Every finding on record at Downey Post Acute

Based on observation, interview, and record review, the facility failed to ensure three of 3 residents (Residents 2, 3, and 4) received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence).The facility failed to ensure:Resident 2 was turned and repositioned every two hours to prevent skin breakdown.Resident 3, who had an unstageable wound (a full-thickness pressure ulcer whose depth and severity cannot be determined because the wound bed is obscured [covered] by dead tissue, slough, or eschar [dead tissues]) at the sacrum (tailbone), had the low air loss mattress pump (LALM, a small electric machine that constantly blows air into a medical air bed to prevent a pressure ulcer/injury from developing or worsening), set according to the resident's weight and was not left on static mode (a setting for a LAL mattress where the bed stays at one steady, firm level rather than circulating air to help prevent pressure injuries) for an extended length of time.Resident 3's unstageable wound at the sacrum was correctly assessed. A care plan was created for Resident 4, who refused to be turned and repositioned, and was at high risk to develop pressure ulcer. These failures had the potential for Resident 3's sacral wound to worsen, leading to infections and hospitalization and placed Residents 2 and 4 at risk for developing pressure ulcers.Findings: a). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included other sequelae (after effect, long-term complication) of cerebral infarction (stroke) and multiple myeloma (a type of blood cancer that starts off in plasma cells [white blood cells that help fight infections]) relapse (a return of cancer). Resident 2 was sent to a general acute care hospital (GACH) on 3/25/2026 and was readmitted on [DATE]. During a review of Resident 2's History and Physical (H&P), dated 6/23/2026, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 2 had severe (extreme) cognitive impairment (problems with the ability to think, learn, use judgement, and make decisions). Resident 2 was dependent (helper does all of the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and showering/bathing self. Resident 2 required partial/moderate assistance (helper does less than half the effort) to perform movements such as rolling left and right. During a review of Resident 2's Braden Scale (a standardized tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers, or bedsores), dated 3/19/2026, the Braden Scale indicated Resident 2 was at high risk for developing pressure ulcer. During a review of Resident 2's care plan titled, Has potential for pressure ulcer development related to (r/t) impaired mobility, bowel incontinence (accidental passing of stool or gas), Type 2 Diabetes Mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), pancytopenia (low counts of blood cells), anemia (a condition where the body does not have enough health red blood cells), multiple myeloma, hyperlipidemia (having too much fat or cholesterol in the blood), thrombocytopenia (low blood platelet [cells that help blood clot or stop bleeding] count), dated 3/31/2026, the interventions indicated to place call light within reach, encourage to turn and reposition, provide assistance as necessary, LALM with bolsters (a built in support feature, often a pillow like structure designed to stabilize the head, neck, or body while the mattress is in use) for wound management setting based on resident's current weight or resident's comfort level. During a review of Resident 2's Documentation Survey Report for the month of 3/2026 and 4/2026, the intervention/ task indicating Turned and Repositioned every 2 hours, had x and did not indicate Resident 2 was turned and repositioned every two hours from 3/31/2026 to 4/7/2026. During an interview on 7/30/2026 at 1:31 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated residents should be repositioned every two hours to prevent skin breakdown and should be documented on resident's ADL turning and repositioning log to indicate it was done according to the resident's care plan. b). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of sacral (tailbone) region, unstageable (a full-thickness pressure ulcer whose depth and severity cannot be determined because the wound bed is obscured [covered] by dead tissue, slough, or eschar [dead tissues]) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) with late onset.During a review of Resident 3's H&P, dated 6/23/2026, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderate cognitive impairment. Resident 3 required substantial/maximal assistance (helper does more than half the effort) to perform ADLs such as upper body dressing and personal hygiene. Resident 3 required substantial/maximal assistance to roll left and right and to change positions from sitting to lying. During a review of Resident 3's Braden Scale, dated 6/16/2026, the Braden Scale indicated Resident 3 had a Braden Scale score of 12 for high risk for developing pressure ulcer. During a review of Resident 3's Order Summary Report, dated 7/8/2026, the Order Summary Report indicated to cleanse sacrococcyx (tailbone) Stage 4 Pressure Injury (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) with normal saline (NS), pat dry, apply medihoney (a special, medical-grade honey used to help heal cuts, burns, and sores), then cover with dry border dressing every dayshift and LAL Mattress with Bolsters for Wound Management setting based on resident's current weight or resident's comfort level every dayshift. During a concurrent observation and interview on 7/23/2026 at 4:12 p.m., with Licensed Vocational Nurse (LVN) 1 at Resident 3's bedside, LVN observed Resident 3's LAL mattress pump was set to 350 lbs. During a concurrent interview and record review on 7/23/2026 at 4:19 p.m., with LVN 1, Resident 3's order dated 6/29/2026, indicating LAL mattress with bolsters for wound management setting based on resident's comfort weight or resident's comfort level every dayshift, and Resident 3's weight was reviewed. Resident 3 weight indicated 130 lbs. LVN 1 stated because Resident 3 weighed 130 lbs., setting of 350 lbs. was not appropriate because it was too firm for Resident 3. During a concurrent observation and interview on 7/23/2026 at 4:58 p.m., at Resident 3's bedside, with the Director of Nursing (DON), the DON stated Resident 3's LAL mattress pump was not set correctly because Resident 3 did not weigh 350 lbs. During a concurrent observation and interview on 7/23/2026 at 4:12 p.m., with LVN 1 at Resident 3's bedside, LVN 1 stated Resident 3's LAL mattress pump's static mode had been on all day. LVN 1 could not provide the potential outcome when a LALM was in a static mode. During an interview on 7/23/2026 at 4:55 p.m., with the DON, the DON stated the static mode on the LAL mattress is used when providing treatment to keep the mattress sturdy. The DON stated static mode should not be left on for a long period of time because it defeats the purpose of the LAL mattress' distributing air and should be the responsibility of the licensed nurse to turn off to prevent skin breakdown. During a review of Resident 3's Change of Condition (COC), dated 6/21/2026, the COC indicated Resident 3 had an unstageable wound at the sacrum. The COC did not indicate the size or characteristics of the wound. During a concurrent interview and record review on 7/24/2026 at 1:52 p.m., with LVN 1, Resident 3's skin assessments were reviewed. LVN 1 stated there was no skin assessment seen dated 6/21/2026. During a concurrent interview and record review on 7/29/2026 at 3:15 p.m., with LVN 2, Resident 3's COC and progress notes, dated 6/21/2026, and skin assessments were reviewed. Treatment LVN 2 stated that when a new skin issue is found, the nurse should assess the wound by measuring it, describe the appearance, and document the wound assessment in the resident's progress notes or the COC and report to the Treatment Nurse. LVN 2 stated Resident 3's COC and progress note from 6/21/2026 did not indicate a full assessment of the wound. LVN 2 stated this could have prevented Resident 3's wound from improving. LVN 2 stated Resident 3's wound was assessed on 6/21/2026 but there was no record and had no COC assessment created. c). During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included urinary tract infection (UTI], an infection in the bladder/urinary tract), site not specified. During a review of Resident 4's H&P, dated 5/28/2026, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions. During a review of Resident 4's Braden Scale, dated 7/21/2026, the Braden Scale indicated Resident 4 was at high risk for developing pressure ulcers. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had severe cognitive impairment. Resident 4 was dependent on staff to perform ADLs such as toileting hygiene, showering/bathing self, rolling left and right and changing from sitting to lying. During an observation on 7/24/2026 at 9:03 a.m., Resident 4 was observed lying on her back, in bed. During an observation on 7/24/2026 at 12:02 p.m., Resident 4 was observed lying on her back, in bed. During a concurrent observation and interview on 7/24/2026 at 12:27 p.m., with CNA 3, CNA 3 stated residents should be repositioned every two hours to prevent skin breakdown. CNA 3 stated Resident 3 preferred to lay on her back despite being educated to be repositioned. During a concurrent interview and record review on 7/29/2026 at 2:30 p.m., with LVN 2, Resident 4's care plan titled, Has potential for impairment to skin integrity related to (r/t) Braden Scale score - high risk for pressure ulcer development, dated 6/20/2026 and Braden Scale dated 6/19/2026, were reviewed. LVN 2 stated Resident 4's care plan indicated to turn and reposition at least every 2 hours or as tolerated. LVN 2 stated Resident 4 had a preference to stay on her back throughout the day and did not like to be repositioned. LVN 2 stated residents who refused to be repositioned should have a care plan that addressed their refusal. LVN 2 stated the Braden Scale is an assessment that is used to determine who are at risk for developing pressure ulcers/injury. LVN 2 stated Resident 4 did not have a care plan for her refusals to be repositioned. LVN 2 stated the care plan should have been created prevent developing pressure ulcers that could occur from Resident 4's refusal to turn and reposition. During a concurrent interview and record review on 7/30/2026 at 3:42 p.m., with the Assistant DON (ADON), the following were reviewed:Resident 2's Turning and Repositioning every 2 hours log for the month of 4/2026.Resident 3's Braden Scale Score, dated 6/16/2026, COC and progress notes dated 6/21/2026.Resident 4's care plan for refusal of any treatment.The ADON stated Resident 2 was at high risk for skin breakdown as indicated in the Braden Scale dated 6/16/2026. The ADON stated Resident 2 was at the facility from 3/31/2026 - 4/7/2026 and should have had documentation to indicate that he was turned and repositioned every two hours to prevent skin breakdown. The ADON stated she did not know what the x meant in the turning and repositioning log. The ADON stated wound should be assessed including color, size, depth, drainage, odor, and pain upon discovery to ensure proper treatment is obtained from the doctor. The ADON stated Resident 3's COC and progress notes, dated 6/21/2026 had incomplete wound assessment. The ADON stated Resident 4 had no care plan for refusal of turning and repositioning. During a review of the facility's policy and procedure (P&P) titled, Turning and Repositioning Program, dated 9/2025, the P&P indicated, all residents who were at high risk for skin breakdown, requiring repositioning, should be repositioned per turning schedule unless another individualized plan is developed. During a review of the facility's P&P titled, Comprehensive Person-Centered Planning, dated 4/2025, the P&P indicated, the resident has the right to refuse treatment. In the event that resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan should identify care or services declined, the associated risks, Interdisciplinary Team (IDT)'s effort to educate the resident and resident representative and any alternative means to address risk. During a review of facility's P&P titled, Change in Condition, dated 4/2025, the P&P indicated, the nurse should perform and document resident assessment, identify the need for additional interventions, consider implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions.

