Every finding on record at Desert Springs Post Acute

Based on observation, interview, and record review, the facility failed appropriate interventions to prevent injuries from repeat fall incidents were implemented, for one of three sample residents (Resident 1).This failure placed Resident 1 at increased risk for serious injury related to falls.Findings:On July 20, 2026, at 9:30 a.m., an unannounced visit was conducted to investigate a complaint related to quality of care.On July 20, 2026, at 11:08 a.m., during a concurrent observation, interview and review of Resident 1 record with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the following:-Resident 1 had a history of placing herself on the floor;-Resident 1 had a fall on July 4, 2026, and was transferred to General Acute Care Hospital (GACH) because of the fall for further evaluation and management. Resident 1 was readmitted back to the facility on July 17, 2026;-Resident 1's room was observed to have no landing mats on each side of the bed. LVN 1 stated she was unsure why Resident 1 did not have landing mats in her room since she had a history of falls;-There was no current order for landing mats on each side of the bed;-It was the nurse's responsibility to get an order for landing mats if the resident had a history of falls;-Resident 1's Fall Risk Assessment score was which indicated high risk for falls; and-Resident 1 should have landing mats on each side of the bed as Resident 1 had the potential risk to experience another fall or sustain further injuries from the fall due to not having landing mats in place as part of the interventions.On July 20, 2026, at 11:30 a.m., during a concurrent interview and review of Resident 1's record with the Director of Nurses (DON), the DON stated the following:-Resident 1 had landing mats prior to transfer to the GACH on July 7, 2026, and did not have landing mats on each side of the bed since readmitted from GACH on July 17, 2026; - Resident 1 could sustain another fall and injury if interventions such as landing mats are not in place;-The DON presented facility document titled, Active Fall Device, and stated the document was being used in interdisciplinary team (IDT - a group of healthcare professionals) meetings to indicate which residents are at high risk for falls. The DON stated the document indicated Resident 1 was a fall risk;On July 20, 2026, at 12 p.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed resting in bed, observed no fall risk band on, observed no falling star on entry of Resident 1's doorway, observed one fall mat in place, observed Resident 1 with right below the knee amputation (BKA). Resident 1 stated she fell a while ago because she was moving her leg and had a lot of falls while she was in the facility. On July 21, 2026, at 8:40 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the following:-She is aware how to identify residents' high risk for fall by a yellow star on the outside of the resident's door;-Residents who are at a fall risk have yellow/orange fall risk bands on person;-Residents who are at risk for falls need to have a low bed, sensor/bed alarm, and fall/landing mats.On July 21, 2026, at 8:40 a.m., an interview was conducted with CNA 2. CNA 2 stated residents who are at risk for falls have two fall mats, sensor/bed alarm on, orange fall risk arm band, and a falling star on their door.On July 21, 2026, at 9:39 a.m., a concurrent interview and record review was completed with the Minimum Data Set (MDS - a resident assessment tool) Nurse (MDSN), the MDSN stated the following:-Resident 1 had 11 total falls since April 6, 2026 (date of admission);-There were Change of Condition (COC), documentation completed for fall incidents on April 15, 2026, May 3, 2026, May 18, 2026, June 5, 2026, July 2, 2026, and July 4, 2026;-There were no COC's completed for fall incidents on April 18, 2026, June 19, 2026, and June 20, 2026;-Stated a COC documentation should have been completed at each episode of COC to monitor the residents for any adverse effects related to the COC; and -Resident 1's care plan, dated April 15, 2026, indicated fall/landing mats as interventions to address falls. On July 20, 2026, Resident 1's record was reviewed. Resident 1's admission Record, was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar) and repeated falls.A review of Resident 1's care plan, dated June 18, 2026, indicated, .Resident is at risk for falls with or without injury related to lethargy, weakness and medication effects.Falling Star fall prevention program.anticipate needs and meet needs.landing mats. A review of Resident 1's MDS, dated June 24, 2026, indicated the resident has a BIMS (Brief Interview for Mental Status) score of 05 (severely cognitive status).A review of Resident 1's Fall Risk Observation/Assessment, dated July 18, 2026, indicated the resident's fall risk score was 20, indicating high fall risk (score of 16-42). The assessment indicated risk factors including a history of falls within the previous 90 days, moderately impaired vision, wheelchair dependence, need for assistance with elimination, and multiple health conditions/risk factors.A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018, indicated, .staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling.a fall is defined as unintentionally coming to rest on the ground, floor or other lower level.a fall without injury is still a fall.residents conditions that may contribute to the risk of falls include, pain; lower extremity weakness; functional impairments and incontinence.medical factors that contribute to the risk of falls include balance and gait disorders.If falling reoccurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was free from sexual abuse when there were no interventions developed to protect Resident 1 after Resident 2 subjected the resident to sexual abuse on May 19, 2026. Resident 1 was witnessed by facility staff being kissed and inappropriately touched on the breast by Resident 2. In addition, the facility staff did not immediately intervene when Resident 1 was witnessed being kissed and sexually inappropriately touched by Resident 2. Resident 1 has dementia (a decline in mental abilities which affects memory, thinking, and social abilities), has severe cognitive impairment, and has history of wandering (act of walking, moving and traveling without a specific destination or fixed route, often in an aimless manner). This failure resulted in Resident 1 being sexually abused the second time at the facility by another male resident (Resident 3) on June 6, 2026. This failure had the substantial probability of resulting in Resident 1 experiencing anxiety, distress, and trauma which negatively affects the resident's psychosocial well-being.Findings: A review of Resident 1's (alleged victim) admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia. A review of Resident 1's Brief Interview of Mental Status (BIMS-a cognitive assessment), dated April 9, 2026, indicated a score of 99, severe cognitive impairment resulting in the inability to complete the assessment. A review of Resident 1's History and Physical, dated, July 4, 2025, indicated, . Has fluctuating capacity to understand and make decisions . A review of Resident 1's IDT (Interdisciplinary Team Notes), dated May 19, 2026, at 6:06 p.m., indicated, . At approximately 10:15 a.m., staff members witnessed (Resident 1) being touched, inappropriately by (Resident 2) . (Resident 1) is unable to recall events . (Law enforcement notified) . A review of Resident 1's care plan initiated on May 19, 2026, indicated, . (Resident 1) has a psychosocial wellbeing problem r/t (related to) other resident(s) kissing and touching this resident inappropriately .Interventions: Allow to verbalize feelings and fears. Increase communication between residents/family/caregivers about care and environment. Monitor and document feelings relative to isolation, unhappiness, anger, loss . Further review of Resident 1's care plan related to the sexual abuse incident on May 19, 2026, did not indicate how the facility will keep the resident safe from further sexual abuse. A review of Resident 2's (alleged perpetrator) admission Record indicated that the resident was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (bacterial infection in the urinary system). A review of Resident 2's BIMS dated April 11, 2026, indicated a score of 11, which meant moderate cognitive impairment. A review of Resident 2's Progress Notes, dated May 19, 2026, at 12 p.m., documented by Licensed Vocational Nurse (LVN) 1, indicated, .was told by the activities staff (AA) that pt. (patient) (name of Resident 2) who is A & O X 4 (Alert and Oriented to Person, Place, Time and Situation) was seen having inappropriate sexual behavior with a resident (Resident 1) who is alert and oriented x 1 (self) since pt. (referring to Resident 2) was conscious of what he was doing police department was contacted . On May 20, 2026, at 10:15 a.m., during an interview, Director of Nursing (DON) 1 stated that on May 19, 2026, a facility staff (Activity Assistant) witnessed Resident 2 inappropriately touching Resident 1 on her breasts and placing his (Resident 2) hands down Resident 1's pants. DON 1 further stated Resident 1 has a history of confusion. On May 20, 2026, at 11:45 a.m., during an interview, the AA stated if resident abuse is occurring, staff were expected to intervene and stop the abuse right away. The AA stated that on May 19, 2026, at approximately 10:15 a.m., she was walking by the resident's lounge in hallway 500 and witnessed Resident 2 kissing Resident 1 on the mouth, touching her breasts and Private area. The AA stated Certified Nursing Assistant (CNA) 1 was in the hallway, close to the lounge, and she (AA) informed CNA 1 that Resident 2 was inappropriately touching Resident 1. The AA stated she should have intervened when she witnessed Resident 2 kissing and touching Resident 1 before reporting to CNA 1. On May 20, 2026, at 12:14 p.m., during an interview, CNA 1 stated the following: -To ensure resident safety during a conflict, immediately separate those involved, assign staff to each resident until the issue is resolved, and notify supervisors; and - On May 19, 2026, after being alerted by the AA, (CNA 1) saw Resident 2 kissing Resident 1 and had his hands down Resident 1's pants in the resident's lounge. On May 20, 2026, at 12:47 p.m., during interview, the CNA Team Leader (TL) stated that staff should immediately separate residents during unsafe interactions, keep them apart, and report incidents to supervisors for safety. She (CNA TL) recalled that on May 19, 2026, CNA 1 informed her that Resident 2 was inappropriately touching Resident 1. CNA TL stated she saw Resident 2 leaving Resident 1's room, noting that staff should have stayed with Resident 2 to ensure safety while reporting the incident. She stated Resident 1 has confusion and is oriented only to person, while Resident 2 is fully aware. On May 20, 2026, at 2:06 p.m., during an interview with the Assistant Director of Nursing (ADON), she stated that in unsafe resident-to-resident situations, residents should be separated immediately, monitored by staff, and proper authorities should be notified. Resident 1 is easily confused and only oriented to person. On May 19, 2026, the AA informed her that Resident 2 was touching Resident 1. She observed Resident 2 being guided away from Resident 1's bedroom after the incident in the resident's lounge and that staff should have been monitoring both residents for safety. A review of Resident 1's Progress Notes, dated, June 8, 2026, at 9:33 p.m. indicated, . ON 06/06/2026 at approximately 12:15 a.m., CNA (CNA 2) witnessed this resident ( Resident 1) a male resident ( Resident 3, alleged perpetrator different from the perpetrator on May 19, 2026) bent over, kissing her (Resident 1), while she (Resident 1) was sitting in a chair . CNA (CNA 2) reported to the nurse (LVN 2) . who immediately separated both residents . Resident (Resident 1) wasseen (sic) for psychosocial well-being, she (Resident 1) is unable to recall the event . A review of Resident 3's (alleged perpetrator on June 6, 2026, incident) admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills). A review of Resident 3's BIMS score, dated May 9, 2025, indicated a score of 3, which meant the resident is severely cognitively impaired. A review of Resident 3's eInteract SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated June 6, 2026, at 12:20 a.m., indicated, . This nurse (LVN 2) was called into the activity T.V. room as I walk (sic) in I observed patient (name of Resident 3) was in front of (name of Resident 1). Patient (name of Resident 3) had his short (sic) down on the floor, the disposable brief was still on, and he (Resident 3) was asking (name of Resident 1) to touch his private area . CNA (CNA 2) reported observing resident (name of Resident 3) kissing (Name of Resident 1) . On June 9, 2026, at 8:40 a.m., during an interview with the ADON, she stated that Resident 1 has a history of wandering onto other units throughout the facility. The ADON stated that on the night of June 6, 2026, Resident 1 wandered off her unit onto another unit's television room where Residents 1 (alleged victim) and 3 (alleged perpetrator different from the first incident on May 19, 2026) were observed kissing by CNA 2. On June 9, 2026, at 10:02 a.m., during an interview, Resident 1 stated she did not remember going to another unit on June 6, 2026, and kissing Resident 3. On June 10, 2026, at 7:38 a.m., during an interview, CNA 2 stated that on the night of June 6, 2026, he was unsure of the exact time, sometime in the middle of the night, he observed Residents 1 and 3 on the (name of facility unit different from the unit where Resident 1 resides), alone in the T.V. room. CNA 2 stated Resident 1 was sitting in a chair, and Resident 3 was standing, bent over, and kissing Resident 1. The CNA stated he immediately notified LVN 2, so that the LVN could intervene, while he went back to provide resident care. CNA 2 stated he should have immediately intervened by asking Residents 1 and 3 to stop kissing and separating them. CNA 2 further stated Resident 1 has a history of confusion and wandering the facility and requires redirection. CNA 2 stated on the night of June 6, 2026, he was not aware Resident 1 was on the (name of the facility unit different from where Resident 1 resides), in the T.V. room with Resident 3, as Resident 1's assigned nurses did not notify CNA 2 that Resident 1 had wandered. On June 10, 2026, at 3:32 p.m., during an interview, LVN 2 stated on the night of June 6, 2026, she was a charge nurse on the (name of the unit different from the unit where Resident 1 resides), and at approximately 12:30 a.m., CNA (CNA 2) notified her (LVN 2) that Residents 1 and 3 were in the T.V. room kissing. LVN 2 stated she immediately went to the T.V. room and observed Resident 3 standing in front of Resident 1 who was sitting in a chair. LVN 2 stated Resident 3 had his shirt off and his pants off, his adult brief was still on, and he (Resident 3) was asking Resident 1 to touch his private parts. LVN 2 stated she immediately intervened by asking Residents 1 and 3 to stop. LVN 2 stated she redirected Resident 1 back to her unit. LVN 2 reported the incident to Resident 1's charge nurse (LVN 3). LVN 2 stated LVN 3 was not aware Resident 1 had wandered off her unit. On June 10, 2026, at 2:06 p.m., during an interview, LVN 3 stated she was Resident 1's assigned LVN on June 6, 2026, and she and CNA 4 were responsible for monitoring Resident 1 during her shift (11 pm to 7 am shift). LVN 3 stated she did visual checks but did not document monitoring residents. LVN 3 stated she did not know the exact time, but she was at the (name of unit where Resident 1 resides) nurses station when a nurse from the (name of unit different from where Resident 1 resides) came over and informed her that Resident 1 was found in the other facility unit's T.V. room kissing Resident 3, and Resident 1 had been returned to her unit. LVN 3 stated she did not know Resident 1 was off her unit and on the other unit at the time. On June 30, 2026, at 3:18 p.m., during an interview, CNA 4 stated she was Resident 1's assigned CNA for the night shift (11 p.m. to 7 a.m.) on June 6, 2026. CNA 4 stated Resident 1 has a history of being confused and would wander into other residents' bedrooms. CNA 4 stated she tried to visually monitor Resident 1's whereabouts every 30 minutes to an hour, between resident care. CNA 4 stated she was not aware Resident 1 was observed kissing Resident 3 in the T.V. room located at the other unit on the night of June 6, 2026. On June 30, 2026, at 4:15 p.m., a concurrent interview and record review were conducted with Director of Nursing (DON) 2, DON 2 verified Resident 1's care plan initiated on May 19, 2026, had no interventions that could safeguard Resident 1 from further sexual abuse incidents by other residents. DON 2 further stated interventions initiated should have included monitoring Resident 1 with set time frames, providing activities, and/or including Resident 1 in outings, which could have helped keep Resident 1 busy and occupied. On July 1, 2026, at 1:55 p.m. during an interview, the ADON stated she would expect staff to effectively monitor their assigned residents, and to know where they are at all times. On July 2, 2026, at 11 a.m., during an interview, Resident 1's (alleged victim) responsible party stated Resident 1's memory is compromised and at times Resident 1 is unable to recall whether she has eaten her meals or if her adult brief requires changing. The responsible party stated Resident 1 has a history of wandering around the facility, and she expressed concern that the facility was not monitoring Resident 1 closely enough to keep her safe, because the second incident (referring to the sexual abuse incident on June 6, 2026) occurred in the middle of the night, when the resident (Resident 1) wandered off her unit without staff's knowledge, at which time she was exposed to sexually inappropriate behavior by Resident 3. A review of the facility Policy and Procedure (P & P) titled, Identifying Sexual Abuse and Capacity to Consent, revised September 2022, indicated, . Policy Statement: A resident's consent to sexual activity is not valid if obtained from a resident who lacks the capacity to consent . Policy Interpretation and implementation: 5. The facility will . protect a resident from non-consensual sexual relations anytime there is reason to suspect that the resident . may not have the capacity to consent . Investigating an Allegation or Suspicion of Sexual Abuse: 1. For any alleged violation or suspicion of sexual abuse, protective measures . include: a. immediately implementing safeguards to prevent further potential abuse .

Based on interview and record review, the facility failed to ensure a referral was sent in a timely manner, to Resident 4's insurance company, for authorization to schedule an oncology appointment for thrombocytopenia (Low platelet count - fragments in the blood that form clots to prevent bleeding). This failure resulted in the delay of Resident 4 from seeing an Oncologist sooner to evaluate his diagnosis of thrombocytopenia. Findings: A review of Resident 4's Resident Information, indicated, resident was admitted to the facility on [DATE], with diagnoses which included end stage kidney disease (ESRD-occurs when the kidneys are no longer able to carry out their daily functions, requiring either dialysis or transplantation to sustain life). A review of Resident 4's Brief Interview for Mental Status (BIMS- a screening test used to evaluate a patient's basic cognitive function, memory, and orientation) indicated a score of 15 out of 15, cognitively intact. On April 18, 2026, at 3:44 p.m., during an interview, the Social Services (SS) staff stated the following: - When a doctor's appointment requires insurance authorization, the process is for SS or the Case Manager (CM) to submit a request for authorization to the insurance company (via a referral form); - The process to receive an authorization should take approximately three to four days; and -The follow-up with an oncologist was ordered on February 23, 2026, and she notified CM 1 that an authorization from the resident's insurance company was needed, so the appointment could be scheduled. However, she was unsure of the approximate date she notified CM 1. A review of Resident 4's physician orders dated February 23, 2026, at 12:56 a.m., indicated, . Follow up with (Oncologist) . for evaluation and management of thrombocytopenia . On April 18, 2026, at 3:55 p.m., during a concurrent interview and record review, CM 1 stated the following: -Receiving authorization to set an appointment should take a couple of weeks; -For appointments needing insurance authorization, she would request an authorization for the appointment from the resident's insurance company, and once obtained, the appointment would be scheduled; -Resident 4 has a physician order dated February 23, 2026, to follow up with an Oncologist for evaluation of thrombocytopenia; -The SS notified CM 1 an authorization was needed for Resident 4's Drs appointment; -She (CM 1) was unsure of the exact date she sent the referral for authorization, but she received authorization on April 23, 2026, and today (May 18, 2026) she followed up with the resident's insurance company and found out Resident 4's Oncology appointment has been set for May 21, 2026; -She (CM 1) and SS do not have a process to follow up with each other to discuss and/or review resident authorizations; and -There was a delay in requesting the authorization for Resident 4's oncology appointment, which may have been due to the transition into her new position, and a lack of communication with SS. A review of Resident 4's, Referral for Authorization form, dated April 23, 2026, indicated, . Specialty Hematology/Oncology . approved . decision date April 23, 2026, . Diagnosis . Thrombocytopenia . On May 22, 2026, at 9:08 a.m., during an interview, the SS staff stated she is responsible for receiving insurance authorizations for Custodial (On-going support of chronic conditions not covered by Medicare) residents. A review of Resident 4's physician order dated, December 30, 2025, indicated . Custodial level of Care effective (January 2, 2026) . A review of the facility policy and procedure, titled, Referrals, Social Services, revised December 2008, indicated, . 1. Social services personnel shall coordinate most resident referrals . 2. Referrals for medical services must be based on . physician(s) order 3. Social Services will collaborate with . other pertinent disciplines to arrange for services that have been ordered by the physician .

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in accordance with the facility policy and procedures and the manufacturer's specifications when:1. An opened and uncapped ophthalmic (eye) medication for Resident 103 was stored without an opened date, with the dropper tip covered by tissue, in one of two reviewed medication rooms (Oasis Medication Room);2. Discontinued medications, including controlled substances (CS - medications with potential for abuse and dependence), for Residents 63 and 153 were stored in two of four reviewed medication carts (Dunes and Oasis Medication Carts); and3. Expired house supply medication and inhalers for Residents 140 and 145 were stored with active medications in two of four reviewed medication carts (Oasis and MedBridge Medication Carts).These failures had the potential for residents to receive deteriorated, discontinued, expired, or ineffective medication, which could result in medication errors and compromised treatment outcomes.Findings:1. On April 21, 2026, at 10:08 a.m., during an inspection of Oasis Medication Room with the Director of Nursing (DON), an opened bottle of latanoprost (Xalatan, an opthalmic medication used to treat glaucoma [a group of eye diseases that damage the optic nerve-the vital connection between the eye and brain-often caused by high fluid pressure within the eye]) 0.005 % (percentage - unit of measurement for the concentration of a medication) was observed stored in the medication refrigerator without an opened date. The dropper tip was uncapped and covered with tissue and stored inside the pharmacy-supplied amber bottle labeled for Resident 103.A review of April 2026 Medication Administration Record (MAR) indicated Resident 103 received the medication daily at bedtime as ordered.On April 21, 2026, at 10:08 a.m., during a concurrent observation, interview, and record review with the DON, the DON confirmed the storage condition was not appropriate and stated the dropper tip could be exposed to contamination.On April 23, 2026, at 4:23 p.m., during an interview with the Infection Preventionist (IP), the IP stated the eye drop should have been discarded if the cap was missing, as exposure of the dropper tip could result in contamination and potential eye infection such as conjunctivitis (pink eye, inflammation of the eye).2a. On April 21, 2026, at 2 p.m., during an inspection of Medication Cart #8 at Dunes Nursing Station with Licensed Vocational Nurse (LVN) 5, the following medications for Resident 153 were observed stored in the medication cart with other active medications:- Tramadol (Scheduled IV controlled substance pain medication) 50 mg (milligram - unit of measurement) blister card containing 11 tablets;- Tramadol 50 mg blister card containing 14 tablets;- Oxycodone - APAP (scheduled II controlled substance, narcotic pain medication containing oxycodone [opioid] and acetaminophen) 5-325 mg blister card containing 12 tablets;- Oxycodone - APAP 5-325 mg blister card containing 30 tablets;- Allopurinol (used to treat gout [painful form of arthritis]) 100 mg blister card containing three (3) tablets; - Sevelamer (phosphate binder used in kidney disease) 400 mg blister card containing three (3) tablets;- Sucralfate (used to treat stomach ulcers) 1 gm (gram - unit of measurement) blister card containing three (3) tablets;- Icosapent Ethyl (Vascepa, used to lower triglyceride [blood fats]) 1 gm blister card containing three (3) capsules;- Hydralazine (used to treat high blood pressure) 50 mg blister card containing six (6) tablets;- Clopidogrel (an antiplatelet medication used to prevent blood clots from forming) 75 mg blister card containing three (3) tablets;- Amlodipine (used to treat high blood pressure) 5 mg blister card containing three (3) tablets;- Escitalopram (used to treat depression) 10 mg blister card containing three (3) tablets;- Furosemide (used to reduce fluid buildup) 80 mg blister card containing two (2) tablets;- Montelukast (used to treat asthma) 10 mg blister card containing five (5) tablets;- Gabapentin (used for nerve pain) 100 mg blister card containing three (3) capsules;- Gabapentin 100 mg blister card containing six (6) capsules;- Atorvastatin (used to treat high cholesterol) 20 mg blister card containing six (6) tablets;- Atorvastatin 40 mg blister card containing 25 tablets;- Clonidine (used to treat high blood pressure) 0.1 mg blister card containing five (5) tablets;- Clonidine 0.1 mg blister card containing 27 tablets;- Clonidine 0.1 mg blister card containing seven (7) tablets;- Clonidine 0.1 mg blister card containing seven (7) tablets;- Clonidine 0.1 mg blister card containing 30 tablets;- Clonidine 0.1 mg blister card containing 28 tablets;- Carvedilol (used to treat high blood pressure) 0.125 mg blister card containing 27 tablets;- Carvedilol 0.125 mg blister card containing two (2) tablets;- Carvedilol 0.125 mg blister card containing seven (7) tablets;On April 21, 2026, at 2 p.m., during a concurrent observation, interview and record review with LVN 5, Resident 153's medical record indicated the resident was transferred to the hospital on April 12, 2026, and discharged from the facility on April 19, 2026. LVN 5 stated discontinued medications should have been removed from the medication cart for proper disposal.On April 21, 2026, at 2:35 p.m., during a concurrent observation, interview, and record review with the DON, the DON confirmed the findings and stated the discontinued medications should have been removed from medication storage areas after discharge.2b. On April 21, 2026, at 3:11 p.m., during an inspection of Medication Cart #9 at Oasis Nursing Station with LVN 6, the following discontinued controlled substance medications labeled for Resident 63 were observed stored with active medications:- Hydrocodone - Acetaminophen (Norco, a narcotic pain medication) 10-325 mg blister card containing six (6) tablets;- Hydrocodone - Acetaminophen 10-325 mg blister card containing 30 tablets; and- Hydrocodone - Acetaminophen 5-325 mg blister card containing 17 tablets. On April 21, 2026, at 3:11 p.m., during a concurrent observation, interview, and record review with LVN 6, LVN 6 stated the medications were discontinued on March 25, 2026.On April 24, 2026, at 10:57 a.m., during a concurrent interview and record review with the DON, the DON confirmed the findings during inspection of the medication carts at Dunes and Oasis Nursing Station of the discontinued medications. The DON stated the discontinued medications should have been removed from the medication cart once discontinued and stated the nursing staff were expected to remove discontinued medications promptly.A review of the facility's policy and procedure titled, Controlled Substances, dated November 2022, indicated, .Controlled substances remaining the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed .The consultant pharmacist or designee routinely monitors controlled substance storage records . 3a. On April 21, 2026, at 3:11 p.m., during an inspection of Medication Cart #9 at Oasis Nursing Station with LVN 6, an opened box of Famotidine (an over-the-counter [medication available without prescription] acid reducer medication) 10 mg house supply (medications available for general use for residents, rather than dispensed or labeled for a specific resident) was observed stored in the medication cart. The manufacturer's expiration date on the box indicated January 2026. Inside the box, four (4) tablets were observed with expiration date of November 2025 and ten tablets with expiration date of January 2026. LVN 6 confirmed the medications were expired and should have been removed from the medication cart and disposed of.3b. On April 21, 2026, at 4:21 p.m., during an inspection of Medication Cart #4 at MedBridge Nursing Station with LVN 5, an opened fluticasone propionate and salmeterol (brand name Advair Diskus - a dry powder inhaler used to treat chronic obstructive lung disease [COPD - a lung disease causing difficulty breathing]) 100 mcg/50 mcg (microgram, unit of measurement) labeled for Resident 145 was observed stored without an opened date. The pharmacy fill date indicated March 2, 2026. The inhaler device displayed a dose counter reading of 25, indicating remaining doses.A review of Resident 145's Medication Administration Record (MAR), dated March 2026 and April 2026, indicated the inhaler was administered daily from March 2, 2026, through April 21, 2026, as ordered by the physician.3c. On April 21, 2026, at 4:21 p.m., during an inspection of Medication Cart #4 in MedBridge Nursing Station with LVN 5, an opened fluticasone propionate and salmeterol 250 mcg/50 mcg labeled for Resident 140 were observed stored without an opened date. The pharmacy fill date on the label indicated March 20, 2026. The inhaler device displayed a dose counter reading of 23, indicating remaining doses.A review of Resident 140's MAR, dated March 2026 and April 2026, indicated the inhaler was administered twice a day from March 21, 2026, at 9 a.m., through April 21, 2026, at 9 a.m. A review of the manufacturer's labeling for Fluticasone propionate and salmeterol inhalation powder indicated: one foil strip of 60 blisters.Discard the inhaler 1 month after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first.On April 21, 2026, at 4:21 p.m., during a concurrent observation, interview and record review with LVN 5, LVN 5 confirmed the inhalers had exceeded 30 days from first use date and acknowledged the inhalers should have been removed from the medication cart. On April 24, 2026, at 11:09 a.m., during an interview and record review with the DON, the DON stated nursing staff are expected to document the opened date on the medications and use the beyond-use date (BUD - the date after opening after which a medication should not be used) cheat sheet available in every medication cart to determine expiration and remove expired medications.A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .The expiration/beyond-use date.is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . A review of the facility's policy and procedure titled, Medication Labeling and Storage, dated February 2023, indicated, .discontinued, outdated or deteriorated medications ., the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .medication label includes .expiration date.

