. The SBAR notes indicated from the nursing station Resident 1 was heard crying out for help. The SBAR notes further indicated an order to monitor the resident. 4. On 3/1/2021 at 9:52 p.m., Resident 1 had an unwitnessed incident of fall. The SBAR notes indicated Resident 1 was found in the resident's room on the floor in a sitting position. The SBAR notes further indicated an order to monitor the resident. 5. On 3/1/2021 at 11:35 p.m., Resident 1 had an unwitnessed incident of fall. Resident 1 was again found sitting on the floor in the resident's room. The SBAR notes further indicated Resident 1 was heard calling for nurses. Resident 1 needed assistance to transfer to the wheelchair. Upon further review of the SBAR, there were no additional interventions documented to address Resident 1's continued and repeated episodes of falls. 6. On 3/3/2021 at 9:36 a.m., Resident 1 had an unwitnessed incident of fall. The SBAR notes indicated to monitor for any signs and symptoms of delayed injury (harm or damage sustained). 7. On 3/4/2021 at 5:55 a.m., Resident 1 had an unwitnessed incident of fall. Resident 1 was found sitting on the floor. Upon further review of the SBAR, there were no additional interventions documented to address Resident 1's episode of falls. 8. On 3/13/2021at 12:52 p.m., Resident 1 had an unwitnessed incident of fall. Resident 1 was found in a sitting position in the hallway by the double doors that lead to the receptionist area. 9. On 3/30/2021 at 2:39 p.m., Resident 1 had an unwitnessed incident of fall. Resident 1 was seen on the floor in the hallway near the beauty shop. The SBAR notes further indicated there were no new orders. 10. On 4/9/2021 at 1:07 p.m., Resident 1 had an unwitnessed incident of fall. The SBAR notes further indicated approximately 30 minutes after the fall, Resident 1 started to complain of left hip pain. Resident 1's physician was notified with orders obtained for STAT (immediate) high frequency electromagnetic [CONDITION(S)] (x-ray - photographic or digital image of the body). A review of Resident 1's physician order dated 4/9/2021 indicated an order for X-ray to left femur (thighbone) and left hip to rule out fracture due to pain. A review of Resident 1's x-ray results of the left femur dated 4/9/2021 indicated a fracture of the left femoral neck (part of the thigh bone). A review of Resident 1's physician order dated 4/9/2021 indicated to transfer Resident 1 to a General Acute Care Hospital (GACH 1) emergency room for further evaluation of left femur. A record review of the Surgical Documentation from GACH 1 dated 4/12/2021 indicated that Resident 1 underwent an operation for ORIF on the left hip. During an interview with Certified Nursing Assistant 1 (CNA 1) on 7/15/2021 at 1:28 p.m., CNA 1 stated that she was assigned to care for Resident 1 the day of 4/9/2021. CNA 1 stated that Resident 1 fell while she was on lunch break. CNA 1 stated that upon her return from lunch, she had noted Resident 1 in tears saying she was in pain. CNA 1 stated that when she reported Resident 1 complaining of pain to Licensed Vocational Nurse 1 (LVN 1), LVN 1 informed her that the resident had fallen. During an interview with Certified Nursing Assistant 2 (CNA 2) on 7/16/2021 at 10:59 a.m., CNA 2 stated she had previously been assigned to care for Resident 1 and was familiar with the resident. CNA 2 stated that had the facility provided more interventions such as one to one observation (an intervention to be under constant observation by one assigned staff member at all times), it could have prevent Resident 1's incidences of falls. During a concurrent interview and record review on 7/20/2021 at 6:00 p.m. with Licensed Vocational Nurse 2 (LVN 2), Resident 1's SBAR dated 2/6/2021 was reviewed. LVN 2 confirmed that the SBAR indicated to consider one to one supervision for Resident 1. LVN 2 stated that she was unable to recall if one to one observation was ever provided to Resident 1. LVN 2 stated that it would have been in Resident 1's best interest to have one to one observation to prevent further falls. During an interview with the Assistant Director of Nursing (ADON) on 7/16/2021 at 11:35 a.m., ADON stated that the facility had interventions in placed being that Resident 1 had been identified as a high risk for falls. ADON stated that staff assisted the resident with transferring in and out of bed, always ensuring the call light is within reach, bed against the wall, and use of double mattress (placing mattress on the floor to minimize injury when a fall occurs to the side of the bed). ADON stated that the interventions provided by the facility were not effective as evident by Resident 1 sustaining 10 unwitnessed falls from 2/6/2021 to 4/9/2021. ADON stated that there was no adequate supervision provided to Resident 1 such as placing the resident on one to one observation. ADON stated that had Resident 1 been provided with one to one observation, it could have prevented further incidences of falls. ADON stated that the facility did not provide Resident 1 with one to one observation from 2/6/2021 to 4/9/2021. A review of the facility's policy and procedure titled Fall Management Program, dated 2/25/2018 indicated that the facility is to prevent resident falls and minimize complications associated with falls through the development of a fall management program. The licensed nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated. 2. A review of Resident 1's care plans from 2/6/2021 to 4/9/2021 indicated that there was no care plan developed to address Resident 1's actual fall on the following dates: a. 2/6/2021 b. 2/27/2021 c. 3/30/2021 During the concurrent interview and record review with ADON on 7/14/2021 at 2:46 p.m., Resident 1's care plan from 2/6/2021 to 4/9/2021 were reviewed. ADON stated the Resident 1 sustained episodes of unwitnessed falls on 2/6/2021, 2/27/2021, and 3/30/2021. ADON confirmed that no actual fall care plan had been developed for Resident 1 for the falls on 2/6/2021, 2/27/2021 and 3/30/2021. ADON stated that there should have been a resident-centered care plan for Resident 1 after each fall incident to identify the risk factors, develop and implement interventions to prevent further falls. A review of the facility's policy and procedure titled Care Planning, dated 11/1/2017 indicated a comprehensive person-centered care plan will be developed for each resident based on their individual assessed needs and the care plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. 3. During a record review of Resident 1's IDT notes, the notes indicated that IDT meetings were conducted on the following dates due to episodes of falls: a. 2/8/2021 b. 3/16/2021 c. 3/28/2021 d. 4/2/2021 During a record review of Resident 1's IDT progress note dated 3/28/2021, the note indicated that the IDT met due to Resident 1's episode of fall incident on 3/13/2021. The note further indicated that the IDT agreed that current interventions such as bed against a wall, double mattress, pad alarm to bed and wheelchair (a device to alert for fall prevention) and pommel cushion (a cushion to prevent a wheelchair resident from sliding down and falling out of wheelchair) were effective in preventing further falls. During a concurrent interview and record review with ADON on 7/14/2021 at 3:15 p.m., Resident 1's IDT notes from 2/8/2021 to 4/2/2021 were reviewed. ADON stated that the facility conducted IDT meetings due to multiple unwitnessed fall incidences, while continuing to provide interventions such as the tab alarm and use of double mattress. ADON stated that the interventions were not monitored for effectiveness and were not evaluated for modification as evident by Resident 1 sustaining two additional unwitnessed falls on 3/30/2021 and 4/9/2021 after the IDT Meeting held on 3/28/2021. ADON stated that Resident 1 could have benefited from additional interventions such as close monitoring by one to one observation to prevent the 10 instances of unwitnessed falls from 2/6/2021 to 4/9/2021. A review of the facility's revised policy dated 2/25/2018 and titled Fall Management Program indicated the IDT will review the plan of care at a minimum of quarterly, with a change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response. 4. A review of Resident 1's Bowel and Bladder assessment dated [DATE], 2/26/2021, 2/27/2021, 3/1/2021, 3/4/2021, 3/13/2021 and 3/30/2021 indicated that Resident 1 was assessed and considered a candidate for bowel and bladder training program. During an interview and concurrent record review with MDS Nurse on 7/16/2021 at 10:12 a.m., Resident 1's Bowel and Bladder assessments from 2/6/2021 to 4/9/2021 were reviewed. After reviewing Resident 1's skilled nursing facility medical records from 2/6/2021 to 4/9/2021, MDS Nurse stated Resident 1 was not provided with Bowel and Bladder training during that time. The MDS nurse stated that the facility should have initiated Bowel and Bladder training for Resident 1 when he was identified as a candidate. During an interview with ADON on 7/16/2021 at 11:35 a.m., ADON stated the purpose of the Bowel and Bladder Assessment is to determine if Bowel and Bladder training is needed so that the facility can provide the training for residents. ADON stated that the facility should have provided the Bowel and Bladder training program when Resident 1 was identified as a candidate. ADON stated that the training was not provided to Resident 1 and stated that receiving the Bowel and Bladder training could have possibly prevented the unwitnessed fall on 4/9/2021 wherein Resident 1 sustained a left femoral fracture while attempting to use the bathroom unassisted. A review of policy and procedure dated 4/1/2019 titled, Bowel and bladder Assessment indicated that the facility will ensure a resident who is incontinent receives appropriate treatment and services to prevent urinary tract infection and to restore as much normal bladder and bowel function as possible. A review of the facility's policy and procedure titled Fall Management Program, dated 2/25/2018 indicated that the facility is to prevent resident falls and minimize complications associated with falls through the development of a fall management program. The licensed nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated.

Based on interview and record review, the facility failed each resident received adequate supervision and assistance devices to prevent falls and minimize injuries for one 3 sample residents (Resident 1), including: 1. Failure to ensure Resident 1, who was assessed as requiring two-person assist for transfers and ambulation, was provided with two-person staff assistance while transferring from bed to wheelchair. 2. Failure to indicate in the Care Plan Resident 1 required two-person assistance with transfers and ambulation as assessed. 3. Failure to implement the facility's Resident Information Care Guide by not using a gait belt when transferring Resident 1 from bed to wheelchair and not indicating the resident's level of assistance required for locomotion/transfers. 4. Failure to implement the facility's policies on Slip Trip and Fall Prevention and Care Plan Development and Communication, by not including in the plan of care interventions designed to assist Resident 1 in meeting their goals; by not developing a plan of care with interventions designed to assist Resident 1 in meeting her goals; and by not communicating to staff the care needs of Resident 1. As a result, on 10/4/17, at 5:27 a.m., Resident 1 fell while being transferred from bed to wheelchair by Certified Nursing Assistant 1 (CNA 1), who was alone and failed to use a gait belt for the transfer. Resident 1 sustained a right distal femur peri-prosthetic fracture (a break in the large thigh bone above prior knee implant hardware), which required surgery. Findings: A review of the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with a recent re-admitted d 10/14/17. Resident 1's [DIAGNOSES REDACTED]. A review of the history and physical examination [REDACTED]. According to the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 8/26/17 indicated Resident 1 was alert and oriented and had no cognitive (reasoning/thinking) problems. Resident 1 required extensive assistance (resident involved in activity, staff provide physical support) of two or more persons (physical assistance) for bed mobility and transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position). The MDS further indicated Resident 1 was not steady, only able to stabilize with staff assistance when moving from seated to standing position and when transferring between bed and chair or wheelchair. A review of a Data Collection Tool (assessment) dated on admission (5/19/17) and 9/2/17 (quarterly) indicated Resident 1 required two-person assistance with transfers. A review of the Care Plan developed on 5/9/17 for Resident 1's risk for falls due to muscle weakness and incontinence, did not address Resident 1's assessed need for two-person assist during transfers. A review of the Resident Information Care Guide dated 10/5/17 indicated Resident 1 required one-person assist with bed mobility and activities of daily living. The Guide did not specify the resident's assist needs for transfers requiring two or more person assist. The box titled, Safety Precautions was left blank. The Guide indicated, Gait belts are to be used during every transfer. A review of the Change in Condition Evaluation form dated 10/4/17, timed at 5:27 a.m. indicated Resident 1 had a fall and complained of constant pain to her right knee and decreased mobility due to right knee weakness. A review of the Investigatory Resident Interview form dated 10/4/17 indicated on assessment and interview, Resident 1 stated her right knee gave way as the CNA was trying to transfer her to the wheelchair. A review of an Employee Interview form dated 10/4/17 indicated CNA 1 was assisting Resident 1 as she stood up from bed to transfer to her wheelchair. CNA 1 reported as she was pivoting Resident 1 to sit in the wheelchair, Resident 1's knee gave out and CNA 1 assisted her to the floor. CNA 1 reported Resident 1 ended up with her back against the wall, leaning on her elbow, with her legs bent back. CNA 1 reported Resident 1 did not complain of pain and stated she was fine. A review of the x-rays results dated 10/5/17, indicated Resident 1's right knee had evidence of total knee replacement with acute mildly displaced (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) supracondylar (at the knee level) fracture of distal (lower end of the long bone of the thigh) femur above knee prosthesis (artificial replacement of the bone). During an interview with Resident 1 on 10/23/17 at 1:20 p.m., she stated on the morning of the incident, CNA 1 was helping her transfer from her bed to her wheelchair. Resident 1 stated her power wheelchair was in manual mode, which was the only mode she used and so CNA 1 had to pull the wheelchair into place for her. Resident 1 stated CAN 1 did not lock the wheels. As CNA 1 started getting her up to pivot toward the wheelchair, the chair rolled back and the resident started sliding off the bed. Resident 1 stated it was the first time CNA 1 had worked with her. During an interview with CNA 1 on 10/24/17 at 7 a.m., she stated it was the first time she had worked with Resident 1 and they were short of staff, so one of the other CNA told her Resident 1 required limited assist, just a little physical help and one person assist for transfers. CNA 1 stated she did not use a gait belt during the incident. During an interview with CNA 2 on 10/24/17 at 8 a.m., she stated Resident 1 required two-person assistance for transfers because she always complained of knee pain and she was not steady, and sometimes her legs give out on her. A review of the Operative Report dated 10/9/17 indicated the pre/post-operative [DIAGNOSES REDACTED]. The procedure performed was right retrograde femur IMN (intramedullary nail) to repair the fracture (Stabilization of the fracture with an implant). The facility's policy and procedure titled, Slip, Trip and Fall Prevention effective 5/1/17 indicated team members will be informed of and expected to comply with procedures to prevent slips and falls in the facility including: Ensure resident assessments are done upon admission and periodically thereafter to identify the most appropriate and safest transfer protocol and any other special mobility needs. The facility's policy and procedure titled, Process for Care Plan Development and Communication revised 9/25/14 indicated direct care staff spends the most time with the residents and are the most knowledgeable about the residents' daily life, needs, problems and strengths. Direct care staff must be informed about the residents' care needs to improve, maintain or minimize decline in the residents' condition and wellbeing. The plan of care will include interventions designed to assist the resident in meeting their goals. The comprehensive care plan will be communicated to all staff. Verbal communication regarding the plan of care will occur during shift report. Information relevant to the resident's plan of care will be provided by the staff to the nurse on a daily basis. The nurse will report to the oncoming staff and CNAs on the resident care needs at the change of shift each day.

