Every finding on record at Desert Mountain Care Center

Based on observation, interview, and record review, the facility failed to ensure care and treatment with the use of indwelling catheter (a tubing that is inserted through the urethra [the tube that carries urine from the bladder out of the body] which drains urine from the bladder into a bag outside the body) was provided timely, for one of three residents reviewed (Resident A), when the resident had low and/or no urine output for eight hours.This failure had a potential for a delay in the care and treatment to address Resident A's low or no urine output. Findings:On April 14, 2026, at 9:30 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue.On April 16, 2026, Resident A's medical record was reviewed. A review of Resident A's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure (lung failure) and obstructive and reflux uropathy (a urinary tract disorder due to a structural or functional obstruction of urinary flow). A review of Resident A's care plan, dated August 31, 2023, indicated, .Has increased risk for infection r/t (related to) prolonged use of invasive devices.Monitor/document/report to MD (physician) PRN (as needed) any s/sx (signs and symptoms) of infection.dysuria (pain, discomfort, or burning sensation during urination), hematuria (blood in the urine), flank pain and foul smelling urine.A review of Resident A's care plan, revised June 23, 2025, indicated, .At risk for infections and trauma due to needs (sic) an Indwelling Catheter r/t urine retention.Monitor and document intake and output.Monitor/record/report to MD for s/sx UTI (Urinary Tract Infection): pain, burning.cloudiness, no output.A review of Resident A's Order Summary Report, included a physician's order, dated January 4, 2026, which indicated, .CHANGE INDWELLING CATHETER #20/30ml (milliliter - unit of measurement) TO CLOSED DRAINAGE SYSTEM.USE: URINARY RETENTION (the inability to completely empty the bladder, or the complete inability to pass urine at all).A review of Resident A's Fluid Output, indicated the resident had urine output of 650 ml on March 29, 2026, at 5:51 a.m., and 50 ml at 2:09 p.m.A review of Resident A's Progress Notes, dated March 29, 2026, at 5:35 p.m., indicated, .Pt (patient) sent out to (name of general acute care hospital) for abnormal vital signs, urinary retention and leaking of brown contents from Gtube (gastrostomy - a medical device inserted through the abdomen into the stomach).1725 (5:25 p.m.) upon report that RN (Registered Nurse) tried to irrigate foley (indwelling catheter) and replace (sic) catheter to retrieve urinary output without success. When irrigating foley, able to retrieve only amount irrigated into the catheter, some sediment present but no additional output noted.On April 16, 2026, at 1:30 p.m., during an interview with the RN, the RN stated she assessed Resident A on March 29, 2026, and noted no urine output. The RN stated she irrigated the foley catheter and the foley drained out sediment but no additional urine, then she replaced the foley catheter and notified the physician and was sent to the emergency room. The RN stated she informed the ER nurse of Resident A's having abdominal distention and excoriation on the Gtube site and buttocks area. The RN stated there was no abdominal distention when she assessed Resident A earlier in the shift.On April 20, 2026, at 10:25 a.m., a follow up interview was conducted with the RN. The RN stated she changed the foley catheter about 30-45 minutes before he was transferred to the ER. The RN stated the Licensed Vocational Nurse (LVN) notified her of Resident A not having urine output and still had no urine output after she replaced the foley catheter. The RN stated the Certified Nursing Assistants (CNAs) and LVNs usually monitor the residents' urine output. The RN stated urine output should normally be approximately 30 ml per hour, and 50 ml within eight (8) hours' time frame is not an adequate amount of urine output. The RN stated the nursing staff should have noted the low or no urine output before the 8 hours and interventions could have been done earlier.A review of the facility's policy and procedure titled, Change of Condition, revised on December 2023, indicated, .It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples.Change in output (bowel or bladder) including amount, color, consistency, odor, or frequency.The nurse will perform and document an assessment of the resident and identify need for additional interventions.

Based on observation, interview, and record review, the facility failed to ensure infection control and prevention measures were implemented according to the facility's policy and procedure and national guidelines, of using a dedicated patient-care equipment (e.g. blood pressure [BP] cuff and pump, thermometer, and pulse oximeter) on residents requiring contact and droplet precautions (infection control measures used to prevent the spread of diseases transmitted through large respiratory droplets), for three of three residents (Residents 1, 2 and 3).This failure had the potential to spread known infections to other residents or staff in the facility.Findings:On May 13, 2026, at 9:10 a.m., an unannounced visit was conducted to investigate a facility reported incident regarding infection control and prevention.On May 13, 2026, at 9:35 a.m., Resident 1's room was observed to have a sign at the door indicating droplet isolation precautions. Licensed Vocational Nurse (LVN) 1 was observed coming out of Resident 1's room. In a concurrent interview with LVN 1, LVN 1 stated they use disposable blood pressure (BP) cuff when taking vital signs on the residents placed on isolation precautions. LVN 1 stated he took Resident 1's blood pressure earlier and had thrown the BP cuff away in the medication room. LVN 1 stated he should have disposed the BP cuff used on Resident 1 in the resident's trash bin. LVN 1 went to the medication supply room to look for the disposable BP cuff and observed looking for the disposable BP cuff with Registered Nurse (RN) 1. RN 1 stated she was uncertain of the process of taking vital signs on residents placed on isolation precautions and where they could get the disposable BP cuffs.On May 13, 2026, at 9:51 a.m., during an interview with Certified Nursing Assistant (CNA) 1, AN 1 stated she was the assigned CNA for Resident 1. CNA 1 stated she was not sure if Resident 1 required contact or droplet precautions. CNA 1 stated they do vital signs of residents on isolation precautions by wiping down the BP cuff, thermometer, and pulse oximeter (a small, non-invasive device that clips onto your finger (or other body parts like the earlobe) to rapidly measure your heart rate and the amount of oxygen in your blood) before using on the other residents.A review of Resident 1's Face Sheet, indicated the resident was admitted to the facility on [DATE], with a diagnoses which included chronic respiratory failure (lung failure).A review of Resident 1's Progress Notes, dated May 6, 2026, at 3;47 p.m., indicated, .pt (patient) tested positive for growth of klebsiella pneumoniae (a type of bacterium that normally lives harmlessly in the human gut and respiratory tract. However, if it spreads to other parts of the body (like the lungs, blood, or urinary tract), it can cause serious, sometimes life-threatening infections) with resistance markers of ESBL (Extended-Spectrum Beta-Lactamase - refers to a group of enzymes produced by certain bacteria such as E. coli and Klebsiella pneumoniae that make them resistant to many common antibiotics) and CARBA (a shorthand prefix typically used to refer to carbapenem antibiotics (like in Carba-R assays) or carbapenemases-the drug-resistant enzymes produced by certain superbug bacteria that make them highly resistant to standard treatments). Pt has been placed on droplet precautions at this time.On May 13, 2026, at 10:11 a.m., an interview was conducted with LVN 2, who stated she was the assigned nurse for Resident 2. LVN 2 stated Resident 2 had recently tested positive for C-Diff (Clostridioides Difficile -a highly contagious germ that infects the large intestines causing severe diarrhea), and is on contact isolation (isolation of resident and precautions taken to prevent the spread of infection through direct contact). LVN 2 stated they use the BP stand central supply where vital signs (VS) supplies were being kept. LVN 2 stated she had already taken Resident 2's VS with the multi-resident use BP pump, cuff, and thermometer, then disinfected it with Clorox bleach wipes. LVN 2 stated the VS equipment were being used to other residents as well after disinfecting them. LVN 2 stated residents on isolation precautions do not have dedicated VS equipment for the nursing staff to use. LVN 2 stated they have disposable BP cuffs but uncertain if they supposed to use them for isolation residents.A review of Resident 2's Face Sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of respiratory failure and anoxic (lack of oxygen) brain damage. A review of Resident 1's, physician's orders, dated April 27, 2026, indicated, . Contact isolation (due to) c-diff.On May 13, 2026, at 10:27 a.m., LVN 1 stated he was not sure how to take VS on residents placed on isolation precautions. LVN 1 stated he conferred with the Infection Preventionist (IP) on the process of taking VS on isolation residents and indicated use of dedicated VS equipment (BP cuff, thermometer strips, and pulse oximeter).On May 13, 2026, at 11:51 a.m., an interview was conducted with the IP, who stated she each resident on Isolation precautions should have a dedicated BP cuff and pump, stethoscope (listens to lungs, heart beat and bowel sounds), and disposable (one use) thermometer strips located in the resident's room. The IP stated staff should use the dedicated equipment then wipe down and sanitize the equipment and leave in the residents' room for the next use. The IP stated replacement of dedicated equipment is in the central supply room, which can be accessed by all shifts. The IP further stated the multi-resident equipment should not be used on isolation residents. The IP stated Resident 1 required droplet isolation precautions, and Residents 2 and 3 required contact isolation precautions. The IP stated LVNs 1 and 2 did not follow the facility's procedure to use dedicated equipment when taking Residents 1 and 2's VS.A review of Resident 3's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke).A review of Resident 3's physician's order, dated April 23, 2026, indicated, Contact Isolation D/T (due to) C. diff.On May 13, 2026, at 4:38 p.m., an interview was conducted with the Director of Nursing (DON), who stated it is preferred that staff use dedicated equipment on isolation residents.A review of the facility's policy and procedure titled, IPCP (Infection Prevention & Control and Control Program, revised, October 2022, indicated, . Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . Patient-care equipment (e.g. blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used.According to the web article titled, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, published on November 27, 2023, indicated, .Contact precautions.Patient-care equipment and instruments/devices.In.long-term care and other residential settings, use disposable noncritical patient-care equipment (e.g. blood pressure cuffs) or implement patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use of another patient.