Based on observation, interview, and record review, the facility failed to follow its policy on Meal Service to provide appetizing food at appropriate temperatures according to residents' preferences, for five of 163 sampled residents (Residents 5, 17, 21, 52, and 54). In addition, meal trays were not served timely.These failures placed residents at potential risk for decrease nutritional intake which may affect the residents' overall nutrition status.Findings: A review of the facility Resident council minutes on January 13, 2026, indicated, Nursing: Concerns: Nursing not serving meals timely.On April 20, 2026, at 3:55 p.m., an interview was conducted with Resident 52. Resident 52 stated, Lunch is 11:00 a.m. but do not get meal tray until 11:30 a.m. or later.On April 21, 2026, at 9:03 a.m., an interview was conducted with Resident 21. Resident 21 stated, All served meals are cold.On April 21, 2026, at 9:06 a.m., an interview was conducted with Resident 5. Resident 5 stated, Served foods are cold; always missing food items from my meal trays; Served foods are unidentifiable.On April 21, 2026, at 9:56 a.m., an interview was conducted with Resident 54. Resident 54 stated, Food has no taste. Food gets here late, so it's cold. Food itself- not good. Worst every meal. They offer sandwich which is lousy too.On April 21, 2026, at 10:27 a.m., an interview was conducted with Resident 17. Resident 17 stated, Meat is overcooked; sometimes cold; flavor not good and always late.A review meal cart delivery schedule indicated, 800 meal cart (are holding some of resident meal trays from room [ROOM NUMBER] until 906) arrived on floor at 8:30 a.m.On April 22, 2026, at 8:47 a.m., meal cart 800 which contained the test meal tray was observed with the Dietary Director (DD) leaving the kitchen and was parked outside room [ROOM NUMBER] hallway at 8:49 a.m. The meal cart stayed in room [ROOM NUMBER] hallway waiting for the nursing staff to grab the meal trays from Meal cart 800 and deliver it to the residents. At 8:58 a.m., observed Certified Nursing Assistant (CNA) 9 started removing first meal tray from Meal cart 800. At 9:09 a.m., CNAs completed delivery of all meal trays in the Meal cart 800 to residents. On April 22, 2026, at 9:10 a.m., a test meal was performed for food temperature and palatability (refers to the taste and/or flavor of the food) of the Regular diet, Pureed diet and Fortified Mince and Moist diet with the DD, at Dunes dining room. The following temperatures were obtained from the test meals by the DD:Regular diet: sausage: 116.1 (degrees Fahrenheit -a unit for measurement), whole milk: 52.2 , Cranberry juice: 55.9 .Puree diet: whole milk: 50.4 ; Cranberry juice 63 .Fortified Mince and Moist diet: whole milk: 51.6 ; Orange juice 56.3 .Temperature findings were verified with the DD. It was noted sausage, whole milk and juice were not served at recommended temperatures per facility policy.On April 22, 2026, at 10:04 a.m., an interview was conducted with the DD. The DD stated it took a long time for the meal trays sitting in the Meal Cart 800 in the hallway waiting for nursing staff to pass the residents' meal trays which resulted in residents receiving food at inappropriate temperatures and also not serving meals timely. The DD stated serving food at inappropriate temperatures and delayed delivery meal trays placed residents in unhappy situation which could lead to decrease meals intake and may affect the residents' overall nutrition status like weight loss.During a review of the facility policy Meal Service, revised January 2023, indicated .5.Trays will be delivered as completed to a designated area at a predetermined time for Nursing to pick up.7. Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot .Recommended Temperature at Delivery to resident .Milk/Cold Beverage 45 ; Hot entree 120 , . While, with the exception of three items (sausage, milk and juice), food temperatures were in accordance with facility policy, it did not fully meet resident needs.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, for 163 out of 163 sampled residents who received foods from the kitchen, when:1. A Dietary Aide did not clean dirty meal carts per facility policy and procedure;2. Calcium buildup found on hot waterspouts in the kitchen;3. Two expired sandwiches found stored inside the nourishment refrigerator;4. Dust observed on several pieces of equipment and area in the kitchen; and5. Chipped paint was observed on the water drain found under the 3-compartment sinks.These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that result from ingesting contaminated foods). Findings: 1. On April 21, 2026, at 9:33 a.m., a concurrent observation and interview were conducted with Dietary Aide (DA) 1 in dishwashing area. DA 1 was observed using detergent to wash the dirty meal carts and then sanitized them with sanitizer. DA 1 confirmed he only used detergent to wash the dirty meal carts and sanitized with sanitizer.On April 22, 2026, at 10:04 a.m., an interview was conducted with the Dietary Director (DD). The DD stated according to the facility policy and procedure, the Dietary staff should wash the dirty meal cart with detergent, then rinse off the detergent, and with final step was to sanitize with sanitizer. The DD stated the detergent chemical would interact with the sanitizer chemical without rinsing off the detergent, which could cause the sanitizer to be ineffective. The DD further explained the ineffective sanitizer would not kill the bacteria and germ on the meal carts which could lead to cross contamination.During a review of the facility's policy and procedure titled, FOOD CARTS, dated 2023, the policy indicated, CLEANING PROCEDURE.Prepare.detergent, clean cart .with a clean cloth.Then rinse with clean warm water.Prepare.sanitizing solution.and spray or wipe down cart.2. On April 20, 2026, at 10:10 a.m., a concurrent observation and interview were conducted with the DD at coffee station inside the kitchen. The hot waterspout was observed to have white grime buildup. The DD stated the white grime was calcium (hard water) buildup and needed to be cleaned up otherwise white grime could fall into the water.During a review of the facility's policy and procedure titled, Sanitation, dated 2023, the policy indicated, .All equipment shall be maintained as necessary and kept in working order. PROCEDURE.All equipment shall be kept clean.3. On April 20, 2026, at 3:46 p.m., a concurrent observation and interview were conducted with the DD in Medbrige nourishment room. There were two house made sandwiches (Chicken Salad Sandwich and Peanut Butter and Jelly Sandwich) labeled with used by date of April 19, 2026, stored in the nurses' station nourishment refrigerator. The DD stated those sandwiches were expired and should be discarded.During a review of the facility's policy and procedure titled, STORAGE OF FOOD AND SUPPLIES, dated 2023, the policy indicated, .POLICY: food and supplies will be stored properly and in a safe manner.No food will be kept longer than the expiration date on the product.4. According to the FDA Federal Food Code 2022, Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris.The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests.During the initial kitchen tour on April 20, 2026, beginning at 9:49 a.m., there were multiple areas and pieces of equipment that were not clean to sight and/or touch which included the following:-Black debris found on door frame leading to Dunes dining room; -Brown debris found on storage shelves located at the coffee station;-Pot and pans storage shelves found with brown debris and observed clean kitchenware were stored on the shelves; -Black and /or brown debris found on fire suppression system which was next to the stove;-Black and /or brown debris found on main entrance door frame; and-Black debris found on walk-in refrigerator fan cover.In a concurrent interview with the DD, the DD confirmed the above findings. The DD stated black and/or brown debris were dust. The DD stated dust could cause cross contamination and the dietary staff should keep the kitchen clean.During a review of the facility's policy and procedure titled, Sanitation, dated 2023, the policy indicated, .All equipment shall be maintained as necessary PROCEDURE.All equipment shall be kept clean.5. On April 20, 2026, at 10:20 a.m., a concurrent observation and interview were conducted with the DD in the kitchen. The water-drain under the 3-compartment sinks (sink that use for wash, rinse and sanitize kitchenware) was observed to have chipped paint. The DD stated the drain's chipped off white paint could create pores which could trap dirt (black grime) and bacteria. The DD stated the drain needed to be replaced.During a review of the facility's policy and procedure titled, Sanitation, dated 2023, the policy indicated, .All equipment shall be maintained as necessary and kept in working order. PROCEDURE.All equipment shall be kept clean, maintained in a good repair and shall be free from.corrosions, open seam, cracks, and chipped areas.

Based on observations, interviews, and record reviews, the facility failed to ensure a homelike environment was provided, for three of three residents reviewed (Residents 52, 53, and 20) when:1.Resident 52 consistently heard yelling or screaming from a confused resident in another room throughout the shift.This failure resulted in Resident 52 experiencing sleep disruption and increased noise levels affecting his immediate environment.2. Resident 53 was not assisted by staff to put away her personal belongings such as clothes and blanket found on the floor of the resident's room.This failure resulted in Resident 53's clothes and blanket left on the floor, creating clutter and making her room less comfortable and homelike; and3.Resident 20's personal credit card was not kept safe and accounted for.This failure resulted in Resident 20 losing his credit card and placed him at risk for financial abuse.Findings: 1.On April 20, 2026, at 11:15 a.m., an observation was conducted outside Resident 177's room. Resident 177 was observed ringing his call bell for assistance by banging the bell against the overhead table and screaming for help in Spanish. A Licensed Nurse was observed in Resident 177's hallway by her medication cart, and did not respond to Resident 177's call for assistance. On April 21, 2026, the following were observed: - At 9:31 a.m., a second observation was conducted outside Resident 177's room. Resident 177 was screaming for help while ringing his call bell at the same time. Staff were observed down Resident 177's hallway and did not respond to his call for assistance; and - At 9:40 a.m., Resident 177 continued to scream loudly for help while banging his call bell against the table. A Licensed Nurse was observed down Resident 177's hallway and did not attend to his call for assistance. On April 21, 2026, at 10:30 a.m., an interview was conducted with Resident 52. Resident 52 stated he was unable to sleep at night due to residents screaming in the hallway across from his room. Resident 52 stated he had notified staff several times over the last month regarding noise level; however, nothing had changed. Resident 52 stated the staff told him to keep his door closed, but he preferred to keep his door open. Resident 52 stated the screaming occurred during the day, evening, and at night. Resident 52 stated he was woken up at 3 a.m. on April 21, 2026, because of Resident 177 screaming. Resident 52 stated he was unable to rest and sleep at night due to the noise. On April 23, 2026, at 10:35 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated there were approximately five residents in Resident 52's hallway who had behavior of screaming and/or yelling due to confusion. CNA 1 stated the screaming and/or yelling occurred throughout the entire shift. CNA 1 stated when this happened, the staff attempt to redirect them, such as having them watch television, but the redirection was unsuccessful most of time. CNA 1 stated there were residents who requested their doors to be closed due to the noise level being too much. CNA 1 further stated that there have been no room changes conducted in the last several months due to residents' complaints about noise level. On April 24, 2026, at 9:03 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the residents have the right to a homelike environment that included comfortable noise levels. The DON further stated she was currently aware of three residents who have the behavior of screaming in Resident 52's hallway. The DON stated that room changes may have been implemented to address these noise concerns, however, this was not done in the last couple of months. The DON stated Resident 52, who notified the staff of the unreasonable noise levels, did not experience a homelike environment. On April 23, 2026, Resident 177's record was reviewed. Resident 177 was admitted to the facility on [DATE], with diagnoses which included left hemiplegia (left side weakness) due to cerebral infarction (stroke caused by sudden lack of oxygen to the brain due to blood clot). On April 24, 2026, Resident 52's record was reviewed, Resident 52 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (lung disease). A review of the facility's policy and procedure titled, Quality of Life – Homelike Environment, dated May 2017, indicated, .residents are provided with a safe, clean, comfortable and homelike environment.characteristics of the facility that reflect a personalized, homelike setting.including comfortable noise levels. minimize.characteristics of the facility that reflect a depersonalized, institutional setting.including environmental disruptions. 2. On April 21, 2026, at 12:27 p.m., during a concurrent observation and interview with Resident 53 in her room, Resident 53's clothes and blanket were observed on the floor. Resident 53 stated she asked the staff to help her put away her clothes multiple times and no one had assisted her. Resident 53's record was reviewed. Resident 53 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (muscle weakness) and hemiparesis (muscle paralysis) following other nontraumatic intracranial hemorrhage (bleeding inside the skull) affecting right dominant side. On April 22, 2026, at 9 a.m., during an interview with CNA 2, CNA 2 stated CNAs were responsible for assisting residents in maintaining a clean room, helping residents put away clothes, making sure rooms were tidy and home-like, and placing soiled clothing in laundry. CNA 2 stated the housekeeping staff cleaned resident's room twice a day. On April 22, 2026, at 2:45 p.m., during an interview with CNA 3, CNA 3 stated Resident 53 had asked her to put away her clothes and blankets that were on the floor today. CNA 3 stated that she had noticed her belongings on the floor prior days and should have offered to put it away. On April 24, 2026, at 9:42 a.m., during an interview with the Director of Staff Development (DSD), the DSD stated it was the responsibility of the CNAs to assist residents in maintaining clean and safe surroundings. The DSD stated CNAs should offer to put away personal items to ensure resident safety, comfort, and infection control daily as part of their routine care. 3. On April 22, 2026, at 8:21 a.m., during an interview with Resident 20 stated his wallet, which contained his credit card, was missing in late January to February 2026 and was later found in the bathroom by an unknown staff member. Resident 20 stated his credit card company contacted him regarding unusual transactions. Resident 20 stated he reported the incident to a facility staff, who stated she would investigate. Resident 20's record was reviewed. Resident 20 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (irreversible kidney damage). A review of Resident 20's Inventory of Personal Effects dated November 5, 2025, indicated Resident 20 had three credit cards, which was signed by Resident 20 and staff. On April 23, 2026, at 9:35 a.m., during a concurrent interview and review of Resident 20's inventory list with Social Service Manager (SSM), the SSM stated residents' credit cards were secured in the facility safe. The SSM stated if a resident chose to keep credit cards at the bedside, a lock box would be provided, and the resident would be given a key. The SSM stated Resident 20's credit cards were to be stored in the facility safe. The SSM further stated CNAs should have offered Resident 20 a lock box. On April 23, 2026, at 9:40 a.m., during a concurrent observation and interview with SSM and Resident 20 in the resident's room, no lock box was observed. Resident 20 stated he had not been informed about the options for safekeeping of his credit cards. The SSM stated Resident 20 should have been informed of the choices of safekeeping of his credit cards to secure personal belongings such as credit cards and prevent psychosocial distress. On April 23, 2026, at 10:38 a.m., during an interview with CNA4, CNA 4 stated she did not recall whether Resident 20 had credit cards at the time of admission. CNA 4 stated when a resident had credit cards upon admission, she would notify the licensed nurse and offer options for safekeeping of his credit cards. CNA 4 stated Resident 20 should have been offered options for safekeeping for safety. On April 24, 2026, at 9:14 a.m., during an interview with Licensed Vocational Nurse (LVN) 7, LVN 7 stated Resident 20 should have been offered options for safekeeping to prevent missing items and psychosocial distress. LVN 4 stated residents' belongings were important and should be secured to ensure residents felt safe. On April 24, 2026, at 10:30 a.m., during an interview with the Assistant Director of Nursing (ADON), the ADON stated Resident 20's wallet went missing during transfer to another unit. The ADON stated unauthorized charges were identified on one of Resident 20's credit cards. The ADON stated options for safekeeping should have been offered to Resident 20 to secure personal belongings while in the facility. A review of the facility's policy and procedure titled, Personal Property, dated August 2022, indicated, .Resident belongings are treated with respect .facility promptly investigates any complaints of misappropriation or mistreatment of resident property .

Based on observation, interview, and record review, the facility failed to ensure dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) services where consistent with professional standards of practice and facility's policy and procedure, for two of five residents reviewed for dialysis (Residents 16 and 137), when:1a. For Resident 16, the dialysis access site was not assessed and maintained. This failure had the potential to result in infection, including bloodstream infection, increased pain, and further decline in the president's health condition.1b. For Resident 16, received more than his physician prescribed 1500 milliliters (ml- a unit of measurement) of fluids per day. This failure placed Resident 16's care needs to go unmet and had the potential to result in fluid overload. 2. For Resident 137, there was no coordination between the facility and the dialysis clinic to address the resident's refusal to go to dialysis treatments, from March 3, 2026, to April 21, 2026. In addition, there was no care and treatment provided for the resident's dialysis access site when it was not being used due to refusal to go to dialysis treatments, including coordination with the dialysis clinic to address care and maintenance of the dialysis access site. These failures had the potential to result in serious complications including fluid overload, electrolyte imbalance, cardiac arrhythmias (irregular heart rate), infection to the dialysis access site, hospitalizations, and could affect overall health condition of Resident 137.Findings:1a. On April 21, 2026, at 8:44 a.m., Resident 16 was observed with a dressing covering a CVC access site (Central Venous Catheter - a catheter inserted into a large vein used for dialysis) on the right upper chest, with a date of April 20, 2026. The dressing was observed with greenish brown drainage.On April 22, 2026, at 8:30 a.m., during a concurrent observation and interview with Resident 16, Resident 16 stated he had pain at the CVC access site since yesterday afternoon. Resident 16 stated the licensed nurses had not checked on it. The dressing was observed to have greenish brown drainage.Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (ESRD - the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). A review of Resident 16's physician order, dated March 9, 2026, indicated, .Resident has IJ catheter (a type of central venous catheter (CVC) or central line inserted into the large internal jugular vein [a paired, deep blood vessel in the neck that drains oxygen-depleted blood from the brain, face, and neck, carrying it toward the heart] in the neck) with (enter number) lumens, which is located on the RUC (right upper chest). Monitor Q (every) shift for signs or symptoms of infection (i.e., redness, swelling, pain, warmth, discharge, induration) or bleeding. Notify physician of abnormal findings every shift.On April 22, 2026, at 11:45 a.m., during an interview with Licensed Vocational Nurse (LVN) 13, LVN 13 stated there had been no report of concerns regarding Resident 16's access site reported to her from the previous shift. LVN 13 stated she had not assessed the resident's access site for today and was not aware of any complaint of pain or drainage. LVN 13 further stated that the CVC dressing was usually changed at the dialysis clinic, but the licensed nurse at the facility monitors and assesses it Q shift and notifies the physician of any abnormal findings.On April 22, 2026, at 2:10 p.m., during an interview with the Director of Nursing (DON), the DON stated she was not aware that Resident 16's dialysis access site had any drainage. The DON stated the licensed nurse were expected to assess the site, report abnormalities and notify the physician. The DON further stated it was important to monitor the access site because it could become infected and lead to serious illness.A review of the facility's policy and procedure titled, Hemodialysis Catheters - Access and Care of, dated June 2025, indicated, .Hemodialysis catheters are only accessed by medical personnel who have received training and demonstrated clinical competency regarding use of this catheter.Central catheters.this is not the preferred site for long-term placement. There is more risk of clotting and infection.the dressing change is done in the dialysis center post treatment.if dressing becomes wet, dirty, or not intact, the dressing will be changed by a licensed nurse trained in this procedure.the central catheter site must be kept clean and dry at all times.the nurse should document in the residents medical record every shift as follows: location of catheter; condition of dressing (interventions if needed); if dialysis was done during shift; any part of report from dialysis nurse post-dialysis being given; and observations post-dialysis.1b. On April 22, 2026, at 8:30 a.m., during an interview with Resident 16, Resident 16 stated every time he goes for his dialysis treatment, they remove at least 3.5 kilograms, he further stated, the facility usually brings him lots of fluids to drink but does not drink it all. On April 22, 2026, at 8:30 a.m., during a concurrent observation and interview with CNA 13, CNA 13 observed bringing Resident 16's breakfast tray with 8 fl. oz. (fluid ounce - unit of measurement) Nonfat milk (240 ml - milliliter [unit of measurement]), cranberry juice (120 ml), Nephro supplement drink (237 ml), a cup of water (180ml), and a cup of coffee (180 ml), total of 957 ml for breakfast. CNA 13 further stated, she was not sure how much fluid intake the resident who was diagnosed with ESRD should have, she thinks it is 1500 ml per meal but will double check. Resident 16's meal tray ticket indicated, thin, Renal.4 fl oz Cranberry juice. 8 fl oz. Non-fat milk.8 fl oz Nepro.On April 22, 2026, at 9 a.m., during an interview with CNA 13, CNA 13 stated that Resident 16 should be only 1500 ml fluid intake for the whole day. CNA 13 further stated she informed she removed the cup of water and juice.A review of Resident 16's physician order, dated April 14, 2026, indicated, . HD fluid restriction of 1500 ml/24 hrs. Nursing: Give 275 for AM shift, 275 ml for PM shift, and 50 ml for Night shift (total= 600ml). Dietary: give 420 m for AM shift, 240 ml for PM shift, and 240 ml for night shift (total= 900 ml) .A review of Resident 16's Fluid Intake Record, for the month of April 2026, indicated the resident consumed more than 1500 ml/day on the following dates:-April 7, 2026; 1615 ml;-April 14, 2026; 2120 ml;-April 20, 2026; 1590 ml; and-April 21, 2026; 1690 ml.On April 22, 2026, at 2:10 pm, during an interview via telephone with Dialysis Clinic Clinical Coordinator (DCCC). The DCCC stated Resident had a weight gain of 6.6 kg (kilogram - unit if measurement) today when he arrived for his treatment. The DCCC further stated resident 16 had problems with too much weight gain in between treatment, and that the facility has been made aware.A review of Resident 16's Hemodialysis Communication Record, dated April 15, 2026, indicated, .to be completed by Dialysis Center following dialysis treatment and to accompany resident on return to facility post dialysis.Recommendations: monitor fluid intake.On April 24, 2026, at 12:04 p.m., during an interview with the DON. The DON stated Resident 16 was on a fluid restriction of 1500 ml per day, and there could be possible outcome for residents who consumed greater than their prescribed amount would be fluid overload, respiratory distress, and edema. The DON further stated her expectation was for staff to follow the order and notify the physician if residents consumed more than their prescribed fluid amount.A review of the facility's policy and procedure titled, Fluid Restricted Diet, revised April 13, 2026, indicated, .Fluid restrictions are usually ordered to treat CHF (congestive heart failure - chronic, progressive condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs for oxygen), hyponatremia (a medical condition where the sodium concentration in the blood is abnormally low), or renal failure. The restriction is an estimate of the amount of fluids which will assist in management of the condition.The following guidelines may be used in distributing fluids between Nursing and Dietary.1500 ml/24 hours.Nursing.600.Dietary.900.2.On April 22, 2026, at 11:08 a.m., during an observation and interview with Resident 137, Resident 137 stated he had dialysis scheduled every Tuesday and reported he had not attended dialysis treatments for approximately two months. Resident 137 stated he was refusing to go to dialysis treatment because he did not like the scheduled time given to him. Resident 137 stated he had CVC access on his right upper chest, and that no one has looked at it. Resident 137's CVC was observed on the resident's right upper chest, exit site exposed, with no dressing covering it.Resident 137's record was reviewed. Resident 137 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD).A review of Resident 137's physician order, dated January 27, 2026, indicated, .Resident to receive dialysis at [name of dialysis clinic].The dialysis schedule is 1 (one) time per week on Tuesdays, dialysis pick up time is 8 a.m., transportation to dialysis provided by [name of transportation company].A review of Resident 137's physician order, dated October 16, 2025, indicated, .Resident has catheter with (enter number) lumens, which is located on the RUC. Monitor Q shift for signs and symptoms of infection (i.e., redness, swelling, pain, warmth, discharge, induration) or bleeding. notify physician of abnormal findings every shift.check dialysis catheter site dressing Q shift. May reinforce dressing as needed. Do not get wet.Dialysis center to provide dialysis catheter access site care including changing caps.A review of Resident 137's care plan, dated November 20, 2025, indicated, .Explain risks vs benefits to resident/ responsible party.interventions: notify MD and responsible party each time they refused.A review of Resident 137's Hemodialysis Communication Records, indicated that Resident 137's last dialysis treatment was on February 26, 2026. Further review of records indicated that Resident 137 has missed his dialysis treatment from March 3, 2026, until April 21, 2026.A review of Resident 137's Progress Notes, documented by Registered Dietitian (RD) 2, indicated Resident 137 refused to go to dialysis once a week because he was upset with the dialysis day and time being changed as documented on the following dates and times:-March 9, 2026, at 7:27 a.m.;-March 15, 2026, at 5:27 a.m.;-March 22, 2026, at 8:26 a.m.;-March 29, 2026, at 6:39 a.m.;-April 6, 2026, at 5:15 a.m.; and-April 12, 2026, at 10:45 a.m.Further review of Resident 137's record indicated there was no coordination between the facility and the dialysis clinic to address the resident's refusal to go to dialysis treatment and make accommodations to the preferred day and time for the resident's dialysis treatments.On April 22, 2026, at 11:28 a.m., during an interview with the Assistant Director of Nursing (ADON), the ADON stated Resident 137 had been refusing dialysis treatments, with the last completed dialysis treatment on February 26, 2026. The ADON stated the dialysis clinic is responsible for doing dressing changes for the CVC.On April 23, 2206, at 8:29 a.m., during an interview with the Dialysis Facility Administrator (DFA), the DFA stated Resident 137 was discharged from the dialysis facility on March 31, 2026, due to missed treatments. The DFA stated Resident 137's last dialysis treatment was on February 10, 2026. The DFA stated the dialysis social worker contacted someone from the facility (unable to state the name of the facility staff member) to inform them that Resident 137 was discharged from the dialysis clinic on March 31, 2026, due to missed dialysis treatments. The DFA stated when a resident refuses dialysis, the facility should coordinate with the dialysis provider to ensure appropriate care of the access site, including cleaning and flushing of the catheter ports. The DFA stated the access site should have been evaluated for removal if not longer in use.Further review of Resident 137's record from March 3, 2026, through April 21, 2026, indicated there was no documented evidence that the facility coordinated with the dialysis provider regarding Resident 137's missed treatments or discharge and the care of the CVC access site. In addition, there was no documented evidence that the facility maintained the resident's dialysis access site following missed treatments.On April 23, 2026, at 5:03 p.m., during an interview conducted with the DON, the DON stated the following:-There was no documentation from nursing that Resident 137 was refusing dialysis treatments on the scheduled date of dialysis from March 3, 2026, to April 21, 2026;-There was no documentation the facility coordinated with the dialysis clinic regarding the reason of Resident 137's refusal to go to dialysis treatments;-The facility should have coordinated with the dialysis clinic to see if Resident 137's preferred schedule for dialysis could be accommodated;-They were not aware Resident 137 was discharged from the dialysis clinic on March 31, 2026;-There was no documentation care and treatment for the CVC access site was provided by the facility; -There was no coordination between the facility and the dialysis clinic regarding care for the CVC dialysis access site since the resident was refusing to go to the dialysis clinic. The DON stated the facility should have coordinated with the dialysis clinic regarding the care for the CVC access site.A review of the facility policy and procedure titled, Hemodialysis Catheters- Access and Care of, dated June 2025, indicated, .Hemodialysis catheters are only accessed by medical personnel who have received training and demonstrated clinical competency regarding use of this catheter.Central catheters.this is not the preferred site for long-term placement. There is more risk of clotting and infection.the dressing change is done in the dialysis center post treatment.if dressing becomes wet, dirty, or not intact, the dressing will be changed by a licensed nurse trained in this procedure.the central catheter site must be kept clean and dry at all times.the nurse should document in the residents medical record every shift as follows: location of catheter; condition of dressing (interventions if needed); if dialysis was done during shift; any part of report from dialysis nurse post-dialysis being given; and observations post-dialysis.A review of the facility policy and procedure titled Requesting, Refusing and/or Discontinuing Care or Treatment, dated February 2021, indicated, .detailed information relating to the request, refusal, or discontinuation of treatment are documented in the resident's medical record.documentation pertaining to a resident's request, discontinuation or refusal of treatment include at least the following: a. the date and time the care or treatment was attempted.b. the type of care or treatment.c. the resident's response and stated reasons for request, discontinuation or refusal.d. the name of person who attempted to administer the care or treatment.e. That the resident was informed of the purpose of the treatment and potential outcome of not receiving of the medication/ or treatment.f. The resident's condition and any adverse effects due to the request.g. The date and time the practitioner was notified as well as the practitioner's response.h. All other pertinent observation.i. the signature and title of the person recording the data.the healthcare practitioner must be notified of treatment in a time frame determines by the resident's condition and potential serious consequences of the request.