Based on observation, interview and record review, the facility failed to identify and reduce the risk of acquiring and spreading infections when: 1. The Maintenance Service Director ((MSD), the Certified Nurse Assistant (CNA 1), and a visitor going into the isolation room (a room used for residents with diseases or germs that are spread by touching the resident or items in the room) without the appropriate Personal Protective Equipment (PPE- gown, mask, face shield/goggles and gloves used alone or in a combination to protect mucous membranes, skin, and clothing from contact with infectious agent) for one of 38 sampled residents (Resident 31), 2. A water pitcher was removed from a contact isolation room (designated room for residents with infectious disease- condition that could spread to others), 3. Licensed Vocational Nurse (LVN 4) did not disinfect (clean something with chemical in order to destroy germs) the blood pressure cuff (a device to check blood pressure) and her stethoscope (a medical instrument used to listen to the action of someone's heart or breathing) before and after resident use for one of 38 sampled residents (Resident 59), 4. LVN 1 did not wash her hands after medication administration for one of 38 sampled residents (Resident 55), 5. The facility did not follow up on a positive urine culture for one of 38 sampled residents (Resident 5), and 6. The gastrostomy tube (GT- tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding formula and tubing was not labeled and dated for one of 38 sampled residents (Resident 17). These failed practices had the potential to spread infections to 70 residents, staff, and visitors in the facility and placed the residents at risk to receive expired feeding formulas via expired tubings. The deficient practices were determined to constitute an Immediate Jeopardy (IJ) situation due to infection control issues related to staff and visitor going to an isolation room with incomplete PPE, staff going to an isolation room without PPE, staff removing a water pitcher from an isolation room and placing it at the nursing station and on the ice chest. The two Administrators (ADMs 1 and 2), Director of Nursing (DON), and the Director of Staff Development (DSD) were verbally notified of the IJ on [DATE], at 9:15 p.m. The ADMs, DON, and the DSD were informed of the MDS, the CNA, and the visitor going into the isolation room without the appropriate PPE. The MDS removing the water pitcher from the isolation room and placing it on the counter at Nursing Station 2 and on the ice chest. The ADMs, DON, and DSD were informed of the risk of infection spreading to other residents, staff, and visitors. Through observations of staff, interviews with the staff members and record reviews of the facility's in-service records, infection control manual, policies and procedures, the facility showed they initiated the plan of action through in-services of employees regarding: - Personal protective equipment, - Isolation signage, - Family and visitor education, - Disinfection of the surfaces, - How to refill a water pitcher when a resident is on isolation, - Extended Spectrum Beta Lactamase (ESBL- is a gram-negative bacterium transmitted by direct person to person contact or indirect contact with the person's environmental surfaces or items in the resident's environment). The IJ was lifted on [DATE], at 6:33 p.m., in the presence of ADMs 1 and 2. Findings: 1. During an observation on [DATE], at 4:12 p.m., CNA 1 entered room [ROOM NUMBER], a contact isolation room, with incomplete PPE. A sign posted outside the contact isolation room indicated to wash hands, don gloves, wear facemask or goggle, and gown before entering the room. CNA 1 worn a gown and gloves, she did not wear a goggle while giving the resident direct care. A review of a urinalysis laboratory report (LR) dated [DATE] indicated Resident 31 was positive for ESBL. The LR indicated, the Medical Director (MD) was notified of the LR on [DATE], at 12:46 p.m. The MD ordered Ertapenem (medication to treat infection) 1 gm (gram- unit of measure) daily for seven days. During an interview with the DON on [DATE], at 4:15 p.m., the DON stated, Staff and visitors entering an isolation room should wear the appropriate PPE as indicated on the isolation door The DON further stated, CNA 1 should have worn a gown, a goggle and gloves. During an observation on [DATE], at 5:13 p.m., a visitor entered the room [ROOM NUMBER] wearing only gloves as PPE. During an interview with the DSD on [DATE], at 5:32 p.m., the DSD stated, The visitor is not giving resident direct care it is okay for the visitor not to wear the complete PPE. During an interview and a concurrent record review with the DSD, on [DATE], at 6:49 p.m., the DSD stated CNA 1 had received training and in-services on infection control and prevention upon hire and regularly as needed and at least annually. However, there were no in-services and training regarding infection control provided to CNA 1 for the past one year. CNA 1 was hired on [DATE]. The DSD was unable to provide documentation CNA 1 had received training and in-services on infection control. The DSD further stated, All employee should have been in-serviced on infection control. During a review of Resident 31's record. The face sheet, indicated Resident 31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the facility's policy and procedure, titled, Personal Protective Equipment Techniques, revised on [DATE], indicated, To minimize risk to employees, all employees must wear appropriate protective attire when providing care to residents in isolation. A review of the facility's policy and procedure, titled, Providing Resident Care While In Isolation, revised on [DATE], indicated, Use gown, gloves and mask according to the type of isolation/precautions. 2. During an observation on [DATE], at 6:15 p.m., the MSD entered room [ROOM NUMBER] without any PPE. The MSD then exited the room with the residents' water pitcher, walked along the hallway towards nursing station two, and sat the pitcher down on multiple areas of the countertop. The MSD then scooped ice from the common ice chest used by other residents. The MSD also filled the residents' pitcher with water from a common water container found in nursing station 2 used by other residents, visitors, and staff. The MSD did not wash his hands when he exited the isolation room. The MDS did not wash his hands after he took the water pitcher back to room [ROOM NUMBER]. A review of an untitled facility document dated [DATE], indicated Resident 31 had ESBL of the urine with an intervention of required contact isolation, educated the resident, family/caregivers regarding the importance of hand washing, and instructed family/visitors/caregivers to wear disposable gloves and gown when in the resident's room and to wash hands before leaving the resident's room. During an interview with ADMs 1 and 2, the DON, and the DSD, on [DATE], at 6:30 p.m., the DON stated the MSD did not follow the infection control protocol. The ADM 1 stated, The staff needs to follow the proper procedure to avoid risk for cross contamination. The ADM 1 further stated, The staff needed to ask if they did not know about resident's isolation. During an interview and a concurrent record review of the document titled, Education Attendance Sheet, dated [DATE], with the DSD, on [DATE], at 6:32 p.m., it indicated not all staff had received training and in-services regarding infection control. The DSD reviewed the document and stated, Not all staff had received infection control training upon hire and regularly as needed. The DSD further stated the facility had 102 staff that included nursing and non-nursing staff. During an interview and a concurrent record review of the Education Attendance Sheet, dated, [DATE], with the DSD, on [DATE], at 6:49 p.m., the DSD stated the MSD had received training on infection control and prevention upon hire and regularly as needed and at least annually. During an interview and a concurrent record review of the MSD's file with the DSD and ADM 1 on [DATE], at 7:04 p.m., there were no documentation of in-services and training on infection control and prevention given to the MSD upon hire and annually. The MSD was hired on [DATE]. The DSD reviewed MSD's file. The DSD stated there were no in-services on infection control and prevention in the MSD's file. The DSD was unable to provide documentation of infection control training given to MSD upon hire, as needed, and annually. During an interview and a concurrent record review with the DSD, on [DATE], at 7:29 p.m., there were no housekeeping staff, laundry staff, maintenance staff and dietary staff included in the in-services. The DSD stated all staff should have been in-serviced on infection control. The DSD provided one-year in-services trainings on infection control. A review of the Education Attendance Sheet, indicated the following: - On [DATE], an in-service was held regarding Policy & Procedure Review/Infection Control. There were 16 staff in attendance, - On [DATE], an in-service was held regarding Infection Control/Isolation Disposal. There were 19 staff in attendance, - On [DATE], an in-service was held regarding Infection Control. There were 15 staff in attendance, - On [DATE], an in-service was held regarding Control Transmission of ESBL. There were eight staff in attendance, - On [DATE], an in-service was held regarding Disposal of contact isolation linens and trash. There were 15 staff in attendance, - On [DATE], an in-service was held regarding Infection Control Education/Hand washing. There were 18 staff in attendance, and - On [DATE], an in-service was held regarding Infection Control. There were 19 staff in attendance. During an interview with the Activities Assistant (AA 1), on [DATE], at 8:16 p.m., the AA 1 stated, Before entering an isolation room we need to read precaution posting by the door and wear appropriate PPE. We need to wash our hands before entering and leaving the room. Also we cannot bring any items out of isolation room. During an interview with the Activities Assistant (AA 2), on [DATE], at 8:17 p.m., the AA 2 indicated, materials such as magazines lent to residents in isolation rooms are either kept in the room or disposed of for infection control. A review of the facility's policy and procedure titled, Personal Protective Equipment Guidelines, dated, [DATE], indicated, Wear appropriate gloves when it can be reasonably anticipated that there may be hand contact with potentially infectious materials and when handling or touching contaminated items or surfaces. A review of the facility's policy and procedure titled, Providing Resident Care While In Isolation, revised on [DATE], indicated, Do Not take the pitcher from the room for a refill. A review of the facility's policy and procedure titled, Infection Control Education, revised on [DATE], indicated, Employees are instructed in infection control practices during the orientation process and thereafter at periodic in-services. At minimum, education shall be provided: at time of hire, at least annually, and at any time job activities result in the need to train employees on new potential .body fluids . A review of the facility's policy and procedure, titled, Infection Control/Standard Precautions, dated, [DATE], indicated, Hand washing shall be done by all staff upon entering and leaving a home after contact with clients. A review of the facility's policy and procedure, titled, Standard Precautions, revised on [DATE], indicated, Handle resident care equipment .in a manner that prevents .contamination of clothing and transfer of microorganisms (includes bacteria, viruses .that are too small to be seen with the naked eye but visible under the use of an instrument) to other residents and environment. A review of the facility's policy and procedure titled, Transmission Precautions: Contact, revised on [DATE], indicated, Wear clean, non-sterile gloves when entering the room. Hand washing is performed after contact with an object or source where there is concentration of microorganisms . A review of the facility's policy and procedure titled, Hand Washing, revised on [DATE], indicated, Hand washing is the most important component for managing the spread of infection. 3. During a medication observation on [DATE], at 8:40 a.m., LVN 4 did not disinfected her blood pressure cuff and stethoscope before and after use on Resident 59. During an interview with LVN 4 on [DATE], at 8: 59 a.m., LVN 4 stated, I should have sanitized the stethoscope before and after resident use. During an interview with the DON, on [DATE], at 10:11 a.m., the DON stated, The nurse should disinfect the blood pressure cuff and stethoscope before and after use on Resident 59 to prevent the spread of infection. On [DATE], at 10:15 a.m., the facility's policy on disinfecting devices such as blood pressure cuff was requested from the DON; however, the policy was not made available. 4. A medication observation was conducted on [DATE], at 5:27 p.m., with LVN 1. LVN 1 administered the following medications to Resident 55 in the resident's room; [MEDICATION NAME] (medication for stomach irritation) 20 milligram (mg- unit for measure), pramipexole [MEDICATION NAME] (medication used to treat disease that affects movement) 0.75 mg, [MEDICATION NAME] (medication to treat mental illness) 0.5 mg, and [MEDICATION NAME] (medication to relieve itching) 25 mg 1 tablet. LVN 1 did not wash hands after administering those medications to Resident 59. During an interview with LVN 4 on [DATE], at 8: 59 a.m., LVN 1 stated, I should have washed my hands before and after the medication pass. During an interview with the DON on [DATE], at 4: 30 PM, the DON stated, LVN 1 should have washed her hands before and after the medication pass. On [DATE], at 10:20 a.m., the facility's policy on hand washing during and after medication administration was requested from the DON; however, the policy was not made available. 5. During a review of the clinical record for Resident 5, a urine culture collected on [DATE] and a report date [DATE], indicated the urine culture was positive for 10,000 - 25,000 colonies per milliliter of Escherichia Coli (type of bacteria). There were no documentation in the clinical record the physician acknowledged the receipt, reviewed the abnormal laboratory results, and no staff follow-up with the physician. During an interview with the Director Of Nursing (DON), on [DATE] at 6:55 p.m., the DON stated, We normally we would call the Doctor and if we can't get the Doctor or if he is busy, we leave a message. No call back within 15 minutes, we call every 15 minutes until we get the physician. The DON further stated, Normally, we have clinical rounds in the mornings at 8 a.m. Myself and the RN Supervisor would check if the abnormal lab was reported to the physician and if new orders were given, if the family was notified, but I do not recall hearing about this one. It should have been documented in the progress notes. I asked a nurse to check and she said there was nothing documented there. The facility's policy and procedures titled, Resident Condition Changes That Require Physician Notification Guidelines, dated [DATE], indicated, Lab (laboratory) results that warrant physician intervention (i.e. new urinary tract infection .) report ASAP .Urgent: A situation/condition that would require physician notification and a physician response within 2 - 4 hours. Such conditions include .Lab results that fall outside clinical reference ranges as per Healthcare Practitioner order. On [DATE] at 2:30 p.m. there had not been a response from the physician's office regarding the positive urine culture that was faxed to the physician on [DATE] at 8:30 a.m. There was no follow up from the facility to determine if the result was received by the physician and if treatment was necessary. A facility policy and procedures titled, Resident Condition Changes That Require Physician Notification Guidelines, was reviewed. The policy indicated, Lab results that warrant physician intervention (i.e. new urinary tract infection, .results) report ASAP. 2. Urgent: A situation/condition that would require physician notification and a physician response within 2 - 4 hours. Such conditions include, but not limited to the following: Lab results that fall outside clinical reference ranges as per Healthcare Practitioner order. 6. During an observation on [DATE], at 9:35 a.m., a GT feeding was hanging on a pole next to Resident 17's bed. The GT feeding bag and tubing were not labeled and dated. During an observation and a concurrent interview with Licensed Vocational Nurse (LVN 2), on [DATE], at 9:56 a.m., LVN 2 verified the finding and stated the GT feeding formula and tubing should have been labeled with the resident's name, start date & time, rate, and initials. LVN 2 further stated the tube feeding formula needs to be changed every 24 hours. The facility's policy and procedure titled, Enteral Feeding: Ready to Hang, with revised date of [DATE], indicated, Fill information on the label (name, room, date/time, and rate). Mark the feeding set with the start time.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not monitor / modify interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as a high fall risk and had prior falls, the facility failed to develop and revise a care plan with interventions to address the resident's identified risk for falls and failed to develop a falls prevention care plan. These deficienct practices resulted in Resident 1 suffering a fall with injuries, which included a fractured hip and required surgery. Findings: According to the admission face sheet, Resident 1 was admitted to the facility, on 9/1/17, with [DIAGNOSES REDACTED]. A review of the Fall Risk Evaluation form, dated 9/1/17, indicated Resident 1 was categorized as a high risk for falls due to history of falls, impaired gait, and impaired mental status. A review of the Minimum Data Set (MDS - an assessment and care-planning tool), dated 9/8/17, indicated Resident 1 was able to make herself understood/sometimes understood others, had disorganized thinking, and severely impaired cognitive skills for daily decision-making. Resident 1 required extensive one person physical assistance with all activities of daily care and was not steady, only able to stabilize with staff assistance. The MDS indicated the resident had one fall with a fracture in the last six months prior to admission, had one fall with no injury, and one fall with non-major injury (abrasions, lacerations, etc) since admission. A review of the care plan titled, The Resident is at Risk for Falls, initiated on 9/2/17, indicated Resident 1 had actual falls on 9/6, 9/9 and 9/23/17. The care plan interventions included bed and chair alarm (initiated 9/5/17), floor mats, and place bed in low position (initiated 9/5/17). The care plan was not revised/updated following Resident 1's actual falls on 9/6/17 and 9/9/17. According to an SBAR Communication Form and Progress Note (a tool used to document incidents/changes of condition affecting a resident, S=Situation, B=Background, A=Assessment, R=Request), dated 9/6/17, Resident 1 had a fall that night (the actual time was not documented). The assessment indicated an unidentified staff member heard an alarm sound and went to check. Resident 1 was found sitting on the floor near her bed, with no complaint of pain, and was assisted to wheelchair. A review of another SBAR form, dated 9/9/17, indicated Resident 1 had a fall with a skin tear to her right elbow. The SBAR indicated the resident had a prior fall and included no explanation of the current incident: where it occurred, what time, who found the resident, why she fell . The primary care physician was contacted at 4 a.m., and provided new orders to treat the skin tear. A review of the third SBAR form, dated 9/22/17, indicated Resident 1 suffered a fall that night. The SBAR was not completed and included no further information regarding the incident. A document titled, Unusual Occurrence, dated 9/24/17 indicated: Incident: Fall With Injury. On 9/23/17, at approximately 6:35 a.m., RNA (Restorative Nursing Assistant) responded to noise coming from Room 34. Resident 1 was found sitting on the floor near her bed (bed was in low position). Resident was assisted to her wheelchair and complained of left leg pain. The MD and family were notified. The MD ordered Resident 1 transferred to the general acute care hospital. During an interview with the Director of Nursing (DON), on 10/10/17, at 1:50 p.m., she stated Resident 1 was admitted from an assisted living facility after she had a fall with a fracture there. The DON stated, on 9/23/17, at 6:30 a.m., Resident 1 was found on the floor beside her bed, sitting on the floor mat. She stated the resident had dementia and was confused as to why she fell . Resident 1 was not in pain at first but eventually complained of leg pain and was transferred to the general acute care hospital emergency room . The DON reviewed the resident's clinical record and provided copies of all the resident's care plans for falls. The DON could not explain why the care plans were not revised after Resident 1's first two falls. When asked what was the importance of revising the care plan after the first two falls, the DON stated the facility could have provided interventions such as moving the resident to a room closer to the nurse's station and reviewing her medications to try and prevent further falls. During an interview with Family Member 1 (FM 1), on 10/10/17, at 2:15 p.m., she stated resident was doing well after surgery and when the resident arrived at the facility, staff knew she was a fall risk. FM 1 stated Resident 1 fell out of her bed the very first morning she was there, and then had a second fall from bed, there were no serious injuries both times. During an interview with Certified Nurse Aide 1 (CNA 1), on 10/10/17, at 2:20 p.m., she stated (on 9/23/15 at around 6:30 a.m.), she passed by Resident 1's room and saw the resident sitting on the floor. CNA 1 stated there was no noise from the room, the call light was not on, the bed alarm was not ringing, no noise at all. She stated she called for assistance and the nurse came from the station and took care of Resident 1 and CNA 1 left the room. On 12/21/17, at 2:20 p.m., during an interview, Registered Nurse 1 (RN 1) stated she was at the nurse's station and heard loud voices from Resident 1's room. RN 1 stated she assessed Resident 1 and put her in a chair. After a while, the resident complained of leg pain and the physician was notified. During an interview with the current DON (DON 2), on 12/21/17, at 1:30 p.m., when asked who was responsible for revising residents' care plans, she stated ideally the RN on the floor would make changes to the care plan. DON 2 stated the facility held high risk meetings for residents who were considered high risk for falls or weight loss. A review of the history and physical examination [REDACTED]. Imaging done in the emergency room demonstrated a new fracture of the intertrochanteric left femoral neck (where the hip meets the upper leg bone) in the setting of an old healed fracture, suffered in a fall in July 2017. The history and physical examination [REDACTED]. A review of the operative report, dated 9/24/17, indicated under general anesthesia, hardware and three screws were removed from Resident 1's left hip area and open reduction/internal fixation of the left hip fracture with a cephalomedullary device was performed. A review of the facility's policy and procedure titled, Slip, Trip and Fall Prevention Policy and Procedures, dated 5/1/17, indicated resident assessments were done upon admission and periodically thereafter to identify the most appropriate and safest transfer protocol and any other special mobility needs. The facility's policy and procedure titled, Process for Care Plan Development and Communication, dated 9/25/14, indicated each facility shall follow a care planning process to ensure timely development and updating of the residents' plan of care. The facility must develop a plan of care specific to each resident which helps to attain or maintain the residents' highest practical level of function. The resident care plan shall identify the residents' needs, problems, strengths, risk factors, and measurable goals. The facility policy indicated the care plan should be viewed as a work in progress and changes made as the residents' needs change. The care plan will include interventions designed to assist the residents to meet their goals. The care plan will be reviewed at re-admission, with a change in condition, and no less than every 90 days.