Based on interview and record review the facility failed to ensure, for one of three residents reviewed (Resident 1):1.A complete skin assessment was conducted and documented upon the resident's admission; and2.Physician's order was obtained for treatment of sacrococcyx (tailbone) pressure ulcer (PU - skin damage due to prolonged pressure).These failures resulted in a delay in the care and treatment of Resident 1's sacrococcyx PU and had the potential for complications of delay wound care such as infection and delayed wound healing, which could compromised the resident's overall health condition.Findings:On March 27, 2026, at 8:01 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue.On April 1, 2026, a review of Resident 1's Face Sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of pneumonia (lung infection).A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated February 4, 2026, indicated a Brief Interview for Mental Status (BIMS - a cognitive assessment) score of 3 (severe cognitive impairment).A review of Resident 1's Progress Notes, dated March 3, 2026, at 9:02 a.m. by the Treatment Nurse (TxN), indicated, Resident 1 was re-admitted to the facility on [DATE], from the General Acute Care Hospital (GACH) with a pressure ulcer (PU) located at his sacrococcygeal area (base of the spine/tailbone area), the PU was unstageable (completely covered by dead skin, unable to determine the stage of the wound), present on admission [DATE]), measuring 9 cm (centimeters - a unit of measurement) in width by (X) 11 cm in depth with discoloration around the surrounding skin.A review of Resident 1's care plans (Individualized plan of care for specific health issues), initiated on March 3, 2026, titled, (Resident 1) Has Unstageable PU . to sacrococcyx area (Base of the spine/tailbone area), which included the intervention of, . Administer treatments as ordered .A review of Resident 1's physician's orders, indicated no wound care treatment orders to treat resident's sacrococcyx PU identified by the TxN on March 3, 2026.A review of Resident 1's Treatment Administration Record, for the month of March 2026, indicated no wound care treatments were administered to Resident 1's sacrococcyx PU.A review of Resident 1's treatment orders, dated March 8, 2026 (six days after the PU was identified on March 3, 2026), indicated, . Medihoney (wound ointment) and.Dressing.to Coccyx (Sacrococcyx).every day shift for open wound Cleanse with (Normal Saline).cover with foam or silicone dressing.A review of Resident 1's. TAR, for the month of March 2026, indicated Resident 1 began receiving treatments for the sacrococcyx PU on March 9, 2026 (seven days after it was first identified).On April 1, 2026, at 2:34 p.m., a concurrent interview and review of Resident 1's record were conducted with the TxN and stated the following:- When a resident is admitted to the facility, the Registered Nurse (RN) completes an admission skin assessment (skin check) to identify any skin issues, then the same day or the following day, the TxN completes an additional skin check to verify and/or identify additional skin issues if any;- If he identifies a skin issue, the wound care physician is to be notified, orders received and carried out, and completed treatments are documented by the nurse in the resident's TAR;- Resident 1 was re-admitted to the facility on [DATE], and a skin check was completed on March 3, 2026, which identified a sacrococcygeal PU with discoloration of the surrounding skin, and no wound care orders were received;- He was responsible for receiving these orders, and he was not sure why the orders were not received, but they should have been;- The Wound Care physician conduct wound care visits every Thursdays and re-evaluates the resident's reported skin issues identified by the TxN. The TxN stated he accompanied the wound care physician and would carry out any treatment orders recommended by the wound care physician. Resident 1's record was further reviewed with the TxN which indicated the following:- SNF Wound Care, note, dated, March 5, 2026, by the Wound Care physician, indicated, . (Resident 1) was (re) admitted on (March 2, 2026), with a DTI (Deep Tissue Injury) on the sacrococcyx . (Resident 1) was transferred from (GACH) with this acquired wound, for which I was asked to evaluate and recommend treatment . Measurement: 9.0 X 11.0 cm UTD (Unstageable depth unknown) . Plan (Orders): Cleanse with normal saline and apply barrier cream daily .- Resident 1's physician's order indicated no treatment orders recommended by the wound care physician on March 5, 2026, was transcribed on Resident 1's record.On April 1, 2026, at 4:17 p.m., a concurrent interview and review of Resident 1's SNF Wound Care note dated March 5, 2026, and the resident's treatment orders were conducted with the TxN. The TxN verified Resident 1's sacrococcyx wound assessed by the Wound Care physician on March 5, 2026, is the same sacrococcygeal wound he identified on March 3, 2026. The TxN verified he received Resident 1's SNF wound care note and treatment orders from the physician, and he did not document or transcribe the orders into the resident's medical record. The TxN further stated a complication of Resident 1 not receiving prompt treatments for his sacrococcyx PU could lead to the PU becoming an open wound and potential for delayed wound healing.On April 1, 2026, at 4:30 p.m., a concurrent interview with the Director of Nursing (DON), and record review of Resident 1's progress notes, admission skin checks dated March 3, 2026, and treatment orders were conducted. The DON stated upon admission to the facility, the resident's admission skin check is to be completed by the RN. If a skin abnormality is identified, the RN will notify the physician and receive treatment orders. The DON stated the TxN will check the resident's skin on day two of admission, and if a skin issue is found, the TxN will notify the Wound Care physician and receive treatment orders. The DON further stated when treatment orders were received they should be transcribed into the resident's medical record, and any identified skin issues should be documented. The DON verified Resident 1 was re-admitted to the facility on [DATE], and RN 1 did not document an admission skin check. The DON stated he was not sure what happened, but RN 1 should have completed an admission skin check and received treatment orders from the physician, if needed. The DON verified the TxN completed a skin check on Resident 1 on March 3, 2026, at which time a sacrococcyx PU was identified and no physician orders were received by the TxN. The DON stated treatment orders should have been received by the TxN and carried out.On April 2, 2026, at 7:11 a.m., a concurrent interview with RN 1, and record review of Resident 1's admission notes and Dr's orders was conducted. RN 1 stated upon a resident's admission to the facility, it is the facilities policy to complete an admission skin check to assess any skin issues. The RN stated the admission skin check should be documented in the resident's medical record. RN 1 further stated it's Important to complete and document the admission skin check because the resident medical record is a continuation of care, and a way nursing staff communicate the resident's health care issues to each other. RN 1 stated if a resident has an identified skin issue on admission there are Batch (treatment) orders, that can be transcribed into the resident's medical records, until the resident's skin is re-checked by the TxN. RN 1 further stated it is important to begin wound treatments on admission to help prevent the skin issue from getting worse. RN 1 reviewed Resident 1's admission orders from March 2, 2026, and verified he transcribed the orders, indicating he was responsible for completing Resident 1's admission skin check. RN 1 reviewed Resident 1's progress notes and verified he did not complete or document an admission skin check, stating he should have, as it is the facilities policy to do so.On April 2, 2026, at 3:28 p.m., an interview was conducted with the DON, who stated when a resident is admitted to the facility, nursing staff should follow the admission Assessments Checklist, which provides a list of assessments, including the skin check, that are to be completed upon admission. The DON stated nursing staff are expected to complete all admission assessments, review and transcribe any Drs orders, and document the admission in the resident medical record at the time of the resident's admission. A review of the facilities, admission Assessments Checklist, undated, indicated .Please refer to checklist to complete upon new patient admission.Assessments that need to be completed.Skin Assessment.A review of the facility's policy and procedure titled, Nursing Administration - Admission, revised, February 2023, indicated, .Obtain information about the resident to establish baseline data .The resident should be admitted according to the procedure by the licenses nurse .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for the residents, staff, and the visitors, when:1.The floors in Hallway 100 were deformed with multiple raised areas; and2. The ceiling in room [ROOM NUMBER] had a crack due to water damage.These failures had the potential for residents, staff, and visitors to be harmed from the unsafe environment.Findings:On January 16, 2026, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding physical environment.On January 16, 2026, at 10 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated there was a ceiling leak in the facility at the end of November from the rains in Hallway 100, but there was no mold noted from the leak, and it was repaired after.On January 16, 2026, at 11 a.m., an interview was conducted with the Director of Maintenance (DM). The DM stated there were three leaks in the roof from the rains, one was in November and two in December. The DM stated one of the leaks did affect a resident's room, and a piece of the dry wall was cut and repaired. The DM stated the facility uses TELS (The Equipment Lifecycle System - a facility wide building management platform-work order system that creates a work order, tracks it, until completion) to keep track of work orders and maintenance repairs.On January 16, 2026, at 1:40 p.m., an observation and concurrent interview was conducted with the Certified Nursing Assistant (CNA) 2. The flooring in Hallway 100 was observed to be deformed with multiple raised areas on the floor while walking. CNA 2 stated the floor had bumps on it, and that it was not safe for the residents or staff as someone could trip and fall.On January 16, 2026, at 1:50 p.m., an observation and concurrent interview was conducted with the DON. The DON observed the flooring in Hallway 100 and stated the flooring should not have bumps in it, and that was a safety hazard for residents and staff.On January 16, 2026, at 2 p.m., an observation and concurrent interview was conducted with the Maintenance Assistant (MA). The MA observed the flooring in Hallway 100 and stated the floors are laminate and the bubbles could occur if there was not enough glue used to put them in place. The MA stated that this could be a safety hazard and someone could trip. The MA stated a work order should be placed through TELS, maintenance needs to assess the area, remove the affected tiles, and replace them with new ones. The ceiling in room [ROOM NUMBER] was concurrently observed with the MA. The MA stated there is a crack in the ceiling from the water damage from a leak which they had repaired before. The MA stated the ceiling needs to be repatched. Resident C was observed in his bed and located under the cracked ceiling.On January 20, 2026, at 1:50 p.m., a concurrent interview and observation was conducted with Resident C. Resident C stated the ceiling was fixed and does not drip on him. The ceiling in Resident C's room was observed to be lumpy with possible water damage, and the paint was cracked and chipped.A review of the facility's undated policy and procedure titled Maintenance Department, indicated, .maintain a clean and safe facility and grounds.through.preventative maintenance.corrective maintenance.certify safe status of the physical plant system and all equipment.floor, wall and ceiling surfaces must be smoothy, dry and cleanable. Any cracks may harbor bacteria.

Based on interview and record review the facility failed to ensure appropriate treatment and services to restore continence (voluntary control to retain urine or feces until an appropriate time) was provided, for one of five residents (Resident B).This failure resulted in Resident B not receiving the appropriate toileting program to restore or maintain as much normal function of her bladder as possible, and prevent accidents and injuries.Findings:On January 16, 2026, at 9:45 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care and treatment.On January 20, 2026, at 12:15 p.m., an interview was conducted with Resident B. Resident B stated care it could take a while for the staff to come and assist her when she calls for assistance. Resident B stated she understands the staff were working with other residents and there were only two to three CNAs on the floor for all the residents, but she wished they could check on her sooner. Resident B stated she tried to take herself to the bathroom, she lost her footing, fell, and soiled herself.On January 20, 2026, at 12:30 p.m., a review of Resident B's medical record was conducted. Resident B was admitted to the facility on [DATE], with diagnoses which included respiratory failure with hypoxia (not enough oxygen reaching the tissue level-causing shortness of breath, confusion, and bluish skin), muscle weakness, and tracheostomy (an opening in the neck, leading into the trachea [windpipe] to establish a secure airway).A review of Resident B's care plans indicated:-dated February 8, 2022, .is on diuretic (water pills-medication to help the body get rid of sodium [salt] and water through increased urination) therapy CHF (congestive heart failure-a condition where the heart cannot pump efficiently and meet the body's needs, blood and fluid buildup in the lungs, legs and abdomen) swelling.interventions. increased risk for falls.monitor for increased risk for falls.-dated September 14, 2022, .has occasional bladder incontinence (involuntary leakage of urine due to loss of bladder control) r/t (related to)-COPD (chronic obstructive pulmonary disease-a lung disease that restricts airflow), respiratory failure has tracheostomy-disease process-impaired mobility-obesity.interventions .brief (diaper) use per pt (patient) request.an unobstructed path to the bathroom.incontinent: check as required.A review of Resident B's History and Physical, dated October 16, 2025, indicated Resident B could make decisions.A review of Resident B's Bowel and Bladder Evaluation, dated October 17, 2025, at 12:41 p.m., indicated; .unlikely candidate for Bowel and Bladder re-training.A review of Resident B's Change in Condition Evaluation, dated December 19, 2025, at 2:08 p.m., indicated; .s/p (status post [after]) fall attempting to go to the bathroom.resident was found in room on the floor lying on her back.neuro-checks (neurological assessment used to evaluate brain and nervous system function) initiated with no abnormalities noted. ROM (range of motion) upper/lower extremities (arms/legs) normal to baseline.resident stated she had pain radiating from her lower back and right wrist.assisted resident back to bed safely. Resident stated she was attempting to go to the bathroom unassisted.lost her balance and landed on her backside.no visual injuries noted.encouraged and educated resident to call for assistance utilizing call light and she agreed.pain assessment.acute.back.abrupt onset of severe pain secondary to fall or injury.A review of Resident B's Fall Risk Evaluation, dated December 19, 2025, at 2:08 p.m., indicated; .balance problem while walking.decreased muscular coordination.requires use of assistive devices.A review of Resident B's Minimal Data Set (MDS - a federally mandated resident assessment tool), dated December 26, 2025, indicated Resident B does not have a toileting program and is frequently incontinent with bladder.On January 20, 2025, at 3:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident B fell when she went to the bathroom by herself. Resident B should be re-evaluated for a toileting program, she has been here a long time and should be able to be continent as much as she can since she can ambulate and could be a candidate for bowel and bladder toileting program.A review of the facility's policy and procedure titled Toileting Program, dated February 2025, indicated, .bowel and bladder retraining will be provided for residents with the potential to benefit from such a program. When medically appropriate, bowel and bladder toileting is the preferred treatment option for incontinence.helps the resident to attain the highest level of independence on bowel and bladder continence.address toileting program on resident's care plan.reassess the program on quarterly basis and as needed.assessing a resident for toileting program.level of awareness-willingness to cooperate.medications. follow the resident specific toileting program.