Based on observation, interview, and record review, the facility failed to ensure a physician-prescribed fortified diet (diet with added extra nutrients to increase the calories and/or protein density to promote improvement in residents' nutrition status) was provided, for four of four sampled residents (Residents 26, 84, 64, and 114) during lunch on April 20, 2026.This failure had the potential to have a negative impact on the residents' nutritional status and further compromise residents' medical status. Findings:On April 20, 2026, at 10:29 a.m., the undated Fortified diet Spreadsheet (the document used to guide dietary staff adding extra calories on food items) was reviewed in the facility kitchen. The Fortified Spreadsheets indicated, Monday Lunch: Hamburger:1 oz extra gravy; Wheat Roll: Extra 1/2 oz melted margarine.On April 20, 2026, at 12:16 p.m., a concurrent observation, interview, and review of Resident 64's meal ticket (contain Resident name and physician diet order) were conducted with Certified Nursing Assistant (CNA) 16 at Dunes dining room. CNA 16 read Resident 64's meal ticket and stated Resident 64 was on Fortified diet. CNA 16 checked Resident 64's served entree and stated she did not see any melted margarine and gravy on the served foods.On April 20, 2026, at 12:22 p.m., a concurrent observation, interview, and review of Resident 114 meal ticket review were conducted with Licensed Vocational Nurse (LVN) 8 at Dunes dining room. LVN 8 read Resident 114's meal ticket and stated Resident 114 on Fortified diet. LVN 8 checked Resident 114's served meal and claimed she did not see melted margarine served on food and extra gravy served on meat.On April 20, 2026, at 12:24 p.m., a concurrent observation, interview, and review of Resident 84's meal ticket were conducted with LVN 8 at Dunes dining room. LVN 8 read Resident 84's meal ticket and stated Resident 84 on Fortified diet. LVN 8 checked Resident 84's served meal and stated there was no melted margarine and gravy served. On April 20, 2026, at 12:30 p.m., a concurrent observation, interview, and review of Resident 26's meal ticket were conducted with LVN 8 at Dunes dining room. LVN 8 read Resident 26's meal ticket and stated Resident 26 on Fortified diet. LVN 8 checked Resident 26's served meal and stated there was no melted margarine served and extra gravy served on meat.On April 21, 2026, at 3:41 p.m., a concurrent interview and a Fortified diet Spreadsheet review were conducted with the Dietary Director (DD). The DD stated Cooks should follow the Fortified diet Spreadsheet providing extra calories from extra melted margarine and gravy to Fortified diet on Monday (April 20,2026) during lunch. The DD explained Resident on Fortified diet was prescribed by doctor to get extra calories to help gain weight and/or promote wound healing. The DD stated residents who were on Fortified diet did not get melted margarine and/or extra gravy with lunch on Monday means he or she did not get extra calories.During a review of Residents 26, 84, 64 and 114's physician's diet order indicated they were on Fortified diet.During a review of the facility policy and procedure titled, FORTIFICATION OF FOOD: INCREASING CALORIES AND/OR PROETEIN IN THE DIET, dated 2023, the P&P indicated, .POLICY: The enrichment of foods will be done on an individual basis for the residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. PURPOSE: The goal is to increase the calories and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutrition status. PROCEDURE.The physician.order a Fortified Diet.Calories and/or protein will be added to selected foods. The Facility Registered Dietitian or Food and Nutrition Service Director will select the fortification method from the.Fortified Menu Plan (Fortified Spreadsheet). Food and Nutrition Services staff will be familiar with the fortification process for each item chosen to be used at the facility.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with physician orders and the facility's policies and procedures, when a medication error rate of 16.13% (five medication errors out of 31 opportunities) was identified during medication pass observations, for two of five residents (Residents 17 and 176), when:1.For Resident 176, medications ordered to administer with food were not followed according to the physician's order and manufacturer's guidelines for administration. In addition, medications were administered outside of administration timeframe; and2.For Resident 17, Vitamin D was not administered according to the physician's order. In addition, Resident 17 was not instructed to rinse mouth after administration of an inhalation medication, according to the physician's order and manufacturer's guideline.These failures had the potential to compromise medication therapy, reduce therapeutic effectiveness, and increase the risk of adverse effects, including gastrointestinal irritation and oral candidiasis (a fungal infection of mouth).Findings:1. On April 20, 2026, at 9:45 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared Resident 176's medications scheduled for 9 a.m., without food or snacks.On April 20, 2026, at 11:06 a.m., during a record review of Resident 176's physician orders indicated the following:- Empagliflozin 10 mg (milligram - unit of measurement), give 1 tablet by mouth one time a day for DM (diabetes mellitus [high blood sugar]). Take with food, dated April 13, 2026;- Metoprolol Succinate (medication to treat high blood pressure) ER (Extended Release) 100 mg, give 1 tablet by mouth one time a day for hypertension.Take with food., dated April 13, 2026; and- Potassium Chloride ER 10 mEq (milliequivalent - unit of measurement), give 1 tablet by mouth one time a day for hypokalemia (low potassium level). Give medication with food or snack and/or with 4-8 oz of water or juice to prevent GI (Gastrointestinal) upset, dated April 13, 2026. A review of Resident 176's Medication Administration Record (MAR), dated April 2026, indicated all 9 a.m. medications were documented as administered, including the following:- Empagliflozin (used to treat diabetes and heart failure) 10 mg;- Metoprolol Succinate ER 100 mg; and- Potassium Chloride ER 10 MEQThese medications were not administered with food according to the physician's order and as documented in the MAR.On April 20, 2026, between 11:54 a.m. and 12:11 p.m., during a medication administration observation with LVN 4, LVN 4 administered the following previously omitted medications without food:- Metoprolol Succinate ER 100 mg;- Potassium Chloride ER 10 mEq;A review of the facility meal schedule indicated breakfast was served at approximately 7:30 a.m., and lunch had not yet been served at the time of administration. In addition, Empagliflozin, scheduled for 9 a.m., was not administered during the medication pass and was not subsequently administered. On April 21, 2026, at 4 p.m., during an interview with LVN 4, LVN 4 acknowledged the medications were administered without food and stated a snack should have been offered when meal trays were not available. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for potassium chloride tablets, dated January 2025, retrieved from DailyMed indicated: .Potassium chloride tablets.should be taken with meals and with a glass of water or other liquid. This product should not be taken on an empty stomach because of its potential for gastric irritation .A review of the Prescribing Information for Metoprolol Succinate ER tablets, dated January 2024, retrieved from DailyMed indicated, .take metoprolol succinate extended-release tablets.as directed, preferably with or immediately following meals.2. On April 20, 2026, at 10:23 a.m., during medication administration observation for Resident 17, LVN 2 prepared and administered medications scheduled for 9 a.m., including inhalation therapies.On April 20, 2026, at 10:38 a.m., LNV 2 initiated administration of budesonide (an inhaled corticosteroid medication used to reduce airway inflammation) through a nebulizer (a device that turns liquid medication into a mist for inhalation into the lungs).On April 20, 2026, at 10:50 a.m., after completion of the nebulizer treatment, LVN 2 removed the nebulizer mask. LVN 2 did not instruct Resident 17 to rinse the mouth and spit out after administration.On April 20, 2026, at 1:42 p.m., during a review of Resident 17's records included a physician's order indicated the following:- Budesonide inhalation suspension 1mg/2mL (milligram per milliliter - unit of measurement), 1 applicator inhale orally every 12 hours for wheezing/COPD (chronic obstructive pulmonary disease [COPD], a lung disease causing breathing problems)/Asthma. Rinse mouth after each use, dated March 27, 2026; and- Cholecalciferol 1000 unit, give 1 tablet by mouth one time a day for supplement, dated November 16, 2025.A review of Resident 17's MAR, indicated cholecalciferol (Vitamin D) 2000 units, scheduled for 9 a.m. was documented as administered. On April 22, 2026, at 11:25 a.m., during a concurrent interview and record review with LVN 2, LVN 2 confirmed the Vitamin D bottle was not present among the prepared medications. LVN 2 acknowledged the medication was not administered despite being documented as given in the MAR. LVN 2 also confirmed Resident 17 was not instructed to rinse the mouth and spit out after administration of budesonide via nebulizer. LVN 2 stated she was not aware rinsing the mouth is required following administration of nebulized corticosteroids and believed this instruction applied only to powder inhalation forms. On April 24, 2026, at 10:39 a.m., during an interview with the DON, the DON stated the nursing staff were expected to administer the medications as ordered, document administration after medications were given, and follow all administration instructions, including rinsing the mouth after budesonide use.A review of the Prescribing Information for Budesonide inhalation suspension, dated January 2026, retrieved from DailyMed indicated: .Candida Albican (type of fungus) infection of the mouth and throat may occur. Monitor patients periodically for signs of adverse effects on the oral cavity.Patients should rinse the mouth after inhalation of budesonide inhalation suspension .A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones .

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services were provided to meet the needs of the residents, for four of 13 residents reviewed (Residents 16, 17, 88, and 146), when:1. For Resident 16, the staff did not follow the physician's order when calcium acetate (medication to treat hyperphosphatemia [high phosphate levels] in patients with end-stage kidney disease) was not given with meals.This failure had the potential to reduce its effectiveness as a phosphate binder, placing the resident at risk for elevated phosphorus levels and related complications.2. For Resident 17, a blood pressure medication with holding parameters was not administered in accordance with the physician's order.This failure had the potential to significantly lower blood pressure and could cause dizziness, confusion, fainting, and a fall.3. For two out of 11 randomly selected residents (Resident 88 and 146), documentation on the Controlled Drug Records (CDR - a medication count sheet, an inventory record used to document the receipt, use, and count of controlled substances [CS, those with high potential for abuse and addiction]) did not reconcile with the Medication Administration Record (MAR - a record used by a licensed nursing staff to document medications administered to a resident).These failures resulted in inaccurate accountability of controlled substances, which had the potential for misuse or diversion (medication taken by someone other than for whom it is prescribed) of controlled substances. Findings: 1. On April 22, 2026, at 8:30 a.m., during an interview conducted while Resident 16 was eating breakfast, the resident stated he is supposed to take his phosphorus binder (calcium acetate) with meals, but the nurses do not give it with meals. A review of Resident 16's admission Record, indicated he was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease (ESRD- the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). A review of Resident 16's Medication Administration Record (MAR), indicated he had an active order for calcium acetate to be administered with meals. On April 22, 2026, at 10:30 a.m., during an interview with Licensed Vocational Nurse (LVN) 15, LVN 15 stated she administered Resident 16's calcium acetate at 9:58 a.m. LVN 15 further stated the order required the medication to be given with meals, and she did not give it while Resident 16 was eating his breakfast. A review of Resident 16's MAR showed calcium acetate was not administered with meals as ordered on multiple occasions. On April 24, 2026, at 12:04 p.m., during an interview with the Director of Nursing (DON). The DON stated calcium acetate should have been given with meals as ordered to ensure it is effective. A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders . 2a. On April 20, 2026, at 10:47 a.m., during a medication administration observation for Resident 17, LVN 2 checked the resident's blood pressure and pulse with a freestanding BP machine prior to medication administration. The blood pressure was 112/72 and the pulse was 85. LVN 2 administered the resident's morning medications but did not administer lisinopril (medication for high blood pressure). On April 20, 2026, at 1:42 p.m., a review of Resident 17's physician order indicated: - Lisinopril 40 mg, give one tablet by mouth one time a day for hypertension. Hold for SBP (systolic blood pressure – top number of a blood pressure reading) < 110 or HR (heart rate – number of heartbeats per minutes) < 60, dated November 16, 2025 On April 20, 2026, at 1:42 p.m., a review of Resident 17's MAR, dated April 2026, indicated the LVN 2 documented code 4 (vital sign out of parameter) for lisinopril. However, no blood pressure or pulse values were documented in the MAR. On April 22, 2026, at 11:25 a.m., during a concurrent interview and record review with LVN 2, LVN 2 confirmed that she did not administer lisinopril and stated she believed the holding parameter was 115. 2b. On April 20, 2026, at 1:42 p.m., a further review of Resident 17's March and April 2026 MAR indicated lisinopril 40 mg was administered when the SBP was below 110 on the following dates: - March 3, 2026, at 0900 (9 a.m.), SBP 85; - April 8, 2026, at 0900 (9 a.m.), SBP 101; and - April 17, 2026, at 0900 (9 a.m.), SBP 105. On April 22, 2026, at 10:39 a.m., during a concurrent interview and record review with the DON, the DON confirmed lisinopril medication was not administered when SBP was above 110 but was administered when SBP was below 100, the ordered holding parameter. The DON stated nursing staff must follow physician orders, including holding parameters. A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders . 3a. On April 21, 2026, at 4:21 p.m., during an inspection of Medication Cart 4 at MedBridge Nursing Station, a blister card of oxycodone 10 mg (a controlled substance pain medication) labeled for Resident 146 was reviewed with LVN 4. A review of Resident 146's physician order indicated: - oxycodone 5 mg, give 10 mg by mouth every 6 hours as needed for moderate pain (4-6 [pain scale]), dated November 24, 2025. A review of Resident 146's CDR and April 2026 MAR indicated: - On April 4, 2026, at 1743 (5:43 p.m.), one tablet was removed and documented on the CDR. However, there was no corresponding documentation of administrations or pain assessment on the MAR; and - On April 15, 2026, at 1708 (5:08 p.m.), one tablet was documented as administered on the MAR. However, there was no corresponding removal documented on the CDR. 3b. On April 21, 2026, at 4:21 p.m., during an inspection of Medication Cart 4 at MedBridge Nursing Station, a blister card of oxycodone 10 mg labeled for Resident 88 was reviewed with LVN 4. A review of Resident 88's physician order indicated an order for oxycodone 5 mg, give 2 tablet[s] by mouth every 4 hours as needed for severe pain (7-10), dated April 1, 2026. A review of Resident 88's CDR and April 2026 MAR indicated: - On April 1, 2026, at 1023 (10:23 a.m.) and April 8, 2026, at 1220 (12:20 p.m.), one tablet was removed and documented on the CDR. However, there was no corresponding documentation of administrations or pain assessments on the MAR; and - On April 4, 2026, at 1859 (6:59 p.m.), April 13, 2026, at 1015 (10:15 a.m.), April 13, 2026, at 1440 (2:40 p.m.), April 14, 2026, at 1648 (4:48 p.m.), and April 19, 2026, at 0353 (3:53 a.m.), oxycodone was documented as administered on the MAR. However, there was no corresponding removal documented on the CDR. On April 24, 2026, at 11:09 a.m., during a concurrent interview and record review with the DON in the DON's office, the DON confirmed discrepancies between the CDR and MAR for Resident 88 and 146. The DON stated nursing staff are expected to document removal of controlled substances on the CDR at the time of removal and document administration on the MAR after administration. A review of the facility's policy and procedure titled, Medication Administration, dated April 2019, indicated, .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones .As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered.e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . A review of the facility's policy and procedure titled, Controlled Substances, dated November 2022, indicated, .Reconciliating Controlled Substances .The system of reconciling .dispensing .of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records .Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count .The nurse coming on duty and the nursing going off duty make the count together and document and report any discrepancies to the director of nursing services .

Based on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required minimum of actual total Certified Nurse Assistant (CNA) Direct Care Hours Per Patient Day (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for the months of November 2025, December 2025, January 2026, February 2026, March 2026, and April 2026.The failure to maintain the required minimum CNA DHPPD hours had the potential to place residents at risk for unmet needs, compromised safety, and decreased quality of care. Findings:On April 24, 2026, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA) 14, CNA 14 stated there were days when there were not enough staff to take care of the residents on the weekends and residents may be calling for assistance for extended period of time which may lead to residents' needs not being met. CNA 14 stated she was responsible to provide care to 13 residents during the morning shift, specially during the weekends, which would make it difficult for them to complete the care to be provided to the residents. On April 24, 2026, at 2:45 p.m., the facility staffing records were reviewed with the Director of Staff Development (DSD). The review indicated the facility's CNA staffing levels were below the minimum required DHPPD of 2.4 hours on the following weekend dates: -November 1, 2025; 2.35-November 8, 2025; 2.19-November 9, 2025; 2.30-November 16, 2025; 2.31-November 29, 2025; 2.34-December 7, 2025; 2.21-December 13, 2025; 2.13-December 14, 2025; 2.31-December 21, 2025; 2.26-December 27, 2025; 2.12-December 28, 2025; 2.32-January 3, 2026; 2.24-January 4, 2026; 2.35-January 11, 2026; 2.33-January 17, 2026; 2.37-January 18, 2026; 2.30-January 24, 2026; 2.38-January 31, 2026; 2.38-February 8, 2026; 2.28-February 14, 2026; 2.28-February 15, 2026; 2.22-February 21, 2026; 1.96-February 22, 2026; 2.10-February 28, 2026; 1.98-March 1, 2026; 2.00-March 7, 2026; 2.23-March 8, 2026; 2.23-March 15, 2026; 2.37-March 21, 2026; 2.32- March 22, 2026; 2.32- March 28, 2026; 2.27- March 29, 2026; 2.12-April 5, 2026; 2.25-April 12, 2026; 2.38In a concurrent interview with the DSD, the DSD stated the facility's CNA DHPPD hours were below 2.4 hours on the above dates that fell on weekends. The DSD further stated CNA DHPPD hours should be maintained at 2.4 hours or above to ensure residents' needs were met and quality care was provided.On April 24, 2026, at 3:12 p.m., during an interview with CNA 8, CNA 8 stated she works full time during the morning shift, and she would be providing care to 10 to 13 residents at a time. CNA 8 stated there were not enough staff to meet the residents' needs.A review of the facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing, dated April 2025, indicated, .facility provides sufficient numbers of nursing staff.to provide nursing and related care and services for all residents.Minimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered determination of sufficient and competent staffing.

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for 21 out of 21 sampled residents (Resident 176, 164, 12, and 18 residents in 800 hallway), when: 1. For Resident 176, medications scheduled at 9 a.m. were administered outside the facility's medication administration timeframe. This failure had the potential for the medications to be ineffective;2. For Resident 176, Empagliflozin (generic for Jardiance, a medication used to treat heart failure [a chronic condition where the heart cannot pump blood efficiently enough to meet the body's oxygen needs] with or without type 2 diabetes mellitus [DM, a condition where the body has trouble regulating blood sugar levels]) was prescribed with an indication for diabetes mellitus despite no documented diagnosis of diabetes, resulting in an incorrect medication indication. This failure had the potential for Resident 176 to receive unnecessary medication;3. For Resident 164, required documentation following administration of Norco (narcotic pain medication) was not completed, including pre-medication pain assessment, confirmation of administration, and post-medication effectiveness. This failure had the potential for ineffective pain management;4. For Resident 164, medication documentation was inaccurate when Senna-S (a medication used to treat constipation) was refused by the resident but documented as administered in the Medication Administration Record (MAR). This failure had the potential for Resident 164 's refusal of medications not to be assessed appropriately ;5. For Resident 12, the correct lunch meal tray was not served according to the diet order. This failure had the potential for Resident 12 to have complications related to wrong diet and texture such as choking and could affect the overall health condition; and 6. The licensed nurse did not check the meal trays for 18 out of 18 residents before serving the meal trays to the residents. This failure placed residents at potential risk for being served wrong physician diet orders, wrong modified texture and/or modified liquid, which could compromise the residents' overall health condition.Findings: 1. On April 20, 2026, at 11:06 a.m., during a record review, a review of Resident 176's Medication Administration Record (MAR), dated April 2026, indicated all 9 a.m. medications were documented as administered, including: - Empagliflozin (used to treat diabetes and heart failure) 10 mg (milligram – unit of measurement); - Metoprolol Succinate ER (extended-release, a medication used to treat high blood pressure) 100 mg; - Potassium Chloride ER (potassium supplement) 10 mEq (milliequivalent – unit of measurement); - Apixaban (anticoagulant, blood thinner) 2.5 mg; - Zonisamide (anti-seizure medication) 100mg; and - Cholecalciferol (Vitamin D supplement) 2000 IU (international unit - unit of measurement) A review of Resident 176's physician orders indicated the above medications were ordered for 9 a.m. administration. On April 20, 2026, between 11:54 a.m. and 12:11 p.m., during a medication administration observation with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed administering the above medications scheduled for 9 a.m. On April 20, 2026, at 12:15 p.m., during an interview with L VN 4, LVN 4 stated that he documented medications scheduled at 9 a.m. as administered but were administered between 11:54 a.m., to 12:11 p.m., which was outside the timeframe of administration of 9 a.m. LVN 4 stated scheduled medications should be administered one hour before or one hour after (between 8 a.m. to 9 a.m.) On April 21, 2026, at 4 p.m., during an interview with LVN 4, LVN 4 confirmed the medications were not administered at the scheduled time and acknowledged documenting the medications as administered prior to actual administration. LVN 4 stated that when medications are not administered within the required time frame, nursing staff should notify the physician, obtain instructions on whether the medications should be administered, and document the physician's guidance in the medical record. LVN 4 acknowledged this process was not followed. On April 23, 2026, at 6:04 p.m., during an interview with the Assistant Director of Nursing (ADON), the ADON stated the facility's medication administration timeframe for medications scheduled for 9 a.m. is between 8 a.m. and 10 a.m. The ADON stated nursing staff are expected to consult with the physician when medications are administered outside the required time frame and to document administration after medications are given. A review of the facility's policy and procedures (P&P) titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.The individual administering the medication checks.right time .of administration before giving the medication .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones . 2. A review of Resident 176's medical record titled, admission Record, indicated, the resident was admitted to the facility on [DATE], with diagnoses including epilepsy (seizure disorder), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels), atherosclerotic heart disease (narrowing of arteries supplying blood to the heart), pulmonary hypertension (high blood pressure in the lungs), atrial fibrillation (irregular heart rhythm), chronic systolic (congestive) heart failure (condition where the heart cannot pump effectively), and presence of cardiac pacemaker (a small, battery-powered device implanted under the skin to keep the heart beating at a healthy, consistent pace). A review of Resident 176's physician orders indicated: - Empagliflozin 10 mg, give 1 tablet by mouth one time a day for DM. Take with food, dated April 13, 2026. A review of Resident 176's medical record, titled Physician diagnosis verification (PDV) V2.0, dated April 14, 2026, indicated: .Diagnosis List.Type 2 Diabetes Mellitus without complication.Physician Attestation Statement. As of the date of admission to the facility: I verify that the above medical diagnosis are ACTIVE and have a DIRECT RELATIONSHIP to the resident's current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death. signed and dated on April 14, 2026. On April 21, 2026, at 11:11 a.m., during an interview with Resident 176 in the resident's room, the resident stated he had not been diagnosed with diabetes. On April 21, 2026, at 11:42 a.m., during a concurrent interview and record review with the MDS Coordinator (MDSC), the MDSC confirmed diabetes mellitus was listed as a diagnosis in the electronic medical record system. However, a review of hospital records, referral documentation, and history and physical reports did not indicate a diagnosis of diabetes mellitus. On April 23, 2026, at 3:25 p.m., during an interview with the Medical Director (MD), the MD confirmed the diagnosis of diabetes mellitus was inaccurate for this resident and stated empagliflozin should have been prescribed for heart failure indication, not diabetes. On April 24, 2026, at 11:35 a.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON confirmed the diagnosis of diabetes mellitus was incorrectly entered for Resident 176 and acknowledged it caused additional interventions, including blood glucose monitoring and a diabetic diet. The DON stated the facility's process includes review of newly admitted residents' orders and diagnoses on a daily basis, however, this discrepancy was not identified and corrected through the facility's review process. A review of the facility's policy and procedure titled, Attending Physician Responsibilities, dated August 2014, indicated, .Providing appropriate care .The Attending Physician will perform accurate, timely, and relevant medical assessments with active and inactive diagnosis relevant to the care of the resident .The physician will verify and clarify symptoms, problems, and diagnoses .In consultation with facility staff, the physician will identify appropriate treatments and services, consistent with each individual's diagnoses, condition .The Attending Physician will provide .appropriate medical orders . A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Empagliflozin tablets, dated January 2026, retrieved from DailyMed, indicated, . JARDIANCE (brand name for Empagliflozin) is.indicated: To reduce the risk of cardiovascular (heart and blood vessel) death and hospitalization for heart failure in adults with heart failure. To reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease. As an adjunct to diet and exercise to improve glycemic (blood sugar) control in adults.with type 2 diabetes mellitus. 3. On April 20, 2026, at 10:14 a.m., during a medication administration observation for Resident 164, LVN 4 was observed preparing and administering medications scheduled 9 a.m. including hydrocodone-acetaminophen (brand name Norco, scheduled II controlled substance used for pain) 10-325 mg after the resident reported a pain level of 8. On April 20, 2026 at 1:22 p.m., during a review of Resident 164's medical record titled, admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses including: spinal stenosis of lumbar region (narrowing of the spinal canal in the lower back), lumbar radiculopathy (nerve pain originating from the lower spine), and low back pain. A review of Resident 164's physician order for Norco 10/325 mg, indicated give 1 tablet by mouth every 4 hours as needed for moderate to severe pain (4-10) [pain scale], dated February 1, 2026. A review of Resident 164's MAR, dated April 2026, indicated missing documentation for Norco administration, including no documented pre-medication pain assessment, no confirmation of administration, and no post-medication effectiveness. On April 20, 2026, at 3:52 p.m., during an interview with LVN 4, LVN 4 confirmed the pain level was assessed but not documented and acknowledged that post-medication effectiveness was not documented. A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; .e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . 4. On April 20, 2026, at 10:14 a.m., during a medication administration observation, Resident 164 stated she did not want to take the stool softener (Senna-S). On April 20, 2026, at 1:22 p.m., during a review of Resident 164's physician order for Senna S indicated: Senna S tablet 8.6-50 mg, give 1 tablet by mouth one time a day for constipation. Hold for loose stool, dated February 2, 2026. A review of Resident 164's MAR indicated Senna-S was documented as administered in the MAR. On April 20, 2026, at 3:52 p.m., during an interview with LVN 4, LVN 4 confirmed Senna-S was not administered because the resident refused the medication. LVN 4 also confirmed the medication was documented as administered for April 20, 2026, at 9 a.m. dose. On April 23, 2026, at 6:30 pm., during an interview with the ADON, the ADON stated medications should be documented after administration and appropriate coding should be used for refused medications, including documentation of pain assessment and post-medication effectiveness for pain medications. On April 24, 2026, at 10:27 a.m., during an interview with the DON, the DON stated nursing staff are expected to document medication administration after giving medications and to accurately document refusals. A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document accordingly. 5. On April 20, 2026, at 1:11 p.m., a concurrent observation and interview was conducted in Resident 12's room. Resident 12 was observed eating her lunch when Certified Nurse Assistant (CNA) 7 was observed attempting to deliver another lunch tray to Resident 12. Resident 12 was observed to be eating the lunch tray that belonged to the resident in bed B (Resident 19). Resident 12 was observed feeding herself and had consumed 30% of the meal from the wrong meal tray. In a concurrent interview with CNA 8, CNA 8 stated she served the wrong tray to Resident 12. CNA 8 stated she should have verified the full name and room number before serving the lunch tray. CNA 8 stated Resident 12 and the resident in bed B have the same first name and she only checked Resident 12's first name. CNA 8 further stated Resident 12 can be at risk for choking or complications if not served the correct diet as ordered by the physician. Resident 12's meal tray ticket indicated, .CCHO (Controlled Carbohydrate), Texture.IDDSI (a standardized framework that classifies food and drinks to improve safety for people with swallowing difficulties) 5 (Minced and Moist).NAS (No Added Salt). Resident 19's meal tray ticket indicated, .Texture: IDDSI 6: Soft and Bite Sized. A review of Resident 12's admission Record, indicated an admission date of August 22, 2017, with diagnoses which included dementia (memory loss). A review of Resident 12's History and Physical, dated January 28, 2026, indicated Resident 12 does not have the capacity to make health care decisions. A review of Resident 12's Physician Orders dated April 22, 2026, indicated, .IDDSI 5: Minced and Moist texture (texture-modified diet that requires minimal chewing). On April 20, 2026, at 1:27 p.m., an interview was conducted with Licensed Vocational Nurse MM (LVN [NAME]). LVN MM stated CNA ES should have checked Resident 12's first and last name to ensure the correct lunch tray was delivered. LVN MM stated it was important to correctly identify the resident to ensure the correct tray was delivered to prevent complications such as choking and allergic reactions. On April 22, 2026, at 3:20 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated CNAs are primarily responsible for delivering meal trays to residents and must ensure the resident's full name matches the resident's identification bracelet. The DSD stated CNA 8 should have verified Resident 12's full name prior to delivering the lunch tray. The DSD stated that failing to correctly identify a resident by their full name could result in choking, allergic reactions, or failure to follow the physician's prescribed diet orders. A review of the facility policy and procedure titled, Assisting the Resident with Meals, dated December 2013, indicated, .Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. 6. A review of the facility Resident council minutes on January 13, 2026, indicated, Nursing: Concerns: Nursing not checking trays . A review of the facility Resident council minutes on February 24, 2026, indicated, Nursing: Concerns: Residents looking for staff to check the food trays for lunch and dinner. On April 22, 2026, at 8:47 a.m., the Dietary Director (DD) was observed to bring meal cart 800 which included the test tray and parked outside room [ROOM NUMBER] hallway at 8:49 a.m. and stayed there in the hallway waiting for nursing staff to grab the meal trays and to deliver to the residents. At 8:58 a.m., Certified Nursing Assistant (CNA) 9 started removing first meal tray from Meal cart 800. At 9:09 a.m., CNAs completed delivery of all meal trays in the Meal cart 800 to residents. In a concurrent interview with the DD, the DD stated that during the whole process of observation delivery of meal trays to residents, no license nurse checked the meal trays before CNAs deliver the meal trays. The DD stated Meal cart 800 was holding 18 residents' meal trays from room [ROOM NUMBER] until 906. On April 22, 2026, at 1:15 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Licensed Nurses should check the residents' meal trays before CNAs deliver them to the residents. The DON stated that without checking meal trays, residents could get wrong therapeutic diets (is a nutritionally planned diet that is ordered by a physician or recommended by a dietitian to meet a specific medical need. It modifies the type, texture, nutrient content, or amount of food to support a patient's treatment plan.), wrong modified texture, wrong modified liquid which could cause harm to residents. A review of the facility's policy and procedure titled, Assisting the Resident with Meals, dated 2013, indicated, .Purpose The purpose of this procedure is to provide appropriate assistance for residents during meals. Preparation .Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. A review of the facility's policy and procedure titled, Meal Service, revised January 2023, indicated, .Nursing personnel will serve the trays immediately upon checking the tray to be sure.the diets are correct.