Based on observation, interview, and record review, the facility failed to prevent dehydration (a condition in which the total body's fluid volume is reduced due to insufficient fluid consumption) and associated health problems, such as severe weight loss and urinary tract infection, for six out of 25 sample residents (2, 8, 9, 11,13, 25) by failing to: 1. Provide adequate fluids as assessed by the registered dietician and as directed by the physician to residents assessed at risk for dehydration. 2. Monitor residents' hydration status, including those on fluid restrictions, by means of an intake and output (I&O) record as indicated in the facility's policy and procedures to assure the resident consumed the volume of fluids indicated in the nutritional assessment and as directed by the physician. 3. Ensure staff assisted residents with hydration consumption for those residents unable to access fluids independently, including having adequate fluids at the bedside. 4. Monitor residents' health conditions and dehydration-associated indicators, such as abnormal laboratory test results, weight loss, skin conditions, urinary tract infection [MEDICAL CONDITION], and falls, and provide timely interventions to correct the reduction or depletion of fluid volume accordingly. These violations resulted in dehydration and associated health conditions that included falls, weight loss, and UTIs. On March 24, 2016, at 11:56 a.m., the facility administrator and director of nursing (DON) were verbally notified of the immediate jeopardy (IJ) situation regarding the failure to provide adequate nutrition and hydration resulting in dehydration, severe weight loss, abnormal lab values, and associated falls resulting in injuries. The facility provided an acceptable immediate plan of action on March 24, 2016, at 6: 00 p.m The remedy for the abatement of the IJ included the following: clinical reassessment of all the identified residents; repeat laboratory values to assess hydration status and need for additional fluids; revision of plans of care. Other residents who were identified at being at risk of dehydration were also reassessed, and plans of care revised. The facility implemented and revised the facility hydration program including water station, fluid pass with snacks, additional fluids on the food tray, infused water flavors, ice chests at each nurses station and reeducation of all certified nursing assistants (CNAs) and licensed nurses on hydration/fluid management, intake measurements for facility containers; and compliance with the plan of correction will be reported to the Quality Assurance Performance Improvement (QAPI) committee. On March 25, 2016, at 3:30 p.m., the Immediate Jeopardy was lifted in the presence of the administrator and the DON. Findings: a. A review of the history and physical (Consultation Report) from the general acute care hospital dated May 9, 2015, indicated Resident 2 had a left dominant hand with the mental capacity of a nine year old. According to the skilled nursing facility record indicated he was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment and care screening tool), dated May 21, 2015, indicated Resident 2 required extensive assistance with eating with one person physical assist, and he was not dehydrated. According to the Registered Dietitian's (RD) initial Nutritional Assessment form dated May 22, 2015, Resident 2 preferred chicken soup at lunch. The RD's Assessment Plan dated May 22, 2015, indicated Resident 2's estimated fluid needs were 2100 cubic centimeters (cc) per day, and his intake was poor. When offered food or drink, Resident 2 became upset. The resident was diagnosed with [REDACTED]. The resident was at risk for decline in nutritional status due to confusion, behavior, and poor intake. The RD's recommendations included feeding by the restorative nursing assistant (RNA), high protein shake three times a day to maintain weight, and monitor intake, lab work, weight, and skin as necessary. A review of Resident 2's physician's orders [REDACTED]. A review of the SBAR (Situation, Background, Assessment of Appearance, Request) Communication Form dated December 12, 2015, indicated Resident 2 had a change of condition of coughing up dark brown emesis (vomit). A review of the ADLs (Activity of Daily Living) Maintenance with Restorative Program Care Plan dated January 27, 2016, indicated self-care performance deficit due to developmental delay (nine-year old mental capacity), and right arm with deformity. Resident 2 required assistance with transfers, eating, and dressing. The approaches included set up at meal time and encourage to eat; provide fluids at bedside and offer between meals as well as encouraging consumption of fluids on tray; cue (prompt), reorient, supervise as needed, and include the resident in the restorative feeding program (specially designed program to directly assist and encourage residents to eat). A review of the RD's quarterly review note dated February 9, 2016, indicated Resident 2's weight was stable but below the ideal body weight. The resident was also receiving Hi-Pro shakes daily for weight maintenance related to low [MEDICATION NAME] (protein) level. He was able to feed self with an average intake of 90 percent; food preference on file; and the resident prefers to eat in his room or in the dining room; continue with current plan of care. A review of the Resident Care Plan-Nutrition dated February 9, 2016, indicated Resident 2 was at risk related to hip surgery, diabetes mellitus, high blood pressure, [MEDICAL CONDITION] disorder and risk for dehydration. The goal included to consume greater than 75 percent of daily meals. The approach plan included to provide diet as ordered; monitor meal intake and offer substitutes if intake is less than 50 percent or refused; allow enough time to eat and assist to feed as needed; drink all fluids on meal tray; monitor pertinent labs; provide supplements as ordered; monitor skin turgor (skin flexibility used for assessing dehydration), for dry mouth, muscle cramps, and change in mental status; and RNA feeding program. The MDS quarterly assessment dated [DATE], indicated Resident 2's cognitive skills for daily decision making was severely impaired, had presence of mood and behavior symptoms, and required limited assistance for eating with one person physical assist. The resident was frequently incontinent for bowel and bladder. The resident had an impairment on both sides of the upper extremity (arms) and impairment on one side of the lower extremity (legs). The resident was also on a therapeutic diet. Under section J of Other Health Conditions, dehydrated was not marked and assessed. A review of SBAR (Situation, Background, Appearance, and Review and Notify) Communication Form (nursing notes) dated February 25, 2016, indicated Resident 2 had a change of condition with loose stools times two that appeared to be diarrhea. On March 21, 2016, at 12:22 p.m., during an observation, Resident 2 was not present in the dining room for the RNA Feeding Program as indicated in the plan of care. The List of Residents on the RNA Feeding Program did not include Resident 2. A review of the SBAR Communication Form dated March 22, 2016, indicated Resident 2 had a low intake for breakfast and dinner. A review of the intake and output (I/O Chart Detail Report) form dated March 22, 2016, indicated Resident 2 did not have any food intake due to refusal of breakfast and lunch. There was no documentation as to why the resident refused; no substitute was offered as indicated in the plan of care. On March 22, 2016, at 5:15 p.m., during an observation of Resident 2's room, there was no water pitcher at the resident's bedside table. At 5:20 p.m. to 6 p.m., Resident 2 was observed up in a wheelchair with a peripheral catheter (inserted into vein in order to administer medication or fluids) on his right upper arm that was wrapped with gauze. A review of Resident 2's I/O Chart Detail Report for fluid intake indicated the following: 1. For January 2016, the resident's estimated total fluid intake ranged from 360 cc to 1920 cc per day. This was an estimated fluid deficit that ranged from 180 cc to 1740 cc per day from the RD's assessed requirement of 2100 cc per day. 2. For February 2016, the resident's estimated total fluid intake ranged from 600 cc to 1980 cc per day. This was an estimated fluid deficit that ranged from 120 cc to 1500 cc per day from the RD's assessed requirement of 2100 cc per day. 3. From March 1 to March 23, 2016, the resident's estimated total fluid intake ranged from 240 cc to 1,810 cc per day. This was an estimated fluid deficit that ranged from 290 cc to 1860 cc per day from the RD's assessed requirement of 2100 cc per day. A review of Resident 2's laboratory reports indicated the following: 1. May 18, 2015 - The BUN (blood, urea, nitrogen) was within normal range of 20 milligrams per deciliter (mg/dL). The reference range is from 7 to 23 mg/dL. The resident's creatinine (by-product of muscle, test that measures kidney function) was in normal range of 0.7 mg/dL. The reference range is from 0.6 to 1.4 mg/dL. 2. June 11, 2015 - The BUN was high at 36 mg/dL, and the creatinine was 0.8 mg/dL (normal). 3. June 15, 2015 - The BUN was high at 29 mg/dL, and the creatinine was 0.8 mg/dL (normal). 4. September 2, 2015 - The BUN was high at 43 mg/dL, and the creatinine was 0.9 mg/dL (normal). 5. October 30, 2015 - The BUN was high at 45 mg/dL, and the creatinine was 0.9 mg/dL (normal). 6. December 12, 2015 - The BUN was high at 57 mg/dL, and the creatinine was 1.1 mg/dL (normal). 7. January 6, 2016 - The BUN was high at 41 mg/dL, and the creatinine was 1.2 mg/dL (normal). The BUN creatinine ratio was high at 34. 8. February 10, 2016 - The BUN was high at 35 mg/dL, and the creatinine was 1 mg/dL (normal). 9. March 9, 2016 - The BUN was high at 49 mg/dL, and the creatinine was 1.3 mg/dL (normal). 10. March 17, 2016 - The BUN was high at 52 mg/dL, and the creatinine was high at 1.7 mg/dL. 11. March 23, 2016 - The BUN was high at 34 mg/dL, and the creatinine was 1.3 mg/dL (normal). 12. March 24, 2016 - The BUN was high at 29 mg/dL, and the creatinine was 1.3 mg/dL (normal). Abnormal laboratory values such as elevated BUN, Creatinine, and Chloride (mineral in the body necessary for nerve and muscle function), are indicators for dehydration. (Centers for Medicaid and Medicare Services (CMS) State Operations Manual, Guidance to Surveyors, Page 222). A review of the Peripheral Catheter - Physician/Licensed Independent Practitioner (LIP) Order Sheet dated March 17, 2016, indicated normal saline (NS) IVF (intravenous fluids) 80 cc per hour for three days for dehydration was administered; continuous infusion, no flushing required. A review of the March 2016 recapitulation of Resident 2's physician's orders [REDACTED]. 1. CNA to provide meal assist as required dated June 5, 2015. 2. Normal saline via intravenous (IV) 80 milliliters per hour (ml/hr) for three days for [DIAGNOSES REDACTED]. On March 18, 2016, the order was changed to run IV fluids from 8 p.m. to 8 a.m. for six days for [DIAGNOSES REDACTED]. A review of documents and interviews with the Director of Nursing (DON) on March 22, 2016, at 6:30 p.m., and March 23, 2016, at 9:45 a.m., indicated the following: the Infusion Medication Administration Record [REDACTED]. On March 20, 2016, the IMAR documentation indicated done. The DON stated the staff missed the physician's orders [REDACTED]. The DON was asked about the inaccuracy of the computer system for documenting fluids, she stated they need to look at the system on how they document fluid intake. She stated the care plan for dehydration should have been updated. The physician's [DIAGNOSES REDACTED]. She stated there was none, and she was not able to provide information as to why the IV fluids were not documented as fluid intake. She agreed that the I/O documentation was inconsistent. Delayed treatment or delayed hydration may lead to acute [MEDICAL CONDITION], which is a sudden decrease in renal function which, if uncorrected, can lead, to irreversible tubular necrosis (kidney failure (American Journal of Nursing, May 1999- Vol. 99-Issue 5 pp. 66-69)). On March 23, 2016, at 10 a.m., during an interview, the Licensed Vocational Nurse (LVN 4), who was also the MDS coordinator, was asked why Resident 2's MDS did not include the assessment of dehydration. She was not able to explain why dehydration was not included in the MDS dated [DATE], even though he had been diagnosed as dehydrated previously. A Risk for Dehydration Care Plan was created on March 23, 2016, indicating Resident 2's potential for dehydration due to cognitive and communication deficits, potential for fluid imbalance, diabetes mellitus type II and developmental delay. The goal was for the resident to be free from signs and symptoms of dehydration for 90 days. The approaches included were if a resident has infection, fever, vomiting, diarrhea, nausea, and excessive sweating, evaluate for dehydration. Assess skin turgor and oral mucous membranes. Assess concentration and color of urine. Monitor laboratories (labs) and report to the physician as appropriate. Keep fluids at bedside and offer between meals. Encourage resident to drink all of the beverages on tray. Give extra fluids with meals. Resident drinks water when offered. Needs reminding for hydration. On March 24, 2016, at 3:47 p.m., an interview and record review was conducted with the director of nursing (DON) and Administrator. Resident 2's I/O forms from January 2016 to March 2016, indicated the percentage of the meal intake was documented inaccurately as the upper percentage (%). For example, if 51% was consumed, the computer reflected 75% consumed. When asked why the computer system reflects the upper limit for intake rather than the actual intake, and the inaccuracy of the fluids, they were not able to provide an explanation other than the computer system does it automatically. The DON stated the I/O documentation was inconsistent. The facility's policy and procedure titled Hydration/Fluid Management dated January 5, 2011, indicated hydration management is the promotion of adequate fluid balance that prevents complications resulting from abnormal or undesired fluid levels. Residents will be monitored for physical signs of dehydration (such as sunken eyeballs, concentrated urine, poor skin turgor, etc.) and excess fluid retention. Residents will be provided with fluids daily (fluids on trays, water at bedside) to meet fluid needs, unless a fluid restriction is ordered by the physician. Fluid intake includes all fluids entering the resident's body, including beverages, and foods that are liquid at room temperature, such as flavored gelatin, custard and ice cream. Additional intake includes enteral/[MEDICATION NAME] feeding and IV fluids. Each resident's hydration/fluid needs will be determined by the nutritional professional upon admission. Fluid will be offered to each resident during, in-between meals and during activities (unless contraindicated). The resident's beverage preference will be identified and provided to the resident. If the resident refuses water, alternative acceptable fluids will be offered. Fresh water and ice will be maintained at the bedside unless contraindicated such as thickened liquids, fluid restrictions. Determine if the resident's nutritional review and MDS identify conditions that may put the resident at risk for dehydration. The care plan interventions related to proper hydration are developed according to the resident's needs. Observe fluids being provided to the resident to determine if the interventions identified in the care plan have been implemented. The physician is to be notified when there is a significant change in the resident's fluid intake or output. Intake and output measurement should be considered for residents according to the following (or as required by specific state regulations) that included residents receiving intravenous therapy for the duration of treatment. During each shift, measure fluid taken in by the resident. Under documentation guidelines, any resident placed on an input and output (I&O) monitoring will have documentation in the progress notes at the initiation of the I&O monitoring and the care plan will be updated to reflect interventions. 