Based on observation, interview, and record review, the facility failed to ensure care and treatment to manage pain was provided, for one of five residents (Resident A), when:1.Resident A received a pain medication ordered by the physician for pain scale of 4 to 10 for a pain scale of 0/10 (no pain); and2.The physician's order for pain management consult was not scheduled since it was ordered on October 26, 2025. These failures could delay the care and treatment needed to manage Resident A's pain effectively.Findings:On January 16, 2026, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment.On January 20, 2026, at 12 p.m., an interview was conducted with Resident A. Resident A stated she hurts all over and it is difficult to move. Resident A stated she was supposed to get her Dilaudid (a potent opioid analgesic medication used to treat moderate to severe pain) every three hours and the nurses did not give it to her as ordered. Resident A stated she had asked to see a pain doctor and it had not happened yet.On January 20, 2026, a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included bilateral osteoarthritis (non-inflammatory, joint disease, cause by breakdown of cartilage, leading to bone-on-bone friction and pain) of hips with artificial hip joints, and fibromyalgia (chronic disorder with widespread musculoskeletal pain).A review of Resident A's Order Summary Report, included the following physician's orders:- Monitor level of pain using 0-10 scale, ordered July 28, 2025;- Dilaudid Oral Tablet 4 (four) MG (milligram - unit of measurement), give 8 (eight) mg by mouth every 3 (three) hours as needed for moderate to severe pain (4-10), ordered September 7, 2025.- Pain consultation d/t (due to) uncontrolled pain management, ordered October 26, 2025; and- Morphine Sulfate ER (extended release) Oral Tablet 15 MG, Give 1 (one) tablet by mouth two times a day for pain management, ordered December 30, 2025.A review of Resident A's care plan, dated December 8, 2025, indicated, .Resident having acute pain.interventions.give medication/treatment as ordered.monitor pain levels. A review of Resident A's Medication Administration Record, for the month of January 2026, indicated Dilaudid 4 mg (to be given as needed for pain rate of 4 to 10) was administered with pain level of 0/10 on the following dates and times:- January 5, 2026, at 7:30 p.m.,- January 7, 2026, at 8:14 a.m.,- January 7, 2026, at 3:13 p.m., and- January 7, 2026, at 6:13 p.m.A review of Resident A's Progress Notes, dated December 1, 2025, at 2:50 p.m., indicated, .Phoned (name of pain clinic) to attempt to schedule pain mgmnt (management) consult and was directed to VM (voicemail).A review of Resident A's Progress Notes, dated December 19, 2025, at 12:12 p.m., indicated, .Contacted (name of pain clinic) to f/u (follow up) on referral.Reached VM.A review of Resident A's Progress Notes, dated January 20, 2026, at 12:20 p.m., indicated; .contacted for new pt (patient) referral/appointment (pain management).reached VM (voicemail).On January 20, 2026, at 3:30 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident A takes morphine twice a day, and Dilaudid as needed. The ADON stated Resident A had not seen a pain management specialist yet since the physician ordered for pain management consult on October 26, 2025. The ADON stated there was a delay in getting an appointment with the pain clinic. The ADON stated the licensed staff should be evaluating Resident A's pain before giving her any pain medication and should follow the physician's orders. The ADON stated if Resident A's pain level is 0 out of 10, she should not be getting any as needed pain medication. The ADON stated Resident A's pain management needed to be re-evaluated.A review of the facility's policy and procedure titled Resident Care-Recognition and Management of Pain, dated January 2023, indicated; .ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident' goals and preferences.assists each resident with pain management to maintain or achieve the highest practicable level of well-being and functioning by.evaluating pain.the resident will be evaluated for pain upon admission, quarterly, and with any change in their status.

Based on observation, interview, and record review, the facility failed to ensure patient care equipment was maintained in a safe operating condition, when two of the mechanical lifts (also referred to as Hoyer lifts - devices used to safely transfer mobility impaired patients between beds, chairs, and toilets) remained in use on the floor despite identified problems.This failure could have put residents at risk by allowing the use of unsafe equipment. Findings:On January 16, 2026, at 9:45 a.m., an unannounced visit was conducted at the facility for a complaint on physical environment.On January 16, 2026, at 11a.m., an interview was conducted with the Director of Maintenance (DM). The DM stated the facility uses TELS (The Equipment Lifecycle System-a facility wide building management platform-work order system that creates a work order, tracks it, until completion) to keep track of all patient equipment requesting to be repaired.On January 16, 2026, at 1:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CAN 1 stated they would take out from the floor wheelchair or equipment used for the residents that were not working properly, and give it to the maintenance for repair.On January 16, 2026, at 1:40 p.m., an observation and concurrent interview was conducted with CNA 2. CNA 2 observed mechanical lift #7 to have Coban (a self-adherent wrap that is designed to stick to itself rather than skin-used for wound care, to support sprains, strains, and secure dressings) wrapped around the mechanical lift's casing. CNA 2 stated the mechanical lift might be broken and should not be used, as it was not safe to use with the residents.On January 16, 2026, at 1:50 p.m., an observation and concurrent interview was conducted with the Director of Nursing (DON). The DON observed mechanical lift #7 and stated mechanical lift #7 should not be wrapped with Coban and continued to be used in the unit. The DON stated he did not know why there was Coban wrapped on the mechanical lift. The DON further stated the staff should tell their direct supervisor if an item is not working properly, a report should be placed in TELS, and the item should be removed from the floor. The DON stated this is a safety problem and could cause an injury if continued to be used.On January 16, 2026, at 2 p.m., an observation and concurrent interview was conducted with the Maintenance Assistant (MA). The MA observed mechanical lift #7 and stated that when equipment is not working and there is an issue, the staff need to let maintenance know, put in a TELS work order with a description of what is wrong, and take the equipment out of service.On January 16, 2026, at 2:08 p.m., an observation was made on Hallway 300. A second mechanical lift was observed in Hallway 300 with a sign which read not working, and a staff member was observed coming out of room [ROOM NUMBER] with mechanical lift #7 with the Coban wrapped around the casing.On January 16, 2026, at 2:10 p.m., an interview was conducted with CNA 3. CAN 3 stated she used mechanical lift #7 to put a resident back in bed after he had his lunch and did not notice there was Coban wrapped around part of the equipment. CNA 3 stated she should not have used the mechanical lift #7, it may not have worked properly and caused an accident for the resident, she should have been more caution with the equipment.On January 16, 2026, at 2:20 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated he had helped CNA 3 put a resident back in bed and he did not notice there was Coban wrapped around part of mechanical lift #7. LVN 1 stated he does not know why Coban was there, and the lift should not have been used for resident care. LVN 1 stated he should have questioned why there was Coban wrapped around the mechanical lift, because the equipment could be faulty, and the resident could have fallen and been hurt.On January 16, 2026, at 2:25 p.m., an observation and concurrent interview was conducted with the DON. The DON observed Hallway 300 with both mechanical lifts and stated mechanical lift #7 with the Coban. The DON stated mechanical lift #7 should not have been used for the resident because it was uncertain if it was operation and safe to use. The DON stated the second mechanical lift with the sign not working should have been removed from the floor and a work order to repair the item should have been placed with the maintenance department.On January 16, 2026, at 3:15 p.m., an interview and concurrent record review was conducted with the DM. The DM reviewed his monthly inspection logs, dated November 19, 2025, and December 19, 2025, and stated there are three mechanical lifts in the facility and there was nothing in TELS requesting work to be done on the two mechanical lifts found in the facility. The DM stated there were no work orders put in for either mechanical lift to be repaired.A review of the facility's policy and procedure titled Physical Environment-Equipment Maintenance, dated February 2025, indicated, .routine and non-routine care of equipment and to ensure that equipment remains in good working order for resident and staff safety.electrical and hydraulic equipment will be inspected by the maintenance supervisor or designee prior to initial use and on a routine basis to ensure that equipment is working properly.routine inspections and maintenance will be recorded in the Preventative Maintenance Log or TELS system.in the event that equipment maintenance or servicing is required.Maintenance Request Log will be available at the nursing station.the log will be checked by Maintenance Supervisor or designee daily.

Based on observation, interview, and record review, the facility failed to ensure provision of pharmacy services to meet the needs of the residents, when: 1. Four discontinued bags of large volume fluid for injections containing normal saline (electrolyte supplement in water) 0.45% remained stored in the medication room available for use; 2. One discontinued bag for IV (intravenous, into vein) infusion containing vancomycin (antibiotic for infection) 1 gram in 250 ml (milliliter, unit of measurement) remained stored in the medication refrigerator available for use; 3. One discontinued blister card containing ondansetron (medication for nausea and/or vomiting [N/V]) 4 mg (milligram, a unit of measurement) tablets remained in the medication cart available for use for Resident 55; 4. One discontinued blister card containing generic Norco (hydrocodone/acetaminophen, opioid pain medication) 5-325 mg tablets remained in the medication cart available for use for Resident 62; 5. Midodrine (medication to raise blood pressure)10 mg (milligram, unit of measurement) doses were not given according to the parameters ordered by the physician for Resident 16; and 6. A laboratory test to measure the effectiveness of diabetes medications was not performed consistently according to the physician order for Resident 15. These failures had the potential for medications errors due to inadvertent administration from discontinued medications and, ineffective medication treatment by not following the physician orders. Findings: 1. On June 23, 2025, at 11:30 a.m., during an inspection of the medication room with the Assistant Director of Nursing (ADON), there were four 1-liter bags of 0.45% normal saline for injection without a pharmacy label. The manufacturer labeling of the product indicated it was, Rx (prescription) only. In a concurrent interview, the ADON stated those 1-liter bags were no longer needed for the resident for whom they were ordered and should have been discarded. On June 26, 2025, at 9:30 a.m., during an interview with the ADON, the ADON confirmed the 1-liter bags were not stored in the medication room as house supplies. The facility's policy and procedure titled, Discontinued Medications, last updated, August 2019, was reviewed, and indicated, .If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose .Medications are removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration) . The facility's policy and procedure titled, House-Supplied (Floor Stock) Medications, last updated, August 2020, was reviewed, and indicated, .The facility maintains a supply of commonly used over-the-counter medications considered as floor stock or house medications (not resident-specific) .Floor stock medications are labeled as floor stock or house supply and kept in the original manufacturer's container . 2. On June 23, 2025, at 12:05 a.m., during an inspection of the medication room with the ADON, one IV piggyback (IVPB, a method of administering medication through an existing intravenous line) bag containing vancomycin 1 gram in 250 ml normal saline Resident 85 for a resident labeled with the direction to infuse 1 gram vancomycin every 12 hours for 3 days with the stop date of June 20, 2025. On June 23, 2025, at 1:50 p.m., during an interview with the ADON, the ADON stated Resident 85 completed the IV therapy and the vancomycin bag should have been discarded. The facility's policy and procedure titled, Discontinued Medications, last updated, August 2019, was reviewed, and indicated, .If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose .Medications are removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration) . 3. On June 23, 2025, at 2:25 p.m., during an inspection of Medication Cart Rx 2 with Licensed Vocational Nurse (LVN) 1, there was one blister card containing ondansetron 4 mg (milligram, a unit of measurement) for Resident 55. In a concurrent interview, LVN 1 stated the medication was discontinued. On June 23, 2025, a review of Resident 55's medical record indicated there was a physician order to discontinue ondansetron 4 mg via PEG ( percutaneous endoscopic gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach stomach) every 8 hours as needed for N/V, on June 3, 2025. The facility's policy and procedure titled, Discontinued Medications, last updated, August 2019, was reviewed, and indicated, .If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose .Medications are removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration) . 4. On June 23, 2025, at 3 p.m., during an inspection of Medication Cart Rx 2 with LVN 1, there was one blister card containing generic Norco (hydrocodone/acetaminophen, an opioid pain medication) 5-325 mg tablets for Resident 62. In a concurrent interview, LVN 1 stated the medication was discontinued. LVN 1 stated when the blister cards containing controlled substances were discontinued and identified, the blister cards needed to be removed, counted, and given to the DON. On June 23, 2025, a review of Resident 62's medical record indicated there was a physician order to discontinue generic Norco 3-325 mg via G-Tube (gastrostomy tube, feeding tube inserted into stomach) every 8 hours as needed for moderate to severe pain 4-10 for 30 days, on May 5, 2025. The facility's policy and procedure titled, Discontinued Medications, last updated, August 2019, was reviewed, and indicated, .If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose .Medications are removed from the medication cart immediately upon receipt of an order to discontinue (to avoid inadvertent administration) . 5. On June 25, 2025, Resident 16's medical record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included heart failure, severe chronic kidney disease on dialysis (a medical procedure that helps remove waste products and excess fluid from the blood when the kidneys are unable to perform this function naturally), and hypertension (high blood pressure); A review of Resident 16's physician order, dated June 18, 2025, indicated for midodrine (medication to raise blood pressure)10 mg (milligram, unit of measurement) to be given to Resident 16 three times a day for hypotension (low blood pressure) with the parameter to hold the dose if systolic blood pressure (SBP, top number in a blood pressure reading, representing the pressure in your arteries when your heart beats) is greater than 120 mmHg (millimeter Mercury, unit of measurement of pressure). A review of Resident 16's Medication Administration Record (MAR), indicated midodrine was administered to Resident 16 when the SBP was above 120 on the following dates & times: - June 19, 2025, 12 p.m., SBP of 121; and - June 21, 2025, at 12 p.m., SBP of 123. On June 25, 2025, at 11:45 a.m., during an interview with the ADON, the ADON stated the 12 p.m. doses on June 19 and 21, 2025 were not held and should not have been given to Resident 16 due to SBP being above 120. The facility's policy and procedure titled, Medication Administration - General Guidelines, last updated, November 2021, was reviewed, and indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices .Medications are administered in accordance with written orders of the attending physician . 6. On June 25, 2025, Resident 15's medical record was reviewed. Resident 15 was admitted to the facility on [DATE], with diagnoses which included, adult-onset diabetes mellitus (T2DM, high blood sugar levels resulting from the body's inability to effectively use the insulin it produces). A review of Resident 15's physician indicated the resident was receiving the following medications for T2DM: - Lantus 10 units by injection; - Ozempic 0.5 mg by injection; and - Humulin R by injection per sliding scale parameters. A review of Resident 15's physician order, date ordered on February 1, 2022, indicated to obtain Hgb A1c (hemoglobin A1c, blood test that provides an average blood sugar level over the past 2 to 3 months, a key tool for managing diabetes) test, every three months; and A review of Resident 15's Hgb A1c test results indicated there was no Hgb A1C test completed between May 2, 2024, and February 5, 2025 (August 2024 and November 2024). On June 25, 2025, at 11:50 a.m., during an interview with the ADON, the ADON stated there were some months that were missed, and the test results were not obtained every three months. The facility's policy and procedure titled, Diagnostic Test Results Notification, last reviewed, February 2025, was reviewed, and indicated, .It is the policy of this facility to obtain laboratory and radiology services when ordered by a Physician .Laboratory .services will be arranged as ordered .Notification of test results will be documented in the resident's clinical record .