Based on observation, interview, and record review, the facility failed to ensure an assessment and/or an evaluation for self-administration of medication was completed, for one of 173 residents reviewed for self-administration assessment (Resident 141), when eye drop medications were found at bedside, readily available for use.This failure places Resident 141 at risk for unsafe self-administration of medications and not monitored for potential side effects and drug interactions.Findings:On April 21, 2026, at 12:04 p.m., an observation with a concurrent interview was conducted with Resident 141. Resident 141 was observed in bed, alert, and interviewable. Resident 141's bedside table was observed to have a small box of eye medication labeled as Sodium Chloride Hypertonicity Solution 5% (a sterile, over-the-counter drop used to temporarily relieve corneal edema (swelling of the eye's transparent outer layer due to fluid buildup) by drawing excess water out of the cornea) 15 ml (millimeter - unit of measurement) and an opened bottle of artificial tears eye drop. In a concurrent interview, Resident 141 stated she had both eye medications by her bedside for a long time and the staff was aware she used both eye drops on herself.On April 22, 2026, at 9:36 a.m., a second observation with a concurrent interview was conducted with Resident 141. Resident was in bed, alert, and interviewable. Both eye drops were observed on her bedside table next to her breakfast tray. Resident 141 stated:- The eye drops were hers and the staff knew about it. She did not recall how long she had been using it;- She administered both eye medications to herself when her eyes get itchy, and because she had glaucoma (type of eye disease). She used the eye drops once or twice a week, it depends, if she remembers it; and- The licensed nurses administer another eye medication for her glaucoma.On April 22, 2026, at 10:05 a.m., an observation, with a concurrent interview was conducted with License Vocational Nurse (LVN) 1. LVN 1 was observed to enter Resident 141's room and saw the two eye drop medications on top of Resident 141's bedside table. LVN 3 stated:- She was the licensed nurse assigned to Resident 141 on April 20 and 21, 2026 morning shift;- She did not recall seeing the two eye drop medications on top of Resident 141's table. The Sodium Chloride Hypertonicity Solution 5% 15 ml and artificial tears were both opened and used;- Resident 141 did not have a physician's order for the two eye drop medications and it was not supposed to be left at bedside; and-Resident 141 did not have an assessment for safe self-administration of medication and should have one.On April 22, 2026, Resident 141's record was reviewed. Resident 141 was admitted to the facility on [DATE], with diagnoses including glaucoma.A review of Resident 142's History and Physical, dated April 13, 2026, indicated Resident 141 had the capacity to understand and make decisions.A review of Resident 141's Order Summary Report, included a physician's order, dated April 11, 2026, which indicated to administer Latanoprost Ophthalmic Solution 0.005% (medication used to treat glaucoma) one drop to both eyes at bedtime.Resident 141 did not have a physician's order for the Sodium Chloride Hypertonicity Solution 5% 15 ml and artificial tears. In addition, there was no documented evidence, an assessment and/or an evaluation was conducted to determine if Resident 141 was able to self-administer medication safely.On April 22, 2026, at 10:48 a.m., an interview with a concurrent review of Resident 141's record was conducted with the Director of Nursing (DON). The DON stated:- Resident 141 should have an assessment for safe self-administration of medications, which included if the resident was alert, oriented, and able to open the bottle by herself;- If Resident 141 wanted to take the medication herself, the licensed nurses should have assessed first then call the doctor for orders; and- Resident 141 did not have a physician's order for Sodium Chloride Hypertonicity Solution 5% 15 ml and artificial tears. The DON stated that both eye drops and a self-administration order were needed prior to Resident 141 to self-administer both eye drops.A review of the facility's policy and procedure titled, Self-Administration of Medications, dated February 2021 indicated, .Residents have the right to self-administer medications if the interdisciplinary team has determined that is clinically appropriate and safe for the resident to do so.As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT - a group of healthcare professionals) assesses each resident's cognitive and physical abilities to determine whether self-administering of medications is safe and clinically appropriate for the resident.The IDT considers the following factors when determining.The medication is appropriate for self-administration.The resident is able to read and understand medication labels.The resident can follow directions and tell time to know when to take the medication.The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff.The resident has physical capacity to open medication bottles, remove medications from a container.The resident is able to safely and securely store a medication.If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan.Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.Any medications found at bedside that are not authorized for self-administration are turned over to her nurse in charge to return to the family or responsible party.

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications, for one of five resident reviewed for unnecessary medications (Resident 18), when there was no documented evidence non-pharmacological interventions (NPIs) were attempted, implemented, monitored, or documented as clinically contraindicated. These failures had the potential to place the resident at risk of unnecessary psychotropic medication use and adverse side effects, including sedation and falls.Findings:1. On April 22, 2026, a review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis (a psychotic disorder characterized by a loss of contact with reality), schizoaffective disorder (a chronic mental illness characterized by dramatic changes in thoughts, moods, and behaviors, mixed symptoms of schizophrenia [hallucinations and delusions] and mood disorder [depression and mania]), major depressive disorder (depression), and anxiety disorder.A review of Resident 18's Order Summary Report, indicated the following physician orders:- Risperidone (generic for Risperdal, an antipsychotic medication to treat various mental and thought disorder including altered sense of reality) 2 mg (milligram - unit of measurement), give 1 tablet by mouth three times a day for psychosis m/b [manifested by] verbalization of hallucination, dated October 3, 2024;- Mirtazapine (generic for Remeron, an antidepressant medication to treat depression) 15 mg, give 15 mg by mouth at bedtime for depression m/b poor appetite, dated December 3, 2025; and- Buspirone (generic for Buspar, an antianxiety medication to treat anxiety) 10 mg, give 1 tablet by mouth three times a day for anxiety m/b verbalization overly worried about health, dated December 3, 2025.A review of Resident 18's Care Plan Report, for antipsychotic medication, dated October 3, 2024, antidepressant medication, dated November 22, 2024, and anti-anxiety medication, dated December 4, 2025, indicated, .Attempt non-pharmacological approaches prior to medication administration.A review of Resident 18's Medication Administration Record (MAR), dated April 2026, indicated Resident 18 received risperidone, mirtazapine, and buspirone as ordered. However, there was no documented evidence non-pharmacological interventions were attempted, implemented, monitored, or evaluated for effectiveness.On April 23, 2026, at 4:04 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON confirmed there was no documented evidence NPIs were attempted, implemented, monitored, or documented as clinically contraindicated for Resident 18. The DON stated the NPI order set available in the PCC system (PointClickCare, a cloud-based electronic health record and care coordination platform designed specifically for the long-term and post-acute care settings) was not added to the resident's chart, resulting in NPIs not being implemented for Resident 18. The DON stated NPI implementation is required for residents receiving psychotropic medications unless clinically contraindicated.On April 23, 2026, at 5:30 p.m., during a concurrent interview and record review with Psychiatric Nurse Practitioner (PNP), the PNP stated he was not aware NPIs had not been implemented for Resident 18. The PNP stated implementation of NPIs would benefit the residents and provide useful clinical information for evaluating the resident's behavioral symptoms and response to treatment. The PNP also stated information regarding behavioral symptoms and effectiveness of NPIs would assist in clinical decision-making, including determining the timing of gradual dose reduction (GDR) and potential medication adjustment. A review of the facility's policies and procedures titled, Psychoactive/Psychotropic Medication Use, dated April 2025, indicated, .behavioral interventions, unless contraindicated, will be used to meet the individual needs of the resident .Psychotropic medication management for the resident will involve the facility interdisciplinary team consideration of the following .identifying person-centered non-pharmacological interventions, unless contraindicated, to meet the individual needs of the resident, and minimize or discontinue the use of Psychotropic medication .

Based on observation, interview, and record review, the facility failed to provide necessary care and services needed to perform ADLs ( Assisted Daily Living - fundamental self-care task required for a person to live independently, such as bathing, dressing, eating, and using the toilet) for one of eight sampled residents reviewed (Resident 36), when Resident 36 was not offered supervision and/or assistance on her upper and lower body dressing.This failure resulted in Resident 36 wearing the same clothing outfit from April 20, 2026, to April 26, 2026. In addition, this failure placed Resident 36 at risk of reduced abilities in activities of daily living (ADLs) due to the lack of appropriate assistance needed to prevent such decline.Findings:The following observations and interviews, were conducted with Resident 36, who was observed to be wearing a matching blue printed flannel top and bottom from April 20, 2026 to April 22, 2026:- On April 20, 2026, at 12:14 p.m., Resident 36 was observed ambulating in the hallway using a Front Wheel [NAME] (FWW). Resident 36 stated she did not get her lunch tray yet and she will go for a stroll;- On April 21, 2026, at 12:30 p.m., Resident 36 was observed ambulating using a FWW near the nurse station. Resident stated she has not received her lunch tray yet and she was going for a stroll.-On April 22, 2026, at 10:02 a.m., Resident 36 was observed walking with a FWW near the nurse station. She was observed searching for a snack and asked staff if she could have one. In a concurrent interview, Resident 36 was asked about whether she had another set of clothes to change into. Resident 36 stated, I do not know, and walked away.-On April 22, 2026, at 2:02 p.m., Resident 36 was asleep in her room without a blanket. Resident 36 was dressed in the same outfit during both the morning and the later observation.-On April 22, 2026, at 2:15 p.m., an interview with a concurrent observation was conducted with Certified Nursing Assistant (CNA) 10. CNA 10 stated the following:- She was the CNA assigned to provide care to Resident 36 on April 22, 2026, morning shift and she did not recall what time she checked on the resident during her first rounds;- Resident 36 was independent with her hygiene and ADLS, she does her own upper body and lower body dressing. Resident 36 was cooperative and she was not aware she had behavior of refusing assistance with her ADLs; and- She did not help her get dressed today, and she couldn't remember whether she had worn the matching blue printed flannel top and bottoms when she arrived this morning.During a concurrent observation, CNA 10 opened Resident 36's closet. The closet was empty except for two knitted sweaters. CNA 10 stated, This is all that she has.On April 22, 2026, at 2:18 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated she was the licensed nurse assigned to Resident 36 in the morning shift of April 22, 2026. LVN 2 stated Resident 36 had history of refusing assistance with her ADLs including showers, but she did not receive a report today that she refused these services.On April 22, 2026, at 2:35 p.m., an interview with concurrent record review was conducted with the Director of Nursing (DON). The DON stated the following:- Resident 36 had a personal belonging inventory list indicating she has clothing including blouses, shirts, slacks, socks, jeans, and shoes;- Resident 36 was confused and forgetful, the staff should report if she has missing personal items including clothing;- Resident 36's MDS - Minimum Data Set (an assessment tool), dated February 19, 2026, indicated Resident 36 needed supervision with ADLS including dressing and hygiene;- The CNAs should supervise and/or assist Resident 36 with her ADLs; and- The staff knew Resident 36 had a behavior of refusing showers and assistance with ADLs however, there was no care plan developed or initiated to address these behaviors. The DON stated these behaviors should have been care planned.On April 22, 2026, at 3:10 p.m., an interview with a concurrent record review of Resident 36's CNA tasks record (record of ADLS performed by the resident and CNA) was conducted with CNA 11. CNA 11 stated the following:- The nurses knew that Resident 36 often refused assistance with her ADLs, but there was no record from the CNAs assigned to her between April 20, 2026, and April 22, 2026, indicating she declined assistance with ADLs like dressing. CNA 11 stated the CNAs documented Resident 36 was independent with her ADLs, meaning she did the task herself and did not need assistance.- Resident 36 has dementia (a progressive, irreversible decline in mental ability severe enough to interfere with daily life, reasoning, and memory) and she required supervision and/or assistance with her ADLs.On April 22, 2026, Resident 36's record was reviewed. Resident 36 was admitted to the facility on [DATE], with diagnosis including dementia.A review of Resident 36's MDS, dated February 19, 2026, indicated resident had a BIM Score (tool used to assess cognitive function) of 03 (0-7 score indicated severe impairment). The MDS further indicated resident needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) on oral hygiene, shower/bathing, Upper body dressing and lower body dressing, and personal hygiene.A review of Resident 36's care plan, dated May 14, 2025, indicated, .Focus.ADL .Resident at risk for mobility decline and requires assistance related to.ALTERED MENTAL STATUS, DEMENTIA.Goal.Will have needs anticipated and met by staff.Encourage to participate in ADLs to promote independence.There was no documented evidence that resident's behavior of refusing assistance with ADL was identified and addressed by the staff.A review of the CNA ADL Task Record, dated April 20, 2026, to April 22, 2026, indicated the CNAs assigned to Resident 36 documented in all shifts, resident was between independent to supervision on upper body and lower body dressing.A review of the facility's policy and procedure titled, Activities of Daily Living (ADL), Supporting, dated March 2018, indicated, .Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL).Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming, and personal hygiene.appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance in the plan of care, including appropriate support and assistance with.hygiene (bathing, dressing, grooming, and oral care.If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.Interventions to improve or minimize a residents functional abilities will be in accordance with the resident's assessed needs, stated goals, and recognized standards of practice.The resident's response to interventions will be monitored, evaluated, and revised as appropriate .

Based on observation, interview, and record review, the facility failed to ensure care and treatment were provided, for two of five residents reviewed for skin management (Resident 95 and 66), when:1.For Resident 95, right anterior wrist skin redness with elevation was identified in a timely manner and was referred to the physician for treatment orders; and2.For Resident 66, the itching with redness on his neck, was identified in a timely manner and was referred to the physician for treatment orders.These failures caused discomfort for Residents 95 and 66 in the affected areas, and had the potential to increase their risk for complications due to delayed treatment. Findings: 1.On April 20, 2026, at 3:30 p.m., an observation with a concurrent interview was conducted with Resident 95. Resident 95 was observed to have a defined circular area of erythema (redness), elevated, dry with visible scaling, and mild textural changes to the top part of right wrist. In a concurrent interview, Resident 95 stated she had a spider bite to her right anterior wrist that was red and elevated. Resident 95 stated the staff applied cream, however, the affected area had not improved. Resident 95 stated she had the spider bite for approximately two to three months and it has not gotten better since then. Resident 95 stated the affected area burned when she scratched it and it has gotten worse. On April 22, 2026, at 1:54 p.m., an interview with a concurrent record review was conducted with Licensed Vocational Nurse (LVN) 11. LVN 11 stated the following: - He was not aware of any skin concerns for Resident 95; -There was no documentation in the nursing notes that Resident 95's current right wrist redness was identified, assessed, and referred to the physician for treatment orders; -Any alteration in skin condition should be assessed, documented, reported to the physician, and followed up with treatment orders the day of identification; and -Anything that goes unreported, can affect the resident's overall well-being and skin issues not addressed or monitored can make the resident at risk for infection. On April 22, 2026, at 2:34 p.m., an observation with a concurrent interview was conducted with LVN 2 and Resident 95. LVN 2 stated Resident 95 had a red, raised, circular area to top of right wrist. LVN 2 further stated, It looked like a bug bite to me. LVN 2 stated new skin condition should be assessed, notify the physician, and wound care team for appropriate treatment. On April 22, 2026, at 2:41 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 10. CNA 10 stated she was the primary CNA for Resident 95 on April 22, 2026, and at morning handoff from previous CNA she did not receive a report regarding any new or existing skin condition on Resident 5's right wrist. CNA 10 stated there was no new skin issues were reported during the resident's shower on April 20, 2026. On April 22, 2026, at 2:59 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 12. LVN 12 stated Resident 95's right wrist skin condition had been present for a couple of months and she was unable to recall documentation of follow-up, current treatment orders, or ongoing monitoring of the right wrist condition. On April 24, 2026, at 9:03 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident reported a new skin concern, licensed nurses were expected to immediately assess the condition, create a Change of Condition Report, notify the physician, document the skin condition, and initiate a care plan, and treatment orders the same day it was identified. The DON stated there was no documentation done for Resident 95 indicating the right anterior wrist skin new skin problem was identified by the licensed nurses. On April 24, 2026, Resident 95's record was reviewed. Resident 95 was admitted to the facility on [DATE], with diagnosis including diabetes mellitus (a condition that affects blood sugar levels), chronic osteomyelitis of the left foot (a bone infection) and muscle weakness. A review of Resident 95's History and Physical, dated April 15, 2026, indicated Resident 95 had the capacity to understand and make decisions. A review of Resident 95's Shower/Bath Sheet, dated April 20, 2026, indicated Resident 95 had no apparent skin issues and no new skin issue or change. A review of Resident 95's Nursing Comprehensive Skin Evaluation/Assessment, dated April 22, 2026, indicated,.Assessment Type.Change in Condition.Length.5.0.Width 3.5.right wrist.dry reddened skin.Additional Notes.patient has new alteration on right wrist skin is dry slightly red/pink in color no drainage no odor. A review of the facility's policy and procedure titled, Acute Condition Changes – Clinical Protocol, dated March 2018, indicated, .assess and report.changes in a resident's condition.including changes in skin condition.contact physician.collect pertinent details.monitor and document the resident/patient's progress and responses to treatment. 2. On April 21, 2026, at 9:02 a.m., during a concurrent observation and interview in Resident 66's room, Resident 66 was observed with redness and irritation on the right side of the neck and was constantly scratching the area. Resident 66 stated his neck had been itching and thought it was probably from the shaving cream. Resident 66's record was reviewed. Resident 66 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (loss of muscle function on one side of the body) affecting the left side. A review of Resident 66's History and Physical, dated September 5, 2025, indicated the resident has the capacity to understand and make decisions. A review of Resident 66's shower sheet, for April 20, 2026, indicated no documentation of a new rash, redness, or itching to the neck from April 20 to April 22, 2026, and no documentation that Resident 66's neck was assessed or monitored for skin changes. On April 22, 2026, at 11:32 p.m., during a concurrent interview and review of Resident 66's shower sheet with Certified Nursing Assistant (CNA) 2, CNA 2 stated she checked residents' skin during showers and daily care and if she observed any new skin issues, she should notify the licensed nurse and document it in the shower sheet. CNA 2 stated she did not notice any skin issues with Resident 66 but had observed him scratching his neck. CNA 2 stated there was no documentation that Resident 66 had any skin issues. On April 22, 2026, at 1:38 p.m., during a concurrent observation and interview with Resident 66, Resident 66 stated the itchiness and irritation on the right side of his neck had started on April 20, 2026, and he believed it was caused by a cheap razor. On April 22, 2026, at 1:42 p.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 9 1 in Resident 66's room, LVN 9 stated skin checks were performed every shift and staff were expected to document skin changes. LVN 9 stated for new skin conditions, the licensed nurse should report the change to the treatment nurse who would complete an assessment, document the change of condition in the progress notes, monitor the resident for 72 hours, notify the physician and the resident's representative, and revise the care plan to prevent worsening of the condition. LVN 9 stated Resident 66 had redness and rashes on the right side of his neck. LVN 9 further stated there was no documented assessment and no revisions of the care plan related to Resident 66's new neck skin condition.

Based on observation, interview, and record review, the facility failed to ensure residents are free from accidents, for two of three residents reviewed for accidents (Residents 177 and 140), when:1.For Resident 177, 1:1 monitoring ( staff who provides continuous, direct observation for a single patient to ensure safety) was implemented as ordered by the physician.This failure had the potential to place Resident 177 at high risk for harm and accidents; and2.For Resident 140, was not allowed to keep the cigarette and lighter by bedside according to the facility's policy and procedure.This failure had the potential to place Resident 140 at high risk of accidents.Findings:1.On April 20, 2026, at 9 a.m., an observation was conducted in Resident 177's room. Resident 177 was observed asleep in bed alone in his room. The call light was observed on top of the resident's dresser and was not within resident's reach. A call bell was observed on top of the resident's bedside table next to his bed. There was no staff observed present in Resident 177's room.A review of Resident 177's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included left sided hemiplegia (left sided weakness).A review of Resident 177's History and Physical, undated, indicated Resident 177 had capacity to understand and make decisions.A review of Resident 177's Progress Notes, dated April 6, 2026, at 12:28 p.m., indicated, .SSM (Social Services Manager) contacted Riverside Crisis Team, regarding patient made suicidal attempt ideation, grabbed call light cord and wrapped it around his neck, then grabbed butter knife and motioned to cut his throat. 1:1 sitter in place.A review of Resident 177's care plan, dated April 6, 2026, indicated, .The resident has a psychosocial well- being problem/ suicidal attempt r/t (related to) Anxiety, Family discord, Ineffective coping.Interventions.1:1 sitter to monitor safety.A review of Resident 177's Physician's Order, dated April 6, 2026, indicated, 1:1 sitter every shift.On April 20, 2026, the following observations and interview were conducted:- At 11:15 a.m., Resident 177 was observed alone in the room, ringing the call bell for assistance and yelling for help in Spanish. A Licensed Nurse was observed down Resident 177's hallway and did not respond to his call for assistance. There was no staff member present inside Resident 177's room;- At 11:17 a.m., Certified Nurse Assistant (CNA) 5 entered Resident 177's room. Resident 177 was yelling for assistance in Spanish. Certified Nursing Assistant (CNA) 5 left the room and walked down the hallway to speak with a licensed nurse. No staff remained in the room with the resident;- At 11:20 a.m., observed Resident 177 remained in the room without staff present. In a concurrent interview with CNA 5, she stated Resident 177 was in pain and she notified the charge nurse; and- At 11:55 a.m., an interview was conducted with CNA 5. CNA 5 stated she was assigned as a sitter for Resident 177 due to his behavior of attempting to harm himself, including wrapping the call light cord around his neck and so they kept the call light away and not within the resident's reach for safety. CNA 5 further stated she started her shift as a sitter on April 20, 2026, at 12 p.m. and did not know who was assigned prior to her shift.On April 21, 2026, the following observations and interviews were conducted: - At 9:47 a.m., Resident 177 was observed in the room, in bed, without a staff member present;- At 9:55 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 stated Resident 177 should have a sitter 24 hours per day due to safety concerns, including risks for self-harm. LVN 5 stated that without a sitter present, the resident could potentially attempt to harm himself. LVN 5 stated Resident 177 was alone in his room and did not have sitter present at that time;- At 10 a.m., an interview was conducted with CNA 1. CNA 1 stated Resident 177 used a bell instead of a call light because he had previously used the call light cord to tie it around his neck. CNA 2 stated Resident 177 should have a sitter present in the room; and- At 10:15 a.m., an interview was conducted with CNA 6. CNA 6 stated she was the sitter assigned to Resident 177 during the morning shift of April 21, 2026. CNA 6 stated she was out of Resident 177's room from approximately 9 a.m. to 10 a.m. and did not ensure a 1:1 sitter coverage at bedside. CNA 6 stated she informed another staff member she was going on break, however, she did not confirm that another staff member relieved her or remained with the resident. CNA 6 further stated Resident 177 required 1:1 supervision due to behavior of being aggressive and was at risk of harming himself if left alone. CNA 6 stated Resident 177 should not be left unattended for safety.On April 24, 2026, at 9:03 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 had a physician order for a 1:1 sitter on April 6, 2026, due to behavior of harming self, including wrapping the call light cord around his neck. The DON stated the assigned sitter was expected to always remain at bedside, and if the sitter needed to leave, another staff must provide continuous observation.A review of the facility's policy and procedure titled, Responsibilities of a Sitter, dated July 2017, indicated, .Purpose.To ensure a safe environment for patients identified as a potential risk to themselves or others. This policy outlines guidance to ensure the safety and well- being of residents requiring close supervision and assistance.Patients at high risk for falls, confusion, impaired mobility, or other safety concerns may require a 1:1 sitter.The sitter will provide continuous bedside observation and basic assistance with activities of daily living (ADL).Seek assistance from the nursing staff or supervisor as needed.Communicate effectively with the nursing staff and other staff members and follow the care plan and instructions provided by the charge nurse or nursing supervisor.2. On April 20, 2026, at 12:40 p.m., during a concurrent observation and interview with Resident 140, Resident 140 was observed lying in bed with oxygen via nasal cannula (a small flexible tube inserted into the nostrils to deliver oxygen). A purse was observed at the resident's bedside, with cigarettes and a lighter were present inside the purse. Resident 140 stated she was supervised when smoking and that she was able to light her own cigarettes.Resident 140's record was reviewed. Resident 140 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (disease that causes difficulty breathing).A review of Resident 140's Smoking Assessment, dated March 25, 2026, indicated, .Resident is a smoker.Smoking adaptive equipment needed. Smoking Apron.Level of Assistance.Supervision required.May smoke with supervision.Patient requires O2 (oxygen) therapy as needed. Refuses to use smoking apron.A review of Resident 140's care plan dated March 26, 2026, indicated .Focus.Resident is a smoker.Goal.safety.Interventions.Cigarettes and lighter will be stored in the nurse's station.A review of Resident 140's History and Physical, dated March 30, 2026, indicated the resident has fluctuating capacity to understand and make decisions.On April 20, 2026, at 12:45 p.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, LVN 2 stated some residents were allowed to keep cigarettes at the bedside if they were alert and oriented. LVN 2 stated residents who were not alert and oriented were not allowed to keep cigarettes at the bedside. LVN 2 stated Resident 140 had cigarettes and a lighter at bedside and stated she was not sure if Resident 140 should have a lighter at bedside, given the resident's use of oxygen.On April 20, 2026, at 12:58 p.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated a smoking assessment should be completed on admission to determine whether residents could safely smoke. RNS 1 stated she was responsible for completing smoking assessments. RNS 1 stated residents on oxygen could not keep lighters at the bedside. RNS 1 stated a smoking assessment for Resident 140 was completed on March 25, 2026, and that the assessment indicated Resident 140 was at risk for smoking related injury due to oxygen use. RNS 1 stated Resident 140 should not have had a lighter at bedside.On April 23, 2026, at 10:50 a.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated residents who used oxygen, were alert and oriented and who did not violate the smoking rules could keep a lighter at the bedside. The ADON stated Resident 140's care plan indicated the resident should not keep lighters at the bedside for safety reasons. The ADON stated Resident 140 having cigarettes and a lighter at the beside was not consistent with the resident's care plan and smoking assessment.A review of the facility's policy and procedure titled Smoking Contract (name of facility), undated, indicated, .maintain safe resident smoking practices.Any smoking-related.restrictions, and concerns.are noted on the care plan, and all personnel caring for the resident shall be alerted.Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc, except under direct supervision.

Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of one sample resident reviewed for nutrition (Resident 12) when:1. The facility failed to monitor the effectiveness of nutrition interventions for Resident 12. This failure had the potential to result in delay in identifying and evaluating the necessity of an alternative nutrition approach; and2. The facility Registered Dietitians failed to follow its policy, WEIGHT CHANGE PROTOCOL to determine if meal intake of Resident 12 would be sufficient to meet Resident 12's nutritional needs. This failure had the potential to result in delay in identifying and evaluating the necessity of an alternative nutrition approach.These failures resulted in Resident 12 experiencing a 12 pound (8.5 percent) significant weight loss during a 4-months period from December 7, 2025, to April 9, 2026, and which could further impair nutrition and health status. Findings:During a review of Resident 12's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included heart failure (clinical condition in which the heart cannot pump enough blood and oxygen to meet the body's needs), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and Type II Diabetes (disease that result in too much sugar in the blood).During a review of Resident 12 's Minimum Data Set (MDS - a resident assessment tool), indicated the following:- December 19, 2025, indicated Resident 12 had a BIMS (Brief Interview for Mental Status) score of 6 which indicated severely impaired cognition;- March 19, 2026, indicated Resident 12 had a weight loss of 5 % or more in the last month or loss of 10% or more in the last 6 months, and was not on physician-prescribed weight-loss regimen (a program that is supervised by a medical professional that specializes primarily in weight loss for individuals that have a hard time losing weight despite their efforts).During a review of Resident 12's Order Summary Report, included a physician's order, dated January 28, 2026, indicated, Diet: Controlled Carbohydrate (CCHO) Diet (a meal plan for diabetic residents), No added salt (NAS) diet, Mince and moist texture (food texture that requires a reduced amount of chewing), Oral Nutrition supplement [(ONS)Nutrition drinks that has high calories and protein] three times a day with meals, Fortified diet (diet with added nutrients to increase the calories and/or protein density to promote improvement in residents nutrition status) for weight lossDuring a review of Resident 12's weight record, the weight indicated the following:-December 7, 2025: 165.4 lbs. (pounds-a unit for measurement);-January 9, 2026: 153 lbs.;-January 15, 2026: 152 lbs.;-January 22, 2026: 150.6 lbs.;-January 30, 2026: 151.4 lbs.;-February 5, 2026: 146 lbs.;-February 7, 2026: 146 lbs.;-February 13, 2026: 152.2 lbs.;-February 19, 2026: 153 lbs.;-February 26, 2026: 153.4 lbs.;-March 5, 2026: 154.8 lbs.;-March 8, 2026: 154.8 lbs.;-March 20, 2026: 154.3 lbs.;-April 9, 2026: 151 lbs.Based on the weight history from December 7, 2025 to April 9, 2026, it was noted Resident 12 lost 14 lbs. (8.5 percent %) in 4 months, is considered as significant weight loss.During a review of Resident 12's Annual Nutrition Assessment, dated September 12, 2025, completed by Registered Dietitian (RD) 1, indicated Resident 12's height: 66 inch, Weight (wt.) 9/6/26: 163 lbs. RD 1 marked all Nutrition intake: 0% -25 % of meals, 26 -50 % of meals, 51 -75 % of meals, 76 -100 % of meals with comments: PO intake variable, 0-100%, average ~ 50-75% per meal record. No intolerance issue noted sometimes 0 -25 % x 1 meal/day and remaining 75 -100 %.During a review of Resident 12's Interdisciplinary Team (IDT- an interdisciplinary team comprised of professionals from various disciplines who work in collaboration) -Weekly Weight Nutrition Note], dated January 13, 2026, indicated, Current Weight: 153 lbs., .Pt remains on a CCHO NAS diet with variable intake. Pt had 12.4 lbs. (#) wt. loss in a month (7.5 %).Recommendations: .Glucerna three time per day (TID) with all meals, weekly wts and wt. variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note, completed by RD 2, dated January 18, 2026, indicated, Current Weight: 152 lbs., .Pt remains on a CCHO NAS diet with variable intake. Pt had a 1 # wt (weight) loss in a week .Glucerna was added TID with meals to increase calories. Recommendations: Continue with weekly wts and wt variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note, completed by RD 2, dated January 26, 2026, indicated, Current Weight: 150.6 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable intake. Pt had a 1.4 # wt loss in a week.Recommendations: Fortify pt's diet for additional calories.During a review of Resident 12's IDT -Weekly Weight Nutrition Note, completed by RD 2, dated February 2, 2026, indicated, Current Weight: 151.4 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable intake. Pt had a 0.8 # wt gain in a week which is beneficial .Pt also started on a fortified diet for additional calories. Pt is receiving excess calories to promote wt gain.Recommendations: Continue with weekly wts and wt variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note completed by RD 2, dated February 8, 2026, indicated, Current Weight: 146 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable intake. Pt had a 5.4 # wt loss in a week . Recommendations: MD to consider changing appetite stimulator to 400 mg twice per day (BID) for 90 days and continue with weekly wts and wt variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note, completed by RD 2, dated February 15, 2026, indicated, Current Weight: 152.2 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable intake. Pt had a 6.2 # wt gain in a week . MD increased appetite stimulator to 400 mg BID. This is a beneficial wt gain. Recommendations: Continue with weekly wts and wt variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note completed by RD 2, dated February 23, 2026, indicated, Current Weight: 153 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable intake. Pt had a 0.8 # wt gain in a week .Recommendations: Continue with weekly wts and wt variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note, completed by RD 2, dated March 1, 2026, indicated, Current Weight: 153.4 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable intake. Pt had a 0.4 # wt gain in a week which is beneficial.Recommendations: Continue with weekly wts and wt variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note, completed by RD 2, dated March 8, 2026, indicated, Current Weight: 154 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable intake. Pt had a 1.4 # wt gain in a week and a 9 # wt gain in a month (6.2%) which is beneficial.Recommendations: Continue with weekly wts and wt variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note, completed by RD 2, dated March 15, 2026, indicated, Current Weight: 152.2 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable to good intake. Pt had a 2.6 # wt loss in a week .Recommendations: Continue with weekly wts and wt variance.During a review of Resident 12's IDT -Weekly Weight Nutrition Note, dated March 22, 2026 completed by RD 2, indicated, Current Weight: 154.3 lbs., .Pt remains on a CCHO NAS diet with Glucerna with meals and a variable to good intake. Pt had a 2.1 # wt gain in a week .Recommendations: Continue with weekly wts and wt variance.1.On April 21, 2026, at 8:55 a.m., a concurrent observation and meal ticket review were conducted with Resident 12 at bedside. Resident 12's meal ticket (contain Resident name, room number, physician diet order, Allergies, and food dislike) indicated, Fortified CCHO, NAS, Minced and Moist, 8 fluid ounce ONS. Resident being served 8 fluid ounce ONS, egg and Mince and Moist bread served as entree, a bowl of cream of wheat, 8 fluid ounce whole milk, 4 fluid oz apple juice.On April 21, 2026, at 9:25 a.m., a concurrent observation and interview were conducted with Resident 12 at bedside. Resident 12 finished entree, ONS and milk. Resident 12 stated she was full, so she did not touch cream of wheat and apple juice. On April 21, 2026, at 3:34 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 12. CNA 12 stated she had been taking care of Resident 12 for a year. CNA 12 stated she documented ONS intake as part of meal consumption. CNA 12 stated she did not individually document the amount intake of ONS.On April 21, 2026, at 3:41 p.m., a concurrent interview and Resident 12 electronic medical record (EMR) review were conducted with Licensed Vocational Nurse (LVN) 8. LVN 8 unable locate in EMR the amount intake of ONS for Resident 12.On April 21, 2026, at 3:54 p.m., a concurrent interview and Resident 12 electronic medical record (EMR) review were conducted with the Director of Nursing (DON). The DON stated the IDT weight variance was held every Tuesday. The DON stated she and RD 2 were the committee of IDT weight variance. The DON stated that since January 15, 2026, Resident 12 was being monitored weekly on IDT weight variance due to weight loss. The DON stated the nutrition interventions for Resident 12 were ONS with meal three times per day and Fortified diet. The DON was unable to locate in EMR the amount intake of ONS for Resident 12. The DON stated Certified Nursing Assistants should document ONS intake individually, not as part of fluid intake or meal intake. The DON was unable to answer how much Resident 12 drank from ONS. The DON was unable to answer whether Resident 12 like the ONS. The DON acknowledged that without monitoring and documenting ONS, it was unable to determine the effectiveness of nutritional interventions.On April 22, 2026, at 10:15 a.m., a phone interview and Resident 12 electronic medical record (EMR) review were conducted with RD 3. RD 3 stated nutrition interventions should be documented and monitored for effectiveness. RD 3 stated if the nutrition interventions were not effective, Consultant RDs could modify or change the nutrition interventions. RD 3 stated her expectation was Consultant RDs should communicate with the IDT regarding nursing did not document and monitor nutrition interventions.On April 22, 2026, at 1:04 p.m., confirmed with MDS (Minimum Data Set) Coordinator (MDSC) that there were no policy and procedure regarding monitoring and documenting nutrition interventions including oral nutrition supplement intake.During a review of the facility's policy and procedure titled, WEIGHT CHANGE PROTOCOL, dated 2023, it indicated, .The Facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions.INTERVENTIONS .diet supplement (ONS) .EVALUATION .Interventions are change if not effective.2. On April 21, 2026, at 3:54 p.m., a concurrent interview and electronic medical record (EMR) review were conducted with the DON. Concurrent review Resident 12's Annual Nutrition assessment dated [DATE], completed by RD 1, where it was marked all Nutrition intake: 0% -25 % of meals, 26 -50 % of meals, 51 -75 % of meals, 76 -100 % of meals with comments: PO intake variable, 0-100%, average ~ 50-75% per meal record. No intolerance issue noted sometimes 0-25 % x 1 meal/day and remaining 75 -100%. Review IDT weight variance completed by RD 2 on January 13, 2026, January 18, 2026, January 26, 2026, February 2, 2026, February 8, 2026, February 15, 2026, February 23, 2026, March 1, 2026, March 8, 2026 indicated, Pt remains on a CCHO NAS diet with Glucerna with meals and a variable intake and March 15, 2026, and March 22, 2026, indicated, Pt remains on a CCHO NAS diet with Glucerna with meals and a variable to good intake. After the DON review RD1 and RD 2 meal intake documentation, the DON stated the statements indicating meal intakes were so vague. The DON stated by documenting with big range 0 -100 % meal intake, variable intake, variable to good intake, there was no way to tell whether Resident 12 meal intake was adequate to meet her nutritional needs, there was no way to address how much Resident 12 consumed from the diet or approximate how many calories Resident 12 obtained from meal consumption.On April 22, 2026, at 10:15 a.m., a phone interview and Resident 12 electronic medical record (EMR) review were conducted with RD 3. Concurrent review Resident 12's Annual Nutrition assessment dated [DATE], completed by RD 2, RD 2 marked all Nutrition intake: 0% -25 % of meals, 26 -50 % of meals, 51 -75 % of meals, 76 -100 % of meals with comments: PO intake variable, 0-100%, average ~ 50-75% per meal record. No intolerance issue noted sometimes 0-25 % x 1 meal/day and remaining 75 -100%. Review IDT weight variance completed by RD 2 on March 15, 2026, and March 22, 2026, indicated, Pt remains on a CCHO NAS diet with Glucerna with meals and a variable to good intake. RD 3 stated it was hard to determine whether Resident 12 meal intake was adequate to meet her nutritional needs with range 0 -100 % and variable to good intake.During a review of the facility's policy and procedure titled, WEIGHT CHANGE PROTOCOL, dated 2023, it indicated, .The Facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions.Assessment Nutrition content of the diet provided and percent of intake for multiple days.Determine if the: .intake of the resident will be sufficient to meet needs .During a review of the facility policy and procedure titled, Weight Assessment and Intervention, Revised September 2008, it indicated, Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation .Analysis 1. Assessment information shall be analyzed by the multidisciplinary team and conclusion shall be made regarding the .Approximate calories, protein, and other nutrient needs compared with the resident's current intake .During a review of the facility policy and procedure titled, Assisting the Resident with Meals dated 2013, it indicated, Purpose The purpose of this procedure is to provide appropriate assistance for residents during meals.Documentation The person performing this procedure should record the following information in the resident's medical record.3. How much of the meal the resident consumed (i.e., 25 %, 50 %, 75 % etc.)

Based on observation, interview, and record review, the facility failed to ensure resident's nasal cannula (a medical device used to deliver supplemental oxygen) was changed on a weekly basis according to the facility's policy and procedure, for one of six residents reviewed (Resident 62).This failure had the potential to result in increased risk of infection.Findings:On April 21, 2026, at 10:45 a.m., a concurrent observation and interview was conducted with Resident 62 in his room. Resident 62 was observed receiving oxygen via nasal cannula at 2 liters per minute (L/min - unit of measurement). The nasal cannula was labeled with a date of 4/12/26 (April 12, 2026), which indicated when it was last changed. In a concurrent interview with Resident 62, he stated he used oxygen continuously. A review of Resident 62's admission Record, indicated an admission date of September 29, 2024, with diagnoses which included shortness of breath.A review of Resident 62's History and Physical, dated November 29, 2025, indicated Resident 62 had fluctuating capacity to understand and make decisions.A review of Resident 62's Physician Orders, dated March 9, 2026, indicated, .Change oxygen tubing/cannula every evening shift every Sun.A review of Resident 62's care plan, dated March 10, 2026, indicated, .Focus.Oxygen: Resident requires the use of oxygen [x] continuous.Interventions.Change.O2 (oxygen) tubing as indicated.On April 21, 2026, at 10:50 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 9. LVN 9 stated nasal cannulas are changed weekly on Sundays by the licensed nurses. LVN 9 validated Resident 62's nasal cannula was dated April 12, 2026, which indicated when the nasal cannula was last changed. LVN 9 stated Resident 62's nasal cannula should have been changed April 19, 2026. LVN 9 stated it was important to change the nasal cannula weekly to prevent infection.On April 22, 2026, at 2:40 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated licensed nurses are responsible for changing nasal cannulas weekly on Sundays. The IP stated the licensed nurse should have changed Resident 62's nasal cannula on April 19, 2026. The IP stated it was important to change Resident 62's nasal cannula weekly to prevent infection.A review of the facility policy and procedure titled, Prevention of Infection Respiratory Equipment, dated November 2011, indicated, .Change the oxygen cannula and tubing every seven (7) days.

Based on observation, interview, and record review, the facility failed to provide a two person assist and use a gait belt during transfer from a regular chair to a wheelchair for one of three sampled residents (Resident A). In addition, the facility failed to ensure the wheelchair's brake was functioning well during the transfer. These failures had resulted in a fall for Resident A, which led to the development of genu valgum (knock-knee - the knees angle in and touch each other when the legs are straightened) deformity. Findings: On June 25, 2024, at 11:55 a.m. during a concurrent observation and interview inside Resident A's room, Resident A was oberved in bed, with surgical incision on the right knee. Resident A stated she was having back pain since she fell a week ago. Resident A stated, she was not able to sleep that night of the fall due to pain. Resident A stated, the Certified Nursing Assistant (CNA) who transferred her to the wheelchair, did not lock the brakes of the wheelchair, she fell and hit her head. Resident A stated the wheelchair moved during transfer. Resident A stated she was brought to the emergency room (a medical department that provides immediate treatment for acute illnesses or injuries) after she fell . A review of Resident A's ADMISSION RECORD, indicated Resident A was admitted to the facility on [DATE], with diagnoses which included aftercare following joint replacement surgery, morbid (severe) obesity, and osteoarthritis (degenerative joint disease). A review of Resident A's Fall Risk Observation/Assessment, dated June 10, 2024, indicated, .Score 20 .Balance .Evaluate resident's balance while standing, sitting and during transitions .Ambulates with problems and with devices (gait is unsteady, slow, lurching) .Scoring .HIGH RISK 16-42 . Resident A is high risk for fall. A review of Resident A's, Progress Note, dated June 18, 2024, indicated .CNA reported to the LPN (Licensed Practical [Vocational] Nurse) that the resident fell during transfer. LPN went in the room and she was sitting down in front of the AC (air condition). Per CNA, they were mid-transfer from chair to wheelchair, but the wheelchair rolled back and the resident fell back, landed onher (sic) buttock and hit her head on the AC unit. Wheelchair was locked on both sides but the wheels were still moving. Per resident she tried to sit back but the chair moved and she fell on her butt and hit her head on the AC unit and has has some pain on the back of her head . On June 26, 2024, at 10:25 a.m., during an interview, the Physical Therapy Assistant (PTA) stated Resident A reported falling because the CNA did not use a gait belt during transfer. The PTA stated the gait belt should be used to guide when the resident is losing her/his balance. The PTA stated the gait belt is used to help restore balance and prevent the resident from falling. The PTA stated according to the resident, although the wheelchair brakes were locked but the wheels still rolled. The PTA stated, he was aware that the wheelchair was not functioning properly before the fall incident and it should have been sent to maintenance for repair. On June 26, 2024, at 3 p.m., during an interview, CNA 1 stated she was not aware that Resident A was considered a fall risk. CNA 1 stated Resident A asked her for support while standing and when Resident A leaned on the wheelchair, the wheelchair moved causing the resident to lose balance and fall on on her bottom, hitting the back of her head. CNA 1 stated, she did not use a gait belt. CNA 1 stated Resident A seemed tired that day. CNA 1 further stated, she should have stayed behind Resident A to prevent the fall. On June 26, 2024, at 3:45 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated she was not aware Resident A was a fall risk and that the resident required substantial (the resident requires significant help where the caregiver performing 50 percent of the task) or maximum assist (the resident needs nearly complete assistance with the caregiver performing most of all the task) with transfer. LVN 1 stated, the CNA was helping transfer the resident (Resident A) from a regular chair to the wheelchair when the resident lost her balance and fell down on her back. LVN 1 stated, she checked the wheelchair after the fall and even when the lock was engaged, the wheels were still rolling. LVN 1 stated CNA 1 did not use a gait belt in transferring the resident, and did not provide two person support, which could have prevented the resident's fall. LVN 1 stated Resident A required two person support with transfers. On July 5, 2024, at 12:32 p.m., during an interview, the Director of Staff Development (DSD) stated during hire, CNAs were given gait belt and should be available. The DSD stated the CNA should be using gait belt when assisting resident, to ensure a safe transfer.The DSD stated CNA 1 should have been using the gait belt during transfers. On July 5, 2024, at 12:42 p.m, during an interview, LVN 2 stated, CNAs had to wear a gait belt all the time for them to use during transfer. LVN 2 stated CNA 1 was supposed to use the gait belt, but she did not. LVN 2 stated CNA 1 not using the gait belt placed the resident at risk for fall during transfer. On July 10, 2024, at 2:46 p.m., during an interview, the Resident Representative (RR) stated, Resident A had an appointment with the orthopedic surgeon (a medical doctor who specialized in diagnosing, treating, preventing, and rehabilitating musculoskeletal system disorders such as the bones and joints) on July 10, 2024. The RR stated, the orthopedic surgeon told him that the fall resulted to a knock knee and the resident would need to have another surgery to fix the problem. A review of Resident A's record from the Orthopedic Surgeon, indicated the following: - Dated June 9, 2024, .presenting today with persistent right knee pain .X-ray (a type of electromagnetic radiation used to create image s of the inside of the body) was negative for any hardware malalignment or periprosthetic fracture (a break in the bone that occurs aroung an artificial joint) . - Dated July 10, 2024, indicated, .Follow-up right knee surgery .The patient has son informs us that when the patient fell the wheelchair that she was going to sit in did not have breaks. So the wheelchair moved and the patient fell on the groung .Incision is healing well .She does have a valgus deformity (knock knee) of the right knee with the weight bearing and at rest .The patient require to have x-rays performed due to she does have a valgus deformity of the right knee with weight -bearing and also while sitting. We needed to evaluate the deformity .Plan .Because of the patient's fall at the skilled nursing facility. The patient did sustain a injury to the tibial plateau which caused her tibial plateau to collapsed when she fell . The patient now has a valgus deformity of the right knee. The patient will require further revision of the right knee . Further review of Resident A's record from the Orthopedic Surgeon, indicated, Resident A has a radiologic examination (x-ray) of the right knee on the following: - On June 9, 2024, Xr (X-ray) Knee 3 Views Right .No acute periprosthetic fracture . - On July 10, 2024, .The 3 images does show a valgus deformity of the right knee. The tibial compartment (one of the sections of the lower leg around the shin bone) has collapsed on the lateral aspect of the right knee .Collapsing of the lateral tibial plateau (upper outer part of the shin bone) . On July 15, 2024, at 2:50 p.m., during an interview, CNA 2 stated, when providing care to a resident, she would consider the medical condition of the resident, and check the assistance required for the safety of the resident. CNA 2 stated, the facility had a KARDEX (a medical information system used to keep track of resident's care plans and essential details) to provide information regarding a resident. CNA 2 stated, Resident A required two person support for transfer. CNA 2 stated CNAs would use gait belt to help resident during transfer. CNA 2 stated when a resident started falling, the use of gait belt will control the resident's descent by holding on the gait belt and put the resident to rest on the floor. On July 15, 2024, at 4:30 p.m., during a concurrent observation and interview, Resident A was observed with her right knee closed to left knee, the right leg was angled outward, with lower extremities in K shape. Resident A stated, she was in pain. A review of Resident A's KARDEX as of July 15, 2024 (five days after the fall incident), indicated, .Mobility .Resident uses recliner to relieve low back pain and increase mobility .two staff assist with transferring . On July 15, 2024, at 4:30 p.m., during a concurrent interview and review of Resident A's KARDEX, CNA 3 stated Resident A required maximum assistance with two-person support for transfer. CNA 3 stated a gait belt was required for maximum assistance. CNA 3 stated CNA 1 should have used a two-person support when transferring Resident A and should have used the gait belt. On July 15, 2024, at 4:45 p.m., during an interview, CNA 3 stated it is a common practice to use the gait belt for the resident's safety and the CNA's safety. CNA 3 stated she would check the wheelchair's brakes if locked on both sides when in used for the resident's safety. CNA 3 stated she is familiar with Resident A, and stated Resident A had obesity with weight bearing limitation due to a knee surgery. CNA 3 stated she would use a gait belt, and would ask for help since Resident A required two person-assist. CNA 3 stated she would check the wheelchair if the brakes were working by sitting on the wheelchair and would move the wheelchair back and forth to check if the brakes were working. CNA 3 stated the use of gait belt would help in slowly lowering the resident on the floor to prevent injury. A review of the facility policy and procedure titled, Falls, and Risk, Managing, dated 2001, indicated, .The staff with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of fall . A review of the facility policy and procedure titled, Transfers, (undated), indicated, .Gereral Principles of Transferring .Use a second person to assist you when indicated .Use appropriate equipment. A transfer belt gives you control of the resident without restricting the resident from assisting you .Type of transfers .Stand Pivot .Verify that the wheelchair's leg rests are out of the way and that the brakes are locked on both the bed and the wheelchair .Take a position on the weaker side or in front of the resident . A review of American Nurse Journal, titled, Gait belts 101: a tool for patient and nurse safety, dated May 13, 2019, indicated, .Tips for assessing patient mobility and using gait belts .Mobility safety tips .Because gait belts allow patients to participate in transfers .use gait belts to safely steady patients .