24-hour totals of fluid intake and output are calculated each day on the Intake and Output Record or in your electronic system (such as care tracker). In the progress note, record significant variations and notification of physician, response, and interventions implemented. Cross Refer to F309. b. According to the admission record, Resident 9 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. in daily functioning), and hypertension (high blood pressure). Resident 9 was readmitted on [DATE], with additional [DIAGNOSES REDACTED]. A review of the registered dietitian's (RD) nutritional assessment dated [DATE], indicated Resident 9's fluid requirements were 1900 cubic centimeters (cc). Resident 9 required 1430 calories and 76 to 95 grams of protein per day. The Minimum Data Set (MDS-a standardized comprehensive assessment of the resident's problems and conditions) dated October 27, 2015, indicated Resident 9's cognitive patterns were severely impaired and required extensive assistance from staff members for eating. The MDS indicated the resident was always incontinent of bowel, had an indwelling urinary catheter (tube inserted into the bladder to drain urine). A review of the vital signs and weight record, indicated Resident 9 weighed 194 pounds on October 20, 2015, and 156 pounds on December 22, 2015. Resident 9 lost 38 pounds in two months, or 19.6 percent (%), which is considered a severe weight loss and an indicator of severe dehydration. A review of Resident 9's care plan for dehydration dated October 21, 2015, indicated a potential for dehydration related to history of poor oral intake and the resident required assistance with eating. The goal of the care plan was for the resident to drink an adequate amount of fluids throughout the day. The care plan did not indicate the volume of fluids the resident required as assessed by the RD, and did not identify the resident's fluid preferences. The interventions included to monitor for decreased appetite, decreased fluid intake, decreased urinary output, monitor intake and output (I&O), encourage fluid intake with medication pass/snacks, provide fluids based on resident choice per interview, and dietary consult. On March 22, 2016, at 3:15 p.m., Resident 9's I&O record was reviewed with the evening registered nurse (RN 3). The time period was from October 28, 2015, to December 28, 2015, which indicated Resident 9 consumed an average of 891.1 cc of fluids per day; had an average urine output of 1255.5 cc per day; and had an average meal intake of 65.6 % per day, according to the I&O report (breakfast, lunch, and dinner). The record indicated Resident 9's fluid consumption was 1009 cc less than the required (1900 minus 891.1 = 1009) volume per day as assessed by the RD. Resident 9's daily output exceeded the volume of fluid intake. RN 3 stated the amount of fluid intake on the I&O record was not accurate, and did not include other fluids offered. She could not provide any other documentation to indicate Resident 9 received other fluids. During the same period of October 28, 2015, to December 28, 2015, Resident 9 lost 38 pounds. This was a weight loss of 19.6 percent. According to the State Operation Manual (SOM) a weight loss greater than 10 percent is an indicator for severe dehydration (SOM Page 366). A review of Resident 9's laboratory test results dated December 8, 2015, indicated the following: 1. An elevated level of blood urea nitrogen (BUN) of 24 mg/dL (milligrams per deciliter- reference range 5-20 mg/dL). BUN is a normal waste product in the blood that results from the breakdown of protein; it is normally removed from the blood by the kidneys, but when kidney function slows down, the BUN level rises. 2. A Creatinine (Cr) of 1.1 mg/dL (reference range 0.6-1.4). Cr is a waste product in the blood that comes from muscle activity. The BUN/Cr Ratio was 22. (A BUN/Cr ratio of 20:1 to 24:1 is an indicator for impending dehydration. A BUN/Cr ratio greater than or equal to 25:1 mg/dL is an indicator for actual dehydration (American Journal of Nursing June 2006, Volume 106, Number 6, Page 47)). 3. An elevated level of serum sodium of 150 mEq/L (milliequivalent per liter- reference range 135-145 mEq/L). An elevated serum sodium of greater than 150 mEq/L is an indicator for dehydration. A review of Resident 9's Medicare Daily Skilled Nursing Note dated December 8, 2015, indicated the Physician's Assistant was notified of the abnormal laboratory results, and an order to encourage fluids was obtained. A review of the interdisciplinary team (IDT) notes dated December 8, 2015, indicated that the team which included the nursing staff discussed the lab results from December 8, 2015 that showed Resident 9's elevated Sodium and BUN levels. The IDT notes indicated that the current care plan was to be followed and no new interventions were discussed. On March 22, 2016, at 11:45 a.m., during an interview the Director of Nursing (DON) was asked why Resident 9's fluid requirements were not met as specified in the nutritional assessment. The DON stated the facility staff members only record fluids consumed by the resident during meals; the fluid given during medication pass, activity sessions, and snacks were not included in the record. The DON stated Resident 9 didn't require strict I&O. A review of the facility's policy titled Hydration/Fluid Management, revised January 5, 2011, indicated I&O measurements should be considered for a catheterized resident (or as required by specific state regulation). The state regulation, Title 22, (j)(2), requires fluid intake and output shall be recorded for all residents with an indwelling catheter. On March 22, 2016 at 2:15 p.m., during an interview, the RD was asked how the facility ensures a resident gets the required fluids to prevent dehydration. The RD stated there is lack of accurate monitoring of fluids. She also stated she is not sure how staff record the fluid in jello, milk, and high protein shakes. A review of Medicare Daily Skilled Nursing Note dated December 28, 2015, at 12:45 a.m., indicated Resident 9 was observed lethargic but responsive to verbal stimuli. At 6:45 a.m., an order to transfer Resident 9 to the general acute care hospital (GACH) was obtained. The resident was transferred by Emergency Technicians (EMT) and admitted to the hospital. According to the GACH history and physical examination [REDACTED]. The H&P indicated Resident 9 had an elevated blood urea nitrogen (BUN) of 29 mg/dL (reference range 7-17 mg/dL), Creatinine of 1.5 mg/dL (reference range 0.6-1.0 mg/dL), and Sodium of 168 mEq/L (reference range 135-146 mEq/L). Resident 9 was treated with intravenous (via vein) fluid therapy, blood transfusion, and IV antibiotics. According to the facility's readmission record, Resident 9 was hospitalized for [REDACTED]. Resident 9 had [DIAGNOSES REDACTED]. c. Resident 8 was admitted to the facility on [DATE]. Resident 8's current [DIAGNOSES REDACTED]. A review of clinical records showed that Resident 8 was on intravenous (IV) fluid therapy on March 17, 2016. The rationale and/or [DIAGNOSES REDACTED]. The pharmacy document indicated for BUN of 31 (reference range is 7-23 mg/dl), and SCr (serum creatinine) of 1.5 (reference range is 0.6 to 1.4 mg/dl). Elevated BUN/Cr provides more precise information about kidney function and its underlying cause. In cases of dehydration, BUN may rise in a higher proportion than creatinine (Webmd.com). This was the case with Resident 8. A review of the clinical record showed that Resident 8's medications included [MEDICATION NAME] (medication that increases urine output), for her high blood pressure. (A serious side effect of [MEDICATION NAME] is dehydration. This could be worsened if adequate fluids are not consumed). Resident 8 was also diagnosed with [REDACTED]. A review of her most recent Minimum Data Set (MDS- a standardized comprehensive assessment and screening tool) dated January 16, 2016, indicated Resident 8 was assessed as needing supervision such as oversight, encouragement, or cueing for eating. On March 22, 2016, at 8:23 a.m., Resident 8 was observed lying in bed with her breakfast tray untouched. Resident 8 was asked why she was not eating but she did not respond. The Certified Nursing Assistant 6 (CNA 6) who was providing care for Resident 9 (roommate of Resident 8) was interviewed as to what type of assistance Resident 8 required with meals. CNA 4, who was next door, overheard the conversation and explained that Resident 8 was independent; she can eat herself. CNA 4 stated he would get help to assist Resident 8, as he was not assigned to her. A review of the clinical record indicated Resident 8 ate 30 percent of her lunch meal, including 160 cc fluids. At 2:15 p.m., Resident 8 was observed lying in bed. She was moving her tongue from one corner of her mouth to the other. Resident 8 was asked if she would like to drink anything. She responded yes. A look around the room did not show the presence of a water pitcher on her tray table. There was an empty grey water pitcher out of her reach. CNA 3 came into Resident 8's room at 2:17 p.m., and stated in an interview that Resident 8 did not like the grey pitcher and did not like water; she preferred ice tea and would fill her cup or bottle in the dining room. There was a stained, dirty red sports bottle half full of a dark colored liquid. CNA 3 stated she would get the bottle cleaned and filled with ice tea. After Resident 8 was offered the clean bottle of ice tea, she took a long sip, looked up and smiled. On March 22, 2016 at 5:15 p.m., Resident 8 was observed in bed with an IV in her arm. A review of the clinical record showed the Peripheral Catheter-Physician/Licensed Independent Practitioner (LIP) Order Sheet dated 3/22 indicated IV therapy had been ordered for Resident 8. The Facility Director of Nursing (DON) was interviewed at 5:54 p.m. on why Resident 8 was being administered IV fluid. The DON said an IV was inserted because the resident wasn't eating. On March 25, 2016, at 12:20 p.m., in an interview with the Physician (MD 2), who was responsible for Resident 8's care, he stated the facility staff had told him Resident 8 was not eating, getting dehydrated, and had urinary tract infections; that was why the issue of [DEVICE] placement was recommended and IV placement was administered two times within 5 days. He stated he was not aware the resident was not assisted with her meals or not being offered adequate fluids. d. A review of the general acute care hospital (GACH) History & Physical report dated March 13, 2016, indicated Resident 25 was admitted for a stroke, and had a urinary tract infection. He was newly admitted to the skilled nursing facility (SNF) on March 17, 2016, with [DIAGNOSES REDACTED]. A review of the vital signs and weight record dated March 17, 2016, indicated Resident 25 was 6 feet tall and weighed 204 pounds (= 92.5 Kg). The Miniumum Data Set (a standardized, comprehensive assessment and screening tool), was still in process of being completed. There had not been a nutritional assessment as of March 24, 2016, to indicate Resident 25's fluid needs. According to the State Operations Manual ((SOM), October 2010, page 331), a general guideline for determining baseline daily fluids needs is to multiply the resident's body weight in kilogram (Kg) times 30 cubic centimeters (cc). Based on this guideline, Resident 25's total daily requirement of fluids to be adequate was 2875 cc (92.5 Kg multiply by 30 cc=2875 cc). According to the History and Physical (H & P) dated March 18, 2016, Resident 25 was alert and oriented to time, place, person, and situation/event. A review of Resident 25's clinical records from March 17, 2016 to March 24, 2016, indicated there were no records of the following: 1. Assessment and identification of dehydration risk factors in accordance with the facility's policy. 2. Monitoring of vital signs for 72 hours upon admission per physician's orders [REDACTED]. 3. Development of an immediate care plan for assisting the resident with meals and fluids because of his right-sided weakness after his stroke on March 12, 2016. A review of Resident 25's Intake and Output (I&O) Flow Sheet Record from March 18, 2016 to March 23, 2016, and (SOM) calculation of estimated fluids required, Resident 25 received less fluid intake than required as follows: 1. On March 18, 2016, Resident 25's total fluid intake within a 24-hour period was 1080 cc; the output section was left blank. Resident 25's fluid intake was less than the required volume by 1795 cc (2875 -1080 =1795 cc). 2. On March 19, 20

Based on observation, interview, and record review, the facility failed to prevent neglect and misappropriation of properties for 3 of 25 sample residents (Residents 2, 20, and 18 ) by failing to: 1. Assess, monitor, and manage Resident 2's abdominal pain, which he complained about for three days. He was sent to the hospital and was diagnosed with [REDACTED]. This deficient practice resulted in repeated neglect of a resident who suffered in pain and whose medical care had been delayed. 2. Respond to Resident 20's call light, who had been calling and waiting for staff for three hours to clean and change his [MEDICAL CONDITION] (surgical opening is formed by drawing the healthy end of the large intestine or colon through an incision in the abdominal wall (stoma), providing an alternative channel for feces to leave the body) bag (applied over the stoma to collect gas and feces), when it burst. The feces spilled all over the resident creating a foul-smelling odor. The resident didn't get help until his roommate, who was in wheelchair and couldn't stand the foul odor, went for help. This deficient practice created an undignified and humiliating situation of lying in one's own feces for an extended time. 3. Provide documentation of disposal of belongings of a resident who passed away that had a potential for misappropriation of property (Resident 18). Findings: a. A review of the history and physical (Consultation Report) from the general acute care hospital (GACH) dated [DATE], indicated Resident 2 had the mental capacity of a nine year old. He was admitted to the skilled nursing facility on [DATE], with [DIAGNOSES REDACTED]. The Resident Pain Review Tool dated February 9, 2016, indicated the facility used a zero to ten numeric rating scale (zero corresponded to no pain and 10 to worst pain imaginable). The section for Resident 2's acceptable level of pain was blank. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 2's skills for daily decision making was severely impaired, needed extensive assistance for transfer, dressing, toilet use, and personal hygiene. The resident was frequently incontinent of bowel and bladder and did not have presence of pain. A review of the Licensed Personnel Progress Notes indicated the following: 1. February 28, 2016 - Resident 2 had loose stools that are foul smelling. 2. [DATE] - Resident 2 complained of stomach discomfort. Received order for [MEDICATION NAME] 30 cubic centimeters (cc) p.o. (by mouth) every four hours PRN (as needed). 3. [DATE] - Resident 2 complained of stomach /gas pain. Contacted the physician assistant (PA). New orders for [MEDICATION NAME] 80 milligrams (mg). p.o. TID (three times a day) and hours of sleep (HS) for one week. Positive bowel sounds in all four quadrants. The abdomen is soft and non-distended, continue to monitor. A review of the Medicare Daily Skilled Nursing Note dated [DATE], indicated there was no documentation regarding Resident 2's abdominal pain; [DATE], did not indicate Resident 2's abdominal pain. Observation of Resident 2 for three days from [DATE] to [DATE], at different locations of the facility at different times of the day, he roams around the facility in his wheelchair by himself. Resident 2 was observed with facial grimacing, massaging his stomach when asked for the location of the pain. He was able to verbalize abdominal pain to several staff members repeatedly. He appeared anxious, and kept telling different and multiple staff members about his pain. He entered the room where the Surveyors were meeting on several occasions to complaint about his pain. He addressed Surveyors out in the open as he wheeled around the facility, to complain about his pain. He was observed begging for medication for his abdominal pain. Most of the time the facility staff members would divert the attention of the resident, would not respond to his needs, or would turn his wheelchair in a different direction. A review of Resident 2's physician's orders [REDACTED]. 1. Assess pain level from zero to 10 every shift. Medicate as needed and notify the physician if ineffective. Every shift: 11 p.m. to 7 a.m., 7 a.m. to 3 p.m., 3 p.m. to 11 a.m. dated [DATE]. 2. Tylenol 325 milligrams (mg) two tablets by mouth every 4 hours as needed (PRN) for pain dated [DATE]. 3. [MEDICATION NAME] 30 cc p.o. (by mouth) every four hours PRN (as necessary) for stomach upset dated [DATE]. 4. [MEDICATION NAME] 80 mg p.o. TID (three times a day) and HS (hour of sleep) for one week for gas dated [DATE]. A review of Resident 2's Medications Flowsheet dated [DATE], indicated the following: 1. [MEDICATION NAME] was administered on [DATE], and 22, 2016. There was no documentation on the assessment for the effectiveness of [MEDICATION NAME] after it was administered. 2. There was no indication Tylenol was administered for pain from [DATE], to [DATE]. 3. The pain level assessment for [DATE] and [DATE], 11 p.m. to 7 a.m. shift, indicated zero pain level. There was no documented evidence of a pain assessment for 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. shift on [DATE], or [DATE]. There was a blank space on the areas where the pain level was supposed to be documented. 