Based on interview, and record review, the facility failed ensure belongings of one of four residents (Resident 1) who was discharged from and readmitted to the facility were created and itemized (list per item) in the resident's inventory list (a detailed record of items).This failure had the potential for the resident's belongings to be lost or stolen.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], readmitted on [DATE]. Resident 1's diagnoses included Alzheimer's disease (a disease characterized by progressive decline in mental abilities) with Late Onset (occurring later in a person's life). The census sheet indicated Resident 1 was transferred out of the facility on 6/21/2026 and returned on 6/25/2026. During a review of Resident 1's History and Physical (H&P) dated 6/14/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 7/2/2026, the MDS indicated Resident 1 had severe (extreme) cognitive impairment. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with Activities of Daily Living (ADLs) such as showering/bathing self and lower body dressing. Resident 1 required substantial/maximal assistance to roll left and right and in changing position from sitting to standing. During a review of Resident 1's discharge belongings list (lists of resident's property) dated 5/26/2026, the belongings list indicated All items kept at facility. The belonging list did not itemize what items were left at the facility. During a review of Resident 1's belongings lists, a belonging list dated 6/12/2026 was created when Resident 1 returned to the facility. There were no belonging lists created when Resident 1 was transferred out of the facility on 6/21/2026 and when Resident 1 returned to the facility on 6/25/2026. During a concurrent interview and record review on 7/29/2026 at 12:48 p.m., with the Social Services Director (SSD), Resident 1's belongings list dated 5/26/2026, was reviewed. The SSD stated Resident 1's belongings should have been itemized in the belongings list when Resident 1 was transferred out of the facility on 5/26/2026. During interview on 7/30/2026 at 3:42 p.m., with the Assistant Director of Nursing (ADON), Resident 1's belongings list and census were reviewed. The ADON stated an inventory list should have been created when Resident 1 was discharged from the facility on 6/21/2026 and during his readmission on [DATE]. During a review of the facility's policy and procedure (P&P) titled, Resident Belongings, dated 1/2026, the P&P indicated, the facility should protect the personal belongings of residents who were transferred or discharged from the facility. During a review of facility's P&P titled, Theft and Loss, dated 2/2023, the P&P indicated, a written resident personal property inventory must be recorded on an appropriate form upon the resident's admission and must be retained during the resident's stay.

Based on observation, interview, and record review, the facility failed to ensure one of four residents' (Resident 1) missing dentures were followed up with the dental consultant timely.This failure resulted in Resident 1 not having dentures while eating for more than a month and placed the resident at risk for poor food intake. Findings: During a review of Resident 1s admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Alzheimer's Disease (a disease characterized by progressive decline in mental abilities) with late onset (occurring later in a person's life). During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 7/2/2026, the MDS indicated Resident 1 had severe (extreme) cognitive impairment. Resident 1 required substantial/maximal assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as showering/bathing self and lower body dressing. The MDS indicated Resident 1 required substantial/maximal assistance to roll left and right and change positions from sitting to standing. During an observation on 7/23/2026 at 12:13 p.m., Resident 1 was observed eating without teeth in the dining room. During an interview on 7/29/2026 at 11:42 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated she has not seen Resident 1 with dentures. During a concurrent interview and record review on 7/29/2026 at 12:05 p.m., with the Speech Language Pathologist (SLP), Resident 1's speech therapy evaluation, dated 6/29/2026, was reviewed. SLP stated because Resident 1 did not have teeth, Resident 1 took a longer time to chew their food. During a concurrent interview and record review on 7/29/2026 at 12:48 p.m., with the Social Services Director (SSD), the email communication between SSD and the dental consultant, dated 6/16/2026, 7/14/2026, 7/23/2026, 7/28/2026, and the dental evaluation dated 6/23/2026, were reviewed. The SSD stated on 6/16/2026, she was made aware by Resident 1's family member regarding the missing dentures. The SSD stated Resident 1 had dental evaluation done on 6/23/2026 but did not indicate if Resident 1 was seen for dentures. The SSD stated she did not follow up on Resident 1's dentures until 7/23/2026 which was more than one month after she was initially made aware. The SSD stated leaving Resident 1 without dentures for a month was not acceptable because it could affect the resident's food intake. The SSD stated Resident 1's denture referral was not followed up timely. During a review of the facility's policy and procedure (P&P) titled, Job Description: Social Services Manager, dated 11/2021, the P&P indicated one of the essential duties and responsibilities of the Social Services was to coordinate social services activities with other departments as necessary and delegate authority, responsibility, and accountability to other responsible department personnel.

Based on interview and record review, the facility failed to ensure the safe discharge planning of one of four sampled residents (Resident 3), who had an unstageable (a full-thickness pressure ulcer whose depth and severity cannot be determined because the wound bed is obscured [covered] by dead tissue, slough, or eschar [dead tissues]) sacral (tailbone) wound, and had home health services (are skilled, physician-directed medical care and related support provided in a patient's home to help them recover from illness, injury, or surgery, manage chronic conditions, or maintain their current health status) ordered prior to the discharge on [DATE].These failures had the potential that Resident 3's needs will not be met at the receiving facility and had the potential for recurrent hospitalization.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 3's diagnoses included Pressure Ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of Sacral Region, Unstageable and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) with late onset (occurring later in life). During a review of Resident 3's H&P, dated 6/23/2026, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderate cognitive impairment. Resident 3 required substantial/maximal assistance (helper does more than half the effort) to perform ADLs such as upper body dressing and personal hygiene. Resident 3 required substantial/maximal assistance to roll left and right and to change positions from sitting to lying. During a review of Resident 3's Order Summary Report, active orders as of 6/22/2026, the Order Summary Report indicated an order placed on 6/19/2026 to Discharge [Resident 3] back to ALF on 6/22/2026 per patient request. No Durable Medical Equipment ([DME], reuseable, doctor-prescribed devices used in a home or long-term care setting), Home Health Physical Therapy (PT)/ Occupational Therapy (OT)/ Registered Nurse (RN) as continuation of care. The Order Summary Report indicated Resident 3 had a low air loss mattress pump (LALM, a small electric machine that constantly blows air into a medical air bed to prevent a pressure ulcer/injury from developing or worsening) and a treatment order to the unstageable sacrum (tailbone) wound (a full-thickness pressure ulcer whose depth and severity cannot be determined because the wound bed is obscured [covered] by dead tissue, slough, or eschar [dead tissues]), to cleanse with normal saline (NS), pat dry, apply Thera-honey (a sterile, medical-grade honey used to treat cuts, burns, and wounds), cover with foam dressing every day shift for 30 days and to apply Ammonium Lactate External Cream 12%, 2-4 grams ([gm], a unit of measurement), topically (on the skin) to the bilateral lower extremity, every day shift for xerosis cutis (a term for abnormally dry skin)/skin management. During an interview on 7/30/2026 at 12:55 p.m., with the Social Services Director (SSD), the SSD stated she was not made aware of Resident 3's unstageable wound at the sacrum on 6/21/2026. The SSD stated that because of Resident 3's unstageable sacral wound, an ALF was not an appropriate setting for Resident 3 to be discharged to. The SSD stated they were not aware if ALF staff had re-evaluated Resident 3 prior to his return to the ALF on 6/22/2026 to determine if he was safe to be discharged back to the ALF. During an interview on 7/30/2026 at 12:55 p.m., with the SSD, SSD stated that they did not coordinate with a home health agency prior to Resident 3's discharge on [DATE] and stated ALF was to coordinate with home health instead. During an interview on 7/30/2026 at 1:47 p.m., with ALF Staff, the ALF staff stated there were no on-staff nurses at the ALF Resident 3 was discharged to. During a concurrent interview and record review on 7/30/2026 at 3:42 p.m., with the Assistant Director of Nursing (ADON), Resident 3's Discharge Order, dated 6/19/2026 and Resident 3's Discharge summary, dated [DATE], were reviewed. The ADON stated that the SSD and Case Manager were not made aware of Resident 3's wounds prior to the discharge to ensure that Resident 3 was discharged appropriately to the right living arrangement and ensure the resident's needs could be met at the receiving facility. The ADON stated, coordinating and confirming home health PT/OT/RN to follow Resident 3 after discharge should have been done prior to the resident's discharge for continuity of care. During a review of the facility's policy and procedure (P&P) titled, Discharge Planning Process, dated 12/2023, the P&P indicated, it was the facility's policy that the discharge planning should focuses on the resident's discharge goals, and effectively transition them to post-discharge care. The P&P indicated the facility's discharge process should include regular re-evaluation of residents (e.g. on a change of condition) to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes and to Consider caregiver/super person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.