Based on interview and record review, the facility failed to provide care and services in preventing development of pressure injury (skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body), for one of three sampled residents (Resident 1), as evidenced by the following: 1. There was no skin evaluation conducted when Resident 1 was admitted on [DATE], in accordance with the policy and procedure titled, Skin Management Guidelines, dated March 2022. 2. There was no interventions developed to address Resident 1's risk for pressure ulcer on admission. The resident was assessed to be at risk for developing pressure injury. 3. Treatments for Resident 1's pressure injury on the right and left heel; sacrococcygeal; and right buttocks identified on October 12, 2023, was not initiated until October 17, 2023 (5 days after the pressure injuries were identified). These failures resulted in Resident 1 developing a Stage 2 pressure injury(partial thickness skin loss with exposed dermis) on the right and left heel, a Stage 2 pressure injury on the right buttock, and an unstageable pressure injury (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [yellow/white material in the wound bed] or eschar [slough or piece of dead tissue that is cast off from the surface of the skin]) on the sacrococcyx area. Findings: On November 30, 2023, at 8:40 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. A review of Resident 1's general acute care hospital wound documents titled, Wound Ostomy Continence Nurse Consult Note, indicated the following: a. On September 29, 2023, skin tear (separation of skin) to left elbow. b. On September 30, 2023, skin tear to left arm. Further review of the general acute care hospital record titled, Discharge Summary, dated October 2, 2023, at 5:05 p.m., indicated the resident has an incision site on the right hip. The discharge summary did not indicate Resident 1 has pressure injuries prior to being transferred to the skilled nursing facility on October 2, 2023. A review of Resident 1's Admission Record Report at the skilled nursing facility dated November 30, 2023, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified fracture (break in continuity) of right femur (thigh bone), lack of coordination, chronic kidney disease (long standing disease of the kidneys), thrombosis (formation of blood clot within the blood vessel) of unspecified deep veins of lower extremity (both legs from hip to the toes) and thrombocytopenia (deficiency of platelets which causes bleeding in tissues, bruising and slow blood clotting after injury). A review of Resident 1's medical record did not indicate a skin evaluation on admission was completed on October 2, 2023. A review of Resident 1's Braden Scale for Predicting Pressure Score Risk assessment dated [DATE], indicated a Braden Score (consists of six subscales and the total scores range from 6-23. A lower Braden scores indicates higher level of risk for pressure ulcer development) of 15, indicating the resident was at risk for developing pressure ulcer. The risk assessment indicated the resident was occasionally moist, chairfast, has very limited mobility, adequate nutrition, and has a potential problem for friction/shear. A review of Resident 1's care plan titled, At risk for alteration in skin integrity related to impaired mobility, initiated on October 2, 2023, did not indicate interventions addressing the risk for alteration in skin integrity. A review of Resident 1's medical record untitled which contained body assessment diagram for October 7, 2023, indicated a surgery site on the right hip, generalized discoloration on the right lower extremity, and discoloration on the waist area. The body assessment did not indicate pressure injuries on the sacro coccyx area, left and right heel, and right buttock. A review of Resident 1's Skin worksheet, dated October 12, 2023, indicated, an open skin to the sacro coccyx area. A review of Resident 1's Progress Notes dated October 12, 2023, (ten days after admission), by the Registered Nursing Supervisor (RNS) indicated, CNA reported patient was displaying skin breakdown at the coccygeal region as well as bilateral heels. RN Supervisor examined lesions and established that coccygeal lesion is unstageable decubitus with eschar with no bone or tendon visible. No undermining or tunneling visualized. Patient reports no pain felt at site. Sacral dressing applied. Heel lesions are stage 2 with island dressings applied, heels elevated on pillow. Patient reports no pain at either heel. A review of Resident 1's Shower Sheet dated October 13, 2023, 11 days after admission, indicated on the posterior (back) side of the body map a cross mark on the coccyx (small triangular bone at the base of the spine) and right and left heels. The worksheet did not indicate a description of the marked areas. A review of Resident 1's Progress Notes dated October 13, 2023, indicated the RNS and the wound nurse visited Resident 1 to assess and treat decubiti. There was no documented physician order for treatments for the open wounds on the coccyx and bilateral heels. A review of the Physician Orders dated October 16, 2023, (4 days after the pressure injuries were documented as identified) indicated treatments for the following: 1. Right heel pressure injury open wound, clean with NS or wound cleanser, pat dry, apply Medihoney (used to clean and debride acute and chronic wounds) , cover with silicone foam dressing. every day shift every 2 day(s) for 21 Days until finished. and as needed for when saturated/soiled/dislodged. 2. Right buttocks pressure injury partial thickness open wound, clean with NS or wound cleanser, pat dry, apply medihoney, cover with silicone foam dressing. every day shift every 2 day(s) for 21 Days until finished. 3. left heel pressure injury open wound, clean with NS or wound cleanser, pat dry, apply medihoney, cover with silicone foam dressing. every day shift every 2 day(s) for 21 Days until finished and as needed for when saturated/soiled/dislodged. 4. sacrococcygeal pressure injury unstageable eschar, clean with NS or wound cleanser, pat dry, apply medhoney, cover with silicone foam dressing. every day shift every 2 day(s) for 21 Days until finished and as needed for when saturated/soiled/dislodged. A review of Resident 1's Care Plan titled, Pressure Ulcers, developed on October 16, 2023, indicated the following: Focus: Resident has pressure ulcers at sacrococcygeal region and bilateral heels related to limited mobility. Goal: Debridement of necrotic tissue; Free from odor; Free from signs and symptoms of infection (such as increased drainage/pain/peri wound erythema) Interventions: Administer treatment per physician orders; Daily body audit; Dietary consult; Friction reducing transfer surface. Further review of Resident 1's Progress notes dated October 17, 2023, (15 days after admission) by Registered Nurse (RN) 1 indicated, Patient was admitted with unstageable pressure ulcer on sacrococcygeal and Pressure injury open wound on right and left heel stage 2 .Wound # 1 Sacrococcygeal unstageable, wound bed 100 % covered with dark non-viable necrotic tissue, soft to touch, patient denies any sensitivity at time of inspection. Measures 8 x 4.5 cm., no depth .Wound # 2 Rt. buttocks stage 2, partial thickness open wound, shallow, pink wound bed, small amount of serosanguinous drainage .wound size 3 x 2 cm shallow, peri wound slightly pink 1 cm. blanchable .Wound # 3 stage 2, rt. heel pressure injury stage 2, pink wound bed, shallow, small amt. of serosanguinous drainage, size 4 x 4 cm. Wound # 4 left heel pressure injury stage 2, pink wound bed, shallow, small amt. of serosanguinous drainage, size 4 x 4 cm . A review of Resident 1's medical record which included: the physician's progress notes on October 4, 2023; the skin worksheet dated October 7, 12, and 13, 2023; the care plan developed on October 2, 2023; did not reflect Resident 1 had the pressure injuries on admission as documented in RN 1's progress notes dated October 17, 2023. The order summary report dated November 30, 2023, did not include physician orders for treatment on Resident 1's pressure injury on sacrococcyx area, right and left heel, and right buttocks, initiated on October 2, 2023, contrary to what was indicated in the progress notes dated October 17, 2023. On November 30, 2023, at 1:59 p.m., during a concurrent interview and record review with the RNS, the RNS stated a skin assessment should be done as soon as a resident was admitted , and the assessment should be documented in the progress notes. The RNS stated skin assessment for a newly admitted resident should be conducted weekly for four weeks. The RNS stated if a change in skin condition was noted, the floor nurse should document in the progress notes, notify the physician and the wound care team right away. The RNS stated Resident 1 was admitted to the facility with no pressure injuries. The RNS verified Resident 1's skin assessment was not done on admission. On November 30, 2023, at 2:41 p.m., during a concurrent interview and record review, RN 1 stated once a pressure injury was identified, a low air loss mattress (a mattress designed to prevent and treat pressure wounds) should be ordered by the nurse after obtaining orders from the physician. RN 1 further stated the physician, the wound care team, the Director of Nursing (DON), and the Registered Dietician (RD) should be informed right away, along with the resident's family and rest of the team that a pressure injury was identified. RN 1 verified Resident 1 was admitted to the facility with no pressure injury and RN 1 stated he should have not indicated on the progress notes dated October 17, 2023, that Resident 1 was admitted with pressure injuries. On November 30, 2023, at 3:20 p.m., during an interview with the DON, the DON stated the policy and procedure in managing pressure injuries indicated if a resident was admitted with a pressure injury or developed a facility acquired pressure injury; a daily body audit, a care plan, wound treatment should be provided to the residents. She added, the physician and the resident's family should be notified of the status of the pressure injury. The DON stated the interventions for pressure injury included the following: to provide a low air loss mattress, scheduled turning /repositioning, float heels to relieve pressure and conducting daily rounds by the wound care team. The DON stated Resident 1's skin assessment should have been done within 24 hours of admission. The DON further stated a change in the skin condition should be noted and reported to the physician, the wound nurse, the DON, and the resident's responsible party. On January 4, 2024, at 9:30 a.m., during an interview with Minimum Data Set nurse (MDS nurse), the MDS nurse stated if a wound was present on admission, it should be reflected under Section M (title Skin Conditions) of the MDS and from the documentation by the wound nurse. On January 4, 2024, at 3:40 p.m., during an interview, LVN 2 stated Body Audits (skin worksheet) was checked and signed by the nurses after every shower. LVN 2 stated the result of the body audit was documented in the computer under the resident's medical record. LVN 2 stated if there was a change in the resident's skin condition, it would be the responsibility of the charge nurse to notify the physician, the treatment nurse, the DON, the RNS and the resident's family and should be documented under the progress notes and skin assessment. LVN 2 stated Resident 1 did not have pressure injury on admission. She stated the skin assessment should be done within two hours of admission. LVN 2 stated if the resident needed dietary consult, it would be the responsibility of the charge nurse to call the physician to obtain an order for the consult. A review of Resident 1's medical record did not indicate a dietary consult was completed as indicated in the care plan developed on October 16, 2023. A review of the facility's policy and procedure titled Skin Management Guidelines dated March 20, 2022, indicated, .Purpose .To describe the process steps required for identification of patients at risk for the development of skin alterations, identify prevention techniques and interventions to assist with management of pressure injuries and skin alterations .Guidelines .Skin alterations and pressure injuries are evaluated and documented by the licensed nurse: using the Admission/Readmission Evaluation upon admission with a head-to-toe skin evaluation .using the Braden Scale, weekly x 3 after admission for a total of 4 weekly evaluations .Body audits are completed: by the licensed nurse daily with pressure injuries .weekly for patients without pressure injuries .by the nursing assistant during scheduled baths/showers .Wound rounds are completed weekly . Skin prevention strategies that can be implemented upon admission for any patient .repositioning and off-loading pressure .pressure reducing support system, skin evaluations .Registered dietician referral .The individualized comprehensive care plan addresses the skin management program, the goal for prevention and treatment, individualized interventions to address the patient's specific risk factors and the plan for reduction of risk. Care plan interventions to consider based upon the Braden risk categories include: .At risk (15-18) potential intervention to consider: Repositioning/off-loading/ heel protection * Manage moisture * Manage nutrition/hydration needs * Manage friction/shear * Pressure reduction support surface .In the event a patient experiences a new pressure injury complete Braden Scale .complete the comprehensive evaluation .notify the attending physician and obtain treatment orders, notify the patient/family/responsible party .

Based on observation, interview, and record review, the facility failed to provide consistent range of motion exercises for five of eight residents reviewed for limited range of motion (ROM - the full movement potential of a joint) (Residents 9, 36, 42, 45, and 52). The facility did not have a restorative nursing program (a program that promotes and maintains resident's function which would include passive range of motion exercises [stretching muscles, moving body part around the joint] and active range of motion exercises [performed solely by the resident, who moves the joint without assistance]) for the residents at the facility. This failure resulted for Residents 9, 36, 42, 45 to develop foot drop (difficulty lifting the front part of the foot) and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and for Resident 52 to develop contractures of right wrist and spastic (stiff or tight muscles) right elbow. Findings: 1. On June 19, 2023, at 3:55 p.m., druing a concurrent observation and interview in the room with Resident 9, Resident 9 was observed both feet had foot drop and with no adaptive feet devices (a device to help with activities of daily living). She stated she could no longer walk and fully dependent on staff for transfer. Resident 9 verbalized she would like to stand and walk again. Resident 9 stated the staff did not provide her with range of motion exercises on her legs. On June 21, 2023, at 9:11 a.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 9 stayed in bed most of the times. CNA 1 stated Resident 9 had limitation on her lower extremities (legs, ankles, and feet) . CNA 1 stated she was unsure if Resident 9 was receiving range of motion (ROM) exercises for her lower extremities. On June 21, 2023, at 12:24 p.m., an interview with the Physical Therapy Assistant (PTA) was conducted. The PTA stated Resident 9 who was admitted to the facility three years ago received physical therapy (PT) services on admission and last year. He further stated Resident 9 was doing well during PT services (care that aims to help function, move and live better) and had potential for improvement with her lower extremities. He stated Resident 9's PT services stopped due to insurance issues six months ago. He stated Resident 9 was to continue with range of motion exercises, once the therapy was discontinued. He stated the CNAs should provide range of motion exercise to the residents to prevent decline on her lower extremities. On June 21, 2023, Resident 9's medical record was reviewed. Resident 9 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar), weakness, and muscle wasting and atrophy (decrease in size or wasting away of body parts). A review of Resident 9's document titled Admission/Re-Admission Evaluation ., dated November 17, 2020, indicated, .The resident will be able to function at the fullest potential possible .evaluate and treat as ordered .The resident's mobility will be improved/restored .assist/encourage the resident needs to change position frequently. Alternate periods of rest with activity out of bed in order to prevent dependent edema (swelling), flexion deformity (inability to fully straighten or extend a joint) . A review of Resident 9's Minimum Data Set (an assessment tool) dated November 24, 2020, indicated Resident 9 had no cognitive impairment. Resident 9 had functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion of the lower extremities. A review of the Physical Therapy PT Discharge Summary, indicated, .Short-Term Goals .Met on 5/13/2022 .safely ambulate (walk) 200 feet .Assessments and Summary of Skilled Services .Patient has met long term/short term goals and Patient has made consistent progress with skilled interventions .Consultation with therapist to facilitate patient's highest level of functional independence .prognosis (likely outcome or course of a disease) .Excellent with consistent staff support . Further review of Resident 9's medical record indicated no documentation the nursing staff provided Resident 9 with range of motion exercises. On June 21, 2023, at 2:27 p.m., an interview and concurrent review of PT notes with Physical Therapist (PT) 1 was conducted. PT 1 stated Resident 9 was referred for PT services on February 23, 2022, due to a decline in her mobility. She stated Resident 9 did well during therapy and was able to walk several hundred feet. She stated if there was a decline in Resident 9's mobility, the nursing staff would have to refer resident to PT for further evaluation and treatment. On June 21, 2023, at 4:10 p.m., an interview with the Administrator (ADM) was conducted. The ADM stated the facility did not have a restorative nursing program and CNAs should perform ROM exercises for the residents. On June 22, 2023, at 8:50 a.m., PT 2 was observed in the room, to assess Resident 9's lower extremities. In a concurrent interview with PT 2, she stated Resident 9's left foot flexion (forward bending) was absent with no outward and/or inward movement. She stated Resident 9's left foot has a definitive decline. She stated Resident 9's right foot was more contracted compared to the left foot. She stated the contractures noted on Resident 9 did not happen overnight and had to develop over time. She stated Resident 9 being confined in bed for extended period and not having any range of motion exercises daily could possibly lead to contractures of her lower extremities. She stated based on her assessment, she stated Resident 9 had a decline in both her lower extremities. PT 2 stated Resident 9's left foot had severe foot drop with stiffness. On June 22, 2023, at 9:45 a.m., an interview with the Director of Nursing (DON) was conducted. The DON was not able to explain the facility's system to evaluate and monitor resident's overall status to improve or maintain range of motion. She stated the facility ddi not have a restorative nursing program. The DON stated there was no documentation that ROM exercises were being provided for Resident 9 after the therapy services were discontinued. She further stated if Resident 9 had a decline in range of motion, the nursing should have assessed the resident and referred to PT for further evaluation. The DON stated lack of communication between the nursing staff and PT may have contributed to Resident 9's decline in ROM of her lower extremities. On June 23, 2023, at 4:40 p.m., an interview and concurrent record review with Registered Nurse (RN) 1 was conducted. RN 1 stated he was aware Resident 9 had limitation on her lower extremities and requiring ROM exercises. RN 1 stated ROM exercises would be provided by the CNAs. RN 1 stated there was no documentation Resident 9 received ROM exercises for her lower extremities after the therapy services were discontinued on May 13, 2022. 2. On June 19, 2023, Resident 45 was observed in bed with left foot in a downward motion away from his body (plantar flexion). In concurrent interview with Resident 45, she stated her left foot was not always like that. Resident 45 stated the staff hardly checked on her except when giving her medications. On June 22, 2023, at 3:10 p.m., a concurrent observation in Resident 45's room and interview with PT 2 was conducted. PT 2 stated resident received PT services (care that aims to help function, move and live better) from May 24, 2021, to June 13, 2021, for functional mobility. She stated Resident 45 should continue with ROM exercises daily, performed by the nursing staff, upon completion of physical therapy on June 13, 2021. PT 2 was observed assessing Resident 45's left foot and stated Resident 45's left foot was contracted and had a drop foot. She stated if Resident 45 had a decline in her range of motion, it should have been referred to PT for further evaluation. On June 22, 2023, Resident 45's medical record was reviewed. Resident 45 was admitted to the facility on [DATE], with diagnoses which included anemia (low condition in which the body does not have enough healthy red blood cells [provides oxygen to the body tissue]), morbid (severe) obesity, occlusion (blockage) and stenosis (abnormal narrowing of passage in the body). A review of Resident 45's document titled, Admission/Re-Admission Evaluation ., dated May 25, 2021, indicated, .lower extremities range of motion no impairment .The resident's mobility will be improved/restored .With .Assist/encourage the resident needs to change position frequently. Alternate periods of rest with activity out of bed in order to prevent .dependent edema (excess fluid in the body influenced by gravity), flexion deformity (inability to fully straighten or extend a joint) . A review of Resident 45's Care Plan dated May 26, 2021, indicated, .ADL (activity of daily living) self-care deficit as evidenced by need for assistance of 2 (two) person asst (assistance) staff with self care and mobility related to weakness, pain, dizziness .will receive assistance necessary to meet ADL needs .Will not develop any complication related to mobility .allow for flexibility in ADL to accommodate mood, preference and customary routine . Further review of Resident 45's MDS, dated [DATE], indicated Resident 45 required extensive to total assistance (the staff performs the entire task) with two-person for support for bed mobility, transfers and locomotion on unit (how resident moves between locations in his/her room adjacent corridor on same floor). On June 22, 2023, at 4:30 p.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated she was aware Resident 45 had contracture of her left foot. CNA 1 stated she provided ROM exercises for Resident 45 but was not offered consistently. On June 23, 2023, at 4:40 p.m., an interview with RN 1 was conducted. RN 1 stated Resident 45 had limited range of motion of her lower extremities. RN 1 stated she was not aware Resident 45 had left foot contracture. RN 1 stated there was no documentation the staff provided ROM exercises to Resident 45 after the therapy services were discontinued on June 13, 2021. He stated if resident had a decline in their ROM, it should have been referred to PT for further evaluation. 44173 3. On June 19, 2023, at 11:23 a.m., Resident 36 was observed in bed and with a left foot drop. In a concurrent interview with Resident 36, Resident 36 stated he had a left sided stroke (damage to the brain from interruption of its blood supply). He further stated, he did not have physical therapy done for a while. A review of Resident 36's medical record indicated Resident 36 was admitted to the facility on [DATE], with diagnoses which included left hemiparalysis (weakness on one side of the body). A review of Resident 36 document titled, Occupational Therapy OT Evaluation & Plan of Treatment, dated July 27, 2021, indicated, Resident 36's left lower extremity was impaired. Resident 36's left lower extremity was flaccid (soft and limpy) with no active range of motion (the resident performs stretching exercises, moving the muscles around a weak joint without any aid). A review of Resident 36's document titled, Physical Therapy PT Evaluation & Plan of Treatment, dated July 27, 2021, indicated, Resident 36 had impaired flaccid left lower extremity. A review of Resident 36's Occupational Therapy's (OT) Discharge Summary dated September 3, 2021, indicated, .Discharge Recommendations .Discharge Recommendations .Home exercise program and 24-hour care .Prognosis .to maintain CLOF (current level of care) .Good with consistent staff follow-through . A review of Resident 36's Physical Therapy Discharge Summary dated September 3, 2021, indicated, . Discharge Recommendations .to prevent further decline .Therapy Follow Up Established/Trained .Restorative Range of Motion Program .assistance by performing the following Therapy interventions: active ROM on RLE (right lower extremity), PROM (passive range of motion - an outside force causes movement of a joint) on LLE (left lower extremity) . A review of Resident 36's care plan dated February 8, 2023, indicated, At risk for loss of range of motion r/t (related to) disease process CVA (cardiovascular accident - stroke), physical limitations .Goal .Will exhibit no decline in ROM .Interventions .Passive ROM to L (left) lower extremity with care/ADLs (activities of daily living) dressing and changing . Further review of Resident 36's medical record indicated no documented evidence the CNAs provided the resident with PROM exercises to LLE during care/ADLs and ROM program. On June 22, 2023, at 7:54 a.m., PT 2 was interviewed. PT 2 stated she provided training to CNAs for the resident's range of motion exercises when she discharged resident from physical therapy. PT 2 stated no screening would be provided to the resident unless nursing made a referral for therapy for a resident's decline in the range of motion. PT 2 stated Resident 36 was re-evaluated on November 9, 2021, and there was decline in ability to move, muscle strength, and balance. PT 2 stated Resident 36 had muscle contraction on LLE. PT 2 stated when she discharged Resident 36 after one treatment, she provided training to the CNA assigned to Resident 36 on November 12, 2021. On June 22, 2023, at 8:25 a.m., during an observation in Resident 36's room and interview with PT 2 and Resident 36, Resident 36 stated the staff did not provide exercises to his left leg after the therapy was completed. PT 2 stated she was familiar with Resident 36. PT 2 stated the therapists evaluated Resident 36 multiple times and the resident did not have a contracture (shortening and hardening of muscles and joints, often leading to deformity) or a foot drop. PT 2 was observed assessing Resident 36 and stated Resident 36 had a decline in his range of motion. PT 2 stated Resident 36 had left foot dorsiflexion contracture (backward bending of the foot) due to immobility. PT 2 stated Resident 36 has a left foot drop. 4. On June 19, 2023, at 2:45 p.m., Resident 42 was observed in bed, with left hand clenched and with left foot drop. A review of Resident 42's medical record indicated Resident 42 was admitted to the facility on [DATE], with diagnoses which included stroke and hemiplegia (paralysis of one side of the body). A review of Resident 42's Minimum Data Set (an assessment tool) indicated: - Dated March 2, 2019, .Balance During Transition and Walking .Moving from seated to standing position .Walking (with assistive device if used) .Turning around/facing the opposite direction while walking .not steady but able to stabilize without staff assistance .Functional Limitation (limited ability to move a joint that interferes with daily functioning) to Range of Motion .Upper extremity .No impairment .Lower extremity .Impairment on one side . - Dated May 19, 2023, indicated, .Balance During Transition and Walking .Moving from seated to standing position Walking (with assistive device if used) .Turning around/facing the opposite direction while walking .Activity did not occur .Functional Limitation in Range of Motion .Upper extremity .Impairment on one side .Lower extremity .Impairment on both sides . A review of Resident 42's document titled, Physical Therapy PT Evaluation and Treatment, indicated: - Dated October 15, 2019, Resident 42's range of motion were within normal limit on left lower extremity. - Dated June 10, 2020, Resident 42's range of motion on left lower extremity was impaired. - Dated March 24, 2021, Resident 42's range of motion on left lower extremity was with functional limitation. - Dated July 11, 2022, Resident 42's range of motion on left lower extremity and ankle was impaired. A review of Resident 42's document titled, Physical Therapy PT Discharge Summary, dated May 27, 2022, indicated .no significant progress due to complicated medical condition . Further review of Resident 42's medical record indicated no documented evidence the Certified Nursing Assistants (CNAs) provided range of motion exercises during care/ADL's to the resident. On June 22, 2023, at 7:54 a.m., PT 2 was interviewed. PT 2 stated the facility did not have restorative nursing program. PT 2 stated the physical therapist trained a CNA on conducting continuous mobility exercises and passive range of motion, when physical therapy discharged a resident from their services. PT 2 stated the trained CNA should train another CNA. PT 2 stated the training provided to the CNA was not documented. PT 2 stated that not having a restorative nursing assistant or a dedicated CNA to perform ROM was ineffective to prevent the decline in resident's range of motion. On June 22, 2023, at 9:46 a.m., the Director of Nursing (DON) was interviewed. The DON stated the facility did not have a restorative nursing program. The DON stated the communication between physical therapy and nursing was done through the Therapy Follow Up Communication form (a communication tool between nursing and therapy for therapy recommendations). The DON stated the therapy recommendations were discussed by the interdisciplinary team (IDT - collaboration of multiple disciplines : nursing, rehabilitation, activity, and social service). The DON stated nursing should have provided range of motion exercises to residents to prevent decline in range of motions. On June 22, 2023, at 10:30 a.m., a concurrent observation in Resident 42's room and interview were conducted with CNA 1 and CNA 2. CNA 1 was unable to show how to perform passive range of motion (an outside force causes movement of a joint) on a resident. CNA 1 stated she had not performed range of motion exercises on a resident. CNA 1 stated she could not remember if she had a training on range of motions. CNA 2 stated the CNAs should perform range of motion exercises to residents with limited mobility to prevent stiffness in their joints. CNA 2 stated no one had told her to perform range of motion exercises to Resident 42. On June 23, 2023, at 3:07 p.m., Registered Nurse (RN) 4 was interviewed. RN 4 stated the facility used a communication form from physical therapy to know if the resident required range of motion exercises. RN 4 stated he did not receive communications from physical therapy. RN 4 stated the CNAs and LVNs (Licensed Vocational Nurses) should tell him if residents had a decline in mobility or a range of motion. 36038 5. On June 19, 2023, at 11:29 a.m., Resident 52, was lying in his bed. Resident 52's right hand was observed with closed fist and flexed inward. Resident 52 stated he did not have exercises for his right upper extremity. A review of Resident 52's medical record indicated Resident 52 was admitted to the facility on [DATE], with diagnoses which included right sided weakness, late effect of stroke (occurs when the blood supply to part of the brain is interrupted or reduced). A review of Resident 52's admission Minimum Data Set (an assessment tool) dated March 11, 2023, indicated, Resident 52 had no cognitive impairment. Resident 52 had impairment on both upper extremities. A review of Resident 52's document titled, Occupational Therapy's OT Discharge Summary, dated on May 19, 2023, indicated, .Discharge Recommendations and Status, indicated, .Range of Motion Program established/Trained .Prognosis to Maintain CLOF (current level of function) = Good with consistent staff follow through . A review of Resident 52's Task Description, for the month of May 2023, indicated, .PASSIVE RANGE OF MOTION OF RIGHT UPPER EXTREMITY DURING ADLS .CNA (Certified Nurse Assistant) .Every Shift . Further review of Resident 52's medical record indicated no documentation Resident 52 was provided passive range of motion exercises (PROM - an outside force causes movement of a joint) of right upper extremity during ADLs. On June 23, 2023, 11:07 a.m., a concurrent observation and interview with CNA 2 and Resident 52 were conducted. CNA 2 stated he was familiar with Resident 52. CNA 2 further stated Resident 52 did not have an order for the range of motion exercises. CNA 2 stated nobody told him. CNA 2 was observed raising Resident 52's right upper extremity and Resident 52 experienced pain and told CNA 2 to stop. On June 23, 2023, at 2:56 p.m., during a concurrent observation and interview with Physical Therapist (PT) 2 and Resident 52, PT 2 stated Resident 52 had contracted right wrist and spastic (stiff muscles) right elbow. Resident 52 stated he could open and close his right hand before, and now he could not do it. PT 2 stated nursing should implement physical therapy recommendations. On June 23, 2023, at 3:05 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, she stated she was unaware of the OT recommendation for PROM exercises to the right hand of Resident 52. LVN 2 stated there was no documentation Resident 52 was provided passive range of motion exercises for his right upper extremity after discontinuation of therapy services on May 18, 2023. A review of the undated facility document titled, Restorative Nursing Guideline, indicated, .Restorative nursing care includes nursing interventions that .prevent unnecessary decline in function .are individualized to specific patient needs .Functional decline can lead to .complications of immobility .contractures .Restorative Interventions .Techniques include .active range of motion (AROM) .passive range of motion (PROM) .Splint or brace assistance (a device used to support or hold a body part) .Interventions are provided by nursing staff who have completed the appropriate competency evaluation .Education on restorative nursing is required for licensed nurses and nursing assistants .

Based on interview and record review, the facility failed to ensure one resident (Resident 1) of three surveyed residents, was safely discharged to an environment where his needs would be met. This failure resulted in Resident 1 to be unable to meet his basic needs and increased his risk for injury from a fall. Findings: On (MONTH) 22, 2019, an unannounced visit was made to the facility for investigation of a complaint regarding an unsafe discharge. On (MONTH) 22, 2019, the facility medical record for Resident 1 was reviewed. Resident 1 was an [AGE] year-old male, admitted to the facility on (MONTH) 3, 2019, with [DIAGNOSES REDACTED]. A copy of the Hospital record, Consultation Report, dated (MONTH) 31, 2019, indicated: Resident 1 lived alone in a condo. Resident 1 stated he did not have a cell phone, landline, or car. He had no relatives in area and does not maintain contact with nephews and nieces in Illinois. He stated that he only sees his neighbors if he happens to run into them at the grocery store. A facility Nursing Progress note, dated (MONTH) 4, 2019, at 12:56 a.m., indicated Resident 1 was found to be alert and oriented to self only and had impaired short term memory. A facility Nursing Progress Note, dated (MONTH) 10, 2019, at 04:03 a.m., indicated he was alert with periods of confusion. A facility Progress Note written by Social Worker (SW), dated (MONTH) 10, 2019, at 14:22 (2:22 p.m.)., indicated, patient assessed for BIMS (Brief Interview for Mental Status- a tool to assess cognitive status, 15 is the highest score indicating no cognitive issues, the lower the number below 15 indicates a cognitive problem) with score 5/15 indicating cognitive impairment r/t (related to) [DIAGNOSES REDACTED]. He is however, able to make needs known and answer simple yes/no questions . Progress Note, dated (MONTH) 12, 2019, at 16:52 (4:52 p.m.), indicated, NOMN[NAME] (Notice of Medicare Non-Coverage) issued today .8/14 will be going home family. The NOMN[NAME] was signed by Resident 1. A facility form, My Transition Home, dated, (MONTH) 15, 2019, indicated, Patient to F/U (follow up) with (name of doctor) has open access so call same day in AM .No home health services per CM (case manager). On this same form Physical Therapy indicated, Pt (patient) is SBA (stand by assist) with bed mobility and transfers, SBA with ambulation 200' using FWW (front wheel walker), able to climb 6 steps SB[NAME] Pt will benefit from HHPT (home health physical therapy), FWW for ambulation. The form indicated the resident was discharged on (MONTH) 15, 2019, at 11:15 a.m. Section G of the MDS (Minimum Data Set- an assessment tool) completed at discharge, dated (MONTH) 15, 2019, indicated the resident needed limited assistance with transfers from bed to standing or to chair and limited assistance with personal hygiene. He needed extensive assistance with locomotion on the unit (walking in his room and hallway), dressing, and toilet use. The resident was totally dependent for bathing. Section H of the MDS indicated the resident was frequently incontinent of urine and always incontinent of bowel. Emergency Department Final Report, dated (MONTH) 17, 2019, indicated, .friend walked in to find him sitting on his own feces. Pt. was discharged from (name of facility) two days prior. Pt had reported he was waiting to go home (while home) to Cathedral City and was unable to tell others when he last ate. Pt. appeared unable to take care of self. The acute care facility's, History and Physical, date (MONTH) 18, 2019, indicated, the patient had been diagnosed with [REDACTED].the patient was accepted at (name of facility) at (name of acute care facility). On (MONTH) 22, 2019, at 1:10 p.m., an interview was conducted with the facility Social Worker (SW). The SW stated she had performed the BIMS. SW stated Resident 1 had a BIMS score of five. SW stated a five would indicate a cognitive deficit. The SW stated having him sign papers like the NOMN[NAME] may not be appropriate. SW stated she was aware the resident lived alone and had planned to have Home Health services (visiting nurse and physical therapy), but the Case Manager (CM) said it was not needed. SW stated the IDT (Interdisciplinary Team, a group compose of nurses, social worker, physician, and physical therapist) does meet and discuss discharges, but she did not recall anyone mentioning any concerns about this resident's discharge. On (MONTH) 22, 2019, at 1:30 p.m., an interview was conducted with the CM. The CM stated the physician made the decision that the resident was alert and oriented. The CM stated she was told the resident's friend, N1 (name of neighbor), would take care of him. The CM stated she had no conversations with N1 and had not seen N1. She stated she was not aware the resident was incontinent or needed help with bathing and toileting, and did not know why Home Health services were not ordered. The CM stated the resident was responsible for calling and making his own follow appointment with his doctor. The CM stated she gave the resident instructions for calling his doctor, and he said he would do it. On (MONTH) 22, 2019, at 2:05 p.m., an interview was conducted with Registered Nurse (RN 1). RN 1 stated she discharged the resident on (MONTH) 15, 2019. She stated discharge means making sure he has medications and answering any questions his family may have if there is family with the resident. RN 1 stated Resident 1 did not have any family with him. RN 1 stated transportation had been arranged and they came and picked him up to go home. RN 1 stated she had not heard any discussion about him being unsafe to go home alone. RN 1 stated that would be up to the case manager, she further stated, We don't get involved in that. If they say he can go home, then he goes home. On (MONTH) 11, 2019, at 11:37 a.m., a phone interview was conducted with Resident 1's neighbor (N2). N2 stated he hadn't seen any friends or family visit (Resident 1's name) at home in a long time. N2 stated, he and N1 would sometimes stop by (Resident 1's name) condo to say hi. N2 stated he saw a van drop off (Resident 1's name) on the day he came home. He and his wife brought (Resident 1's name) some dinner and juice that night. N2 stated (Resident 1's name) gobbled the dinner and drank the juice like he hadn't eaten in a long time. N2 stated a couple days later, they went over to check on (Resident 1's name). N2 stated, they found (Resident 1's name) in the same chair as the first night and, .that's when we found him in his own poop, I don't think he had moved from that chair. N2 stated he called Adult Protective Services On (MONTH) 11, 2019, at 12:09 p.m., a phone interview was conducted with the Emergency Contact (EC) for resident 1. EC stated he was not told by the facility that (Resident 1's name) was to be discharged . EC stated he had called the facility shortly before (Resident 1's name) was discharged and they never mentioned anything about (Resident 1's name) being sent home. EC stated a neighbor of (Resident 1's name) called him to tell him that (Resident 1's name) had been dropped off by someone in a van. N2 called EC two days later and told EC that they hadn't seen (Resident 1's name) for two days. EC stated he told N2 to please go into the condo and check on (Resident 1's name). EC stated N2 found (Resident 1's name) sitting in his own feces and they didn't think he had moved since the first night home. When asked about N1 as a caretaker for (Resident 1's name) , EC stated, N1 is elderly, has health issues, and he isn't even home. N1 left the area for cooler weather.