4. [MEDICATION NAME] was administered as ordered by the physician. A review of the care plans developed for Resident 2, indicated there was no documented evidence that a care plan was developed to address the resident's abdominal pain. On [DATE], at 10:50 a.m., during an interview with Resident 2, while holding his stomach he stated that his stomach hurts. When asked what pain level he had, he was not able to tell. Instead, he walked away and told the other staff members regarding his pain, who redirected him and did not address his pain. On [DATE], at 2:30 p.m., during an observation and interview with Resident 2, he had facial grimacing, was anxious, and stated he had stomach pain. When asked what was the pain like, he stated it was like cramps and demonstrated making a claw-like movement with his fingers half open and half closed. He asked the Surveyor for pain medication for his stomach. When asked what his pain level was, he stated nothing happens. He walked away and told his concerns to other staff members in the hallway; no one addressed his stomach pain but instead redirected him. A review of the Licensed Personnel Progress Notes dated [DATE], at 10:30 a.m. indicated there was no documentation that Resident 2's stomach pain was addressed and acted upon by the facility's staff members. A review of the Licensed Personnel Progress Notes dated [DATE], 9 p.m. entry, indicated Resident 2 complained of a pain level of seven out of 10 at 6 p.m. The PRN medication sheet indicated [MEDICATION NAME] (for pain) PRN (for both knee pain) was given. Pain was assessed at three out of 10 at 7 p.m. The notes also indicated orders for BMP (basic metabolic panel - lab tests) to be done in the a.m. A review of the correlating Resident Pain Review Tool did not indicate what Resident 2's acceptable level of pain was, it was blank. On [DATE], at 9:35 a.m., during an interview with Resident 2, he stated he still had stomach pain. He was unable to tell his pain level. He stated nothing happens. When asked what he meant, he was not able to elaborate. He asked for pain medication. A review of the Licensed Personnel Progress Notes dated [DATE], at 9:50 a.m., indicated Resident 2 had cramps in the abdomen. He was asked when his last bowel movement was, and he said yesterday. He reported cramps not resolved. A message was left for the physician to ask for KUB (kidney, ureter, bladder - lab tests) to evaluate the resident's abdominal pain. There was no documentation that the physician was notified of Resident 2's unrelieved pain prior to this time. On [DATE], at 10:35 a.m., during an interview with the Director of Nursing (DON), she was unable to provide an explanation as to why Resident 2's unrelieved pain was not addressed by the licensed nurses or reported to the physician until the third day of his complaints. The DON could not provide documented evidence that Resident's 2 pain level was assessed per shift as ordered by the physician. A review of the Final X-ray Report for portable KUB dated [DATE], indicated there was no evidence for obstruction, however, fecal loading was seen in the large bowel. A review of the GACH's Procedures and Tests dated [DATE], indicated Resident 2 was examined for abdominal pain. The CT (computed tomography, a special x-ray) scan of the abdomen and the pelvis indicated cholelithiasis (frequently known as gall-stones). The facility's policy and procedure titled Abuse Prohibition And Prevention Program dated [DATE], indicated every resident has the right to be free from neglect and mental abuse. The facility will take reasonable, appropriate steps to ensure that each resident is free from neglect and abuse by anyone, including but not limited to staff . The policy's definition of abuse included the willful infliction of physical or psychological injury, pain, mental anguish, or deprivation. Neglect was defined as the failure of a caregiver to provide the goods or services that are necessary to maintain the health or safety of an elder, or the failure to provide goods and services necessary to avoid physical harm or mental harm, or mental illness. Cross Refer to F309 b. According to the admission record, Resident 20 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 20's Physician order [REDACTED]. A review of Resident 20's care plan dated [DATE], for a [MEDICAL CONDITION] had a goal that included for the resident to be clean as demonstrated by no body odor. The approach included to change [MEDICAL CONDITION] bag (covers the stoma for feces collection) PRN (as necessary), [MEDICAL CONDITION] care every shift and PRN, and provide cheerful dialogue while rendering care. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 20's cognitive patterns were intact, he required limited assistance from staff members for transfers and personal hygiene, and needed extensive assistance for toilet use. The resident used a walker and a wheelchair for mobility devices. The resident was occasionally incontinent of urine and had a [MEDICAL CONDITION] for bowel incontinence. A review of the Treatment Flowsheet indicated [MEDICAL CONDITION] care was not provided every shift as ordered. For example: On [DATE] - There were no signatures in the 11 p.m. to 7 a.m. shift for 10 days out of 31 days and no signatures in the 3 p.m. to 11 p.m. shift for 15 out of 31 days. On February 2016 - There were no signatures in the 11 p.m. to 7 a.m. shift for six out of 29 days and no signatures in the 3 p.m. to 11 p.m. shift for six out of 29 days. On [DATE] - There were no signatures in the 11 p.m. to 7 a.m. shift for five out of 31 days. There were no signatures in the 3 p.m. to 11 p.m. shift for six out of 31 days. On [DATE], at 11:10 a.m., during an interview with Licensed Vocational Nurse 8 (LVN 8), she stated the call light should be answered in less than 10 minutes. On [DATE], at 2 p.m., during an observation and interview of Resident 22 (roommate of Resident 20), he was able to get out of bed by himself in the wheelchair. When asked how long he waited for the staff members to respond to the call light, he stated from 45 minutes to one hour, but it was especially worse at night. He stated his roommate (Resident 20) puts his urinal on his table, then he pulls his call light on. He then asks him to find somebody to help him. On [DATE], at 2:50 p.m., during an observation of and interview with Resident 20, he was lying in bed, alert, awake, and oriented to person, place, and time. His [MEDICAL CONDITION] bag was had fecal material in it, and was almost full (past half of the [MEDICAL CONDITION] bag) of air. When asked about staff response, he stated that the average waiting time usually was between 45 minutes to one hour on all shifts. When asked how he felt about this, he stated in a very angry voice, I am pissed off. He stated he tells them and still they do not respond. He stated the waiting time to get help is more at night. There was one time at night that he had to wait for three hours and a couple of times for about two hours. He stated, I have to stay in my bed with s--t all over the place. If not for my roommate, I will be dead. He calls outside the room for help. I press the call light, they do not come. I smelled so bad. You can ask him. He is my witness. On [DATE], between 3:15 p.m. to 3:20 p.m., an observation and interview with Resident 22, Resident 20's roommate, was conducted. He was awake, alert, and oriented to person, place, and time. He was sitting in his wheelchair, able to wheel himself. He stated that he had to ask for help for his roommate. Sometimes, he had to press the call light for Resident 20, and stated the staff members do not come. If they come, they walk away. He stated, I cannot stand the smell of the s--t. It stinks the whole room. On [DATE], at 3:25 p.m., during an interview with the Director of Nursing (DON), she stated the [MEDICAL CONDITION] bag is supposed to be changed by the nurses, and the call lights should be answered (timely). The facility's policy and procedure titled [MEDICAL CONDITION] and [MEDICAL CONDITION] Care dated [DATE], indicated a [MEDICAL CONDITION] bag or [MEDICAL CONDITION] is an external pouch worn to collect emerging fecal matter, control odor, and to protect the stoma and [MEDICATION NAME] skin. Most disposable pouching systems can be used from two to seven days. Any system needs immediate changing if leaks develop and should be emptied when it is one-third to one-half full. A nurse performs this procedure. A review of another facility's policy and procedure titled Answering Call Lights dated [DATE], indicated to respond to resident's call lights in a timely manner. Answer emergency lights immediately. Turn off the call light in the room so that others will know it is answered. Complete (if able) the task the resident/family requests. The facility's policy and procedure titled Abuse Prohibition And Prevention Program dated [DATE], indicated every resident has the right to be free from neglect and mental abuse. The facility will take reasonable, appropriate steps to ensure that each resident is free from neglect and abuse by anyone, including but not limited to staff . The policy's definition of abuse included the willful infliction of physical or psychological injury, pain, mental anguish, or deprivation. Neglect was defined as the failure of a caregiver to provide the goods or services that are necessary to maintain the health or safety of an elder, or the failure to provide goods and services necessary to avoid physical harm or mental harm, or mental illness. c. On [DATE], a review of a closed record (a discharged resident) indicated Resident 18 was originally admitted on [DATE], and expired on [DATE]. A review of Resident 18's clothing and possessions form revealed the resident and facility representative signed and dated on [DATE], for the inventory taken on admission. However, the portion of the form to be filled out upon discharge was blank. At 4 p.m., the Social Service Director (SSD) presented a binder titled Residents' discharge belongings log. During a concurrent interview, the SSD confirmed that there was no record that the possessions of Resident18 had been returned to the family upon his death. At 4:20 p.m., the SSD confirmed that the Resident Storage log did not contain a record of the possessions for Resident18. A review of the undated facility policy & procedure, titled Facility criteria for the retention of personal possessions did not reveal a policy or procedure to return resident's possessions upon discharge.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for 6 of 25 sample residents (Residents 2, 6, 8, 13, 25, 9), by failing to: 1a. Assess, monitor, and manage a resident's abdominal pain, which he complained about for three days. He was sent to the hospital and was diagnosed with [REDACTED]. This deficient practice resulted in prolonged pain and suffering, and a delay in medical care (Resident 2). 1b. Effectively manage pain for Resident 9, who was cognitively impaired and had dementia by not assessing the need for pain medication before a treatment and a dressing change for a Stage 4 pressure ulcer in the coccyx (a bone at the base of the spinal column),area. 2. Ensure a residents blood sugar levels were closely monitored and effectively managed as ordered by the physician, to prevent [DIAGNOSES REDACTED] (low blood sugar), for 4 of 25 sample residents (Residents 2, 6, 8, and 25). This deficient practice resulted in Resident 25's transfer to the general acute care hospital (GACH) due to low blood sugar level of 24 milligrams per deciliter (mg/dl), and had the potential to result in uncontrolled blood sugar levels that may lead to a diabetic coma for residents. 3. Assess and monitor a resident's vascular access site (vein access) used for [MEDICAL TREATMENT] (procedure to removed waste products from the blood), and communicate to the [MEDICAL TREATMENT] center pre-[MEDICAL TREATMENT] assessment information (Resident 13). This deficient practice had the potential to result in for complications during or after [MEDICAL TREATMENT] treatment. Findings: a.1. According to the admission record, Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the history and physical (Consultation Report) from the GACH dated May 9, 2015, indicated Resident 2 had a left dominant hand with the mental capacity of a nine year old. The Resident Pain Review Tool dated February 9, 2016, indicated the facility used a zero to ten numeric rating scale (zero corresponded to no pain and 10 to worst pain imaginable). The section for Resident 2's acceptable level of pain was blank. The Minimum Data Set (MDS - an assessment and care screening tool), dated February 11, 2016, indicated Resident 2's skills for daily decision making was severely impaired, needed extensive assistance for transfer, dressing, toilet use, and personal hygiene. The resident was frequently incontinent of bowel and bladder and did not have presence of pain. A review of the Licensed Personnel Progress Notes indicated the following: 1. February 28, 2016 - Resident 2 had loose stools that are foul smelling. 2. March 1, 2016 - Resident 2 complained of stomach discomfort. Received order for [MEDICATION NAME] 30 cubic centimeters (cc) p.o. (by mouth) every four hours PRN (as needed). 3. March 16, 2016 - Resident 2 complained of stomach /gas pain. Contacted the physician assistant (PA). New orders for [MEDICATION NAME] 80 milligrams (mg). p.o. TID (three times a day) and hours of sleep (HS) for one week. Positive bowel sounds in all four quadrants. The abdomen is soft and non-distended, continue to monitor. A review of the Medicare Daily Skilled Nursing Note dated March 17, 2016, indicated there was no documentation regarding Resident 2's abdominal pain; March 21, 2016, did not indicate Resident 2's abdominal pain. During observation of Resident 2 for three days from March 21, 2016 to March 23, 2016, at different locations of the facility, at different times of the day, the resident roamed around the facility in his wheelchair by himself. Resident 2 was observed with facial grimacing, massaging his stomach and when asked for the location of the pain, the resident was able to verbalize abdominal pain to several staff members repeatedly, was anxious, and kept telling different and multiple staff members about his pain. He entered the room where the Surveyors were meeting on several occasions, and addressed Surveyors out in the open as he wheeled around the facility, to complain about his pain. He was observed begging for medication for his abdominal pain. Most of the time the facility staff members would divert the attention of the resident, would not respond to his needs, or would turn his wheelchair in a different direction. A review of Resident 2's physician's orders [REDACTED]. 1. Assess pain level from zero to 10 every shift. Medicate as needed and notify the physician if ineffective. Every shift: 11 p.m. to 7 a.m., 7 a.m. to 3 p.m., 3 p.m. to 11 a.m. dated May 14, 2015. 2. Tylenol 325 milligrams (mg) two tablets by mouth every 4 hours as needed (PRN) for pain dated May 14, 2015. 3. [MEDICATION NAME] 30 cc p.o. (by mouth) every four hours PRN (as necessary) for stomach upset dated March 1, 2016. 4. [MEDICATION NAME] 80 mg p.o. TID (three times a day) and HS (hour of sleep) for one week for gas dated March 16, 2016. A review of Resident 2's Medications Flowsheet dated March 2016, indicated the following: 1. [MEDICATION NAME] was administered on March 17, 21, and 22, 2016. There was no documentation on the assessment for the effectiveness of [MEDICATION NAME] after it was administered. 2. There was no indication Tylenol was administered for pain from March 21, 2016, to March 23, 2016. 3. The pain level assessment for March 21, 2016 and March 22, 2016, 11 p.m. to 7 a.m. shift, indicated zero pain level. There was no documented evidence of a pain assessment for 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. shift on March 21, 2016, or March 22, 2016. There was a blank space on the areas where the pain level was supposed to be documented. 