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when wooden storage shelves in the dry supply area were observed to be chipped, splintered and the lacquered varnish peeled off. This failure had the potential to cause food-borne illness in a highly susceptible resident population. Findings: On June 23, 2025, at 9:52 a.m., an observation with the Dietary Supervisor (DS), was conducted in the dry goods supply room. The wooden shelving was observed to have bare chipped, splintered wood, and the lacquered varnish had peeled off in many places. In a concurrent interview with the DS, the DS stated the staff always use gloves before reaching into the shelves for food items, to avoid splinters from the wood. The DS stated the staff safety related to splinters was a risk. On June 23, 2025, at 10:30 a.m., an interview and observation with Plant Director (PD) was conducted. The PD stated the wooden shelves should not be chipped, splintered or unsealed because of possibility of staff injury and cross-contamination of resident food. On June 24, 2025, at 10:27 a.m., an interview with the Registered Dietician (RD) was conducted. The RD stated she was aware of the state of the damaged shelving in the dry goods supply room and had notified both the PD and the Administrator at different times through this year. The RD stated the wooden shelves should not have opened, unsealed, chipped wood as it was possible for staff injury and cross-contamination leading to possible illness in the vulnerable resident population. A review of the facility's policy and procedure titled, Food Storage, dated February 2025, indicated, .All food .items purchased for the Food & Nutrition Services Department should be properly stored .all food items .shall be stored .on shelves .which facilitate thorough cleaning .

Based on observation, interview, and record review, the facility failed to ensure an assessment for safe self-administration of medication was conducted, for one of one resident reviewed (Resident 44), when two open white plastic containers of topical ointment was found on the overbed table. This facility failure increased the potential for unsafe self-administration of medication. Findings: On June 23, 2025, at 3:08 p.m., during a concurrent observation and interview with Resident 44 in her room, two white plastic containers of topical ointment were observed on top of her over bed table. Resident 44 stated she applied the topical ointment to her lower legs when she felt itchy. Resident 44 further stated she would put more ointment if she wanted to. The two plastic containers were observed to have a label which indicated, .Oxide de Zinc 25% (zinc oxide). On June 23, 2025, Resident 44's admission RECORD, was reviewed. Resident 44 was admitted on [DATE], with diagnoses which included personal history of infectious and parasitic (organism that lives on a host) diseases. A review of Resident 44's HISTORY AND PHYSICAL, dated August 14, 2024, indicated Resident 44 was mentally capable to make decisions. Further review of Resident 44's medical record indicated there was no documented evidence a self-administration assessment was conducted. On June 23, 2025, at 3:14 p.m., a concurrent interview and review of Resident 44's medical record was conducted with Registered Nurse (RN) 1. RN 1 stated Resident 44 had two open white plastic containers of medication on top of the overbed table. RN 1 stated there was no assessment conducted for self-administration of medications for Resident 44. RN 1 stated Resident 44 should not have been allowed to self-administer the ointment without a proper assessment for self-administration. RN 1 further stated it was not safe for Resident 44 to have medications at the bedside, and an assessment for self-administration of medication should have been conducted for Resident 44. On June 25, 2025, at 9:02 a.m., during an interview with the Assistant Director of Nursing (ADON), the ADON stated she expected the licensed nurses to follow the policy and procedure regarding self-administration assessment and administration of medications for all residents. The ADON further stated if the policy and procedures were not followed, there was a potential for the residents to not receive medications according to the physician's order, and to not be monitored for any adverse (negative) effects. A review of the facility's policy and procedure titled, SELF ADMINISTRATION OF MEDICATIONS, dated February 2025, indicated, .It is the policy of this facility to respect the wishes of alert, competent residents to self-administer prescribed medication choosing to and capable of self-administration .To determine the ability of alert residents to participate in self-administration of medications .the interdisciplinary team will assess and periodically re-evaluate . A review of the facility's policy and procedure titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated November 2021, indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications .

Based on observation, interview, and document review, the facility failed to ensure medications were labeled with the name of the resident for whom they were intended to be administered. This failure had the potential for medications to be shared by multiple residents. Findings: On June 23, 2025, at 2:25 p.m., during an inspection of Medication Cart Rx 2 with LVN 1, there was one Saline Nasal Spray, not labeled with the name or room number of the resident. In a concurrent interview with LVN 1, LVN 1 confirmed there was no name or room number on the spray bottle or the spray bottle's manufacturer box. LVN 1 stated the spray bottle needed to be labeled with the resident's name. LVN 1 stated she would not know who the medication was for without the name on the medication box. The facility's policy and procedure titled, Labeling and Storage, last revised, February 2025, was reviewed, and indicated, .Each prescription medication label includes .Resident's name . The facility's polity and procedure titled, Medication Administration - General Guidelines, updated November 2021, was reviewed, and indicated, .Medications supplied for one resident are never administered to another resident .

Based on observation, interview, and record review, the facility failed to follow up the dental needs of a resident, for one resident reviewed for dental services (Residents 15) . This failure has the potential to place Resident 15 at high risk for complications related to dental and nutritional needs due to the delay in providing dental services. Findings: On June 24, 2025, at 9:15 a.m., during a concurrent observation and interview with Resident 15 in her room, Resident 15 was observed with missing partial upper teeth. Resident 15 stated she wanted to have dentures so she requested to be seen by the facility dentist, but no one updated her if she would receive the dental service or not. On June 24, 2025, Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE], with diagnoses which included tracheostomy status (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). A review of Resident 15's Initial admission Record, dated February 2, 2022, the oral assessment indicated Resident 15's natural teeth were missing, and was unable to function without natural teeth and dentures. A review of Resident 15's History and Physical Note, dated January 18, 2025, indicated Resident 15 had the capacity to understand and make decisions. A review of Resident 15's Nutrition/Hydration Risk Evaluation, dated February 4, 2025, indicated Resident 15 had several missing teeth. A review of Resident 15's Order Summary Report, dated June 25, 2025, included a physician's order for low concentrated sweets diet (a type of diabetic diet), regular consistency. A review of Resident 15's dentist notes titled, Impressions Mobile Dentistry, indicated Resident 15 had multiple upper missing teeth and had recommendations as follows: - On October 23, 2024, Resident 15 wanted to have upper dentures, and eligibility for full upper denture (FUD) would be checked; and - On April 10, 2025, Resident 15 wanted to have a dentures on the upper arch and eligibility would be checked for FUD. Further review of Resident 15's medical record indicated there was no documented evidence a follow up was made by the Social Services and Nursing Department regarding Resident 15's eligibility for FUD. On June 25, 2025, at 7:53 a.m., a concurrent interview and review of Resident 15's record was conducted with Registered Nurse (RN) 2. RN 2 stated Resident 15 had dental consultations on October 23, 2024 and April 10, 2025, with a note from the dentist that Resident 15 expressed she wanted to have an upper denture. RN 2 stated, Resident 15's dental request should have been followed up. RN 2 further stated if Resident 15's dental requests were not followed up, there would be a delay of dental care services which could lead to nutritional health issues such as weight loss due to poor oral intake. On June 25, 2025, at 8:09 a.m., during an interview with the Social Service Director (SSD), the SSD stated she did not do a follow up regarding Resident 15's need for dental services. The SSD stated there should have been a follow up with the dentist for Resident 15 to have dentures. The SSD stated if dental services were not followed up, a delay of dental care could worsen Resident 15's health status. On June 25, 2025, at 8:50 am, during an interview with the Director of Nursing (DON), the DON stated the Social Services Department was responsible for the dental needs of the residents, and Resident 15's dental care should have been followed up. The DON further stated if Resident 15 did not receive dental services, she could not eat food properly and this could lead to weight loss. A review of the facility's policy and procedure titled, Dental Services, dated January 2022, indicated, .It is the policy of this Facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier .For Medicare and private pay residents, the Facility will ensure that the needed dental services are available . A review of the facility's policy and procedure titled, Social Services, Provision of Medically-Related, dated February 2025, indicated, .It is the policy of this facility to provide medically-related social service to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident .Social service is responsible for providing for medically related social service needs of each resident .Examples of these services may include but are not limited to .Scheduling appointments .

2. On June 23, 2025, at 12:10 p.m., Resident 64 was observed eating lunch in his room. Resident 64 was eating one of two burritos served on a separate plate from the main entree, which contained a piece of meat, parslied rice, and braised cabbage. When asked if he did not like the main dish served for lunch, Resident 64 stated, I don't like pork, so he asked for burritos instead. Resident 64 further stated he disliked pork, but I get it always. Resident 64's meal ticket was reviewed, which indicated, LCS (low calorie sweeteners) Diet .Regular Consistency .GARLIC HERB PORK CHOP 1-EACH .Dislikes: PORK . On June 23, 2025, at 12:30 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated Resident 64 should not have been served pork since that was his dislike, and kitchen staff should follow what it says on the diet slip. A review of Resident 64's record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses which included end-stage renal disease (a condition in which kidneys cannot filter waste from the blood) and diabetes (abnormal blood sugars). Resident 64's MDS indicated a BIMS score of 15 (cognitively intact). On June 24, 2025, at 10:27 a.m., an interview was conducted with the Registered Dietician (RD). The RD stated the residents were interviewed by the Dietary Supervisor (DS) on admission, quarterly, and as needed for allergies, preferences, and dislikes. The RD stated the preferences, dislikes, and allergies were printed on the dietary meal ticket, which would guide the cook and dietary aides during the process of plating the correct therapeutic diet, preferences, and to avoid the chance of allergy food being included by mistake. The RD stated Residents 64 and 76 should not have been served pork for their meals as they had a dislike for pork. The RD stated the goal was to provide a satisfying, nutrient filled meal that can be enjoyed by the residents. The RD further stated food intake may be inadequate by not making reasonable efforts to adjust to the residents' food plan and preferences. A review of the facility's policy and procedure titled, Alternates on the Menu & Meal Substitution, dated January 2018, indicated, .Patient food preferences shall be adhered .the DFNS keep tray card updated with dislikes .the cook keeps tallies of diets and dislikes .provides alternate menu item as dictated by the resident's food dislikes . Based on observation, interview, and record review, the facility failed to ensure food preferences were honored, for two of 15 sampled residents (Residents 64 and 76), when the residents were served pork during the lunch meal service on June 23, 2025. This failure had the potential for Residents 64 and 76's dietary intake to be inadequate, by not making reasonable efforts to adjust to the residents' food plan and preferences. Findings: 1. On June 23, 2025, at 11:55 a.m., an observation of Resident 76 was conducted in the dining room. Resident 76's plate contained chopped pork meat, parslied rice, chopped braised cabbage, cornbread with margarine, peach crisp and a beverage. Resident 76 ate his food without assistance and ate the contents of the plate with only a few bites of the pork meat consumed. A concurrent interview with Resident 76 was conducted. Resident 76 stated he liked most of the food, but had a dislike for pork. A review of Resident 76's lunch ticket indicated REGULAR Diet Mech Soft/Grnd (mechanical soft/ground- food prepared to be easily chewed and swallowed by grinding or chopping) Texture .GARLIC HERB PORK CHOP 1-EACH .Dislikes: PORK . A review of Resident 76's record indicated Resident 76 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty or discomfort swallowing). A review of Resident 76's Minimum Data Set (MDS- a clinical assessment tool), dated May 16, 2025, indicated a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact).