Based on interview, and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was free from physical abuse, when another resident (Resident 2) witnessed a facility contracted sitter (provided by an in home care provider) rough handling Resident 1. This failure resulted in Resident 1 to be physically abused, and had the potential to cause anxiety and feeling of being unsafe while at the facility. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility initially on (MONTH) 6, 2019, and readmitted on (MONTH) 17, 2019, with [DIAGNOSES REDACTED]. Resident 1's MDS (minimum data set- an assessment tool) dated (MONTH) 13, 2019, was reviewed. The MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status- an assessment for cognitive status) score of 00. (meant severe impairment). Resident 1's progress notes dated (MONTH) 16, 2019, at 14:06 (2:46 p.m.), was reviewed. The progress notes indicated, .concern voiced at this time by patients (Resident 1) RP (Responsible party) investigation in progress; patient denies any continued complaints of pain or discomfort, skin assessment performed with 2 licensed nurses with no concerns observed. notifications made to state agencies immediately, law enforcement notified. MD (medical doctor) made aware. Resident 1's progress notes dated (MONTH) 16, 2019, at 17:31 (5:31 p.m.), was reviewed, and indicated, .Patient (Resident 1) with 1:1 (1 on 1) sitter and family member roommate speaking with (Resident 1's family member) re (regarding) 1:1 sitter on pm (evening) shift 3-11 . On (MONTH) 22, 2019, at 2:32 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated he heard about the sexual allegation involving Resident 1 and the sitter. LVN 1 stated he heard the sitter's hands were in her (Resident 1) brief. On (MONTH) 22, 2019, at 2:39 p.m., LVN 2 was interviewed. LVN 2 stated Resident 1's roommate (Resident 2) saw the sitter did something inappropriate to Resident 1. Resident 2's written statement dated (MONTH) 16, 2019, provided by the facility was reviewed and indicated, .saw Caregiver (sitter) rough house (sic) pat (patient) Through (sic) her legs as hard as he could over onto bed, several times she was screeming (sic) at him. I went into bathroom & (and) when I was coming out she was fighting with him & screaming at him. he was leaning over her and his hands were all over her, her pants were off her shirt was above her head when he saw me he jumped back through his hands up into the air and had a frightful look on his face . Resident 2's record was reviewed. Resident 2 was admitted to the facility on (MONTH) 14, 2019, with [DIAGNOSES REDACTED]. Resident 2's MDS dated (MONTH) 21, 2019, was reviewed, and indicated Resident 2 had a BIMS score of 15 (meant cognitively intact). On (MONTH) 22, 2019, at 2:44 p.m., the LVN Supervisor was interviewed. She stated Resident 1's family member reported the sitter for being rough. In addition, the family member stated the sitter probably sexually assaulted Resident 1. On (MONTH) 22, 2019, at 2:55 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated she heard the sitter's hands were seen under the sheet of Resident 1. RN 1 stated she heard Resident 1's legs were thrown on the bed by the sitter. On (MONTH) 22, 2019, at 3:15 p.m. Resident 1 was observed lying quietly in bed. Resident 1 was observed with a bruise, circular in shape approximately 1 centimeter on the lateral left upper arm. On (MONTH) 22, 2019, at 3:22 p.m., the RN Supervisor (RNS) was interviewed. The RNS stated Resident 1 family member approached her (RNS) and reported Resident 1 had stated to the family member, Why did you guys let him do this to me? This big man. The RNS stated the resident's (Resident 1) family member had reported that Resident 1 was touched and beaten by the sitter. On (MONTH) 9, 2019, at 11:05 a.m., the Supervisor Resource Specialist of a medical group was interviewed regarding the sitter being used at the facility. He stated the sitter came from a private agency contracted by the medical group affiliated with the facility. On (MONTH) 28, 2019, at 1:35 p.m., a phone interview was conducted with Resident 2. Resident 2 stated while she was in the bathroom on (MONTH) 15, 2019, she heard screams. Resident 2 stated she turned the bathroom light off, opened the bathroom door, and observed Resident 1 sitting up in bed, leaning way forward and screaming, No, Stop, No. Resident 2 stated, the bed sheet was over Resident 1 hands which was moving rapidly in her private area trying to keep the sitter's hands away from her. Resident 2 stated she saw the sitter's hands under the sheet, with the Resident 1's diaper at the end of the bed. Resident 2 further stated when the sitter turned around, he had a frightful look on his face. In addition, Resident 2 stated she had observed Resident 1 trying to get up from her bed and he (sitter) threw Resident 1's legs back onto the bed. Resident 2 stated the sitter threw Resident 1's leg so hard she (Resident 1) nearly fell out of the bed. Resident 2 stated she had seen the sitter throwing Resident 1's legs onto the bed several times. A document provided by the facility which indicated the contracted agency's schedule of the sitter was reviewed. The document indicated the contracted sitter was scheduled with Resident 1 on (MONTH) 13, 2019, (11 p.m. to 9 a.m.) and (MONTH) 15, 2019 (3:15 p.m. to 11 p.m.). On (MONTH) 14, 2019, at 11:18 a.m., a phone interview was conducted with the Director of Nursing (DON). The DON stated the sitter was expected to sit and watch the resident to ensure safety. The DON stated the sitter was supposed to call for assistance from a facility staff when resident does unsafe things. She stated the sitter was not supposed to touch the resident. On (MONTH) 18, 2019, at 11:15 a.m., the RNS was interviewed regarding the duties of a contracted caregiver/sitter. She stated the sitter was not supposed to provide care. The RNS stated the sitter was expected to sit, call for facility staff when needed to prevent fall and injury for the resident being watched. A document provided by the County Sheriff Department on (MONTH) 12, 2019, was reviewed. The document titled, INCIDENT REPORT, prepared on (MONTH) 16, 2019, indicated, .Details . (Name of the law enforcer) spoke with (name of the facility staff). (Name of the facility staff) stated (name of Resident 1's family member) reported that (relationship to the family member), a [AGE] year-old victim, who is a client (name of the skilled nursing facility), told her (Resident 1's family member) she (Resident 1) was sexually assaulted by an employee at the facility. (Name of a facility staff) assessed the victim (Resident 1) for injuries and noticed multiple bruises to the victim's shoulder/arms and back. (Name of a facility staff) said the bruises were consistent with the application of force or pressing on the skin . (Name of Resident 2) further stated she noticed as the night progressed (Name of the sitter) became irritated with the victim. The victim continually tried getting out of her bed and (Name of the sitter) would lift her legs and throw them back onto the bed. As his (the sitter) irritation increased, (Name of the sitter) became more forceful with the victim (Resident 1) .About 2215 (10:15 p.m.) hours, (Name of Resident 2) got out of bed to use the restroom. While in the bathroom, she could hear the victim yell no' several times . (Name of Resident 2) exited the bathroom and saw (Name of the sitter)'s hand underneath the victim's bed sheets near her (Resident 1) genitals. (Name of Resident 2) witnesses the victim (Resident 1) making an attempt to move (name of the sitter) hands . The incident report from the county sheriff further reflected the investigator's notes related to the allegation of physical and sexual abuse involving Resident 1 and the sitter. The document indicated, .I (the investigator from the sheriff's department) spoke with the victim's (Resident 1) (relationship of the family member) (name of the family member) at (name of the acute care hospital). Bruising consistent with fingertip impressions was located on the victim's (Resident 1) left inner thigh. There were also bruises located on the victim's shoulder area. The Forensic Nurse Examiner stated due to the victim's age and condition it is possible she sustained the injuries by someone's simple moving her from one position to another. There were no signs of trauma or penetration to the victim's vaginal area . The document indicated the case was closed by arrest. The facility policy and procedure was reviewed. The policy titled, PRIVATE DUTY COMPANIONS AND SITTERS, dated (MONTH) 2013, indicated, PURPOSE: To describe the process of accommodating a patient's desire for private duty companions and sitters. NOTE: A companion or sitter . is only allowed to sit with the patient and provide companionship. No direct or hands-on care is provided by companions or sitters, regardless of licensure status. Direct or hands-on care includes but not limited to bathing, dressing, transferring, toileting, feeding, or ambulating .3. Administrative Director of nursing Services, administrator or designee verifies that the employer of the private duty companion or sitter (patient, family or legal representative) verifies [MEDICAL CONDITION] screening completed and conducts background investigation. Results are made available to the center designee prior to the companion or sitter beginning their first shift. 4. After verifications are completed, a center overview is conducted prior to the first scheduled shift and included but is not limited to: a. tour of center b. resident rights c. abuse and neglect prevention d. confidentiality and privacy e. emergency and fire procedures f. infection control g. incident/accident reporting . The facility policy and procedure titled, PATIENT PROTECTION . dated (YEAR), indicated: SYSTEM COMPONENTS .483.12 Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect. and exploitation .(a) The facility must (1) Not use verbal, mental, sexual, or physical abuse ., (2) Ensure that the resident is free from physical or . imposed for purpose of discipline or convenience and that are not required to treat the resident's medical symptoms .

Based on interview and record review the facility failed to manage the pain of one (Resident 1) of three sampled residents, when Resident 1 fell and was not provided with interventions for pain control. This failure caused Resident 1 to experience pain for five days prior to treatment of [REDACTED]. Findings: On (MONTH) 11, 2019, an unannounced visit was made to the facility to investigate a complaint regarding quality of care. On (MONTH) 11, 2019, Resident 1's facility medical record was reviewed . Resident 1 was an elderly female admitted to the facility on (MONTH) 29, 2019, at 3:20 p.m., with [DIAGNOSES REDACTED]. A review of a nursing Progress Note written at the time of admission, (MONTH) 29, 2019, at 5:26 p.m., did not indicate Resident 1 was experiencing any pain. A review of the nursing Progress Note dated, (MONTH) 29, 2019, at 8:15 p.m., indicated, Patient was found on floor in her room by the door .A/O x1 (alert and oriented to name only). Patient had no visual bruising but c/o (complained of) pain to her right leg. Patient was placed in bed and patient given call light. A review of a second nursing Progress Note, dated, (MONTH) 29, 2019, at 8:15 p.m., indicated, called to room to assess patient who was found on the floor in her room. Patient is a new admit. A&O (alert and oriented) to self and city. And states she was walking and fell , unable to elaborate on why she fell . LVN (Licensed Vocational Nurse) to contact provider and family, update Care Plan. A review of a facility Physician's Progress Note, dated (MONTH) 3, 2019, at 1:05 p.m., indicated, pt (patient) c/o pain hip R (right). A review of a Progress Note dated (MONTH) 3, 2019, at 10:02 p.m., indicated an x-ray report came back with the findings .right femoral neck Fx (right [MEDICAL CONDITION]). Certified Nursing Assistant (CNA 1) was interviewed on (MONTH) 11, 2019, at 11:30 a.m. CNA 1 stated it would take two CNAs to turn Resident 1 after the fall. CNA 1 stated Resident 1 would moan when we turned her. CNA 1 stated she told Registered Nurse (RN 1) about the pain. Registered Nurse (RN 1)1 was interviewed on (MONTH) 11, 2019, at 11:40 a.m. RN 1 stated that Resident 1 was confused and did not have any pain. RN 1 denied being told by CNA 1 that Resident 1 had pain. RN 2 was interviewed at 12 p.m. (noon) on (MONTH) 11, 2019. RN 2 stated the IDT (Interdisciplinary Team, a team composed of health care professionals from different disciplines) meeting regarding Resident 1's fall on (MONTH) 29, 2019, was held on (MONTH) 1, 2019. During the meeting they found out the physician and family had not been notified. RN 2 stated the physician and family should have been notified when the fall occurred on (MONTH) 29, 2019. RN 2 was asked about the documentation by the LVN (LVN 1) which indicated Resident 1 had right leg pain after the fall. RN 2 stated the RN documented there was no pain, and they (facility staff) would go by the RN's assessment. RN 2 stated no x-rays would be needed since the RN had found Resident 1 had no pain. LVN 1 was interviewed by phone on (MONTH) 10, 2019. LVN 1 did not remember Resident 1. LVN 1 stated she would need to look at her progress notes in the computer. LVN 1 was asked about the notation she made in Resident 1's medical record dated (MONTH) 29, 2019 at 8:15 p.m., Patient had no visual bruising but c/o pain to her right leg. LVN 1 stated she thought she meant pain that Resident 1 had before the fall. CNA 2 was interviewed by phone on (MONTH) 13, 2019, at 6:30 a.m. CNA 2 stated he took care of her after the fall. CNA 2 stated Resident 1 was confused, but cooperative. CNA 2 stated,There was always two CNAs to turn Resident 1 and Resident 1 would moan. CNA 2 stated he would tell the nurse and he thought the nurse would give Resident 1 a pain pill. Resident 1's Family Member 1 (FM 1) was interviewed on (MONTH) 21, 2019, at 12:15 p.m. FM 1 stated she was not told of the resident's fall until (MONTH) 1, 2019, three days after the fall. FM 1 stated she called Family Member 2 (FM 2) and asked her to go see Resident 1. FM 2 told FM 1 that Resident 1 was in a lot of pain. Resident 1's Family Member 1 (FM 1) was interviewed on (MONTH) 21, 2019, at 12:15 p.m. FM 1 stated she was not told of the resident's fall until (MONTH) 1, 2019, three days after the fall. FM 1 stated she called Family Member 2 (FM 2) and asked her to go see Resident 1. FM 2 told FM 1 that Resident 1 was in a lot of pain. On (MONTH) 21, 2019, at 12:15 p.m., a phone interview was conducted with Family Member 1 (FM 1). FM 1 stated she was not notified of Resident 1's fall until (MONTH) 1, 2019, three days after the fall. FM 1 stated she called FM 2 and asked her to go see Resident 1. FM 1 stated she was told by FM 2 that Resident 1 was in a lot of pain. FM 2 was interviewed by phone on (MONTH) 21, 2019, at 12:45 p.m. FM 2 stated the following: Her family was not told of Resident 1's fall until (MONTH) 1, 2019, three days after the fall occurred. They were told Resident 1 had no pain and there were no injuries. On (MONTH) 1, 2019, she went to visit Resident 1, and found her in excruciating pain. She watched the CNAs try to turn Resident 1 and told them to stop because of the pain. She immediately asked the nurses to have an x-ray of Resident 1's hip. The nurses told her they would need to call the doctor. She visited Resident 1 the following days and found her in pain everyday. FM 2 stated it took two more days of insisting that an x-ray be done before the x-ray was actually done. They (facility staff) found Resident 1 did have a broken hip and sent her to the hospital. FM 2 denied Resident 1 had right hip pain prior to her fall on (MONTH) 29, 2019. FM 2 felt the prolonged amount of time that Resident 1 was in pain contributed to the rapid heart rate and her death two weeks later. On (MONTH) 26, 2019, the medical record from the acute care hospital was reviewed. The Emergency Department Encounter, dated (MONTH) 3, 2019, at 11:41 p.m., indicated, .[MEDICAL CONDITION] 5/10 (Tool for indicating the severity of pain, 10/10 would be severe pain and 0/10 would be no pain) severity hip pain.