4. [MEDICATION NAME] was administered as ordered by the physician. A review of the care plans developed for Resident 2, indicated there was no documented evidence that a care plan was developed to address the resident's abdominal pain. On March 21, 2016, at 10:50 a.m., during an interview with Resident 2, while holding his stomach he stated that his stomach hurts. When asked what pain level he had, he was not able to tell. Instead, he walked away and told the other staff members regarding his pain, who redirected him and did not address his pain. A review of the Medicare Daily Skilled Nursing Note dated March 21, 2016, did not indicate that Resident 2's pain was addressed by the staff member. On March 22, 2016, at 2:30 p.m., during an observation and interview with Resident 2, he had facial grimacing, was anxious, and stated he had stomach pain. When asked what was the pain like, he stated it was like cramps and began demonstrating in his hand with his fingers half open and half closed. He asked the Surveyor for pain medication for his stomach. When asked what his pain level was, he stated nothing happens, and walked away and told his concerns to other staff members in the hallway who did not address his pain but went ahead to redirect him. A review of the Licensed Personnel Progress Notes dated March 22, 2016, at 10:30 a.m. indicated there was no documentation that Resident 2's stomach pain was addressed and acted upon by the facility's staff members. A review of the Licensed Personnel Progress Notes dated March 22, 2016, indicated Resident 2 complained of a pain level of seven out of 10 at 6 p.m. The PRN medication sheet indicated [MEDICATION NAME] (for pain) PRN (for both knee pain) was given. Pain was assessed at three out of 10 at 7 p.m. The notes also indicated orders for BMP (basic metabolic panel - lab tests) to be done in the a.m. A review of the correlating Resident Pain Review Tool did not indicate what Resident 2's acceptable level of pain was, it was blank. On March 23, 2016, at 9:35 a.m., during an interview with Resident 2, he stated he still had stomach pain. He was unable to tell his pain level. He stated nothing happens. When asked what he meant, he was not able to elaborate. When he was asked where it hurts, rubbed his stomach and asked for pain medication, by rubbing his stomach and saying, Pain medicine, pain medicine, pain medicine. A review of the Licensed Personnel Progress Notes dated March 23, 2016, at 9:50 a.m., indicated Resident 2 had cramps in the abdomen. He was asked when his last bowel movement was, and he said yesterday. He reported cramps not resolved. A message was left for the physician to ask for KUB (kidney, ureter, bladder - lab tests) to evaluate the resident's abdominal pain. There was no documentation that the physician was notified of Resident 2's unrelieved stomach pain prior to this time. On March 23, 2016, at 10:35 a.m., during an interview with the Director of Nursing (DON), she was unable to provide an explanation as to why Resident 2's unrelieved stomach pain was not addressed by the licensed nurses (comprehensively assessed by using inspection, auscultation, palpation, and percussion), or reported to the physician until the third day of his continued complaints. The DON could not provide documented evidence that Resident's 2 pain level was assessed per shift as ordered by the physician. A review of the Final X-ray Report for portable KUB dated March 23, 2016, indicated there was no evidence for obstruction, however, fecal loading was seen in the large bowel. A review of the GACH's Procedures and Tests dated March 29, 2016, indicated Resident 2 was examined for abdominal pain. The CT (computed tomography, a special x-ray) scan of the abdomen and the pelvis indicated cholelithiasis (frequently known as gall-stones). The facility's policy and procedure titled Pain Risk Review And Management Program dated May 5, 2009, indicated to review pain level prior to administration of PRN and standard scheduled pain medications and after administration for effectiveness of medication. Document all findings in the resident's record. Pain level is to be reviewed as needed based on each resident's individual need. Observe resident for indicators of pain. Indicators include but not limited to wincing or frowning and other facial expressions and body posture such as guarding or protecting an area of the body. Symptoms can be manifested by particular behaviors such as calling out for help and pained facial expressions. Medications/pain scale effectiveness will be documented on the resident's MAR (Medication Administration Record) or facility specific pain flow record. Non-pharmacological approaches will be documented in the resident record and recorded on the resident current care plan. Resident plan of care will reflect all interventions both pharmacological as well as non-pharmacological. An individualized resident plan of care will be developed according to the level and type of pain experienced by the resident. a 2. A review of Resident 2's interdisciplinary team (IDT) notes dated February 9, 2016, indicated to continue to monitor for signs and symptoms of hypo/[MEDICAL CONDITION] (low/high blood sugar). Resident 2 had a physician's orders [REDACTED]. The order was changed on February 2, 2016, to monitor FSBS at 6:30 a.m. only, due to not needed at this time, BS within normal limits. There were special instructions to notify the physician if BS is less than 70 or greater than 350 mg/dl. A review of Resident 2's Care Plan titled Nutrition, dated February 9, 2016, indicated nutrition risk related to diabetes mellitus, hypertension (high blood pressure), therapeutic diet, potential for weight loss, and risk for dehydration. The goals included for Resident 2 to consume greater than 75 percent daily. The approach included to monitor meal intake, offer substitute, if intake is less than 50 percent or refused, allow enough time to eat, provide Hi-Pro (6 ounce shake), and RNA (restorative nursing assistant); assist with eating as needed, and encourage to eat over 75 percent of meals, and drink all fluids on meal tray; and monitor for pertinent laboratories. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident needed limited assistance with one-person physical assistance for eating, and had a therapeutic diet. A review of the medication record (MAR) for March 2016, indicated the FSBS were being done before breakfast (6:30 a.m.), and Resident 2's BS levels were within the reference range for March 9, 17, 23, and 24, 2016. A review of Resident 2's laboratory reports for glucose monitoring (reference range is from 65 milligrams (mg) per deciliter (dL)) mg/dL to 99 mg/dL indicated the following: 1. March 9, 2016 drawn at 3:25 a.m. - glucose was 62 mg/dL - low 2. March 17, 2016 drawn at 3:25 a.m. - glucose was 61 mg/dL - low 3. March 23, 2016 drawn at 3:40 a.m. - glucose was 53 mg/dL - critical low 3. March 24, 2016 drawn at 3:30 a.m. - glucose was 54 mg/dL - critical low 4. March 30, 2016 drawn at 3:30 a.m. - glucose was 58 mg/dL - critical low There was no documentation the physician was notified regarding the correlation between the low intake and blood sugar levels, verified when reviewed with the director of nursing (DON) on March 24, 2016. A review of Resident 2's I/O (intake/output) Chart Detail Report indicated the following: On March 16, 2016, the lunch was blank (no entry), and there was no indication an HS snack was offered or consumed; On March 21, 2016, both the breakfast and lunch were blank (no entry); On March 22, 2016, breakfast was refused (no reason), lunch was refused (no reason); and On March 23, 2016, lunch was refused (no reason), dinner was blank (no entry), and there was no indication the HS snack was offered or consumed. There was no documented evidence that Resident 2 was given a meal substitution when he refused meals. On March 21, 2016, at 12:22 p.m., during an observation in the Station I therapy dining room, Resident 2 was not in the RNA feeding program. A review of the residents listed in the RNA Feeding Program did not include Resident 2. On March 25, 2016, during an observation Resident 2 didn't eat his lunch. Certified Nursing Assistant 1 (CNA 1), stated that Resident 2's lunch tray was untouched. The Care Plan - Nutrition, did not indicate other factors assessed, such as pain, that may contribute to low meal intake. A review of the pain assessments and nursing notes for March 21, 2016, and March 22, 2016, indicated there was no evidence a pain assessment was done for the 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. shifts. A review of the SBAR Communication Form (licensed notes) records for change in condition, indicated no documentation of Resident 2's low or no intake and critically low blood sugar except for March 22, 2016. Recommendations indicated to monitor the resident for 72 hours. The SBAR section to assess abdominal pain was blank, but decreased appetite/fluid intake was selected. On March 24, 2016, after Surveyor intervention, there was a new order to check Resident 2's FSBS before all meals and at bedtime. On March 25, 2016, at 4:20 p.m., during an interview and record review with the director of nursing (DON) regarding Resident 2's low glucose levels and low or no daily intake, she could not provide documentation to indicate nursing staff were closely monitoring Resident 2's glucose levels when there was a change in condition (low intake), or that the physician was notified every time Resident 2 had low or no meal intake and/or low or critically low blood sugar levels. When asked for a policy and procedure in managing a resident with diabetes or [DIAGNOSES REDACTED], she stated that the facility did not have a policy. Cross Refer to F327 b. According to the admission record, Resident 13 was originally admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 13's mental status was intact and was independent in eating with set up help only. The resident used a walker and wheelchair as mobility devices. The resident received [MEDICAL TREATMENT] (artificial means of cleansing waste products from the blood when the kidneys fail, by means of a surgical entrance into the blood vessels (shunt); this will allow a larger amount of blood to flow through your body during the [MEDICAL TREATMENT] treatment to be purified). A review of Resident 13's March 10, 2015, Physician order [REDACTED]. A review of the care plan dated April 17, 2015, indicated Resident 13 received [MEDICAL TREATMENT] and was currently on fluid restriction. The approach included [MEDICAL TREATMENT] as scheduled, monitor shunt site for signs and symptoms of infection (redness, swelling, pain, warmth, drainage, fever, etc.). No BP (blood pressure) or vein punctures in extremity of the shunt. A review of Resident 13's [MEDICAL TREATMENT] communication form dated March 21, 2016, on the pre-[MEDICAL TREATMENT] assessment section (from the facility), did not indicate the required information as follows: medication given in the last six hours prior to sending the resident to [MEDICAL TREATMENT], mental status, vital signs (blood pressure, pulse, respiratory rate, and temperature), time of last meal, last weight, date of last weight, physical condition: changed, unchanged, access site, bruit/thrill present, signs of infection, bleeding after last treatment, and special instructions/comments were all blank. The nurse signature was also blank. On March 29, 2016, at 2:45 p.m., during an observation and interview with Resident 13, she was sitting in the wheelchair in the patio, alert, awake, and oriented. She indicated she had a left arm shunt. On March 29, 2016, at 3:15 p.m., during an interview with Licensed Vocational Nurse 7 (LVN 7), she stated Resident 13 had a left arm shunt. When asked about the missing information on the [MEDICAL TREATMENT] communication form, she stated the pre-[MEDICAL TREATMENT] assessment section should have been assessed and completed. She stated this is the facility's means of communicating the resident's status to the [MEDICAL TREATMENT] center, prior to the [MEDICAL TREATMENT] treatment. c1. A review of Resident 8's medical record revealed she was admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of clinical records showed that Resident 8 was on intravenous (IV) fluid therapy on March 17, 2016. The rationale and or [DIAGNOSES REDACTED]., 2016. The pharmacy document indicated BUN 31, SCr (serum Creatinine) 1.5. Normal range for BUN is 7-23 mg/dl and 0.6 to 1.4 mg/dl for Creatinine. Elevated BUN/Cr provides more precise information about kidney function and its underlying cause. In cases of dehydration, BUN may rise in a higher proportion than creatinine (Webmd.com). This was the case with Resident 8. Review of the clinical record showed that Resident 8 ' s medications included [MEDICATION NAME], for her high blood pressure. (A serious side effect of [MEDICATION NAME] is dehydration), which could be worsened if adequate fluids are not consumed. Resident 8 was also diagnosed with [REDACTED]. (Signs and symptoms of dehydration in the elderly include fatigue, tiredness, confusion and falls). Review of her most recent Minimum Data Set (MDS) dated [DATE], indicated Resident 8 was assessed as needing supervision such as oversight, encouragement, or cueing for eating. On March 22, 2016 at 8:23 am, Resident 8 was observed lying in bed with her breakfast tray untouched. The tray had one biscuit, 2 boiled eggs, a cup of milk and juice. Resident 8 was asked why she was not eating but she did not respond. The certified nursing assistant (CNA 6) 4) stated the resident was independent and can eat herself. He then got someone to help Resident 8 because he said he was not assigned to her. On March 22, 2016 at 8:25 a.m., CNA 5 came and asked if Resident 8 needed any help with eating. Resident 8 allowed CNA 5 to assist her. At 9: 15 am, CNA 5 removed the breakfast tray which had been mostly consumed except for a piece of biscuit and the yolk of a boiled egg. Resident 8 stated I ' m still hungry, but said she didn ' t want the biscuit. The tray was removed but Resident 8 was not offered anything else to eat. At 11:06 am, 6 chocolate chip cookies were observed on Resident 8 ' s tray table. At 12:02 pm, Resident 8 was up in her wheelchair wheeling herself to the dining room, and stated she ate 4 of the 6 cookies in her room. At 1:45 pm Resident 8 was returning to her room, looking uncomfortable and unhappy. Resident 8 complained she had nausea and wanted to return to her room. According to the intake records Resident 8 had consumed 30% of her meal and 160 cc fluids. At 2:15 pm, Resident 8 was observed lying in bed. She was moving her tongue from one corner of her mouth to the other. Resident 8 was asked if she wanted to drink anything. She responded yes. There was no presence of a water pitcher on her tray table. CNA 3 came into the room at 2:17 pm, and stated Resident 8 did not like the grey water pitcher, stored by the wall, and she did not like water. She prefers ice tea and will fill her cup or bottle in the dining room. There was a red colored sports bottle half full of a dark colored liquid. The bottle was stained and the lid was dirty with dried on brown stains. CNA 3 had the bottle cleaned and refilled with ice tea. Resident 8 was then offered the cleaned bottle with ice tea. She took a long drink, and smiled. On March 22, 2016 at 1:52 p.m., the Director of Nursing was interviewed about the facility ' s monitoring of hydration and liquid intake for Resident 8. She stated it was difficult to determine intake because Resident 8 wheeled herself around the facility and was able to get fluids herself. On March 22, 2016 at 5:15 pm, Resident 8 was observed with an IV in her arm. Review of the clinical record showed the Peripheral Catheter-Physician/Licensed Independent Practitioner (LIP) Order Sheet dated March 22, 2016, indicated IV therapy had been ordered for Resident 8. The facility Director of Nursing (DON) was interviewed on March 22, 2016, at 5:54 pm on why Resident 8 was being administered IV fluid. The DON said it was because she was not eating because when she went to the room at 8:20 am that morning, she was asleep and that was unusual for the resident. The DON stated she was not aware that Resident 8 had eaten her breakfast after she was provided assistance. On March 24, 2016, clinical record review indicated that the physician had a licensed nurse discuss with Resident 8, the possibility of the placement of gastrointestinal tube for nutrition. The DON was interviewed on March 25, 2016 at 12:05 pm why the possibility of [DEVICE] was being discussed. She stated she did not know why and the nurse who discussed the [DEVICE] placement was not available for interview. On March 25, 2016 at 12:20pm in an interview with the Physician (MD2), who was responsible for Resident 8 ' s care, he stated the facility staff had told him Resident 8 was not eating, getting dehydrated, and had urinary tract infections and that was why the issue of [DEVICE] was recommended. He stated he was not aware the resident was not receiving adequate assistance with her meals, and was not offered adequate fluids. c2. Diabetes Management - The facility failed to supervise Resident 8 with her meals and monitor her intake as it related to the management of diabetes. This resulted in low intake which resulted in low blood sugar at times. Other times, she was offered food items that would cause the raising of blood sugar that would result in the administration of high amounts of insulin before meals. She in turn would have a low appetite or not consume bedtime snacks given to her. Her Hemoglobin A1 was 7.7. (Normal less than 6) HGB A1c or glycated hemoglobin test is an important blood test that provides an average of a person ' s blood sugar control over a two to three month period. (webmd.com). It is reflective of how well diabetes is controlled. There is a correlation between Hgb A1C and average blood sugar. A Hgb A1C of 7.7 correlates with average blood sugar of 197 mg/dl. (webmd.com) Review of clinical records showed Resident 8 had two episodes of low blood sugar within two days, the month of March 2016. On March 22, 2016 at 1:50 a.m., Resident 8 was found in bed unresponsive. A check of her blood sugar showed it to be 35. (Normal 70 - 110), and [MEDICATION NAME] (to raise blood sugar) injection was given. On March 22, 2016 at 8:23 am, Resident 8 was observed lying in bed with her breakfast tray untouched. The tray had one biscuit, 2 boiled eggs, a cup of milk and juice. Resident 8 was asked why she was not eating but she did not respond. The certified nursing assistant (CNA 4) stated the resident was independent and can eat herself. He then got someone to help Resident 8 because he was not assigned to her. On March 22, 2016 at 8:25 a.m., CNA 5 came and asked if Resident 8 needed any help with eating. Resident 8 allowed CNA 5 to assist her. At 9: 15 am, CNA 5 removed the breakfast tray which had been mostly consumed except for a piece of biscuit and the yolk of a boiled egg. Resident 8 stated I ' m still hungry, but said she didn ' t want the biscuit. The tray was removed but Resident 8 was not offered anything else to eat. At 11:06 am, 6 chocolate chip cookies were observed on Resident 8 ' s tray table. At 12:02 pm, Resident 8 was up in her wheelchair wheeling herself to the dining room, and stated she ate 4 of the 6 cookies in her room. A test of her blood sugar revealed it was 262mg/dl. The medication LVN 3 gave her insulin injection. At 1:45 pm Resident 8 was returning to her room, looking uncomfortable