Based on observation, interview, and record review, the facility failed to ensure food safety and food preparation practices was observed for all 95 residents. The facility failed to:1. Maintain cold food items at safe temperatures when glasses of milk and flan measured 50 to 61 degrees Fahrenheit ( F, a scale of temperature).2. Ensure staff did not wear a beaded bracelet during trayline service.3. Ensure one bottle of Martinelli's Sparkling Cider was labeled with the date received.These deficient practices had the potential to allow bacterial growth in potentially hazardous foods (PHFs- foods that require strict time and temperature control to prevent the growth of harmful bacteria or the formation of toxins) and increased the risk for food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for residents who consumed food prepared and served from the kitchen.Findings:1. During a concurrent observation and interview on 5/5/2026 at 12:15 p.m., with the Dietary Supervisor (DS) during tray line, one pre-plated glass of milk measured 53.2 F and another glass of pre-plated milk measured 51.8 F was observed. One bowl of flan measured 60.4 F, another bowl of flan (made with milk) measured 60.2 F, 61.8 F, and 60.8 F. The DS stated the glasses of milk, and the bowls of flan were pre-plated approximately five minutes prior to observation. The DS stated the milk and the flan were potentially hazardous foods that required to be maintained at or below 41 F. The DS stated if temperatures of the milk and flan were not maintained below 41 F, there was potential for bacterial growth and food borne illness. During a concurrent interview and record review on 5/7/2026 at 11:47 a.m. with the DS, the facility's Policy and Procedure (P&P) titled, Food Preparation, revised 2023, was reviewed. The P&P indicated cold food were to be held at 41 F or below. The DS stated the kitchen staff did not follow the P&P if temperatures of the milk and bowls of flan measured 50 F to 61 F. The DS confirmed the elevated temperatures were not identified prior to the temperature checks conducted with the state surveyor on 5/5/2026.During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19. Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less.During the facility's Policy and Procedure (P&P) titled, Food Handling, revised 2023, the P&P indicated food would be prepared and served in a safe and sanitary manner. 2. During a concurrent observation and interview on 5/5/2026 at 12:07 p.m. with the DS, DA 1 wore a red beaded bracelet while serving food onto the plates during tray line. The DS stated bracelets worn during tray line had the potential to harbor bacteria and lead to cross contamination. The DS stated wearing jewelry during tray line had the potential to lead to cross contamination and food borne illness. During the facility's Policy and Procedure (P&P) titled, Dress Code, revised 2023, the P&P indicated kitchen staff were not to wear excessive jewelry, just wedding rings on hand, non-dangling earrings on ears, and wristwatch. The P&P indicated the wristwatch and wedding rings need to be covered with gloves when handling food.During the facility's Policy and Procedure (P&P) titled, Food Handling, revised 2023, the P&P indicated food would be prepared and served in a safe and sanitary manner. 3. During a concurrent observation and interview on 5/4/2026 at 8:10 a.m., in the kitchen, with the Dietary Supervisor (DS), one bottle of Martinelli's Sparkling Cider stored in the facility's walk-in refrigerator lacked a received date. The DS stated every item stored in the refrigerator should have a received date label to ensure the food item was safe for consumption.During the facility's Policy and Procedure (P&P) titled, Labeling and Dating of Foods, revised 2023, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation. The P&P indicated food delivered to the facility needed to be marked with a delivery or received date.

Based on observation, interview, and record review, the facility failed to follow infection control measures for four of eight sampled residents by failing to: 1. Ensure Resident 10's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) collection bag did not touch the floor.2. Ensure Licensed Vocational Nurse (LVN) 1 performed hand hygiene (cleaning hands to remove dirt and bacteria) after preparing Resident 86's medications and before administering Resident 86's medications.3. Ensure LVN 1 sanitized the blood pressure cuff before using on Resident 101 after using on Resident 86.4. Ensure Certified Nursing Assistant (CNA) 1 wore personal protective equipment when changing Resident 82, who was on Enhanced Barrier Precaution (EBP- an infection control measure to protect residents at high risk for multidrug-resistant organisms [MDRO- bacteria resistant to multiple classes of antibacterial medication]).These deficient practices had the potential to result in the avoidable spread of bacteria and disease to Residents 10, 86, 101, and 82. Findings: 1. During a review of Resident 10's Face Sheet, the Face Sheet indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included end stage renal disease (irreversible kidney failure), obstructive and reflux uropathy (a blockage in the urinary tract prevents urine from flowing out of the body and will flow backward towards the kidneys), and benign prostatic hyperplasia (BPH- enlargement of the prostate gland in older men). During a review of Resident 10's Physician Order, dated 2/11/2026, the Physician Order indicated for Resident 10 to have an indwelling catheter, 16 French (size of the catheter's diameter) to gravity drainage for BPH and obstructive uropathy. During a review of Resident 10's History and Physical (H&P), dated 2/13/2026, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool), dated 3/6/2026, the MDS indicated Resident 10's cognition (process of thinking) was severely impaired. The MDS indicated Resident 10 required maximal assistance (helper does more than half the effort) with bathing, upper/lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 10 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine).During an observation on 5/4/2026 at 9:52 a.m., in Resident 10's room, Resident 10 was lying in bed and had an indwelling urinary catheter collection bag hung on the left side of the bed frame. Resident 10's bed was in the lowest-to-the-floor position, and the indwelling urinary catheter collection bag was touching the floor. During an interview on 5/6/2026 at 10:23 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated Resident 10 had an indwelling urinary catheter, which increased his risk for infection. The IPN stated the indwelling urinary catheter collection bag should be hung below the level of Resident 10's bladder and should never touch the floor. The IPN stated the collection bag could get caught on something and rip, which would introduce bacteria through the urinary catheter tubing and into Resident 10's bladder. The IPN stated when Resident 10's bed was in the lowest position; a basin should be kept underneath to hold the collection bag to prevent the collection bag from touching the floor directly. The IPN stated having the urinary catheter collection bag touching the floor increased Resident 10's risk of infection, such as a urinary tract infection (UTI- an infection in the bladder/urinary tract). During an interview on 5/7/2026 at 11:27 a.m., with the Director of Nursing (DON), the DON stated Resident 10 was at an increased risk for infection due to the presence of an indwelling urinary catheter. The DON stated the indwelling urinary catheter was a direct passage to Resident 10's bladder. The DON stated Resident 10's indwelling urinary catheter collection bag should not touch the floor. The DON stated bacteria could enter through the collection bag and enter Resident 10's bladder, which could cause infection. During a review of the facility's Policy and Procedure (P&P) titled, Catheter Care, revised 11/2017, the P&P indicated the facility was to promote hygiene, comfort, and decrease risk of infection for catheterized residents. 