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, when: 1. For Resident 47, a black stand fan in the resident's room was observed with dust accumulated on the front and back guard covers; and 2. For Resident 287, one used plastic urinal was found inside the resident's personal belonging's storage closet. These failures had the potential to increase the spread of pathogens (germs) and infections to residents which could lead to serious illness. Findings: 1. On June 23, 2025, at 10:55 a.m., during a concurrent observation and interview with Certified Nursing Assistant (CNA) 1 in Resident 47's room, a black stand fan was observed with black and gray debris accumulated on the front and back guard covers. CNA 1 stated it was dust, and the fan should have been cleaned. On June 25, 2025, Resident 47's record was reviewed. Resident 47 was admitted to the facility on [DATE], with diagnoses which included respiratory failure with tracheostomy (trach-an opening in the neck, directly into the trachea [windpipe], to facilitate breathing). A review of Resident 47's HISTORY AND PHYSICAL, dated January 25, 2024, indicated Resident 47 was mentally incapable of understanding. A review of Resident 47's Minimum Data Set (MDS- a resident assessment tool), dated March 31, 2025, indicated Resident 47 had tracheostomy care treatment. A review of Resident 47's Care Plan Report, dated January 30, 2024, indicated, .Tracheostomy care per facility protocol . A review of Resident 47's Order Summary Report, dated June 25, 2025, indicated Resident 47 was on enhanced barrier precaution due to gastric tube (a tube inserted directly into the stomach) and trach. On June 23, 2025, at 11 a.m., during a concurrent observation and interview with the Respiratory Therapist (RT), the RT stated the stand fan was dusty and it should have been cleaned. The RT further stated the dust from the fan could potentially fly through the air and go to Resident 47's mouth or trach site, and could cause respiratory infection. On June 25, 2025, at 2:47 p.m., during an interview with the Infection Preventionist (IP), the IP stated the stand fan and other equipment used for residents must be free from dust. The IP further stated dust accumulated in the fan could cause the spread of germs and result in respiratory infection. On June 25, 2025, at 3:10 p.m., during an interview with the Assistant Director of Nursing (ADON), the ADON stated she expected the staff to clean equipment surfaces, and these should be free from dust. The ADON further stated any accumulated dust that floats through the air and goes to the resident's trach, could cause respiratory infection. A review of the facility's policy and procedure titled, Rooms, Cleaning Residents, dated February 2025, indicated, .It is the policy of this facility to provide a clean, comfortable, homelike and sanitary living area .Damp wipe surfaces .with germicidal solution . A review of the facility's policy and procedure titled, Infection Control, dated February 2025, indicated, .The infection prevention and control program as a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .Recognize infection control practices while providing care .Effective cleaning and disinfecting equipment as needed . 2. On June 23, 2025, at 10:10 a.m., during a concurrent observation and interview with CNA 1, one used plastic urinal was found inside Resident 287's personal belonging's storage closet. CNA 1 stated it should not be placed on top of the storage closet shelves and should be placed in urinal holder. CNA 1 further stated It should not be placed anywhere. On June 25, 2025, Resident 287's record was reviewed. Resident 287 was admitted to the facility on [DATE], with diagnoses which included kidney failure (kidney disease), malignant melanoma of skin (skin cancer). A review of Resident 287's HISTORY AND PHYSICAL, dated June 19, 2025, indicated Resident 287 was mentally capable of understanding. A review of Resident 287's Order Summary, dated June 19, 2025, indicated Resident 287 had abdominal surgical dehiscence (the separation of a surgical incision in the abdomen, exposing underlying tissues or organs) and had a trach in neck area. On June 23, 2025, at 10:15 a.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3, LVN 3 stated used urinal should be placed in urinal holder and or should be discarded if Resident 287 did not use it. LVN 3 stated proper storage of urinal should have been implemented to prevent spread of germs. LVN 3 further stated It is infection control issue. On June 25, 2025, at 2:46 p.m., during an interview with the IP, the IP stated plastic urinals should be placed in urinal holder when not in used and should not be stored anywhere. The IP further stated if not properly stored, it would result to surface contamination and would spread of infection. On June 25, 2025, at 3:10 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected the nurses to follow proper storage of urinals and follow the facility's policy and procedure in infection control. The DON further stated if proper storage of urinals would not follow, it would result to cross contamination and would spread infection. A review of the facility's policy and procedure titled, Infection Control, dated February 2025, indicated, .The infection prevention and control program is comprehensive in that it addresses detection, prevention and control of infections among residents and personnel .Safe use of disposable and single use supplies and equipment . A review of the facility's policy and procedure titled, Bedpan and Urinal, Cleaning and Storage, dated February 2025, indicated, .It is the policy of this facility to provide clean and sanitary bedpans and urinals as well as store them for residents .urinal will be labeled with resident's name .Place the urinal in the urinal holder by the bed side .

Based on observation, interview, and record review, the facility failed to ensure resident's wheelchairs were maintained in a safe operating condition, for two of 15 residents (Residents 45 and 70). These failures had the potential to result in injury to the residents. Findings: 1. On June 24, 2025, at 1 p.m., a record review for Resident 45 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis (the spaces inside the bone become too small), aftercare following joint replacement surgery and diabetic neuropathy (type of nerve damage that occurs with diabetes). A review of Resident 45's Minimum Data Set (MDS - a resident assessment tool), dated June 3, 2025, included a Brief Interview for Mental Status (BIMS) score of 15 (cognitive intact). On June 24, 2025, at 1:58 p.m., an interview and concurrent observation with Resident 45 was conducted. Resident 45 stated the wheelchair he was using was broken including the left-hand break which does not lock up, the left-hand armrest was loose, and wobbles when the chair was being used, and the right-hand wheel had a metal hand rim which was missing part of the rim leaving sharp edges easily available to the resident's hand. Resident 45 stated this was dangerous and someone could be hurt. On June 24, 2025, at 2 p.m., an interview and concurrent observation with Plant Director (PD) was conducted in Resident 45's room. The PD assessed Resident 45's wheelchair and acknowledged the need for parts replacement. The PD stated he had not known the wheelchairs had broken parts. The PD stated the cracked upholstery was an infection control issue and could cause cross-contamination leading to illness of the residents and the broken metal and inoperative brake were a risk for resident injury. On June 24, 2025, at 2:34 p.m., an interview with Physical Therapy Assistant (PTA) was conducted. The PTA stated he had assisted with Resident 45's wheelchair problem. The PTA stated he had looked for a working/new wheelchair but was unable to find another more appropriate replacement. The PTA stated Resident 45's current wheelchair had a metal piece that needed to be replaced and the resident agreed to be careful and would refused another exchange. The PTA stated he had sent a work request to maintenance for repair of wheelchair in PCC, describing the issue. The PTA stated he had completed the following process for Resident 45's broken wheelchair: - Replace the broken equipment for the resident; - Send a work order in the computer system noting the repair needed; and - Remove the broken equipment and place it in the workshop with a note attached documenting the repair needed. 2. On June 24, 2025, at 1 p.m., a record review of Resident 70's record indicated Resident 70 was admitted to the facility on [DATE], with diagnoses which included unilateral primary osteo arthritis (occurs when cartilage wears down on joint bone ends), right knee pain, hemiplegia (paralysis or extreme weakness on one side of the body). A review of Resident 70's MDS, dated April 13, 2025, included a BIMS score of 15 (cognitive intact). On June 24, 2025, at 11:50 a.m., an interview and concurrent observation with Resident 70 was conducted. Resident 70 stated his wheelchair had been fixed once though the wheelchair remained shaky and the armrest still had cracked and peeling upholstery. Resident 70 stated the left wheel of the wheelchair was loose and Resident 70 have reported the issue. Resident 70 stated the left armrest's upholstery and padding was cracked and peeling with holes for the padding to stick out. On June 24, 2025, at 2 p.m., and interview and concurrent observation with the PD was conducted. The PD assessed Resident 70's wheelchair and acknowledged the need for parts replacement. The PD stated he had not known the wheelchairs had broken parts. The DP stated the cracked upholstery is a infection control issue and could cause cross-contamination leading to illness of the residents and loose wheel were a risk for resident injury. A review of the facility's policy and procedure titled, Physical Environment - Equipment Maintenance, dated February 2025, indicated, .to ensure equipment remains in good working order for resident and staff safety . A review of the facility's policy and procedure titled, Resident's Rights - Accommodation of Needs, dated February 2025, indicated, .the facility to be aware of the importance of accommodation of needs for each resident .nursing staff will communicate .any specific accommodation of a particular resident .