and unhappy. Resident 8 complained she had nausea and wanted to return to her room. The CNA documented Resident 8 only consumed 30% of her meal. On March 23, 2016, at 8:50 am, the tray of leftover food for Resident 8 was observed. It showed that she left the bread (1/2 English muffin) uneaten. She had also left one yolk. An estimate of the calories consumed for that meal was approximately 386 calories. On March 24, 2016 at 2:20 a.m., Resident 8 was found on the floor by a CNA , unable to speak but moaning when spoken to. A check of her blood sugar revealed a blood sugar of 41. Both times she was given [MEDICATION NAME] injection to raise blood sugar. On March 24, 2016 at 7:52 a.m., a plastic bag containing peanut butter which was observed on her night stand, it was the snack from the night before. On March 25, 2016, at 8:35 a.m., Resident 8 was asked why she did not eat her bread most days. She stated Bread is fattening. Resident 8 was intentionally excluding from her diet the main food item that would help in the maintenance of blood sugar. The facility failed to identify the exclusion of breads from the diet and educate Resident 8 on the diet especially since she ate cookies, a carbohydrate food. c3. Bowel and Bladder - Review of the latest minimum data set (MDS) assessment dated [DATE], indicated under toilet use, Resident 8 was able to use the toilet commode with assistance from staff with one staff person support. The resident was capable of making her toileting needs known. On March 22, 2016 at 1:52 p.m., in an interview with the DON, Resident 8 ' s frequent falls were blamed on her determination to go the bathroom without staff assistance. Resident 8 was observed on March 22 at 9:15 a.m. telling nurse she wanted to use the bathroom and was helped. On March 25, 2016, she was observed using the bathroom independently without staff assistance. On March 23, 2016, at 12:15 p.m., Resident 8 was observed with briefs on. She was unable to explain why she had briefs on. In an interview with LVN 9 on March 30, 2016, at 10:37 a.m., she stated yearly assessments were conducted on every resident on the facility form titled 3-day Bowel and Bladder Evaluation. A review of the document dated January 21, 2016 indicated Resident 8 was identified as being occasionally incontinent of bowel. The facility failed to make the determination on whether she was eligible for retraining. The area on the form that needed to be completed showing evaluation of the resident ' s ability to be retrained was left blank. d1. According to the admission record, Resident 6 was originally admitted to the skilled nursing facility on May 3, 2013, and was readmitted on [DATE], with [DIAGNOSES REDACTED]. to process glucose (sugar). The Minimum Data Set (MDS-a standardized comprehensive assessment and screening tool) dated October 1, 2015, indicated Resident 6's cognitive patterns were intact and needed extensive assistance from staff members for dressing, transferring, toileting, and personal hygiene and total dependence on bathing. The MDS indicated the resident is always incontinent of bowel and bladder elimination. On March 22, 2016, at 2 p.m., during a Resident Group Meeting, Resident 6 stated she was diabetic. However, she is not getting proper diabetic care, such as checking the blood sugar level on time and getting regular insulin accordingly. As a result, her blood sugar level fluctuates all the time and it contributes to her fatigue. She stated she was not offered bedtime snacks and she was not aware that she could have snacks. According to Resident 6, at one point in time, her sugar level went down to 34 milligram per deciliter (mg/dL-reference range: 80-120) which was critical. After she received apple juice mixed with several packets of sugar for low blood sugar, she felt sick. Sometimes, she was unable to eat after this type of episode, when she received meals. A review of the Licensed Personnel Progress Notes dated December 23, 2015, at 10:45 p.m., indicated Resident 6's finger stick blood sugar at 9:10 p.m., was 40 mg/dl (reference range: 80-120 mg/dl). The licensed nurse gave the resident glucose gel, peanut butter and jelly sandwich, cookies, and protein shake. The licensed nurse rechecked Resident 6's blood sugar after 10 minutes and it went down to 34 mg/dl.(low and critical) The licensed nurse called hospice (Resident 6 is under hospice care), and notified the nurse on call. The on call nurse will notify the physician. The licensed nurse rechecked the resident's blood sugar at unspecified time after giving Resident 6 another glucose gel. The blood sugar result was 51 mg/dl. The licensed nurse gave Resident 6 a juice mixed with sugar again and rechecked the blood sugar after ten minutes and the result was 158 mg/dl. A review of the care plan dated January 26, 2015, indicated the resident was at risk for hypo

Based on observation, interview, and record review, the facility failed to ensure staff answered the call lights in a timely manner for eight out of 10 residents who attended the group meeting; 5 out of 25 sample residents (Resident 6, 13, 14, 20, and 22) for two residents who wish to remain anonymous; and failed to ensure a non-English speaking resident's needs were not affected by the existing language barrier and potential cultural difference for one out 25 sample residents (Resident 11). This deficient practice created situations of avoidable humiliation, discomfort and delayed response to manage emergency situations, and avoidable frustration. Findings: a. According to the admission record, Resident 20 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 20's cognitive patterns were intact, he required limited assistance from staff members for transfers and personal hygiene, and needed extensive assistance for toilet use. The resident used a walker and a wheelchair for mobility devices. The resident was occasionally incontinent of urine and had an [MEDICAL CONDITION] for bowel incontinence. On March 30, 2016, at 11:10 a.m., during an interview with Licensed Vocational Nurse 8 (LVN 8), she stated the call light should be answered in less than 10 minutes. On March 31, 2016, at 2 p.m., during an observation and interview of Resident 22 (roommate of Resident 20), he was able to get out of bed by himself in the wheelchair. When asked on how long did he wait for the staff members to respond to the call light, he stated from 45 minutes to one hour, especially at night it is worse. He stated his roommate (Resident 20) puts his urinal on his table, then he pulls his call light on. He asks him to find somebody to help him. On March 31, 2016, at 2:50 p.m., during an observation of and interview with Resident 20, he was lying in bed, alert, awake, and oriented to person, place, and time. His [MEDICAL CONDITION] bag was had fecal material in it, and was almost full (past half of the [MEDICAL CONDITION] bag) of air. When asked about staff response, he stated that the average waiting time usually was between 45 minutes to one hour on all shifts. When asked how he felt about this, he stated in a very angry voice, I am pissed off. He stated he tells them and still they do not respond. He stated the waiting time to get help is more at night. There was one time at night that he had to wait for three hours and a couple of times for about two hours. He stated, I have to stay in my bed with s--t all over the place. If not for my roommate, I will be dead. He calls outside the room for help. I press the call light, they do not come. I smelled so bad. You can ask him. He is my witness. On March 31, 2016, between 3:15 p.m. to 3:20 p.m., an observation and interview with Resident 22, Resident 20's roommate, was conducted. He was awake, alert, and oriented to person, place, and time. He was sitting in his wheelchair, able to wheel himself. He stated that he had to ask for help for his roommate. Sometimes, he had to press the call light for Resident 20, and stated the staff members do not come. If they come, they walk away. He stated, I cannot stand the smell of the s--t. It stinks the whole room. On March 31, 2016 at 3:25 p.m., during an interview with the DON, she was unable to provide an answer as to why nursing staff members did not answer Resident 20's call lights and provide [MEDICAL CONDITION] care in a timely manner. The DON stated, I don't know what to tell you. A review of the facility's policy and procedure titled Answering Call Lights dated January 1, 2001, indicated to respond to resident's call lights in a timely manner. Answer emergency lights immediately. Turn off the call light in the room so that others will know it is answered. Complete (if able) the task the resident/family requests. b. According to the admission record, Resident 14 was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. blood glucose). A review of the Minimum Data Set (MDS- a standardized comprehensive assessment of the resident's problems and conditions) dated July 6, 2015, indicated Resident 14 was cognitively intact but needed extensive assistance from staff in transfers, toileting, dressing, personal hygiene and toileting, and personal hygiene. Th MDS also indicated Resident 14 used the wheelchair as a mobility device. On March 31, 2016, during an interview with Resident 14, he stated that when his room was in Station 1, his call light was not answered promptly during the evening shift. Resident 14 stated it took the staff members 45 minutes to an hour to come into his room to assist him to transfer from the wheelchair to the bed so he can go to sleep, usually around 10:00 p.m. When resident was asked how it made him feel to wait for help, the resident stated he felt like he was not being attended to, and stated he would like the staff to speed it up. A review of the facility's policy and procedure titled Answering Call Lights dated January 1, 2001, indicated to respond to resident's call lights in a timely manner. Answer emergency lights immediately. Turn off the call light in the room so that others will know it is answered. Complete (if able) the task the resident/family requests. c. According to the admission record, Resident 13 was originally admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 13's mental status was intact and was independent ineating with a need for set up help only. The resident used a walker and wheelchair as mobility devices. The resident received [MEDICAL TREATMENT] (artificial means of cleansing waste products from the blood when the kidneys fail, by means of a surgical entrance into the blood vessels (shunt); this will allow a larger amount of blood to flow through your body during the [MEDICAL TREATMENT] treatment to be purified). On March 30, 2016, at 2:00 p.m., during an interview with Resident 13, stated there are times when she had to wait for an hour especially during night time before she gets assistance from the nursing staff and that some residents would get up in their wheelchair to let the nursing staff know they needed help. Resident 13 also stated that there were times when she had to wait for at least 30 minutes to get her pain medication. The resident also stated it was hard to wait because she felt weak from the [MEDICAL TREATMENT]. A review of the facility's policy and procedure titled Answering Call Lights dated January 1, 2001, indicated to respond to resident's call lights in a timely manner. Answer emergency lights immediately. Turn off the call light in the room so that others will know it is answered. Complete (if able) the task the resident/family requests. d. On March 28, 2016, at 3:00 p.m. during an interview with a resident who wished to remain anonymous for fear of reprisal from the facility, stated that there was a problem getting call lights answered after 11:00 p.m. The resident stated sometimes he had to wait 30 minutes while on the commode to get assistance. The resident stated in one instance he had to yell for the nurses to come help him even though he could hear them in the hallway. e. On March 31, 2016 at 10:00 a.m., during an interview with a resident who wished to remain anonymous for fear of reprisal from the facility, she stated call lights were not answered in a timely manner. The resident stated she fell from her wheelchair a year and half ago while trying to ask assistance to go to the bathroom and screamed for help but nobody came. The resident said she did not sustain injuries from the fall. She stated that there was an instance when her legs and buttocks got numb while sitting on the commode for one hour and a half waiting for a nursing staff member to help her. f. According to Resident 6's Admission Record, the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. to produce or use insulin which is hormone). A review of the Minimum Data Set (MDS- a standardized comprehensive assessment tool and care screening tool), dated October 1, 2015, indicated Resident 6 was alert, oriented, and able to make her needs known. According to the MDS, the resident required extensive assistance from the staff for activities of daily living (ADLs), such as, dressing, transferring, personal hygiene, and toilet use. She was always incontinent of bowel and bladder elimination. On March 22, 2016, at 2:40 p.m., during an interview with Resident 6, she stated sometimes she forgets why she pushed the call light, because it takes too long to respond. Sometimes, the staff do not respond to her call light at all. Resident 6 stated she had to sit in urine and/or feces-soaked bed linens for long periods of time; sometimes, more than 3 hours. According to the facility's policy and procedure dated January 1, 2001, titled, Answering Call Lights, indicated the staff to provide an environment that promptly helps meet the resident's needs and respond to resident's call lights in a timely manner and answer emergency lights immediately. A review of the facility's policy and procedure titled Answering Call Lights dated January 1, 2001, indicated to respond to resident's call lights in a timely manner. Answer emergency lights immediately. Turn off the call light in the room so that others will know it is answered. Complete (if able) the task the resident/family requests. g. During the resident Council meeting conducted on March 22, 2016 at 2:00 p.m., 8 of 10 alert and oriented residents stated that call lights were not being answered timely. The residents stated the facility needed more staffing to answer call lights. The residents stated it was worse during the 11 p.m. to 7 am shift. One of the residents stated that staff took so long he would sometimes forget why he had called them when they finally showed up. Another resident stated that it took a long time to get help to go to the bathroom. h. A review of the medical record indicated Resident 11 was an [AGE] year-old female originally admitted to the facility on [DATE] and last readmitted on [DATE]. On March 21, 2016, a review of the [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, a standardized, comprehensive assessment and screening tool) dated February 14, 2016, Resident 11 required an interpreter to communicate with a doctor or health care staff and preferred her native language. On March 22, 2016 at 8:50 a.m. during an interview with Resident 11, using a Surveyor to interpret, she stated she did not like to bother staff for her needs and that the words in the communication tools were too small. Resident11 stated she would yell or be angry sometimes because the staff would not understand her. At 3 p.m. during an observation, facility staff certified nursing assistant 6, (CNA 6) was with Resident 11. Resident 11 was speaking to CNA6 in her native language making unspecific gestures with her hands. CNA6 stated she did not understand what Resident 11 was saying. CNA 6 said she could speak a few words such as pain, bathroom, cold, and sleep; CNA 6 proceeded to speak those words to Resident 11 but the resident did not respond. CNA 6 then tried to use the communication cards which contained pictures of items and words underneath the pictures. However, Resident 11 pushed that communication tool away and looked annoyed. At 3:20 p.m., during an interview, the Director of Nursing (DON) stated there was one part-time night shift CNA who could interpret. That CNA was not scheduled to work throughout the survey. The DON stated the facility also relied on the family member or the communication tools. At 5 p.m., the DON confirmed there was no specific policy and procedure that address any language barrier or communication issues for non-English speaking residents. A review of Resident 11's current care plans did not show an individualized plan to ensure accurate communication between Resident 11 and staff when communication tools fail, when family member could not be reached to assist in translation, or when the only staff to interpret was not on duty. Also, there was no care plan or assessment to address the potential of cultural difference between staff and the resident. Review of the psychosocial review for Resident 11 dated on October 13, 2015 showed that in cultural traditions, Resident 11 always celebrated regular holidays and that Resident 11 could speak mainly in her native language. The plan was to provide one to one visits to keep her socially and mentally active. However, there was no mentioning of how to accomplish the plan with the existing language barrier when there was no day or evening shift staff that could speak the language.