2. During a review of Resident 86's Face Sheet, the Face Sheet indicated Resident 86 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 86's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- caused by a blocked blood vessel in the brain) affecting the left side and dementia (a progressive state of decline in mental abilities). During a review of Resident 86's H&P, dated 12/12/2025, the H&P indicated Resident 86 had fluctuating capacity to understand and make decisions. During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86's cognition was intact. The MDS indicated Resident 86 was dependent on staff's assistance with toileting, lower body dressing, putting on and taking off footwear. During an observation on 5/5/2026 at 8 a.m., in Resident 86's room, Licensed Vocational Nurse (LVN) 1 introduced himself to Resident 86 and explained he would be administering her medications. After LVN 1 checked Resident 86's vital signs, LVN 1 excused himself back to the medication cart to prepare Resident 86's medications. During an observation on 5/5/2026 at 8:03 a.m., outside of Resident 86's room, LVN 1 returned to the medication cart and performed hand hygiene (cleaning hands to remove dirt and bacteria). LVN 1 proceeded to prepare a total of nine medications for Resident 86 and placed each medication in a separate medication cup. LVN 1 placed the nine medication cups onto his tray and entered Resident 86's room. During an observation on 5/5/2026 at 8:12 a.m., in Resident 86's room, LVN 1 reentered Resident 86's room and pulled the curtain to provide privacy. LVN 1 did not perform hand hygiene upon entering Resident 86's room. LVN 1 put on a pair of gloves and assisted Resident 86 with her medications. During an interview on 5/5/2026 at 8:18 a.m., with LVN 1, LVN 1 stated he forgot to perform hand hygiene after he prepared Resident 86's medications. LVN 1 stated he should have performed hand hygiene prior to entering Resident 86's room and putting on gloves. LVN 1 stated hand hygiene was essential in preventing cross contamination (the physical transfer of harmful bacteria from one person, object, or surface to another) and infection. LVN 1 stated he delivered oral medications to Resident 86, which was a portal for infection to enter her body. During an interview on 5/6/2026 at 10:27 a.m., with the IPN, the IPN stated hand hygiene was essential to prevent the spread of bacteria from residents and staff. The IPN stated during medication administration, the licensed nurse was responsible for performing hand hygiene throughout the process. The IPN stated bacteria could be present on the medication cart, the laptop, and the medication containers. The IPN stated hand hygiene was especially important after preparing the medications to ensure the licensed nurse's hands were clean prior to administering the medications. The IPN stated the lack of hand hygiene increased the risk of spreading bacteria and infection to Resident 86. During a review of the facility's P&P titled, Hand Hygiene, revised 4/2025, the P&P indicated hand hygiene was performed before and after direct contact with residents. 3. During a review of Resident 101's Face Sheet, the Face Sheet indicated Resident 101 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 101's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right side, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and low back pain. During a review of Resident 101's H&P dated 4/16/2026, the H&P indicated Resident 101 had the capacity to understand and make decisions. During a review of Resident 101's MDS, dated [DATE], the MDS indicated Resident 101's cognition was intact. The MDS indicated Resident 101 required maximal assistance with toileting, lower body dressing, and putting on/taking off footwear. During an observation on 5/5/2026 at 8:03 a.m., outside of Resident 86 and 101's room, LVN 1 returned to the medication cart after taking Resident 86's blood pressure. LVN 1 placed the blood pressure cuff on top of the medication cart and proceeded to prepare and administer Resident 86's medications. During an observation on 5/5/2026 at 8:19 a.m., outside of Resident 101's room, LVN 1 picked up the blood pressure cuff, which was not sanitized, and entered Resident 101's room. LVN 1 prepared to place the blood pressure cuff onto Resident 101's arm until he was stopped by the observer and was excused out of the room. During an interview on 5/5/2026 at 8:21 a.m., with LVN 1, LVN 1 stated he did not sanitize the blood pressure cuff after checking Resident 86's blood pressure. LVN 1 stated after using the blood pressure cuff on Resident 86, he should have immediately sanitized the blood pressure cuff to ensure it was clean and ready to use on Resident 101. LVN 1 stated sanitizing equipment between residents was important to prevent cross contamination. LVN 1 stated sanitizing the blood pressure cuff ensured any bacteria transferred from Resident 86 skin to the blood pressure cuff was removed prior to using it on Resident 101. During an interview on 5/6/2026 at 10:30 a.m., with the IPN, the IPN stated the licensed nurse was responsible for disinfecting any equipment used on a resident to ensure the equipment was clean to use on the following resident. The IPN stated the blood pressure cuff should have been sanitized after its use on Resident 86. The IPN stated any kind of bacteria could have been present on Resident 86's skin and transferred to the blood pressure cuff. The IPN stated the bacteria would have been transferred to Resident 101. The IPN stated although bacteria could be harmless, if there was an open wound on Resident 101's skin, the bacteria could enter Resident 101's bloodstream and make her sick. During an interview on 5/7/2026 at 11:24 a.m., with the DON, the DON stated hand hygiene and equipment sanitation were necessary to stop the spread of bacteria from one individual to another. The DON stated by not abiding by the facility's infection control practices, LVN 1 increased Resident 86 and 101's risk for infection. During a review of the facility's P&P titled, Infection Control Program, revised 5/2010, the P&P indicated the facility's infection control goal was to decrease the risk of infection to residents and staff. 4. During a review of Resident 82's Face Sheet (admission Record), the Face Sheet indicated the facility initially admitted Resident 82 on 3/13/2026 and was re-admitted on [DATE] with diagnosis including displaced comminuted fracture (a severe injury where a bone breaks into three or more pieces and shifts out of alignment) of shaft of right femur, subsequent encounter for closed fracture with routine healing (a broken bone that does not puncture the skin, progressing through normal repair stages). During a review of Resident 82's Minimum Data Set (MDS – a resident assessment tool), dated 4/16/2026, the MDS indicated Resident 1's cognition (ability to think) was moderately impaired. The MDS indicated Resident 82 needed substantial assistance (helper does more than half effort) with toileting hygiene, showering, upper body dressing, and lower body dressing. During a review of Physician orders dated 4/10/2026, indicated Enhanced Barrier Precautions (EBP): personal protective equipment (PPE) required for high resident contact care activities. The indication for EBP was Resident 82's surgical site. During a review of Resident 82's Care Plan dated 4/23/2026, indicated The resident is on enhanced barrier precautions (EBP) related to surgical site. The care plan interventions include direct care staff to utilize gowns and gloves for all personal care. During an observation on 5/4/2026 at 9:30 a.m. in Resident 82's room, outside of the room an enhanced barrier precautions (EBP) sign was observed outside the door. Certified nurse assistant (CNA) 1 was observed not wearing personal protective equipment (PPE) while cleaning and changing Resident 82 with Resident 82's surgical site exposed. During an interview on 5/6/2026 at 9:30 a.m. with the Infectious Preventionist Nurse (IPN), the IPN stated personal protective equipment (PPE) was worn with enhanced barrier precautions (PPE) when performing direct care such as Activities of Daily Living (ADLs)and cleaning residents. The IPN stated the importance of wearing PPE was to protect the residents. The IPN stated if PPE was not worn, resident can get an infection or go septic (a life-threatening blood infection). During an interview on 5/6/2026 at 2:30 p.m. with the Director of Nursing (DON), the DON stated personal protective equipment (PPE) was worn by direct care staff to protect the resident. The DON stated PPE should be worn for enhanced barrier precautions (EBP) with incontinent brief changes, showers, or any direct contact with residents were being performed. The DON stated due to the fact direct care staff go from resident to resident, direct care staff must protect the resident to prevent infection. The DON stated EBP was placed to protect the resident. During a review of facility's policy and procedure (P&P) titled IPCP (Infection Prevention and Control Program) Standard and Transmission-Based Precautions, dated 6/2021, last revised 4/2025, the P&P indicated Enhanced Barrier Precautions (EBP) used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs (multi drug resistant organism – bacteria or other microorganisms that have developed resistance to multiple common antibiotics, making infections difficult to treat). Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting.