Based on interview and record review, the facility failed to ensure care and treatment was provided timely, for one of five residents reviewed (Resident 1), when Resident 1 had an elevated pulse rate (heart beat per minute {BPM}) and decreased oxygen saturation ({O2 Sat} - the amount of hemoglobin carrying oxygen within the blood). The failure had the potential for a delay in the care and treatment and affect the resident's overall health condition of Resident 1. Findings: On May 22, 2025, at 1210 p.m., an unannounced visit was conducted to the facility to investigate a complaint regarding quality of care. A review of Resident 1 ' s medical records titled, Resident Information, dated May 23, 2025, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of respiratory failure (respiratory system is unable to adequately provide oxygen to the body) with hypoxia (low blood oxygen). A review of Resident 1 ' s Progress Notes, dated December 26, 2024, at 1:48 a.m., by Licensed Vocational Nurse (LVN) 1, indicated, . (Resident 1) found unresponsive. Upon assessment .oxygen level at 65% (normal values 95 -100%) on room air (no added oxygen). PT (Resident) placed on oxygen via nasal canula (nostrils) 5L (liters) ineffective .Pulse 132 (elevated, normal values 60 -100 beats per minute); O2 (sats): 73% (low) via nasal cannula. RN (Registered Nurse) made aware . Further review of Resident 1's record indicated the physician was not notified of Resident 1 ' s elevated pulse and low oxygen level. A review of Resident 1 ' s Progress Notes, dated December 26, 2024, at 2:12 a.m., by RN 1, indicated, . (Resident 1) Resting in bed with eyes closed, known to staff (resident) is fine .skin is cold to touch .(Pulse) 126 (elevated) . (Resident agree(s) if get(s) worse will go to hospital . Further review of Resident 1's record indicated the physician was not notified of Resident 1 ' s elevated pulse and rate. A review of Resident 1's Progress Notes, dated December 26, 2024, at 7:52 a.m., by Respiratory Therapy (RT), indicated, .Pt (Resident 1) refusing to wear oxygen mask .(O2 sat) 87% (low), (Pulse) 143 (elevated) .explained to the (resident) he was in need of oxygen .(resident) .said no .RN and LVN notified at this time . Further review of Resident 1's record indicated the physician was not notified of Resident 1 ' s elevated pulse rate and low O2 sats. A review of Resident 1 ' s documented pulse and O2 sats, dated December 26, 2024, indicated resident ' s values were not closely monitored between the hours of 01:58 a.m. and 10:28 a.m.: - 1:48 a.m.; P (pulse) 132 (elevated); O2 Sat 65 - 73% (low), - 1:58 a.m.; P 132; O2 Sat 73%, - 2:12 a.m.; P 126 (elevated); no documented O2 Sat noted, - 5:11 a.m.; Pulse 107 (elevated); O2 sats 90% (low), - 7:52 a.m.; P 143 (elevated); O2 sat 87% (low), and - 10:28 a.m.; O2 Sats 84-86%, no Pulse noted. A review of Resident 1 ' s, Progress Notes, dated, December 26, 2024, at 10:28 a.m., by RN 2, indicated, . RT did not made (sic) aware (resident) was refusing Oxygen mask, upon arrival found (resident) in bed .(Oxygen) mask on the left side of the bed (not on resident) .O2 (Sats) ranges from 84-86 (%-low) .(Resident 1) is refusing the oxygen .keeps refusing oxygen, and (resident) stated he's aware but still refuses .Called Dr .and made aware (resident) is refusing to go to the ER (Emergency Room) to get evaluated and refusing oxygen. (Dr) stated he is making rounds in another facility, but he will come to evaluate (Resident 1) today as soon as he can .(resident representative) is requesting (Resident 1) to be sent to the ER. Dr (physician) .said sent (sic) to ER per (representative) request . A review of Resident 1 ' s, Progress Notes, dated December 26, 2024, at 11:41 a.m., by RN 2, indicated, . Called 911 to transfer (resident) out (to ER) for low oxygen level 84% .(Resident 1) refused to go to the ER .DR . stated he will be here (facility) in person to evaluate .(resident) . Further review of Resident 1's record indicated the physician did not come to the facility on December 26, 2024 to evaluate Resident 1 and there was no follow up to the physician when he would present to the facility. A review of Resident 1 ' s, COC,, dated, December 27, 2024, at 1050 a.m., by RN 3, indicated, . Abnormal vital signs .started on (December 27, 2024) . morning .Pulse 163 (elevated); O2 Sats 91%; Blood Pressure 76/66 (low, normal values 90/60 to 130/80); Temperature 98.0 (normal value); Respirations (Breaths per minute) 11 (low, normal values 12 - 20) .Decreased level of consciousness (sleepy, lethargic) .Gradual change in level of consciousness .(physician notified, December 27, 2024) at 10:55 (a.m.) .Recommendations of (Dr): Send to (GACH-General Acute Care Hospital) for evaluation . A review of Resident 1 ' s, Progress Notes, dated, December 27, 2024, at 11:10 a.m., by RN 3, indicated, 911 was called. Paramedics arrived . approximately (at) 1100 a.m. (Resident 1) left the facility approximately (at) 1115 a.m. A review of Resident 1 ' s, Progress Notes, by the physician (MD), dated December 27, 2024, at 8:42 p.m., indicated, .(Resident 1) in bed, very drowsy but responds to commands only to dose off again; alert upon evaluation, per nursing staff (resident) had similar episode yesterday (December 26, 2024) including hypoxic (low O2 Sats) episodes but refused (oxygen); (Resident 1) refused to be taken to the ED yesterday .(Resident) agreed to go to the ED today .Physical Exam: (Pulse) 163; (O2 Sats) 91% .Cardiovascular (heart rate) .irregular .DIAGNOSIS: CHANGE IN MENTAL STATUS/ (RULE OUT) SEPSIS (Infection that has traveled to the blood stream)/CARDIAC ARRHYTHMIA (Irregular heart beat)/SEPTIC SHOCK (A life threatening, severe infection, causing organ failure) .PLAN: transfer to (Emergency Room) for further evaluation and treatment . A review of Resident 1 ' s GACH, ER notes, dated, June 3, 2025, at 2:10 p.m., indicated Resident 1 was admitted to the ER on [DATE], at 11:21 a.m., with a chief diagnosis of, . (Altered Level of Consciousness), with (low blood pressure) and (Elevated Pulse rate) . Further review indicated, Resident 1 was diagnosed in the ER with, . 1: Septic Shock; 2. Atrial fibrillation (Irregular Heart Beat, usually rapid) with RVR (fast heartbeat of lower chambers, affecting blood flow); 3: Pneumonia . On May 27, 2025, at 12:58 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the nursing staff should perform a detailed assessment on the resident, notify the physician, and complete a COC documentation, when a resident ' s vital signs were outside of normal range. The ADON further stated completing a COC would trigger nursing staff to monitor and document on condition every shift. The ADON further stated she would expect staff to recheck resident ' s vital signs multiple times. On May 27, 2025, at 1:06 p.m., an interview was conducted with RN 1. RN 1 stated she would notify the physician, follow-up with the physician's orders, and complete a COC, when a resident ' s vital signs (pulse, O2 sats) were outside of normal values. RN 1 further stated she would monitor and document the resident ' s vital signs every 15 minutes, until resident ' s condition improves or become stable. RN 1 verified a pulse rate of 126 was outside of normal values, and the physician should have been notified. On May 27, 2025, at 1:50 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the staff should immediately assess the resident, call for help, and call 911, when a resident was found unresponsive. The DON stated it is expected of the nursing staff to reassess the resident, including vital signs, notify the physician, closely monitor the resident at their bedside to assess for any other COCs, at least until the resident returns to stable condition, document a COC, progress note, and physician ' s notifications, if the resident becomes responsive and refuses to go to the hospital for further evaluation. The DON further stated the physician should have been notified, the nurse should follow the physician ' s orders, and monitor the resident ' s vital signs every 10 – 15 minutes, until resident ' s heart rate went down (to normal values), when Resident 1 started to have a COC on December 26, 2024, at 01:48, and onwards. The DON stated the nursing staff should have called 911 when Resident 1 ' s O2 sats were 84% and pulse rate of 143, on December 26, 2024, at 7:52 a.m. The DON further stated she expected the nursing staff to be proactive and follow up with the physician to evaluate the resident at the facility as the physician indicated to the licensed nurse, on December 26, 2024, at 11:41 a.m. On May 28, 2025, at 9:22 a.m., an interview was conducted with RN 2. RN 2 stated she would notify the physician, and the physician would give orders, interventions and expectations to monitor the resident when a resident has a low O2 saturation. RN 2 further stated interventions were provided for the resident according to the physician ' s orders. RN 2 verified, the physician was notified on December 26, 2024, at 11:41 a.m., of Resident 1's refusal to go to the hospital due to low O2 sats and was informed by the physician that he would come to facility to assess and talk to resident, to find out why Resident 1 was refusing treatment (oxygen & transfer to ER). RN 2 stated she was not sure if the physician came to the facility on December 26, 2024. RN 2 further stated, she should have assess Resident 1's vital signs every 15 minutes, and should have followed up with the physician that he needed to evaluate Resident 1 as previously discussed. On May 28, 2025, at 11:41 a.m., a follow up interview was conducted with the ADON. The ADON stated there was no documentation the physician came to evaluate Resident 1 on December 26, 2024. The ADON stated there was no documentation the nursing staff followed up with the physician to evaluate Resident 1. The ADON stated she expected the physician to come to the facility to evaluate the resident if the physician stated he would be coming to evaluate the resident. The ADON stated she expected the licensed nurses and respiratory therapist to check the resident's vital signs every 15 minutes. On May 28, 2025, at 5:48 p.m. an interview was conducted with the MD (physician). The MD stated the on call physician should have been notified, when Resident 1 was found to have abnormally high pulse rates, and low O2 saturations, on December 26, 2024, between the hours of 1:48 – 7:52 a.m. The MD stated, if he was the on-call physcian, he would have given the nursing staff orders to place Resident 1 on O2 and send to the ER for further evaluation. The MD further stated, he could not remember if he presented at facility to assess Resident 1 in person on December 26, 2024. A review of the facility's policy and procedure titled, Change of Condition, revised December 2023, indicated, . Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being . Procedure .If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to) .Change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation .Change in ability or decline in physical function .Change in medical condition .The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident ' s provider using SBAR or similar process to obtain new orders or interventions .The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs, needed assist and resident behavior/acceptance of increased need of assistance will be monitored .There will be certain circumstances where immediate attention will be warranted and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use he/her clinical judgement and shall contact the physician based on the urgency of the situation .The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident(s) electronic Medical Record (EMR) . Based on interview and record review, the facility failed to ensure care and treatment was provided timely, for one of five residents reviewed (Resident 1), when Resident 1 had an elevated pulse rate (heart beat per minute {BPM}) and decreased oxygen saturation ({O2 Sat} - the amount of hemoglobin carrying oxygen within the blood). The failure had the potential for a delay in the care and treatment and affect the resident's overall health condition of Resident 1. Findings: On May 22, 2025, at 1210 p.m., an unannounced visit was conducted to the facility to investigate a complaint regarding quality of care. A review of Resident 1's medical records titled, Resident Information, dated May 23, 2025, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of respiratory failure (respiratory system is unable to adequately provide oxygen to the body) with hypoxia (low blood oxygen). A review of Resident 1's Progress Notes, dated December 26, 2024, at 1:48 a.m., by Licensed Vocational Nurse (LVN) 1, indicated, . (Resident 1) found unresponsive. Upon assessment .oxygen level at 65% (normal values 95 -100%) on room air (no added oxygen). PT (Resident) placed on oxygen via nasal canula (nostrils) 5L (liters) ineffective .Pulse 132 (elevated, normal values 60 -100 beats per minute); O2 (sats): 73% (low) via nasal cannula. RN (Registered Nurse) made aware . Further review of Resident 1's record indicated the physician was not notified of Resident 1's elevated pulse and low oxygen level. A review of Resident 1's Progress Notes, dated December 26, 2024, at 2:12 a.m., by RN 1, indicated, . (Resident 1) Resting in bed with eyes closed, known to staff (resident) is fine .skin is cold to touch .(Pulse) 126 (elevated) . (Resident agree(s) if get(s) worse will go to hospital . Further review of Resident 1's record indicated the physician was not notified of Resident 1's elevated pulse and rate. A review of Resident 1s Progress Notes, dated December 26, 2024, at 7:52 a.m., by Respiratory Therapy (RT), indicated, .Pt (Resident 1) refusing to wear oxygen mask .(O2 sat) 87% (low), (Pulse) 143 (elevated) .explained to the (resident) he was in need of oxygen .(resident) .said no .RN and LVN notified at this time . Further review of Resident 1's record indicated the physician was not notified of Resident 1's elevated pulse rate and low O2 sats. A review of Resident 1's documented pulse and O2 sats, dated December 26, 2024, indicated resident's values were not closely monitored between the hours of 01:58 a.m. and 10:28 a.m.: - 1:48 a.m.; P (pulse) 132 (elevated); O2 Sat 65 - 73% (low), - 1:58 a.m.; P 132; O2 Sat 73%, - 2:12 a.m.; P 126 (elevated); no documented O2 Sat noted, - 5:11 a.m.; Pulse 107 (elevated); O2 sats 90% (low), - 7:52 a.m.; P 143 (elevated); O2 sat 87% (low), and - 10:28 a.m.; O2 Sats 84-86%, no Pulse noted. A review of Resident 1's, Progress Notes, dated, December 26, 2024, at 10:28 a.m., by RN 2, indicated, . RT did not made (sic) aware (resident) was refusing Oxygen mask, upon arrival found (resident) in bed .(Oxygen) mask on the left side of the bed (not on resident) .O2 (Sats) ranges from 84-86 (%-low) .(Resident 1) is refusing the oxygen .keeps refusing oxygen, and (resident) stated he's aware but still refuses .Called Dr .and made aware (resident) is refusing to go to the ER (Emergency Room) to get evaluated and refusing oxygen. (Dr) stated he is making rounds in another facility, but he will come to evaluate (Resident 1) today as soon as he can .(resident representative) is requesting (Resident 1) to be sent to the ER. Dr (physician) .said sent (sic) to ER per (representative) request . A review of Resident 1's, Progress Notes, dated December 26, 2024, at 11:41 a.m., by RN 2, indicated, . Called 911 to transfer (resident) out (to ER) for low oxygen level 84% .(Resident 1) refused to go to the ER .DR . stated he will be here (facility) in person to evaluate .(resident) . Further review of Resident 1's record indicated the physician did not come to the facility on December 26, 2024 to evaluate Resident 1 and there was no follow up to the physician when he would present to the facility. A review of Resident 1's, COC, dated, December 27, 2024, at 1050 a.m., by RN 3, indicated, . Abnormal vital signs .started on (December 27, 2024) . morning .Pulse 163 (elevated); O2 Sats 91%; Blood Pressure 76/66 (low, normal values 90/60 to 130/80); Temperature 98.0 (normal value); Respirations (Breaths per minute) 11 (low, normal values 12 - 20) .Decreased level of consciousness (sleepy, lethargic) .Gradual change in level of consciousness . (physician notified, December 27, 2024) at 10:55 (a.m.) .Recommendations of (Dr): Send to (GACH-General Acute Care Hospital) for evaluation . A review of Resident 1's, Progress Notes, dated, December 27, 2024, at 11:10 a.m., by RN 3, indicated, 911 was called. Paramedics arrived . approximately (at) 1100 a.m. (Resident 1) left the facility approximately (at) 1115 a.m. A review of Resident 1's, Progress note, by Dr, dated, December 27, 2024, at 8:42 p.m., indicated, .(Resident 1) in bed, very drowsy but responds to commands only to dose off again; alert upon evaluation, per nursing staff (resident) had similar episode yesterday (December 26, 2024) including hypoxic (low O2 Sats) episodes but refused (oxygen); (Resident 1) refused to be taken to the ED yesterday .(Resident) agreed to go to the ED today .Physical Exam: (Pulse) 163; (O2 Sats) 91% .Cardiovascular (heart rate) .irregular .DIAGNOSIS: CHANGE IN MENTAL STATUS/ (RULE OUT) SEPSIS (Infection that has traveled to the blood stream)/CARDIAC ARHYTHMIA (Irregular heart beat)/SEPTIC SHOCK (A life threatening, severe infection, causing organ failure) .PLAN: transfer to (Emergency Room) for further evaluation and treatment . A review of Resident 1's GACH, ER notes, dated, June 3, 2025, at 2:10 p.m., indicated Resident 1 was admitted to the ER on [DATE], at 11:21 a.m., with a chief diagnosis of, . (Altered Level of Consciousness), with (low blood pressure) and (Elevated Pulse rate) . Further review indicated, Resident 1 was diagnosed in the ER with, . 1: Septic Shock; 2. Atrial fibrillation (Irregular Heart Beat, usually rapid) with RVR (fast heartbeat of lower chambers, affecting blood flow); 3: Pneumonia . On May 27, 2025, at 12:58 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the nursing staff should perform a detailed assessment on the resident, notify the physician, and complete a COC documentation, when a resident's vital signs were outside of normal range. The ADON further stated completing a COC would trigger nursing staff to monitor and document on condition every shift. The ADON further stated she would expect staff to recheck resident's vital signs multiple times. On May 27, 2025, at 1:06 p.m., an interview was conducted with RN 1. RN 1 stated she would notify the physician, follow-up with the physician's orders, and complete a COC, when a resident's vital signs (pulse, O2 sats) were outside of normal values. RN 1 further stated she would monitor and document the resident's vital signs every 15 minutes, until resident's condition improves or become stable. RN 1 verified a pulse rate of 126 was outside of normal values, and the physician should have been notified. On May 27, 2025, at 1:50 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the staff should immediately assess the resident, call for help, and call 911, when a resident was found unresponsive. The DON stated it is expected of the nursing staff to reassess the resident, including vital signs, notify the physician, closely monitor the resident at their bedside to assess for any other COCs, at least until the resident returns to stable condition, document a COC, progress note, and physician's notifications, if the resident becomes responsive and refuses to go to the hospital for further evaluation. The DON further stated the physician should have been notified, the nurse should follow the physician's orders, and monitor the resident's vital signs every 10 – 15 minutes, until resident's heart rate went down (to normal values), when Resident 1 started to have a COC on December 26, 2024, at 01:48, and onwards. The DON stated the nursing staff should have called 911 when Resident 1's O2 sats were 84% and pulse rate of 143, on December 26, 2024, at 7:52 a.m. The DON further stated she expected the nursing staff to be proactive and follow up with the physician to evaluate the resident at the facility as the physician indicated to the licensed nurse, on December 26, 2024, at 11:41 a.m. On May 28, 2025, at 9:22 a.m., an interview was conducted with RN 2. RN 2 stated she would notify the physician, and the physician would give orders, interventions and expectations to monitor the resident when a resident has a low O2 saturation. RN 2 further stated interventions were provided for the resident according to the physician's orders. RN 2 verified, the physician was notified on December 26, 2024, at 11:41 a.m., of Resident 1's refusal to go to the hospital due to low O2 sats and was informed by the physician that he would come to facility to assess and talk to resident, to find out why Resident 1 was refusing treatment (oxygen & transfer to ER). RN 2 stated she was not sure if the physician came to the facility on December 26, 2024. RN 2 further stated, she should have assess Resident 1's vital signs every 15 minutes, and should have followed up with the physician that he needed to evaluate Resident 1 as previously discussed. On May 28, 2025, at 11:41 a.m., a follow up interview was conducted with the ADON. The ADON stated there was no documentation the physician came to evaluate Resident 1 on December 26, 2024. The ADON stated there was no documentation the nursing staff followed up with the physician to evaluate Resident 1. The ADON stated she expected the physician to come to the facility to evaluate the resident if the physician stated he would be coming to evaluate the resident. The ADON stated she expected the licensed nurses and respiratory therapist to check the resident's vital signs every 15 minutes. On May 28, 2025, at 5:48 p.m. an interview was conducted with the MD (physician). The MD stated the on call physician should have been notified, when Resident 1 was found to have abnormally high pulse rates, and low O2 saturations, on December 26, 2024, between the hours of 1:48 – 7:52 a.m. The MD stated, if he was the on-call physcian, he would have given the nursing staff orders to place Resident 1 on O2 and send to the ER for further evaluation. The MD further stated, he could not remember if he presented at facility to assess Resident 1 in person on December 26, 2024. A review of the facility's policy and procedure titled, Change of Condition, revised December 2023, indicated, . Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being . Procedure .If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to) .Change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation .Change in ability or decline in physical function .Change in medical condition .The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions .The resident will then be placed on the 24 Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs, needed assist and resident behavior/acceptance of increased need of assistance will be monitored .There will be certain circumstances where immediate attention will be warranted and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use he/her clinical judgement and shall contact the physician based on the urgency of the situation .The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident(s) electronic Medical Record (EMR) .