Based on interview and record review, the facility failed to inform the physician and the responsible person when one (Resident 1) of three sampled residents, fell and complained of pain in her right leg. This failure had the potential for delay in treatment of [REDACTED]. Findings: On (MONTH) 11, 2019, an unannounced visit was made to the facility to investigate a complaint regarding quality of care. On (MONTH) 11, 2019, a review of Resident 1's facility medical record was conducted. Resident 1 was a elderly female admitted to the facility on (MONTH) 29, 2019, with [DIAGNOSES REDACTED]. A review of a Progress Note written at the time of admission, (MONTH) 29, 2019, at 5:26 p.m., did not indicate Resident 1 was experiencing any pain. A review of the Progress Notes for (MONTH) 29, 2019, at 8:15 p.m., indicated, Patient was found on floor in her room by the door .A/O x1 (alert and oriented to name only). Patient had no visual bruising but c/o (complained of) pain to her right leg. Patient was placed in bed and patient given call light. A review of a second Progress Note for (MONTH) 29, 2019, at 8:15 p.m., indicated, called to room to assess patient who was found on the floor in her room. Patient is a new admit. A&O (alert and oriented) to self and city. And states she was walking and fell , unable to elaborate on why she fell . LVN (Licensed Vocational Nurse) to contact provider and family, update Care Plan. A review of the Progress Note for (MONTH) 1, 2019, at 10:03 p.m., indicated, IDT (Interdisciplinary Team, a team of health care professionals from different disciplines) met to review fall that occurred on 3/29/19 . MD (Medical Doctor) notified. Family Notified . A review of a facility Physician's Progress Note, dated (MONTH) 3, 2019, at 1:05 p.m., indicated, pt (patient) c/o pain hip R (right). A review of the Progress Note dated (MONTH) 3, 2019, at 10:02 p.m., indicated an x-ray report came back with the findings .right femoral neck Fx (right [MEDICAL CONDITION]). A review of the Incident Report dated (MONTH) 29, 2019, at 8:15 p.m., indicated the date of the fall was (MONTH) 29, 2019, at 8:15 p.m. The physician was notified on (MONTH) 1, 2019, at 1:56 PM. and the responsible person was notified on (MONTH) 1, 2019, at 12: 00 AM (sic) On (MONTH) 11, 2019, at 12 p.m. (noon), an interview was conducted with Registered Nurse 2 (RN 2). RN 2 stated the IDT meeting regarding Resident 1's fall on (MONTH) 29, 2019 was held on (MONTH) 1, 2019. During the meeting they found out the physician and family had not been notified. RN 2 stated the physician and family should have been notified when the fall occurred on (MONTH) 29, 2019. On (MONTH) 21, 2019, at 12:15 p.m., a phone interview was conducted with Family Member (FM 1). FM 1 stated she was not told about the fall until (MONTH) 1, 2019, three days after the fall. FM 1 stated she called Family Member 2 (FM 2) and asked her to go see Resident 1. FM 2 told FM 1 that Resident 1 was in a lot of pain. On (MONTH) 21, 2019, at 12:45 p.m., a phone interview with FM 2 was conducted. FM 2 stated the following: Her family was not told of Resident 1's fall until (MONTH) 1, 2019, three days after the fall. They were told Resident 1 had no pain and no injuries. After receiving the call from FM 1, she immediately went to see Resident 1. She found Resident 1 in excruciating pain. She watched the CNAs try to turn Resident 1 and told them to stop because Resident 1 was in too much pain. She went straight to the nurse's station and asked the nurses to have an x-ray of Resident 1's hip. The nurse told her she would call the doctor. She visited Resident 1 on the following days and found her in pain every day. FM 2 stated it took two more days of insisting that an x-ray be done, before the x-ray was actually done on (MONTH) 3, 2019. They (facility staff) found Resident 1 did have a broken hip and sent her to the emergency room . FM 2 denied Resident 1 had right hip pain prior to her fall on (MONTH) 29, 2019. Resident 1 developed a rapid heart beat while in the emergency room . FM 2 felt the prolonged amount of time that Resident 1 was in pain contributed to the rapid heart rate and her death two weeks later. On (MONTH) 11, 2019, the facility policy and procedure (P&P), dated (MONTH) 2011, and titled, Falls Practice Guide was reviewed. The P&P stated, Upon completion of the evaluation, the physician is notified and orders are documented, noted and implemented, as indicated. The family and responsible party is (sic) notified of the fall event or change in fall risk factors and the patient's current condition.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services in accordance with the plan of care, nursing assessments, and physician orders for 3 sampled and 8 unsampled residents (Sampled Residents 30, 68 and 88. Unsampled Residents 12, 17, 27, 23, 39, 40, 90, and 123). These failures had the potential to affect the residents' overall health, emotional well-being, and quality of life as evidenced by the following: 1. The facility failed to implement pain management interventions for Residents 30, 12, 27, 39, 40, and 123). The nurse failed to evaluate the status of the residents' pain and the effectiveness of the pain management regimen when the residents continued to complain of increasing pain. The facility also failed to notify the physician of the residents' continued pain for possible adjustment in medication and modification of the plan of care. These failures resulted in significant changes of the residents' psychological status. Residents 39 and 40 were observed being emotional, tearful, sad, and angry. Resident 123 expressed being unable to sleep and not having enough rest at night due to pain. Resident 12, 27, and 30 complained of having continued pain and not getting enough relief from their pain. 2. Unsampled Resident 23's [MEDICATION NAME] level ([MEDICATION NAME] is a medication used to treat heart failure and rhythm problems that requires routine laboratory test to determine the amount of [MEDICATION NAME] needed and the effectiveness) was reported to the facility with a critically high result of 4.2 (normal range is 0.8 - 2.0). The facility staff did not immediately notify the physician until the following day. Resident 23 was transferred to the acute hospital Stat (immediately) with a significant decrease in level of consciousness. 3. During observation of the medication administration, unsampled Resident 17 complained of nausea and vomiting. Resident 17's health condition and discomfort was not assessed prior to notifying the physician. In addition, Resident 17 continued to complain of abdominal discomfort and nausea, and did not receive medication to relieve the symptoms until two hours and 36 minutes later. 4. The blood pressure for Residents 68 and 88 were not monitored as ordered by the physician and the physician was not notified. In addition, Resident 68's overall health condition, level of consciousness, and [MEDICAL TREATMENT] site were not assessed before and after the resident's [MEDICAL TREATMENT] treatment on five occasions. 5. The blood pressure for Resident 88 was not monitored as ordered by the physician and the physician was not notified of the resident's low blood pressure. Resident 88 was given [MEDICATION NAME] (a medication that lowers blood pressure) when his blood pressure was below the limit set by the physician and no follow up blood pressure monitoring was obtained after administering the [MEDICATION NAME]. 6. Resident 90 had vomited a large amount of medication and was not assessed and evaluated by the nurse for potential gastroinestinal complications, and potential adverse effects from not receiving the medications. In addition, the facility failed to ensure Resident 90 received appropriate treatment to relieve nausea and vomiting. 7. Resident 12's continued complaints of moderate to severe pain was not re-evaluated and reported to the physician for possible treatment adjustment when the resident's pain indicated a pain score level of 4 to 7 out of maximum 10 (most severe pain) in a 7 day period. This failure resulted in the resident not getting enough pain relief and rest at night due to pain. Findings: 1. On May 23, 2016, from 10:15 a.m. - 10:40 a.m., an initial tour of the facility was conducted with Registered Nurse (RN) 1, the unit manager for Station A. During the observation of residents, multiple residents complained of continued pain and not getting enough relief from their current pain management regimen as follows: a. Resident 39 was observed in bed awake, alert and able to communicate her needs verbally. When asked how she was doing, Resident 39 stated she was not getting enough relief from pain and had been having continued abdominal pain. When asked about the intensity of her pain, Resident 39 stated, 9 (meaning severe pain on the pain scale of 0-10 with 10 being the worst). Resident 39 started to show a sad facial expression with tearful eyes as she explained, I don't want to be seen a complainer, but I don't want to live in pain. When RN 1 explained to the resident she had the right to complain of pain, Resident 39 stated she had told the nurses about her complaints of pain and had not received a response. Resident 39 further stated, No use. A review of the facility's pain scale levels indicated the following: 0 = no pain; 1-3 = mild pain, 4-6 = moderate pain, 7-9 = severe pain, and 10 = very severe/horrible pain. A review of Resident 39's medical record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission physician orders dated May 19, 2016, included the resident's pain management regimen which consisted of [MEDICATION NAME] tablet (a potent narcotic drug used to relieve moderate to severe pain) 7.5 milligrams (mg) by mouth every four hours as needed for mild pain (1-5/10); [MEDICATION NAME] tablet 15 mg by mouth every four hours as needed for moderate to severe pain (6-10/10). The resident's comprehensive care plan for pain dated May 20, 2016, indicated a goal that the resident Will express the pain management is within acceptable limits, and nursing interventions included to administer pain medication per physician orders. A review of the electronic Medication Administration Record [REDACTED]. The eMAR indicated Resident 39 was medicated multiple times for pain and there was no documentation the pain medications were effective, or the resident was getting pain relief. There was no documented evidence in Resident 39's medical record, including the nurse's notes and eMAR, that a pain assessment/evaluation was conducted to evaluate and ensure the resident's current pain management regimen was effective. There was no documentation to indicate the physician had been notified of the resident's continued complaints of pain until May 23, 2016, after the surveyor intervened. Review of the physician's assessment progress notes dated May 23, 2016, after the physician was notified included the following: . anxious, appears depress .(depressed) (+) positive for constant pain, states she was on [MEDICATION NAME] (a controlled narcotic pain medication) 3 x/day (three time a day) before . Plan = [MEDICATION NAME] 5 mg TID (three time a day . Review of a facility document titled, PAIN PRACTICE GUIDE, dated November 2011, indicated that an evaluation of the resident's pain was recommended on a daily basis, and a pain evaluation was completed before and after PRN (as needed) pain medication administration. Residents with a pain score of 4 to 7/10 twice in a seven day period, or who had one score of 8, 9, or 10 would be reported to the physician for possible treatment adjustment. On May 24, 2016, at 4 p.m., RN 1 was interviewed regarding Resident 39's pain management regimen and the facility's pain management policy and procedure. RN 1 reviewed Resident 39's medical record and acknowledged there was no pain assessment conducted to evaluate and ensure the resident's pain management regimen was effective. RN 1 acknowledged Resident 39 had multiple complaints of moderate pain without staff intervention and the physician was not notified until after 5 days later when surveyor intervened on May 23, 2016. b. Resident 40 was observed in bed awake, alert and able to communicate needs verbally. When asked how she was doing, Resident 40 started to become tearful and in an angry mood. With an increasing tone of voice, Resident 40 stated she had previous surgery on her back (decompression and fusion of the spine/back bones) and was not getting enough relief from her pain management regimen. Resident 40 stated she had talked to the nurses about her pain but was told her pain medication was Now on every 12 hours, you can't have it now. Resident 40 further stated in an angry tone of voice, They treat me like I'm a drug addict. When asked about the intensity of her pain, and if the physician had been made aware, Resident 40 stated she wanted to know what medications had been ordered for her pain, and had not discussed with the physician about the every 12 hours pain medication order. Resident 40 further stated her level was a 7 out of 10 (severe pain). A review of Resident 40's medical record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission physician orders dated May 20, 2016, included the resident's pain management regimen which consisted of [MEDICATION NAME] (Tylenol) 650 mg by mouth every six hours as needed for pain. Additional pain medications were ordered on May 22, 2016, which included, [MEDICATION NAME] ER ([MEDICATION NAME] Extended Release - a potent narcotic pain medication), 15 mg tablet by mouth every 12 hours for pain management; [MEDICATION NAME] (a potent narcotic pain medication) 5-325 mg tablet, one tablet by mouth every 3 hours as needed for mild to moderate breakthrough pain (1-5/10); and [MEDICATION NAME] tablet 10-325 mg every 3 hours as needed for severe breakthrough pain (6-10/10). The resident's comprehensive care plan for pain dated May 23, 2016, indicated a goal that the resident Will express the pain management is within acceptable limits, and interventions that included to administer pain medication per physician orders. A review of the eMAR from May 21 - 25, 2016, indicated Resident 40 had recurrent complaints of pain despite administration of the current pain management therapy. The eMAR indicated Resident 40 complained of moderate pain at 4-6/10 (four to six out of 10) 14 times, and severe pain of 7/10 four times from admitted to May 25, 2016. There was no documentation in Resident 40's medical record including the nurse's notes and eMAR the nurse had conducted a pain assessment/evaluation to ensure the resident's pain management regimen was effective. There was no documentation of the physician being notified or aware of the resident's continued complaints of pain. On May 24, 2016, at 4:25 p.m., the Director of Nursing (DON) was interviewed regarding the resident pain management regimen. The DON stated the facility policy was for the IDT (such as the licensed nurse) to conduct pain assessment (using the pain management tool/form) every week to evaluate if the resident continued to have 4-6 or 8-10/10 pain level. The physician would be notified if the resident had experienced 4-6 pain level twice or more in the last 7 days, or 8-10/10 pain level once in the last seven days for possible adjustment of the pain plan of care. The DON reviewed Resident 40's medical record and acknowledged Resident 40 had multiple complaints of moderate to severe pain and that the physician was not notified. c. Resident 30 was observed in bed awake, alert and able to communicate needs verbally. During an interview with Resident 30 on May 31, 2016, at 1:05 p.m., She stated, I'm having pain right now on my abdomen and on my right hip down to my thigh. When asked if she was getting enough relief from pain, Resident 30 stated, I just have a pain pill a couple of hours ago. Maybe it will go away. A review of Resident 30's medical record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The current physician orders for May 2016 included the resident's pain management regimen which consisted of [MEDICATION NAME]-[MEDICATION NAME] (a potent narcotic pain medication) 10-325 mg one tablet by mouth every six hours as needed for pain, and [MEDICATION NAME] (a potent narcotic pain medication) 50 mg one tablet by mouth daily. A review of the eMAR for May 2016, indicated Resident 30's complaints of pain had been increasing in intensity and frequency despite administration of the current pain management therapy. The eMAR indicated the following: 1st week (May 2, 3, 4, 5, 2016) - complained of moderate pain (4-6/10) four times. 2nd week (May 11, 12, 13, 14, 15, 2016) - complained of moderate pain (4/10) three times and severe pain (7) one time. 3rd week (May 17, 18, 19, 20, 21, 23, 2016) - complained of moderate pain (4-5/10) four times and severe pain (7/10) two times. 4th week (May 25, 26, 27, 28, 29, 30, 31, 2016) - complained of moderate pain (4-6/10) seven times and severe pain (7/10) one time. The facility form titled, Pain/Pain Assessment in Advanced Dementia (PAINAD) Evaluation dated May 29, 2016, indicated the type, location, frequency and duration of the resident's pain was . shooting/radiating, .frequently, . in the last 5 days, . on the right hip, right lower leg . can occur anytime throughout the day, . unable to determine (specific event causing the pain). The pain evaluation further indicated the pain management regimen had been effective even though the resident's pain frequency and intensity was worsening, and that Resident 30's day to day activity over the last 5 days had been limited due to pain. There was no documentation to indicate the physician had been notified of the resident's continued complaints of increasing frequency of pain for possible adjustment in pain management plan of care until after surveyor intervened on May 31, 2016. The comprehensive care plan for pain dated May 15, 2016, indicated care plan interventions included to notify the physician if the pain frequency/intensity was worsening or if the pain, management had become ineffective. On May 31, 2016, at 1:50 p.m., Licensed Vocational Nurse (LVN) 1, was interviewed regarding Resident 30's pain management regimen, and the facility's pain management policy and procedure. LVN 1 stated a pain evaluation using the Pain/Pain for Advanced Dementia (PAINAD) Evaluation form would be completed weekly to evaluate the resident's pain and the effectiveness of the pain management therapy. LVN 1 further stated the physician would be notified if the resident continued to have a pain level of 4-6 twice in seven days or one 7-10 pain level in seven days. On May 31, 2016, at 1:05 p.m., the DON was interviewed regarding the Resident 30's pain management regimen. The DON stated the physician would be notified if the resident had experienced 4-6 pain level twice or more in the last 7 days, or 8-10 pain level once in the last seven days for possible adjustment of the pain plan of care. The DON reviewed Resident 30's medical record and acknowledged Resident 30 had increasing complaints of moderate/severe pain and that the physician was not notified. d. During the medication pass with RN 2 on May 24, 2016, at 8:33 a.m., Resident 123 was observed up in his wheelchair in his room, alert and able to communicate needs verbally. Resident 123 was receiving oxygen therapy by nasal cannula (a two pronged plastic tube used to deliver oxygen through the nose) at 2 liters. When asked how he was doing, Resident 123 stated, It was worse at night. The resident explained he was not getting enough pain relief and he was unable to sleep at night due to pain on his mid-chest incision and lower leg incision area despite his current pain medication therapy. A review of Resident 123's medical record indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission physician orders dated May 15, 2016, included the resident's pain management regimen which consisted of Hydocodone-[MEDICATION NAME] 5-325 mg (a potent narcotic drug used to relieve moderate to severe pain) one tablet by mouth every three hours as needed for moderate pain; and Hydocodone-[MEDICATION NAME] 5-325 mg two tablets by mouth every three hours as needed for severe pain. The resident's comprehensive care plan for pain dated May 15, 2016, indicated a goal that the resident Will express the pain management is within acceptable limits, and intervention to notify the physician if pain frequency/intensity was worsening, or if the pain management had become ineffective. A review of the nurse's notes and eMAR for May 2016, indicated Resident 123 had recurrent complaints of pain despite administration of the current pain management therapy. The nurse's notes and eMAR indicated Resident 123 complained four times of severe pain and one time of moderate pain from admitted [DATE]- May 25, 2016. There was no documentation in Resident 123's medical record including the nurse's notes and eMAR that the nurse had conducted a pain assessment/evaluation to ensure the resident's pain management regimen was effective. There was no documentation to indicate the physician had been notified of the resident's complaint of recurrent pain, and his complaints of inability to sleep at night due to pain. On May 24, 2016, at 4 p.m., RN 1 was interviewed regarding Resident 123's pain management regimen and the facility's pain management policy and procedure. RN 1 reviewed Resident 123's medical record and acknowledged there was no pain assessment conducted to evaluate and ensure the resident's pain management regimen was effective. RN 1 acknowledged there was no documentation that the physician was notified of Resident 123's complaints of inability to sleep at night due to pain. e. Resident 27 was observed in bed awake, alert and able to communicate needs verbally. Resident 27 stated he continued having Constant pain on his hip and back despite his current pain medication therapy. Resident 27 further stated the pain medications had been ineffective and he had requested the nurses to ask the physician for possible modification of his pain medication. When asked about the intensity of his pain, Resident 27 stated his pain level was at, 7-8 (severe pain). A review of Resident 27's medical record indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission physician orders dated May 15, 2016, included the resident's pain management regimen which consisted of [MEDICATION NAME] (a potent narcotic pain medication used to relieve moderate to severe pain) 5-325 mg one tablet by mouth every six hours as needed for pain; and [MEDICATION NAME] Tablet 5-325 mg, two tablets by mouth every six hours as needed for severe pain. The physician's assessment progress notes dated May 19, 2016, indicated the resident had health problems that included pain, arthritis, fatigue, and depression. The plan of care included pain management and PT/OT (physical therapy/occupational therapy). The resident's comprehensive care plan for pain dated May 15, 2016, indicated a goal that the resident Will express the pain management is within acceptable limits,' and intervention to notify the physician if pain frequency/intensity was worsening or if the pain management had become ineffective. A review of the eMAR for May 2016, indicated Resident 27 had recurrent complaints of pain despite administration of the current pain management therapy. The eMAR indicated Resident 27 complained seven times of moderate pain (4-6/10) and three times of severe pain (7-8/10) for the past 9 days, from admitted to present May 23, 2016. There was no documentation in Resident 27's medical record including the nurse's notes and eMAR that the IDT had conducted a pain assessment/evaluation to ensure the resident's pain management regimen was effective). There was no documentation to indicate the physician had been notified of the resident's continued complaints of pain until May 23, 2016 after the surveyor intervened. On May 24, 2016, at 4 p.m., RN 1 was interviewed regarding Resident 27's pain management regimen and the facility's pain management policy and procedure. RN 1 reviewed Resident 27's medical record and acknowledged there was no pain assessment conducted to evaluate and ensure the resident's pain management regimen was effective. RN 1 acknowledged Resident 27 had recurrent complaints of moderate and severe pain and the physician was not notified until after 9 days (on May 23, 2016). 2. During the initial tour of the facility with RN 1 on May 23, 2016, at 9:55 a.m., Resident 23 was observed in bed. The resident's Responsible Party (RP) was at the bedside. The resident was awake, alert, and able to communicate verbally in Spanish language. When asked how Resident 23 was doing, the RP stated, She's ok now, she was hospitalized because she had a high [MEDICATION NAME] level. The RP further stated she did not understand why the resident's [MEDICATION NAME] level went so high. A review of Resident 23's medical record indicated she was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The physician orders dated May 4-9, 2016, included [MEDICATION NAME] 0.5 mg tablet, one tablet by mouth one time a day, and [MEDICATION NAME] 0.25 mg by mouth one time a day on May 9, 2016. A review of the nurse's notes dated May 5-11, 2016, indicated Resident 23 had been having repeated episodes of anxiety, restlessness (five times), and nausea and vomiting (five times) despite administration of medication to relieve the nausea/vomiting, and anxiety/restlessness. Review of the Physician Desk Reference (PDR-medication reference), 2010 Edition, indicated the most common signs and symptoms of [MEDICATION NAME] toxicity (poisoning) included nausea and vomiting, weakness, confusion, dizziness, and mental disturbances such as anxiety and [MEDICAL CONDITION] (which included restlessness). A review of Resident 23's [MEDICATION NAME] level (blood test to determine [MEDICATION NAME] level in the blood) result dated and reported to the facility on [DATE], at 4:04 p.m., indicated a critically high (CH) [MEDICATION NAME] level of 4.2 mg per milliliter (mg/ml). The laboratory normal/therapeutic range for [MEDICATION NAME] was indicated at 0.8-2.0 mg/ml. There was no documentation in Resident 23's medical record indicating the physician had been notified of the resident's frequent nausea and vomiting, including signs and symptoms of frequent anxiety and restlessness. There was no documentation that the physician was notified immediately on May 10, 2016 of the resident's critically high [MEDICATION NAME] level of 4.2 until the following day of May 11, 2016. The physician progress notes [REDACTED]. Dig ([MEDICATION NAME])- 4.2 - Sleepy . Dig toxicity . Plan to send patient to ER (emergency room ) Stat (immediately). The nurse's notes dated May 11, 2016, at 7:52 a.m., indicated the physician was made aware of the critically high [MEDICATION NAME] level and ordered to send Resident 23 Stat to the ER. Resident 23 was transferred to the acute hospital ER approximately 16 hours after the critically high [MEDICATION NAME] level was reported to the facility on [DATE], at 4:04 p.m. On May 25, 2016, at 9:50 a.m., RN 3 was interviewed regarding why Resident 23's critically high [MEDICATION NAME] level was not reported immediately to the physician. RN 3 reviewed the resident's medical record and acknowledged there was no documentation that the physician was notified immediately of the resident's abnormally high [MEDICATION NAME] level. The facility policy and procedure titled, Laboratory Tracking Guidelines, indicated a licensed nurse would document in the progress notes, that notification was made to the physician and any additional orders received. If the physician failed to respond to the notification of abnormal lab values, the ADNS (Assistant Director of Nursing Services) would be contacted for referral to the Medical Director. The policy further indicated that if the laboratory value was a panic or critical value, contact 911 for hospital transfer if a direct conversation with the physician did not take place within 30 minutes of receiving the result. 3. During a medication pass observation with RN 2 on May 24, 2016, at 8:10 a.m., Resident 17 was observed standing at the bedside leaning forward with his head down towards a trash can on the floor. Resident 17 stated he just vomited and was holding his abdomen. Resident 17 stated he was not able to eat his breakfast and only took 3 bites of the food. The resident continued to complain of nausea and abdominal discomfort. RN 2 immediately returned to the medication cart to check for medication to relieve the resident's nausea and vomiting. RN 2 then told Resident 17 there was no available PRN medication for nausea/vomiting, and had to notify the physician to obtain an order for [REDACTED]. Resident 17's health condition and continued complaint of abdominal discomfort was not assessed by the nurse for potential complications such as such as abdominal tenderness or distention, presence of blood in vomitus, and absence or hyperactive bowel sounds prior to notifying the physician. There was no available medication in the facility to relieve Resident 17's continued nausea/vomiting and abdominal discomfort. RN 2 sent repeated messages to the physician at 8:58 a.m., and 9:11 a.m. RN 2 had to wait for the physician's response when RN 2's medication requests (for [MEDICATION NAME] and [MEDICATION NAME] by mouth) were not available at the facility's medication storage (including the Omnicell - an automated drug dispensing machine). At 10:46 a.m., (two hours and 36 minutes later) Resident 17 received PRN injectable [MEDICATION NAME] (drug used to relieve nausea and vomiting) 6.5 mg intramuscularly (through the muscle). In an interview with RN 2 on May 24, 2016, at 11:32 a.m., she acknowledged there was no appropriate and immediate medication available for Resident 17's complaint of nausea/vomiting and abdominal discomfort. RN 2 further acknowledged she did not assess Resident 17's health condition and continued complaints of abdominal discomfort prior to notifying the physician. The facility's policy guidelines titled, Care Path for Gastrointestinal (GI- the gut/digestion organ) Symptoms, dated 2011, indicated for new or worsening signs and symptoms such as nausea and vomiting and abdominal pain, the resident would be assessed and signs and symptoms would be evaluated (such as abdominal tenderness or distention, presence of blood in vomitus, and absence or hyperactive bowel sounds), and to notify the physician of the residents current condition. 4a. The medical record for Resident 68 was review on May 23, 2016, starting at 3:50 p.m. Resident 68 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 68's physician order dated April 27, 2016, indicated, BP (blood pressure) check Q6h (every six hours). If BP greater than 160, see PRN (as needed) [MEDICATION NAME] (medication given to lower blood pressure) order. The electronic medical record blood pressure readings list starting on April 27, 2016, to May 23, 2016, was reviewed. The blood pressure readings list indicated a blood pressure reading was not monitored and documented as ordered every six hours as ordered on the following dates and times: May 7, 2016 at 3:38 a.m. and 1:16 p.m. May 9, 2016, at 10:04 a.m. and 9:24 p.m. May 12, 2016, at 1:34 a.m. and 9:56 a.m. May 12, 2016, at 2:30 p.m. and 10:59 p.m. May 15, 2016, 2 a.m., and 9:55 a.m. May 16, 2016, at 1:19 a.m., and 8:10 a.m. May 16, 2016 at 9:54 a.m., and 9:01 p.m. May 18, 2016, at 2:40 a.m., and 10:05 a.m. May 19, 2016 at 2:48 a.m., and 9:45 a.m. May 22, 2016 at 1:12 a.m., and 9:33 a.m. May 23, 2016, at 12:31 p.m., and 10:06 p.m. May 24, 2016, at 2:18 a.m. and 11:12 a.m. On May 23, 2016, at 3:45 p.m., an interview was conducted with the DON. The DON reviewed the electronic record for Resident 68 and confirmed the blood pressure monitoring was not completed as ordered by the physician. The DON stated, I see no other BP was taken. It should have been retaken, that's how to confirm if the medication was effective. No the physician wasn't notified. 4b. The medical record for Resident 88 was review on May 23, 2016, starting at 3:50 p.m. Resident 88 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 88's physician order dated December 22, 2016, indicated, Monitor blood pressure every 6 hours (See PRN [MEDICATION NAME] order) every 6 hours for HTN-see PRN [MEDICATION NAME] order. The physician order for [REDACTED]. The blood pressure readings list dated April 30, 2016 to May 23, 2016, was reviewed. The blood pressure readings list indicated a blood pressure reading was not documented every six hours for Resident 88 a total of 29 times. On May 23, 2016, at 3:45 p.m., an interview was conducted with the DON. The DON reviewed the electronic record for Resident 88 and confirmed the blood pressure monitoring was not completed as ordered by the physician. The DON stated, I see no other BP was taken. It should have been retaken, that's how to confirm if the medication was effective. No the physician wasn't notified. On May 26, 2016, a review of the facility policy and procedure titled, Medication and Treatment Administration Guidelines, dated December 2014, indicated, Medications and treatments administered are documented immediately .Medications not administered according to physician orders are reported to the attending physician and documented in the clinical record . The licensed nurse is responsible for validating documentation is completed for any medication administered during the shift. 5a. The medical record for Resident 88 was review on May 23, 2016, starting at 3:50 p.m. Resident 88 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician order for [REDACTED]. A review of the vital signs summary sheet indicated on May 18, 2016, at 12:01 p.m., the SBP for Resident 88 was 170, which is below the parameter of SBP greater than 180. A review of the May 2016, Medication Administration Record [REDACTED] A review of the progress note indicated on May 18, 2016, at 12:01 p.m. [MEDICATION NAME] 0.1 mg was give

2. A review of sampled Resident 42's record on April 25, 2012, at 10 a.m., indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's physician orders [REDACTED]. "[MEDICATION NAME] HCI 0.1 mg (milligram) by mouth (po) -prn (when necessary) every 6 hours" ([MEDICATION NAME] was indicated in the treatment of [REDACTED].S. Library of Medicine, National Institutes of Health, 12/2006). In an interview with the registered nurse supervisor on April 25, 2012, she was asked how would the nurse know when to give the medication. The nurse supervisor stated, "I know what you mean and that there were no parameters as to when to give the medication." Based on observation and record review, the facility: 1. Failed to provide the necessary care, failed to develop plans of care to manage acute mental and physical changes, and failed to implement the facility Falls Practice Guide, for one of 24 sampled residents (Resident 47). Resident 47 was readmitted to the facility from the hospital on March 6, 2012, after experiencing acute mental changes, two falls, and a skin tear at the facility on March 3-4, 2012. The facility did not develop plans of care to manage the altered level of consciousness (ALOC, a change from normal mental ability) or the recent hallucinations (a sensory experience of something that does not exist). Resident 47 was readmitted to the facility from the hospital on March 24, 2012, after experiencing acute mental changes, one fall, lacerations (a jagged wound) to the face, and severe neck/back pain, at the facility on March 15-16, 2012. The facility did not develop plans of care to manage the ALOC, or the recent hallucinations, or the closed cervical spine fracture (C-spine fracture: closed--does not cause an open wound on the skin; cervical--neck; vertebra--spine; and, fracture--a break or rupture of the bone). Resident 47 subsequently experienced acute mental changes for a third time and was found wandering outside the facility, hallucinating, on April 17, 2012, at approximately 2:45 a.m. During the acute mental changes, the resident experienced three falls, was hospitalized twice, and sustained lacerations, skin tears, and a C-spine fracture. These failures placed Resident 47 at risk for increased hallucinations and worsened ALOC, further falls, injuries, lacerations, fractures, infection, loss of mobility, or death. 2. Failed to ensure that one of 24 sampled residents (Resident 42) received the necessary care and services to attain her highest practicable physical, well being, in accordance with her plan of care by failing to ensure parameters for the use of blood pressure medication. This failed practice placed the resident at risk for not receiving the oral medication as ordered and placed the resident at risk for stroke, loss of function or death. Findings: 1. On April 26, 2012, the facility policy and procedure for falls was reviewed. The facility Falls Practice Guide indicated, in the planning section, "Managing falls can be complex as many falls do not have a single cause but include a combination of risk factors and causes ....a key factor to success if the time review of the interventions as the patient's condition and needs change." The Guide indicated, in the implementation section, "Some risk factor management interventions that can be reviewed and considered as ongoing potential fall prevention strategies include ...identification and management of acute changes in patient condition, such as [MEDICAL CONDITION] (confusion, generally considered to be reversible and temporary)." The Guide indicated, "...a bedside evaluation (after a fall occurs) may include ...identification of any changes in patient's risk factors, condition and functional status ..." Resident 47 was observed to be wearing a cervical collar (a medical device to support the neck and head) during the initial tour, April 23, 2012, at 12:05 p.m. Resident 47 was admitted on [DATE]. The doctor's physical examination, dated February 18, 2012, indicated Resident 47 was alert and oriented to person, place, and time. Nursing progress notes, throughout February 2012, indicated Resident 47 was alert and oriented. On March 3-4, 2012, Resident 47 experienced an altered level of consciousness, complained of severe pain, was hallucinating and had two falls. The nursing progress notes, between March 3, 2012, at 2:06 a.m., and March 4, 2012, at 7:10 p.m. (approximately 17 hours), indicated the change of condition, as follows: a) March 3, 2012, 2:06 a.m.: Resident 47 was alert, with confusion, in severe pain (rated at 10, on a scale of 0 - 10, with 10 being the most severe). Resident 47's blood pressure was high (172/78, normal below 120/80) and oxygen saturation low (86%, normal 95% -100%). b) March 3, 2012, 3:33 p.m.: Resident 47 was alert, with confusion, and talking to himself. c) March 4, 2012, 12:21 a.m.: Resident 47 was "found on (the) floor...he was trying to reach the urinal and slipped out of bed ...." d) March 4, 2012, 10:30 a.m.: Resident 47 was "...found laying on the floor beside (the) bed at this time ...." e) March 4, 2012, 5:32 p.m.: Resident 47 was, "...standing up stating that...(physical therapy) told him to get out of bed to get beer bottles out of his pants." Resident 47 was placed at the nurses station for close monitoring. (This was the first documentation Resident 47 was placed on line-of-sight monitoring. There was no care plan with interventions related to Resident 47's hallucinations/behavior.) f) March 4, 2012, 7:10 p.m.: Resident 47 was transferred to the hospital for evaluation and for a computed tomography (CT) scan for "possible bleed to the brain." On March 6, 2012, Resident 47 was readmitted , with new [DIAGNOSES REDACTED]. The record did not indicate plans of care were initiated to address the new [DIAGNOSES REDACTED]. The nursing progress notes for March 7-11, 2012, indicated Resident 47 was alert and intermittently confused, as follows: a) March 7, 2012, at 3:50 p.m.: alert and oriented to person, place, and time b) March 10, 2012, at 2:51 p.m.: alert and able to make needs known c) March 11, 2012, at 7:03 a.m.: alert, with confusion On March 11, 2012, there was no care plan with interventions related to Resident 47's confusion. On March 15-16, 2012, Resident 47 sustained a skin tear on the left arm of unknown origin, experienced increased confusion, was hallucinating, had one fall with injury to the forehead and nose, and complained of severe pain. The nursing progress notes, between March 15, 2012, at 4:14 a.m., and March 16, 2012, at 4:01 a.m. (approximately 24 hours), indicated the change of condition, as follows: a) March 15, 2012, at 4:14 a.m.: Resident 47 was "...laying on his bed the other way around his head on feet area of the bed. patient was confused. Noticed a skin tear (on the left arm) ....Patient appeared confused and keeps changing position ...." (There was no care plan with interventions related to Resident 47's confusion or abnormal position changes in bed.) b) March 15, 2012, at 11:15 p.m.: Resident 47 had "...a fall at (8:30 p.m.) ...alert with confusion. (According to patient) 'he is flying. he fell .'" Resident 47 was "irritated ...and combative ...(was) put back to bed but ...(patient was) noted grabbing something in the air and trying to get out of bed so (patient) was put on the wheelchair ...in the nursing station." (This was the first documentation Resident 47 was placed on line-of-sight monitoring during this acute change of mental status. There was no care plan with interventions related to Resident 47's hallucinations or combative behavior.) c) March 16, 2012, at 4:01 a.m.: Resident 47 had "...significant (increase) in visual hallucination and confusion compared to 2 nights that I worked for this patient. Noted skin alteration on forehead area and a dressing to nose bridge r/t (related to) to fall ....(Patient stated), 'I had a very very bad pounding headache and backpain and all over the body.' Patient keeps manifesting visual hallucination by acting like he is drinking and eating .... Called (doctor) ...and received an order to send patient to (hospital) ...when medical transport arrived ...and assessed the patient and tried to transfer patient to gurney by placing him on a backboard, patient started to complain again of sever (severe) pain in the neck and back. assessed by paramedics and afterwards said that he (paramedic) will call 911 for transport ....911 crew arrived .... Patient was transported out of the facility @2430 (12:30 a.m.) via gurney....At around 0405 (4:05 a.m.) ...called the...(emergency room )...to inquire about patient status ...patient was admitted ...neck fracture." On March 24, 2012, Resident 47 was readmitted , with a new [DIAGNOSES REDACTED]. The doctor's physical examination, dated March 24, 2012, indicated Resident 47 was alert and oriented to person, place, and time, and needed a cervical collar for 12 weeks. The record did not indicate plans of care were initiated to address the recent ALOC; or, the hallucinations Resident 47 had experienced March 3-4, 2012, and March 15-16, 2012; or, the management of the C-spine fracture. Nursing progress notes, from March 24, 2012, through April 15, 2012, indicated Resident 47 was alert and oriented. On April 17, 2012, Resident 47 was found wandering outside the facility, was hallucinating, and had sustained a skin tear on the left hand. The nursing progress notes indicated the change of condition, as follows: a) April 17, 2012, at 3:08 a.m.: "...At around 0245 (2:45 a.m.)...patient was found outside the front lobby close to the parking area by himself. Patient...keep (kept) saying that he's trying to pick up a child that belongs to a physical therapist that works here...assisted him back to his room and patient went back to his bed...." (There was no care plan with interventions related to Resident 47's wandering or hallucinations.) b) April 17, 2012, at 4:26 a.m.: Resident 47 was noted to have "...a skin tear to his left hand...patient stated 'I was fixing my car and trying to fix it when I got hurt' Patient was also manifesting talking to himself....patient was pointing his finger toward the wall and...stated: 'I saw a man watching us here and then left.' ...Patient in bed..." (There was no care plan with interventions related to Resident 47's hallucinations.) The record indicated plans of care addressing acute mental changes were created on April 17, 2012, more than 30 days after Resident 47 exhibited the acute mental changes March 3-4, 2012. Since March 4, 2012, there were no new care plans to address the reason or circumstances for the subsequent fall on March 15, 2012. As of April 26, 2012, the facility did not have a plan of care for the C-spine fracture or use of the cervical collar.