Based on observation, interview, and record review, the facility failed to provide timely notification to the responsible party (RP) and physician for one of six sampled residents (Resident 58) by failing to:Ensure the licensed nursing staff notified the Responsible Party (RP) that Resident 58 exhibited increased confusion and had partially slid off the bed on 4/20/2026.Ensure the licensed nursing staff notified the physician that Resident 58:Exhibited increased confusion during the early morning hours of 4/20/2026.Partially slid off the bed between approximately 2:30 am to 3:00 a.m. on 4/20/2026.Developed bruising to the left arm on 4/22/2026.These deficient practices had the potential to place Resident 58 at risk for delayed diagnosis, delayed treatment, worsening injury, unmanaged pain, and further decline. Resident 58 was later hospitalized and diagnosed with a left elbow fracture (broken bone).Cross Reference F689 and F842.Findings: During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included a displaced comminuted supracondylar fracture (a severe elbow injury where the humerus bone breaks into multiple pieces, with the bones separating), osteoarthrosis (a progressive disorder of the joints, caused by a gradual loss of cartilage), muscle weakness, and repeated falls. During a review of Resident 58's Minimum Data Set ([MDS], a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 58 required maximal assistance (helper does more than half the effort) for bed mobility, showering, toileting, and upper body dressing. During a review of Resident 58's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 58 could make needs known but could not make medical decisions. During a review of Resident 58's care plan, titled, At risk for Bleeding or Bruising Related to Anticoagulant Therapy, initiated 3/13/2026, the care plan interventions indicated to monitor, document, and report to the physician as needed for signs of bruising. During a review of Resident 58's care plan, titled, Fluid Deficit, initiated 3/24/2026, the care plan interventions indicated to monitor, document, and report to the physician as needed when signs and symptoms of dehydration like new onset confusion was present. During a review of Resident 58's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 4/20/2026, timed at 7:00 a.m., and authored by the Director of Nursing (DON), the note indicated Resident 58 was caught in the process of sliding from the bed on 4/20/2026 at 7:00 a.m. The SBAR did not indicate physician notification related to Resident 58's acute confusion. During a review of Resident 58's SBAR Note, dated 4/20/2026, timed at 9:55 a.m., the SBAR note indicated Resident 58 complained of two out of ten acute pain to the left arm and Physician 1 ordered an in-house x-ray (a medical imaging test). During a review of Resident 58's SBAR Note, dated 4/23/2026, the note indicated Resident 58 was ordered to be transferred to the General Acute Care Hospital (GACH) for further evaluation and treatment for abnormal labs. There was no documentation to indicate Physician 1 was made aware of Resident 58'S bruising (injury where blood vessels under the skin are damaged and leak blood without breaking the skin surface) of the left arm or reminded of Resident 58's previous incident of partially sliding off the bed. During a review of Resident 58's GACH Physician Progress Notes, dated 4/24/2026, the notes indicated Resident 58 recently suffered a fall and had left arm swelling, bruising, mild redness, pain with elbow range of motion. During a record review of Resident 58's GACH X-Ray (medical imaging technique) Results, dated 4/24/2026, the results indicated Resident 58's clinical history included a fall and the final impression indicated an impacted transverse comminuted left distal humeral supracondylar fracture with approximately 1.2 centimeters (a unit of measurement) of medial displacement (a significant shift of the bone fragments). During an observation and interview on 5/5/2026 at 8:10 a.m. with Resident 58, in Resident 58's room, Resident 58 was in her bed with a left arm sling (suspension device to immobilize the elbow) and demonstrated limited movement of the left arm secondary to pain. Resident 58 stated she believed she fell but she could not recall and stated that her granddaughter, Responsible Party (RP) 2, would be able to provide more details. 1. During an interview on 5/5/2026 at 8:29 a.m. with RP 2, RP 2 stated Resident 58 sustained a left elbow fracture. RP 2 stated the DON contacted her on 4/20/2026 during the daytime hours but did not clearly explain what had occurred. RP 2 stated facility staff were unable to clearly explain what had occurred and informed her x-rays would be obtained. RP 2 stated she visited Resident 58 on 4/22/2026 and observed swelling and bruising to Resident 58's left arm. RP 2 stated, on 4/22/2026, she later learned Resident 58 had been found hanging off her bed during the early morning hours of 4/20/2026. RP 2 stated Resident 58 was not normally confused, did not typically attempt to get out of bed independently, and required assistance for mobility. During an interview on 5/5/2026 at 1:08 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 confirmed she was Resident 58's nurse on 4/20/2026 during the 11:00 p.m. to 7:00 a.m. shift. LVN 3 stated at approximately 2:00 a.m., Resident 58 exhibited acute confusion, repeatedly threatened to get up from bed, and stated she needed to go to an appointment. LVN 3 stated Certified Nursing Assistant (CNA) 4 initiated one-to-one supervision and sat outside of Resident 58's room to maintain safety. LVN 3 stated, at some point, CNA 4 went to lunch. LVN 3 stated, during her rounds at approximately 3:00 a.m., she heard Resident 58 moan and caught Resident 58 in the act of sliding off the bed and landed in an inverted 'L' position with legs dangling off the left side of the bed. LVN 3 stated she did not notify RP 2 immediately after the changes of condition because she believed the DON would do so. LVN 3 stated RP 2 should have been notified immediately because RP 2 had the right to be informed of any changes of condition for Resident 58. During a concurrent interview and record review on 5/6/2026 at 10:55 a.m. with DON, Resident 58's Nursing Progress Notes, dated 4/22/2026, and SBAR Notes, dated 4/2026, were reviewed. The SBAR note, dated 4/20/2026, indicated Resident 58 experienced an episode of partially sliding off the bed at 7:00 a.m. and that RP 2 and Physician 1 were notified at 8:00 a.m. The DON stated LVN 3 notified her at approximately 2:30 a.m. to 3:00 a.m. on 4/20/2026 that Resident 58 partially slid off the bed. The DON stated RP 2 should have been promptly notified because RP 2 was actively involved in Resident 58's care and had the right to be informed of significant changes. The DON stated that she attempted to notify RP 2 regarding the incident at approximately 8:00 a.m. on 4/20/2026 but did not verify whether RP 2 understood the circumstances of the incident. 2. During a concurrent interview and record review on 5/5/2026 at 12:49 p.m. with Licensed Vocational Nurse (LVN) 2, two of Resident 58's SBAR Notes, dated 4/20/2026 and timed at 7:00 a.m. and 9:55 a.m., were reviewed. LVN 2 stated timely physician notification was important during any change in condition to ensure prompt assessment, monitoring and treatment. LVN 2 stated a delay in physician notification delayed treatment opportunities for Resident 58. LVN 2 further stated he was unaware Resident 58 experienced an earlier incident involving partial sliding from the bed and increased confusion when he later notified Physician 1 regarding Resident 58's left arm pain. LVN 2 stated knowledge of the earlier incident would have allowed more complete clinical information to be communicated to Physician 1 for treatment decisions. During an interview on 5/5/2026 at 1:08 p.m. with LVN 3, LVN 3 confirmed she was Resident 58's nurse on 4/20/2026 during the 11:00 p.m. to 7:00 a.m. shift. LVN 3 stated at approximately 2:00 a.m., Resident 58 exhibited acute confusion, repeatedly threatened to get up from bed, and stated she needed to go to an appointment. LVN 3 stated CNA 4 initiated one-to-one supervision and sat outside of Resident 58's room to maintain safety. LVN 3 stated, at some point, CNA 4 went to lunch. LVN 3 stated, during her rounds at approximately 3:00 a.m., she heard Resident 58 moan and caught Resident 58 in the act of sliding off the bed and landed in an inverted 'L' position with legs dangling off the left side of the bed. LVN 3 confirmed Resident 58's acute confusion and partial slide from the bed represented changes in condition that warranted physician notification. LVN 3 stated that she alerted the DON of the incident but did not notify Physician 1. LVN 3 stated that she should have made Physician 1 of the acute confusion to ensure orders for safety and supervision were obtained. LVN 3 further stated that she should have notified the physician immediately after Resident 58 was found partially off the bed because the position had the potential to cause injury. LVN 3 stated the lack of timely physician notification placed Resident 58 at risk for missed assessments, delayed treatment, and delayed hospital evaluation. During an interview on 5/6/2026 at 9:04 a.m. with Physician 1, Physician 1 stated that she was not made aware of Resident 58's partial slide off the bed until 4:00 p.m. on 4/20/2026 (approximately 13 hours post incident). Physician 1 further stated that she was never notified of Resident 58's episode of acute confusion before her incident on the bed. Physician 1 stated that she expected to be notified right aware of both changes of condition to allow for further evaluation at the GACH and ensure consideration of additional interventions following an acute change in condition and possible injury event. Physician 1 stated she would have wanted to know about Resident 58's acute onset of confusion because it could have been signs and symptoms of an infection or early signs of dementia (a progressive state of decline in mental abilities). Physician 1 stated that it was important to be made aware of every clinical detail pertinent to Resident 58 so that she could rule out any potential issues and provide accurate orders and the best plan of care. 2c. During an interview and concurrent record review on 5/5/2026 at 3:03 p.m. with LVN 4, Resident 58's Nursing Progress Notes, SBAR Notes, and Changes in Condition Notes, dated 4/22/2026, were reviewed. LVN 4 stated it was important to notify the physician of all changes of condition and ensure appropriate monitoring and treatment. LVN 4 stated Resident 58 developed left arm bruising on 4/22/2026 but the physician was not notified regarding the bruising. LVN 4 further stated bruising should have been documented and reported to ensure complete clinical information was communicated to the physician for ongoing treatment decisions. During a concurrent interview and record review on 5/6/2026 at 10:55 a.m. with the DON, Resident 58's Nursing Progress Notes, dated 4/22/2026, and SBAR Notes, dated 4/2026, were reviewed. The records did not indicate Physician 1 was made aware of Resident 58's development of bruising to the left arm. The SBAR note, dated 4/20/2026, indicated Resident 58 experienced an episode of partially sliding off the bed at 7:00 a.m. and that RP 2 and Physician 1 were notified at 8:00 a.m. The DON stated LVN 3 notified her at approximately 2:30 a.m. to 3:00 a.m. on 4/20/2026 that Resident 58 partially slid off the bed, did not report Resident 58 exhibited acute confusion prior to the incident. The DON stated acute confusion and the incident involving partially sliding off the bed both represented significant changes in condition that should have been immediately reported to Physician1 and RP 2.The DON stated timely physician notification was important to ensure appropriate assessment, treatment, monitoring, and physician orders were implemented following Resident 58's acute change of condition and possible injury event. The DON stated it was important to inform Physician 1 of any development of bruising to ensure all clinical information was provided to ensure proper orders were obtained. The DON stated the lack of timely physician notification for Resident 58's acute onset of confusion, and partial slide from the bed, and the subsequent development of a bruise had the potential to lead to inappropriate orders and delay in Resident 58's improvement in medical condition. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, revised 4/2025, the P&P indicated the facility would ensure each resident received quality of care and services to attain and maintain the highest practicable physician mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. The P&P indicated licensed nursing staff would ensure the physician would be notified based on the urgency of the situation and the resident representative would be notified of the change of condition and any changes in the resident's medical or nursing care. The P&P indicated the nurse would perform and document an assessment of the resident and identify need for additional interventions, through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. During a review of the facility's LVN Job Description (undated), the job description indicated the LVN was to chart nurses' notes in a professional and appropriate manner that timely, accurately and thoroughly reflected the care provided to the residents, as well as the resident's response to the care. The Job Description indicated to chart the following:1) all reports of accidents/incidents involving residents.2) all changes in resident condition and the response to those changes.3) all communications with the residents attending physician regarding the resident, the residents treatment, or the response to that treatment.The Job Description indicated to perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations.