Based an observation, interview, and record review, the facility failed to ensure trained staff were utilized to provide one on one (1:1) supervision of a resident with wandering behavior, for one of four sampled residents (Resident 4). This failure resulted to untrained staff providing 1:1 supervision to Resident 4 and had the potential for wandering residents to experience physical and psychosocial harm due to lack of training to handle residents with wandering behavior. Findings: On April 22, 2025, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding quality of care. On April 22, 2025, at 12:15 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated the housekeeping staff began to be utilized to provide 1:1 supervision to Resident 4 in April 2025. CNA 3 further stated she believe the housekeeping staff did not have training how to handle at-risk residents or provide 1:1 supervision (sitter) or residents. CNA 3 further stated utilizing the housekeeping staff to be sitters for residents placed both the residents and the housekeepers at harm because they were not trained to handle residents at risk for behaviors. On April 22, 2025, at 3:50 p.m., an interview and concurrent record review was conducted with the Director of Staff Development. The DSD stated housekeepers (HK) were utilized as sitters for Resident 4 in April 2025. During a concurrent review of the hourly sitter log (document where the sitter signs hourly to show they were monitoring the resident), the DSD confirmed that the following housekeepers were utilized throughout April 2025: - HK 1 on April 4, 9, and 15, 2025; - HK 2 on April 4, 5, and 12, 2025; - HK 3 on April 8, 2025; - HK 4 on April 5, and 7, 2025; - HK 5 on April 6, and 14, 2025; and - HK 6 on April 7, 2025. In a concurrent interview with the DSD, she stated housekeeping staff were not trained to manage provide 1:1 supervision for a resident with behaviors prior to being a sitter to Resident 4. On April 22, 2025, at 5 p.m., during an interview with the Director of Nursing (DON), the DON stated that housekeeping should have had proper training on one-to-one sitting duties, prior to being utilized as a sitter. The DON further stated the facility did not have a policy for managing residents who required a sitter. On April 22, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included unspecified psychosis (a state where a person's perception of reality becomes distorted, leading to difficulties distinguishing between real and imagined experiences) not due to a substance or known physiological condition, altered mental status unspecified, impulse disorder, unspecified, unspecified dementia (memory loss). A review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated April 17, 2025, indicated Resident 4 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 (severely impaired cognition). A review of Resident 4's physician ' s orders, dated November 4, 2024, indicated, .1:1 sitter d/t (due to) wandering r/t (related to) dementia dx (diagnosis) . A review of Resident 4 ' s care plan indicated, .Focus .Elopement (when a patient leaves a healthcare facility against medical advice) risk/wanderer r/t (related to) Resident wanders aimlessly .Has episodes of wandering around . Goal .Safety will be maintained through the review date .Interventions/Tasks .1:1 sitter as ordered .r/t Resident wanders aimlessly ., date initiated, November 5, 2024. On May 1, 2025, at 11:57 a.m., a telephone interview was conducted with HK 1. HK 1 stated she was a sitter for Resident 4 for multiple days in April 2025. HK 1 stated she had not received any training on how to provide one-to-one sitter services for a resident with behaviors prior to being a sitter for Resident 4. A review of a facility document titled, Inservice Lesson Plan, dated April 22, 2025, indicated, .Topic: sitter/watcher for dementia patients .Educational Objective At the end of this in-service, the student will be able to: 1. Know what to do when patients trying to leave the building. 2. Know who to call when pt is in danger or trying to hurt themselves. 3. Not try to stop when patient is combative, but yell for help call the CNAs or license nurses who are more experience in handling dementia patients .

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented when Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after provision of care to a resident and after touching the linen cart. These failures had the potential to spread infection among the vulnerable residents of the facility. Findings: On April 22, 2025, at 9:35 a.m. an unannounced visit was conducted to investigate a infectious disease outbreak. On April 22, 2025, at 9:50 a.m. CNA 1 was observed exiting room [ROOM NUMBER] (resident's room). CNA 1 was observed to remove her gloves outside of room [ROOM NUMBER], then touched the linen cart in the hallway outside of room [ROOM NUMBER]. CNA 1 did not perform hand hygiene when she exited the resident's room. CNA 1 entered room [ROOM NUMBER] again without performing hand hygiene. In a concurrent interview, CNA 1 stated, Sorry, I should have used the hand sanitizer to prevent spreading germs. On April 22, 2025, at 12:15 p.m., during an interview with CNA 3, she stated it was important to perform hand hygiene before and after entering a resident ' s room. On April 22, 2025, at 3:15 p.m., during an interview with the Infection Prevention Nurse (IP), she stated CNA 1 should have performed hand hygiene before entering and after leaving the resident ' s room and before and after touching anything outside the room, specially they have an infectious disease outbreak. On April 22, 2025, at 5 p.m., during an interview with the Director of Nursing (DON), she stated the staff were supposed to perform hand hygiene before and after entering a resident ' s room. A review of the facility's undated policy and procedure titled, Infection Prevention and Control Program, indicated, .prevention of spread of infections is accomplished by use of Standard Precautions [ according to the Centers for Disease Control and Prevention, Standard Precautions include hand hygiene] .The hand hygiene procedures will be followed by staff involved in direct resident contact . According to the web article published by Centers for Disease Prevention and Control, titled Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, indicated, .Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with .Handwashing with water and soap .Antiseptic hand rub (alcohol -based foam or gel hand sanitizer .Cleaning your hands reduces .The potential spread of deadly germs to patients .The spread of germs .The risk of healthcare personnel colonization or infection caused by germs received from the patient .When to clean your hands .Immediately before touching a patient .before performing an aseptic task such as placing an indwelling device or handling invasive medical devices .After touching a patient or patient's surroundings .After contact with blood, body fluids, or contaminated surfaces .Immediately after glove removal .