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent incidents and/or falls with serious injuries, for 2 of 25 sample residents (Residents 1 and 11) by failing to: 1. Monitor and supervise a resident who had muscle weakness and unsteadiness, with a history of fall with injuries, and develop care plans to address the actual and/or potential for falls with injuries (Resident 1). 2. Monitor, supervise, and provide assistance to a non-English speaking resident, who received multiple medications that cause increased risk for falls. Resident 11 received Ativan (medication to treat anxiety), Klonopin (medication to treat seizure or panic disorders, also a sedative), and Risperdal (an antipsychotic to treat schizophrenia). Resident 11 had nineteen falls. One of the falls was associated with fracture of the left hip, and another one with an injury to the head that required surgery. This deficient practice caused avoidable injuries, unnecessary suffering, pain, and delay in treatment. Findings: a.1. According to the admission record, Resident 1 was admitted to the skilled nursing facility on November 13, 2015, and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment and care screening tool) dated November 26, 2015, indicated Resident 1's cognitive skills for daily decision making were moderately impaired, needed total dependence from staff members for bed mobility with two persons physical assist, transfer with two persons physical assist and toilet use with one person physical assist. The resident needed extensive assistance from staff members for moving on and off the unit, dressing, eating, and personal hygiene, with one person physical assist. The resident had impairment on both sides of upper and lower extremities (arms and legs) for functional limitation in range of motion. For balance during transitions and walking, the resident was not steady and was only able to stabilize with staff assistance for moving from seated to standing position and from surface-to-surface transfer (transfer between bed and chair or wheelchair). The resident normally used a wheelchair as a mobility device. The resident was always incontinent for bowel and bladder. The area for falls was not indicated. Resident 1's Care Area Assessment (CAA) Summary dated December 2, 2015, triggered for falls indicated a decision had been made for care planning. The analysis of findings indicated: the resident was admitted from the hospital on November 19, 2015, for multiple falls with a scalp hematoma (collection of blood). [DIAGNOSES REDACTED]. History and physical indicated the resident lost balance, tripped and fell . She had both knees replaced after a fall, with a left collar bone displacement with arm sling. She had an alarming mattress pad in bed to remind the resident to ask for assistance getting out of bed, bolsters applied to remind her where the edge of bed is and a landing pad. At risk due to having a history of falls. Care plan to be implemented to facilitate a safe environment and prevent falls or injury related to falls. A review of the Medicare Daily Skilled Nursing Note on December 20, 2015, at 1:30 p.m. indicated the licensed nursing staff was at the nursing station when Resident 1's alarm went on and the resident had stood up. The staff ran to the room but by the time arrived, the resident had fallen. The resident landed on her coccyx (very bottom of the spine) area. The resident had a skin tear to her left forearm, treated and monitor after fall. A review of Resident 1's care plan indicated initially there was no care plan developed for the risk for falls, and no care plan developed after the incident that happened on December 20, 2015, to address preventing further falls. A review of Resident 1's Post Fall Investigation dated December 22, 2015, indicated fall had been evaluated/analyzed and interventions are deemed appropriate for the following reasons: safety devices in place and working, changed bed to low bed, and identifiers outside the door for all devices. On March 28, 2016, at 10:15 a.m., during an interview with the Director of Nursing (DON), when asked regarding the care plan for falls before and after the fall on December 20, 2015, she stated they just made a care plan today (March 28, 2016). A review of the care plan provided by the DON did not indicate when the care plan for status [REDACTED]. a2. A review of Resident 1's Situational Background Assessment Reccommendation (SBAR) Communication Form dated February 19, 2016, indicated status [REDACTED]. A review of the Medicare Daily Skilled Nursing Note dated February 19, 2016, indicated at approximately 9:35 p.m., Resident 1 was sitting in the wheelchair and was being pushed to her room to be helped into the bed. Resident scooted forward in the wheelchair as the certified nursing assistant (CNA) was holding onto the back of the resident's pants and assisted resident to the floor. The resident landed on her right hip area. Resident 1 was assisted into the bed by three CNAs using a mechanical lift. Resident will be monitored. There was no documentation of how staff would monitor the resident to prevent further falls and/or injuries. A review of the Medicare Daily Skilled Nursing Note dated February 20, 2016, indicated at 10 a.m., Resident 1 was up in the wheelchair and was noted with discoloration to the right knee. There was no complaint of pain and discomfort. Resident 1 did not know how it happened. The resident had a fall last night, and could have done that in the fall. At 11:20 p.m., Resident 1 was being monitored status [REDACTED]. There was no documented evidence of how the resident was being monitored to prevent further falls and/or injuries. A review of the Potential for Falls Care Plan dated February 20, 2016, indicated at risk for fall or injury due to history of falls, poor safety awareness, behavior problems, unsteady gait, and assisted fall on February 19, 2016. The goal was to minimize risk for injury for next 90 days. The approaches included observation to minimize falls, assist with all transfers, bolsters on bed, resident did not like sensor alarms because it woke the resident and was restless, and the resident was moved closer to the nursing station for frequent monitoring. However, there was no care plan developed prior to the fall incident on February 20, 2016, to address fall prevention. a3. A review of Resident 1's SBAR Communication Form, (a licensed nurse progress notes used for change of condition) dated March 11, 2016, indicated skin tear on top of the right hand with discoloration. A review of the Medicare Daily Skilled Nursing Note dated March 11, 2016, indicated on the 3 p.m. to 11 p.m. shift at 4:10 p.m., Resident 1 had a skin tear to the top of the right hand. Continue to monitor for signs and symptoms of infection. A review of the Investigatory Interview Form indicated: Employee interviewed regarding Resident 1's skin tear to her right hand dated March 11, 2016. While the licensed vocational nurse (LVN 3) was doing the 5:00 p.m. medication pass and came back to her medication cart, she observed Resident 1 had a fresh new skin tear to the top of the right hand; registered nurse (RN) supervisor was notified. When the resident was asked what happened, she stated a cat scratched her. The Minimum Data Set (MDS- an assessment and care screening tool) dated February 27, 2016, indicated Resident 1's cognitive skills for daily decision making were severely impaired, needed extensive assistance from staff members for bed mobility, walking in the room and corridor, locomotion on unit, needed extensive assistance with two person physical assist for toilet use, and was totally dependent with two person physical assist for transfers. The mobility devices included a walker and wheelchair; the resident was always incontinent of bowel and bladder. There were no falls since admission/entry or reentry or the prior assessment. The two falls after admission on December 20, 2015, and February 19, 2016, were not indicated. On March 21, 2016, at 12:22 p.m., during an observation in the Therapy Dining Room in Station I, Resident 1 was sitting in the wheelchair talking to herself with a dressings to both arms. On March 21, 2016, at 12:30 p.m., during an interview with Licensed Vocational Nurse 5 (LVN 5), he stated Resident 1 had a scratch on the left forearm and a skin tear on the right forearm. On March 22, 2016, at 11:40 a.m., during an observation and interview with LVN 5, Resident 1's right hand skin tear was red and open. A review of Resident 1's care plan revealed no care plan developed to address the resident's skin tear to the left forearm and right hand to address prevention of further skin tears. On March 28, 2016, at 10:15 a.m., during an interview with the Director of Nursing (DON), when asked regarding the care plan for falls before and after the fall on December 20, 2015, she stated they just made a care plan today (March 28, 2016). A review of the care plan provided by the DON did not indicate when the care plan for status [REDACTED]. The DON provided a care plan for status [REDACTED]. The DON stated the care plan was just made today. b. According to the admission record Resident 11 was an [AGE] year-old female, originally admitted to the facility on [DATE], and last readmitted on [DATE]. On March 21, 2016, a review of the [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, a standardized, primary screening and assessment tool) dated February 14, 2016, indicated Resident 11 had both short-term and long-term memory problems, needed or want an interpreter to communicate with a doctor or health care staff in her preferred native language. In regards to the daily activities (specifically walking or locomotion), Resident 11 would need limited, and sometime extensive, assistance with one person physical assist. A review of the Resident 11's medication orders indicated that she had been on medications including Ativan (lorazepam, medication to treat anxiety), Klonopin (Clonazepam, medication to treat seizure or panic disorders, also a sedative), and Risperdal (an antipsychotic to treat schizophrenia). According to the package inserts (or prescribing information by the manufacturers), these medications could affect cognitive and motor performance and could cause dizziness, drowsiness, sedation, and/or weakness and falls. On March 22, 2016 at 8:50 a.m. during an interview with the Resident 11 and the assistance from a surveyor interpreting, Resident 11 stated she did not like to bother staff for her needs and that the words in the communication tools were too small. Resident 11 also stated she would yell or be angry sometimes because the staff would not understand her. According to the interpreter, the resident mentioned the resident prefers to sit on the floor sometimes, which is a traditional or cultural preference for many elderly. On the same date at 3 p.m. during an observation, Certified Nursing Assistant 6 (CNA 6) was with Resident 11. Resident 11 was speaking to CNA 6 in her native language, and making unspecified gestures with her hands. CNA 6 stated she did not understand what Resident 11 was saying about. CNA 6 said she could speak a few words such as pain, bathroom, cold, and sleep; CNA 6 proceeded to speak those words towards Resident 11 but the resident did not respond. CNA 6 then tried to use the communication cards which contained pictures of items with identifying words underneath the pictures. However, Resident 11 pushed that communication tool away and looked annoyed. On March 22, 2016, at 3:20 p.m., during an interview, the Director of Nursing (DON) also stated there was one part-time night shift CNA who could interpret. However, that CNA was not scheduled to work throughout the survey. Additionally, DON stated the facility relied on the family member or the communication tools. A review of the facility's record indicated Resident 11 had nineteen falls since she was first admitted on [DATE]. From May 1, 2015 to the end of 2015, Resident 11 fell twice in May, once in June, three times in July, four times in August, three times in September, four times in October, and once in November. The resident last fell on [DATE]. A review of the Medicare Daily Skilled Nursing Notes for Resident 11 indicated that most of these nineteen falls were related to finding Resident 11 on the floor or she fell in attempts to access the bathroom on various dates. According to a nursing note dated May 8, 2015, Resident 11 was status [REDACTED]. The fall occurred on August 16, 2015, was associated with a left hip intertrochanteric fracture (a type of fracture at the proximal or upper part of the femur or thigh bone). Resident 11 was transferred to a general acute care hospital (GACH) then later readmitted to the facility on [DATE]. Another fall occurred on October 6, 2015, resulted in a subdural hematoma (a collection of blood outside of the brain) with surgery. According to the operative report from the GACH dated October 6, 2015, Resident 11 had surgery to remove a large hematoma (collection of blood), mostly subacute (a condition between acute and chronic) and chronic (over time) subdural hematoma on the left side of the brain. A review of the Resident 11 plan of care summary on various dates indicated that the interdisciplinary team had identified Resident 11 for having fall risk with history of multiple falls associated with poor safety awareness, gait difficulty and behavioral problems. However, the review of the resident's care plans related to falls, fractures and use of behavior medications did not indicate how the facility and its staff would overcome the language barrier while carrying out the plans, including but not limited to: encouragements of involvement in activities, redirections, and verbal reminders. There was no individualized plan to ensure accurate communication between Resident 11 and staff when communication tools fail, when family member could not be reached to assist in translation, and/or when the only staff able to interpret was not on duty. Also, there was no care plan to address the possibility of any existing cultural difference between staff and the resident. While Resident 11 received miscellaneous medications that could cause increased risk for falls, and when Resident 11experienced nineteen falls, the facility did not prevent the injuries from falls by means of a plan of care that included frequent structured nursing rounds. A review of the literature indicates that falls frequently occur when patients get out of bed and go to the bathroom, walk to or from the bathroom, or experience an episode of incontinence. Frequent structured Nursing rounds- in which the nursing staff would perform specific tasks at set intervals could help reduce the incidence of falls. Studies have demonstrated the benefits of having structured frequent rounds and performing specific nursing actions, such as asking whether the patient needed anything and assisting with toileting, at set intervals was associated with statistically significant reductions in patients' use of call lights and the incidence of falls, and with an increase in patient satisfaction (Stefancyk, Amanda. Safe and Reliable Care, American Journal of Nursing, July 2009, Volume 109 No. 7, Pages 70-71.