Based on observation, interview, and record review, the facility failed to ensure a care plan was initiated for a resident's development of a bruise for one out of six sampled residents (Resident 58). These deficient practice had the potential to place Resident 58 at risk for delayed treatment, delayed assessment, and further injury. Resident 58 was later hospitalized and diagnosed with a left elbow fracture (broken bone). Cross Reference F580, F689, and F842. During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included a displaced comminuted supracondylar fracture (a severe elbow injury where the humerus bone breaks into multiple pieces, with the bones separating), osteoarthrosis (a progressive disorder of the joints, caused by a gradual loss of cartilage), muscle weakness, and repeated falls. During a review of Resident 58's Minimum Data Set ([MDS], a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 58 required maximal assistance (helper does more than half the effort) for bed mobility, showering, toileting, and upper body dressing. During a review of Resident 58's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 58 could make needs known but could not make medical decisions. During a review of Resident 58's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 4/20/2026, timed at 7:00 a.m., and authored by the DON, the note indicated Resident 58 was caught in the process of sliding from the bed on 4/20/2026 at 7:00 a.m. During a review of Resident 58's General Acute Care Hospital (GACH) Physician Progress Notes, dated 4/24/2026, the notes indicated Resident 58 had left arm swelling, bruising, mild redness, pain with elbow range of motion and had recently suffered a fall. During a record review of Resident 58's GACH X-Ray (a type of medical imaging) Results, dated 4/24/2026, the results indicated Resident 58's clinical history included a fall and the final impression indicated an impacted transverse comminuted left distal humeral supracondylar fracture with approximately 1.2 centimeters (a unit of measurement) of medial displacement (a significant shift of the bone fragments). During an observation and interview on 5/5/2026 at 8:10 a.m. with Resident 58, in Resident 58's room, Resident 58 was in her bed with a left arm sling and demonstrated limited movement of the left arm secondary to pain. Resident 58 stated she believed she fell but she could not recall and stated that her granddaughter, Responsible Party (RP) 2, would be able to provide more details. During an interview on 5/5/2026 at 8:29a.m. with RP 2, RP 2 stated she observed bruising to Resident 58's left arm when she visited Resident 58 on 4/22/2026. During an interview and concurrent record review on 5/5/2026 at 3:03 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 58's Nursing Progress Notes, SBAR Notes, and Changes in Condition Notes, dated 4/22/2026, were reviewed. LVN 4 stated changes in condition should be assessed, monitored and care planned. LVN 4 stated Resident 58 developed left arm bruising on 4/22/2026 but LVN 4 did not document her assessment nor initiate a care plan. During an interview and record review on 5/6/2026 at 10:55 a.m. with the Director of Nursing (DON), Resident 58's Care Plans, dated 4/2026, were reviewed. There was no care plan for Resident 58's development of a bruise to the left arm on 4/22/2026. The DON stated Resident 58's bruising should have been care planned to ensure proper monitoring and interventions were implemented. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Resident Centered Care Plan, revised 1/2021, the P&P indicated the facility would ensure the interdisciplinary team (IDT) would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to revise two of two sampled residents' (Residents 52 and 10) care plans to reflect their need for the Hoyer Lift (a mechanical device used to lift and/or transfer a person) during transfers.This deficient practice had the potential to result in the miscommunication of the transfer needs for Residents 52 and 10, which could lead to unsafe transfers.Cross Reference F689.Findings:1. During a review of Resident 52's Face Sheet, the Face Sheet indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included generalized muscle weakness, Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 52's History and Physical (H&P), dated 3/24/2026, the H&P indicated Resident 52 did not have the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set (MDS- a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 52's cognition (process of thinking) was severely impaired. The MDS indicated Resident 52 was dependent on staff's assistance with activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) such as toileting, bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 52 required maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfers. During a review of Resident 52's Physical Therapy (PT) Progress Report, dated 4/22/2026, the PT Progress Report indicated Resident 52 required maximal assistance with chair/bed-to-chair transfers. During a review of the facility's Special Needs List, updated 5/6/2026, the Special Needs List indicated Resident 52 required the Hoyer Lift (a mechanical device used to lift and/or transfer a person) during transfers.During an observation and interview on 5/6/2026 at 1:41 p.m., with the Director of Staff Development (DSD), outside of Resident 52's room, a pink sticker was observed next to Resident 52's name. The DSD stated stickers were placed next to the resident's name to inform the staff of the resident's safe transferring needs. The DSD stated the pink sticker next to Resident 52's name indicated the Hoyer Lift was needed during transfers. The DSD stated the Hoyer Lift was used when transferring Resident 52 out of the bed to the chair and vice versa.During an interview on 5/6/2026 at 1:57 p.m., with Physical Therapist (PT) 1, PT 1 stated the rehab department evaluated each resident's safe transferring needs and informed the nursing department, who then placed the stickers next to the resident's name. PT 1 stated a resident with maximal assistance required the Hoyer Lift during all transfers because the resident could help a little bit, but the individual assisting did most of the effort. During an interview on 5/6/2026 at 2:08 p.m., with PT 2, PT 2 stated Resident 52 was evaluated, and the rehab department recommended the nursing department to use the Hoyer Lift during all transfers to maximize safety and prevent falls and other injuries. During an interview on 5/6/2026 at 3:07 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated care plans provided the interventions the facility's staff were to follow to treat certain conditions and the goals to be met. LVN 1 stated care plans encompassed everything about each resident. LVN 1 stated the care plans should be specific to ensure no confusion on how to care for the residents. During a concurrent interview and record review on 5/6/2026 at 3:10 p.m., with LVN 1, Resident 52's Care Plan titled, ADL Self Care Performance Deficit, dated 3/23/2026. The Care Plan's goals indicated safe transfers would be performed. The Care Plan's interventions indicated Resident 52's transfers from chair/bed-to-chair required staff participation with transfers. LVN 1 stated staff participation with transfers could be interpreted in different ways. LVN 1 stated Resident 52's care plan was not specific and did not indicate Resident 52's need for the Hoyer Lift during transfers. LVN 1 stated Resident 52's care plan should have been revised to indicate Resident 52's need for the Hoyer Lift. LVN 1 stated due to Resident 52's care plan not indicating the need for the Hoyer Lift during transfers, Resident 52 was at risk for improper transfers which could lead to injury.2. During a review of Resident 10's Face Sheet, the Face Sheet indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included end stage renal disease (irreversible kidney failure), obstructive and reflux uropathy (a blockage in the urinary tract prevents urine from flowing out of the body and will flow backward towards the kidneys), and benign prostatic hyperplasia (BPH- enlargement of the prostate gland in older men).During a review of Resident 10's H&P, dated 2/13/2026, the H&P indicated Resident 10 did not have the capacity to understand and make decisions.During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognition was severely impaired. The MDS indicated Resident 10 required maximal assistance with bathing, upper/lower body dressing, and putting off footwear. The MDS indicated Resident 10 required maximal assistance with chair/bed-to-chair transfers.During a review of Resident 10's PT Progress Report, dated 4/30/2026, the PT Progress Note indicated the chair/bed-to-chair transfers were not attempted due to medical conditions or safety concerns. During a review of the facility's Special Needs List, updated 5/7/2026, the Special Needs List indicated Resident 10 required the Hoyer Lift during transfers.During an interview on 5/7/2026 at 9:30 a.m., with PT 1, PT 1 stated Resident 10 was dependent during his transfers. PT 1 stated he recommended to the nursing department to use the Hoyer Lift for all transfers. PT 1 stated Resident 10 did not put any effort into his transfers therefore to maximize safety; the Hoyer Lift was used. During a concurrent observation and interview on 5/7/2026 at 9:40 a.m., with LVN 5, outside of Resident 10's room, a pink sticker was observed next to Resident 10's name. LVN 5 stated the pink sticker next to Resident 10's name indicated the Hoyer Lift was necessary during transfers. During an interview on 5/7/2026 at 9:42 a.m., with LVN 5, LVN 5 stated care plans were used to identify an issue, create a goal, and implement interventions to obtain the goal. LVN 5 stated every part of the care plan should be resident-specific and detailed.During a concurrent interview and record review on 5/7/2026 at 9:42 a.m., with LVN 5, Resident 10's Care Plan titled, ADL Self Care Performance Deficit, dated 2/11/2026. The Care Plan's goals indicated safe transfers would be performed. The Care Plan interventions indicated Resident 52's transfers from chair/bed-to-chair required physical assistance with transferring. LVN 5 stated Resident 10's care plan was not specific and did not indicate the need for the Hoyer Lift. LVN 5 stated Resident 10 was dependent on staff assistance and required maximal assistance when transferring. LVN 5 stated Resident 10's care plan should have been revised to indicate Resident 10's need for the Hoyer Lift. LVN 5 stated due to Resident 10's care plan not indicating the need for the Hoyer lift during transfers, Resident 10 was at risk for the staff not using the Hoyer lift during transfers, which could lead to injury.During an interview on 5/7/2026 at 11:36 a.m., with the Director of Nursing (DON), the DON stated care plans guided the staff on how to provide care to the residents. The DON stated the care plans should be individualized and specific. The DON stated by not specifying Resident 10 and 52's level of transfer assistance in their care plans, there was a risk of miscommunication on how to perform a safe transfer. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Resident Centered Care Plan, revised 1/2021, the P&P indicated a comprehensive person-centered care plan should be developed and implemented for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 52 and 58) were free of accidents and hazards by failing to:1. Use a Hoyer Lift (a mechanical device used to lift and/or transfer a person) when Resident 52 was transferred from the shower chair to the bed on 4/29/2026.2. Conduct an Interdisciplinary Team (IDT- a coordinated group of experts from several different fields) meeting after Resident 52 sustained two injuries to the lower left leg from a shower chair-to-bed transfer on 4/29/2026.3. Ensure adequate supervision and timely physician notification occurred after Resident 58 exhibited acute confusion and displayed urgent desire to leave her bed. These deficient practices resulted in Resident 52 sustaining two wounds on her lower left leg and had the potential for additional accidents to occur. These deficient practices also resulted in Resident 58 being found partially sliding from the bed, which placed Resident 58 at risk for injury and delayed physician evaluation and treatment. Resident 58 was subsequently diagnosed with a left upper extremity fracture (broken bone). Cross Reference F580, F657, and F842. Findings: 1. During a review of Resident 52's Face Sheet, the Face Sheet indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included generalized muscle weakness, Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 52's Care Plan titled, ADL Self-Care Performance Deficit, dated 3/23/2026, the Care Plan's interventions indicated Resident 52 required staff participation with transfers from the chair/bed-to-chair. During a review of Resident 52's History and Physical (H&P), dated 3/24/2026, the H&P indicated Resident 52 did not have the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set (MDS- a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 52's cognition (process of thinking) was severely impaired. The MDS indicated Resident 52 was dependent on staff's assistance with activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) such as toileting, bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 52 required maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfers. During a review of Resident 52's Physical Therapy (PT) Progress Report, dated 4/22/2026, the PT Progress Report indicated Resident 52 required maximal assistance with chair/bed-to-chair transfers. During a review of Resident 52's Change in Condition (COC), dated 4/29/2026, the COC indicated, on 4/29/2026, Resident 52 sustained an open ecchymosis (a bruise that opens, breaks, or tears) during transfer to the bed. The COC indicated Resident 52's wounds were located on the left lower posterior (area of the leg near the calf) and left lower lateral leg (outer side of the left shin, below the knee and above the ankle). During a review of Resident 52's Surgical Wound Consult Progress Note, dated 4/30/2026, the Progress Note indicated Resident 52 had a trauma wound (a sudden, severe physical wound caused by an external force requiring immediate medical attention) on the left lower lateral part of her leg. The Progress Note indicated the wound on the left lower lateral part of Resident 52's leg measured 5 centimeters (cm, a unit of measurement) in length, 6cm in width, and 1cm in depth. During a review of Resident 52's Skin Issues Assessment, dated 5/1/2026, the Skin Issues Assessment indicated Resident 52's wound on the left lateral calf measured 3.5cm in length, 0.2cm in width, and 0.1cm in depth. The Skin Issues Assessment indicated Resident 52's wound on the left lateral lower leg measured 5cm in length, 6cm in width, and 1cm in depth. During a review of the facility's Special Needs List, updated 5/6/2026, the Special Needs List indicated Resident 52 required the Hoyer Lift (a mechanical device used to lift and/or transfer a person) during transfers. During an interview on 5/4/2026 at 12:22 p.m., with Responsible Party (RP) 1, RP 1 stated, on 4/29/2026, the facility notified her that Resident 52 sustained trauma injuries to her left leg. RP 1 stated Resident 52's injuries occurred when Resident 52 was transferred to the bed and Resident 52's leg got caught on something. During a concurrent observation and interview on 5/4/2026 at 2:44 p.m., with Treatment Nurse (TN) 1, in Resident 52's room, Resident 52 was lying in bed and Registered Nurse (RN) 1 was at the bedside to assist TN 1 with Resident 52's wound treatment. Resident 52's dressings were removed from her left leg. Two wounds were observed on the lower left leg. The first wound was the shape of a half circle, with irregular edges along the rounded border, closest to the foot. The area of the wound closest to the foot was moist, with a pale pink wound bed, and a small amount of bright red bleeding. The second was located near the left calf. The area of the wound near the calf was covered by thin, pale, purplish-gray, flaps of skin that were fragile in appearance. The skin flaps were wrinkled and did not cover the entire wound. TN 1 stated Resident 52's wounds were classified as a trauma wound and Resident 52 sustained both wounds from the same accident, on 4/29/2026. During an interview on 5/6/2026 at 12:05 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 4/29/2026, Resident 52 received a shower and after Resident 52 was transferred to the bed, Certified Nursing Assistant (CNA) 2 noticed two wounds on Resident 52's leg. LVN 1 stated CNA 3 assisted CNA 2 with Resident 52's transfer back to bed. LVN 1 stated CNA 2 notified him and when he initially assessed Resident 52's leg, he saw open skin on the top part of Resident 52's leg and a skin flap on Resident 52's calf. During an interview on 5/6/2026 at 12:29 p.m., with CNA 3, CNA 3 stated, on 4/29/2026, CNA 2 requested his assistance to transfer Resident 52 back to bed. CNA 3 stated they did not use the Hoyer Lift during the transfer. CNA 3 stated when he and CNA 2 transferred Resident 52 from the shower chair to the bed, they stood on both sides of Resident 52, held under her arms to assist her to a standing position, and turned her until she sat at the edge of the bed. CNA 3 stated after he and CNA 2 assisted Resident 52 into a sitting position at the edge of the bed, CNA 2 assisted Resident 52 into a lying position on the bed. CNA 3 stated he had his back turned when CNA 2 positioned Resident 52 into a lying position on the bed. CNA 3 stated during Resident 52's transfer from the shower chair to the bed, he did not notice any bleeding or wounds on Resident 52's left leg. During a phone interview on 5/6/2026 at 12:55 p.m., with CNA 2, CNA 2 stated on 4/29/2026, Resident 52 was scheduled to have a shower. CNA 2 stated Resident 52 required a Hoyer Lift for all transfers CNA 2 stated she knew showering Resident 52 would take about an hour from start to finish. CNA 2 stated after she showered Resident 52, she asked CNA 3 to assist her in transferring Resident 52 to the bed. CNA 2 stated she and CNA 3 assisted Resident 52 into a standing position from the shower chair to allow Resident 52 to sit at the edge of the bed. CNA 2 stated once Resident 52 was at the edge of the bed, she lifted Resident 52's legs and while supporting Resident 52's back and turned Resident 52 to her right and laid Resident 52 into the bed. CNA 2 stated when she attempted to put Resident 52's pants on, she noticed the injuries to Resident 52's legs and blood on Resident 52's bed frame. CNA 2 stated she did not use the Hoyer Lift to transfer Resident 52 from the shower chair to the bed because she wanted to save time. CNA 2 stated Resident 52 was injured during the transfer and Resident 52's injuries could have been prevented if the Hoyer Lift was used. CNA 2 stated she thought she could safely perform a two-person transfer without the Hoyer Lift because she assisted the rehab staff with that transfer in the past. During an observation and interview on 5/6/2026 at 1:41 p.m., with the Director of Staff Development (DSD), outside of Resident 52's room, a pink sticker was observed next to Resident 52's name. The DSD stated stickers were placed next to the resident's name to inform the staff of the resident's safe transferring needs. The DSD stated the pink sticker next to Resident 52's name indicated the Hoyer Lift was needed during transfers. The DSD stated the Hoyer Lift was used when transferring Resident 