Based on interview and record review, the facility failed to ensure one on one (1:1) supervision was provided according to the physician's order and plan of care, for one of four residents reviewed (Resident 4) when there was no assigned sitter (staff to supervise the resident's whereabouts) to monitor Resident 4's wandering behavior. This failure had the potential to result in Resident 4 wandering out of the facility, leading to potential physical or psychosocial harm. Findings: On April 22, 2025, at 9:35 a.m., an unannounced visit to the facility was conducted to investigate complaints regarding quality of care. On April 22, 2025, at 12 p.m., during an interview with Certified Nursing Assistant (CNA) 2, CNA 2 stated there were situations where there was not a sitter for Resident 4 which was reflected as blank in the assignment sheet. CNA 2 further stated administration would ask staff to keep an eye on Resident 4 until someone was able to come in and sit with Resident 4. CNA 2 stated keep an eye on a resident meant that Resident 4 would not have a 1:1 sitter, instead, all the nurses and CNAs were responsible for monitoring the resident for any harmful behaviors while attending to their own assigned residents. CNA 2 stated it should not happen because someone should only be responsible for taking care of the one resident who required a sitter, because you do not want something to happen to the resident. On April 22, 2025, at 12:15 p.m., during an interview with CNA 3, CNA 3 stated Resident 4 had a wandering behavior due to dementia (memory loss). CNA 3 stated if the box on the staffing assignment sheet for the assigned sitter for Resident 4 was blank, it would indicate to staff that there was either no assigned sitter and it was everyone ' s job to keep an eye on the resident until they could get a CNA to come in, or a housekeeper was the assigned sitter for the resident. CNA 3 stated she found Resident 4 wandering in the hallway about three weeks ago. CNA 3 stated this incident happened when a housekeeper was assigned to Resident 4. During a concurrent record review with CNA 3 the staff assignment sheet for April 4 to April 6, 2025, indicated a blank box for the assigned sitter for Resident 4 on the staff assignment sheet for those dates. CNA 3 stated the blank on the assignment sheet indicated that either a housekeeper was the assigned sitter for Resident 4, or they were attempting to find a CNA to come in and be the sitter for Resident 4. On April 22, 2025, at 3:50 p.m., an interview and concurrent record review with the Director of Staff Development (DSD) was conducted. A review of the facility document titled, Sitter Schedule, for the month of April 2025 was conducted. The DSD stated the assigned sitter signed their name for every hour they monitored Resident 4. The facility document indicated there were no staff signatures for the following date and times: - April 1, 2025, 8 a.m. to 2 p.m., and 11:00 p.m.; - April 2, 2025, 12 a.m. to 6 a.m.; - April 4, 2025, 4 a.m. to 6 a.m.; - April 7, 2025 a.m., 12 a.m.- 5 a.m.; - April 8, 2025, 12 a.m. to 5 a.m.; - April 11, 2025, 7 a.m. to 3 p.m.; - April 12, 2025, 12 a.m. to 6 a.m.; - April 13, 2025, 7 a.m. to 2 p.m.; - April 14, 2025, 1 a.m. to 6 a.m., and 8 a.m. to 9 a.m.; and - April 16, 2025 1 p.m. to 2 p.m., 12 a.m. to 6 a.m. In a concurrent interview with the DSD, she stated there were occasions where there was no assigned sitter for Resident 4, so all the staff would keep an eye on the resident. The DSD confirmed the blank spaces indicated Resident 4 did not have an assigned 1:1 sitter assigned to monitor him. On April 22, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with a diagnoses which included unspecified psychosis (a state where a person's perception of reality becomes distorted, leading to difficulties distinguishing between real and imagined experiences) not due to a substance or known physiological condition, altered mental status unspecified, impulse disorder (mood disorder), and dementia. A review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated April 17, 2025, indicated Resident 4 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 (severely impaired cognition). A review of Resident 4 ' s care plan indicated, .Focus .Elopement (when a patient leaves a healthcare facility against medical advice) risk/wanderer r/t (related to) Resident wanders aimlessly .Has episodes of wandering around .Goal .Safety will be maintained through the review date .Interventions/Tasks .1:1 sitter as ordered r/t Resident wanders aimlessly ., date Initiated, November 5, 2024 . A review of Resident 4's physician ' s orders, dated November 4, 2024, indicated, 1:1 sitter d/t wandering r/t dementia dx (diagnosis). On April 22, 2025, at 5 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 4 should not have gone without a sitter, at any time that the order for a sitter was in place as this could place the resident at risk for wandering. The DON further stated the facility did not have a policy for managing residents who require a sitter. A review of the facility's policy and procedure titled, Elopement/Unsafe Wandering, dated June 2018, indicated, .The facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement .Wandering is defined as random or repetitive locomotion and can be either goal directed or non-goal directed/aimless. Elopement is when a resident leaves the facility premised or a safe area without authorization .and/or any necessary supervision to do so .Residents with high risk factors identified on an elopement/wandering evaluation are considered at risk and will have an individualized care plan developed that includes measurable objectives and time frames .These interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering .

Based on observation, interview, and record review the facility failed to ensure physician's orders were followed, for one out of four residents (Resident 4) when Resident 4's blood sugar of 403 mg/dl (milligram/decilitier - unit of measurement) was not reported to the physician according to Resident 4's physician's order. This failure had the potential for Resident 4 to have abnormal blood sugar not controlled or managed and could affect the resident's overlal health condittion. Findings: On March 3, 2025, at 11 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. On March 3, 2025, at 1 p.m., Resident 4 was observed sitting on the edge of the bed. In a concurrent interview with Resident 4, he stated he was unhappy with his care. On March 3, 2025, at 1:05 p.m., Resident 4's record was reviewed. indicated Resident 4's Admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar). A review of Resident 4's Medication Administration Record (MAR), for the month of January 2025, included a physician's order, dated January 11, 2025, which indicated, FSBS (finger-stick blood sugar) before meals and at bedtime .Call MD (physician) if less than 60 OR greater than 400 . A review of Resident 4 MAR, for the month of January 2025, indicated on January 22, 2025, at 8 p.m., Resident 4's bedtime blood sugar was 403. There was no documented evidence the physician was notified when Resident 4 had a blood sugar of 403 (above 400) on January 22, 2025, at 8 p.m. On March 3, 2025, at 5:30 p.m., a concurrent interview and review of Resident 4's record was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 4 had a blood sugar level of 403 on January 22, 2025, at 8 p.m. The ADON stated there was no documentation the physician was notified when Resident 4's blood sugar was above 400 on January 22, 2025, at 8 p.m. as indicated in the resident's physician order. The ADON stated the licensed nurse should have notified the physician when Resident 4's blood sugar was 403 on January 22, 2025, at 8 p.m. A review of the facility's policy and procedure titled, Physician Services .Physician's orders, dated January 2023, indicated, .When noting orders, if the licensed staff member is not able to implement the order .then the following procedure is followed to ensure follow-up and timely implementation of the order .the time frame cannot exceed 48 hours for the physician to respond .The physician does not respond within 48 hours, the physician is contacted by telephone or fax indicating he/she has 24 hours to respond .If the physician does not respond within 24 hours, the licensed staff will notify the Director of Nursing who will involve the Administrator and/or Medical Director to ensure a response from the physician .

Based on observation, interview and record review, the facility failed to assess and monitor the skin integrity underneath the right arm sling immobilizer (a device used to support and keep still an injured part of the body), for one of three residents reviewed (Resident A) for pressure injury (the breakdown of skin integrity due to pressure). This failure to assess and monitor skin integrity resulted in the development of a Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon, or muscle) on Resident A ' s right elbow area, during admission at the skilled nursing facility. Findings: On November 9, 2022, at 9:20 a.m., an unannounced visit was conducted at the facility to investigate an allegation related to quality care issue. On November 9, 2022, a review of Resident A ' s clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses that included fracture (broken bone) of the upper end of the right humerus (a long bone in the arm), fracture of the right femur (a long bone in the thigh) status-post nailing (a surgical procedure), and dementia (memory loss). Resident A was alert and oriented, with occasional forgetfulness, and able to make needs known. The history and physical indicated Resident A did not have the capacity to understand and make decisions. A review of the Progress Notes upon admission, dated September 26 and 27, 2022, indicated a humeral (referring to the humerus bone) fracture brace to the right arm. A review of the Physician Order Summary Report dated October 2, 2022, indicated an order to monitor the honeycomb dressing (a type of dressing pad that allows direct visibility of the wound through the dressing) to the right hip. The Physician Order did not include an order to assess and monitor the skin integrity underneath the right arm humeral fracture brace. A review of the Weekly Skin Evaluation for October 11, 2022, and October 19, 2022, did not document an assessment was conducted on the right elbow. A review of the Treatment Administration Record (TAR) dated October 1 to 31, 2022, documented the monitoring of the honeycomb dressing to the right hip. However, the TAR did not document any monitoring of the skin integrity underneath the right humeral fracture brace. A review of the Braden Scale for Predicting Pressure Sore Risk (an assessment tool), dated October 25, 2022, indicated a score of 14 (moderate risk). A review of the Discharge Summary and Post-Discharge Plan of Care, dated October 25, 2022, did not document any skin problem in the body, nor indicated if the skin underneath the right arm brace was assessed prior to discharge. A review of Resident A ' s minimum data set (MDS- a comprehensive assessment tool) upon discharge, dated October 25, 2022, indicated no pressure injury. On November 9, 2022, at 10:25 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated Resident A was admitted to the facility with a right arm sling immobilizer made of hard plastic. LVN 1 stated there was no doctor ' s order to monitor the skin integrity on the resident ' s right arm. LVN 1 stated there should have been an assessment and monitoring of the skin integrity underneath the sling immobilizer. LVN 1 stated she was not aware of any skin integrity issue on the right elbow of Resident A. LVN 1 confirmed the discharge summary did not document any skin issues. On November 9, 2022, at 10:41 a.m., during interview, LVN/Treatment Nurse (LVN/TN) 2 stated if a resident is admitted to the facility with an arm sling immobilizer, the facility staff should have obtained a doctor ' s order to check the skin integrity of the skin underneath the sling immobilizer. LVN/TN 2 stated there was no documented evidence the skin integrity of the resident ' s right arm had been assessed or monitored for any skin injury from the arm sling immobilizer. On November 9, 2022, at 12:45 p.m. Resident A was visited at the board and care facility where he was transferred on October 25, 2022. Resident A was observed eating lunch, with the right arm sling immobilizer removed. A bandaged dressing was observed in the right elbow area. During a concurrent interview, the Board and Care Administrator (BCA) stated, Resident A was transferred at the Board and Care facility on October 25, 2022. The BCA stated that on October 26, 2022 (one day after discharge from the skilled nursing facility), the facility staff provided the resident a bed bath, and upon removal of the right arm immobilizer, they observed a foul-smelling pressure inury on the right elbow of Resident A. The BCA took a picture of the pressure injury, and informed the home health nurse about their finding. A review of the OASIS (Outcome and Assessment Information Set, a home health assessment tool) comprehensive assessment upon admission, dated October 28, 2022 (three days after discharge from the skilled nursing facility), indicated a Stage 4 pressure ulcer on the right elbow, measuring 3.20 cm (centimeter- a unit of measurement) in length X (by) 2.70 cm in width X 0.30 cm in depth. On December 12, 2022, at 11:43 a.m., a telephone interview was conducted with the Director of Nursing (DON). The DON stated there was no documented evidence the facility had assessed and monitored the skin integrity underneath the resident ' s right arm sling immobilizer. The DON stated there should have been a physician order, obtained by the nurse, to assess or monitor the skin integrity underneath the right arm sling immobilizer of Resident A. The DON stated the facility was unaware that a pressure ulcer had developed on the right elbow of Resident A. The facility policy and procedure titled, Skin and Wound Monitoring and Management, dated January 2022, was reviewed. The policy indicated, A resident who enters the facility without pressure injury does not develop pressure injury .The facility provides care and services to promote interventions that prevent pressure injury development .Procedure: a. Resident Assessment: The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: a. Complete Initial Admission Record and Braden Scale to identify the risk and to identify any alterations in skin integrity noted at that time .c. Identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure injury which include, but are not limited to: Impaired/decreased mobility and decreased functional ability .6. Monitoring .Skin Inspection on Showering * On shower days, CNAs (Certified Nursing Assistant) to observe resident skin. * Identify any areas of skin breakdown, discoloration, tears or redness . d. Weekly skin conducted by a licensed nurse * All residents will have a head to toe skin check performed at least weekly by a licensed nurse .e. Weekly for those residents admitted with a dressing to a wound or cast/ splint to an extremity or who receive a dressing to a wound or cast/ splint to an extremity during the course of the facility admission. * When a resident is admitted .with, a dressed wound or a cast/splint that is being managed outside the facility, nursing staff shall assess and evaluate the dressed/casted/splinted area at least weekly to check the status of the skin. Factors to consider under these circumstances include .2. Whether there is a smell coming from the area underneath or around the dressing/cast/splint .4. Whether there is any abnormality or condition which requires attention in the area .