52 out of the bed to the chair and vice versa. During an interview on 5/6/2026 at 1:57 p.m., with Physical Therapist (PT) 1, PT 1 stated the rehab department evaluated each resident's safe transferring needs and informed the nursing department, who then placed the stickers next to the resident's name. PT 1 stated a resident with maximal assistance required the Hoyer Lift during all transfers because the resident could help a little bit, but the individual assisting did most of the effort. During an interview on 5/6/2026 at 2:08 p.m., with PT 2, PT 2 stated when the rehab therapist transferred a resident, despite the need of the Hoyer Lift, the transfer was done with another therapist. PT 2 stated the therapists in the rehab department were trained to perform two-person assists safely. PT 2 stated Resident 52 was evaluated, and the rehab department recommended the nursing department to use the Hoyer Lift during all transfers to maximize safety and prevent falls and other injuries. During an interview on 5/6/2026 at 2:39 p.m., with CNA 3, CNA 3 stated when CNA 2 asked for his assistance, he was attending to another resident at that time. CNA 3 stated he knew Resident 52 required the Hoyer Lift during transfers, however, CNA 2 had Resident 52 at the bedside in the shower chair. CNA 3 stated CNA 2 did not have the Hoyer Lift at Resident 52's bedside and he needed to attend to his other resident. CNA 3 stated the Hoyer Lift should have been used to transfer Resident 52 to promote safety and prevent injuries. During an interview on 5/7/2026 at 11:28 a.m., with the Director of Nursing (DON), the DON stated, on 4/29/2026, Resident 52 was transferred from the shower chair to her bed and sustained two wounds on the left leg. The DON stated Resident 52 required the Hoyer Lift during all transfers because Resident 52 was a maximal assist and could not help during transfers. The DON stated CNA 2 and CNA 3 transferred Resident 52 from the shower chair to the bed without the Hoyer Lift therefore Resident 52's leg got caught on the bed frame. The DON stated on 4/29/2026, Resident 52 had a bed with gaps in the bed frame, which allowed for different segments of the bed to be adjusted. The DON stated Resident 52 had fragile skin and was at risk of injuries. The DON stated the two-person assist, without the Hoyer Lift, was not a safe transfer for Resident 52. The DON stated accidents could happen during any transfers, however, Resident 52 was not transferred in a way to maximize safety and Resident 52's wounds on her legs could have been prevented. During a review of the facility's Policy and Procedure (P&P) titled, Transfer Assist Program, dated 6/2023, the P&P) indicated residents identified to need a Hoyer Lift with transfers would have a pink sticker next to the resident's door tag. During a review of the facility's Certified Nursing Assistant (CNA) Job Description, dated 12/17/2021, the Job Description indicated CNAs were to perform all assigned tasks in accordance with the facility's policies and procedures, perform restorative and rehabilitative procedures as instructed, and follow all safety precautions in the performance of all duties. 2. During an interview on 5/7/2026 at 11:49 a.m., with the DON, the DON stated the Interdisciplinary Team (IDT- a coordinated group of experts from several different fields) met at least quarterly or sooner, if needed. The DON stated additional IDT meetings were conducted if requested by the family, a fall occurred, a change in weight, or other incidents that required the IDT to discuss the circumstances and develop interventions to implement. During a concurrent interview and record review, on 5/7/2026 at 11:53 a.m., with the DON, Resident 52's IDT Change in Condition Care Plan Review, dated 4/29/2026, was reviewed. The Care Plan Review indicated Resident 52's COC, on 4/29/2026, did not require an IDT meeting. The DON stated Resident 52's incident on 4/29/2026, should have had an IDT meeting to include other departments, such as rehab, and RP 1 to discuss the incident and create a plan to prevent the incident from occurring again. The DON stated that without an IDT meeting, there could be miscommunication with RP 1 regarding Resident 52's care and the potential for another incident to occur. During a review of the facility's P&P titled, Change in Condition, revised 4/2025, the P&P indicated, The interdisciplinary team (IDT) shall collaborate with the attending physician, resident, and/or resident representative to review risk factors and the plan of care. The IDT will document this collaboration in the [electronic medical record] EMR in the next scheduled Comprehensive Care Plan Meeting or sooner if deemed necessary by the IDT. 3. During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included a displaced comminuted supracondylar fracture (a severe elbow injury where the humerus bone breaks into multiple pieces, with the bones separating), osteoarthrosis (a progressive disorder of the joints, caused by a gradual loss of cartilage), muscle weakness, and repeated falls. During a review of Resident 58's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 58 could make needs known but could not make medical decisions. During a review of Resident 58's MDS, dated [DATE], the MDS indicated Resident 58's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 58 required maximal assistance (helper does more than half the effort) for bed mobility, showering, toileting, and upper body dressing. During a review of Resident 58's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 4/20/2026, timed at 7:00 a.m., and authored by the DON, the note indicated Resident 58 was caught in the process of sliding from the bed on 4/20/2026 at 7:00 a.m. During a review of Resident 58's General Acute Care Hospital (GACH) Physician Progress Notes, dated 4/24/2026, the notes indicated Resident 58 had left arm swelling, bruising (injury where blood vessels under the skin are damaged and leaked blood without breaking the skin surface), mild redness, pain with elbow range of motion and recently suffered a fall. During a record review of Resident 58's GACH X-Ray (a type of medical imaging) Results, dated 4/24/2026, the results indicated Resident 58's clinical history included a fall, and the final impression indicated an impacted transverse comminuted left distal humeral supracondylar fracture with approximately 1.2 centimeters (a unit of measurement) of medial displacement (a significant shift of the bone fragments). During an observation and interview on 5/5/2026 at 8:10 a.m. with Resident 58, in Resident 58's room, Resident 58 was in her bed with a left arm sling and demonstrated limited movement of the left arm secondary to pain. Resident 58 stated she believed she fell but she could not recall and stated that her granddaughter, Responsible Party (RP) 2, would be able to provide more details. During an interview on 5/5/2026 at 8:29a.m. with RP 2, RP 2 stated Resident 58 sustained a left shoulder and elbow fracture. RP 2 explained, on 4/20/2026, during the daytime, the DON contacted her to come to the facility. RP 2 stated facility staff were unable to clearly explain what had occurred and informed her x-rays would be obtained. RP 2 stated, upon visiting Resident 58 on 4/22/2026, she observed side pads placed on her bed and noted swelling and bruising to Resident 58's left arm. RP 2 stated she later learned Resident 58 had been found hanging off her bed during the early morning hours of 4/20/2026. RP 2 stated Resident 58 was not normally confused, did not typically attempt to get out of bed independently, and required assistance for mobility. During an interview on 5/5/2026 at 1:08 p.m. with LVN 3, LVN 3 confirmed she was Resident 58's nurse on 4/20/2026 during the 11:00 p.m. to 7:00 a.m. shift. LVN 3 stated at approximately 2:00 a.m., Resident 58 exhibited acute confusion, repeatedly threatened to get up from bed, and stated she needed to go to an appointment. LVN 3 stated CNA 4 initiated one-to-one supervision due to Resident 58's confusion and attempts to get out of bed. LVN 3 stated CNA 4 later left for lunch and one-to-one supervision was not maintained. LVN 3 stated that during rounds at approximately 3:00 a.m., she heard Resident 58 moaning and observed Resident 58 in the act of sliding off the bed in an upside down 'L' position with the resident's legs dangling off the left side of her bed. LVN 3 confirmed Resident 58 exhibited increased confusion and experienced an episode of sliding from the bed, both of which represented changes in condition requiring physician notification. LVN 3 stated that she notified the DON regarding the incident but did not notify Physician 1. LVN 3 stated Physician 1 should have been notified to obtain orders and clinical direction related to Resident 58's confusion, safety needs, and interventions. LVN 3 stated one-to-one supervision should have been maintained during CNA 4's lunch break, and stated Resident 58 was at risk for an accident or fall. During an interview on 5/5/2026 at 3:33 a.m. with CNA 4, CNA 4 stated, she recalled Resident 58 in her bed prior to the start of her lunch at approximately 2:00 a.m. or 2:30 a.m. CNA 4 confirmed that she initiated one to one supervision because Resident 58 was confused and telling her roommate that she needed to get out of there. CNA 4 stated she did not endorse Resident 58's condition to another nursing staff member prior to her lunch break and confirmed one-to-one supervision was not maintained during her break. During an interview on 5/6/2026 at 10:55 a.m. with the DON the DON stated supervision should be maintained when a resident exhibited confusion or attempted to get out of bed. The DON stated CNA 4 should have endorsed Resident 58's condition to other nursing staff before leaving for lunch to ensure safety was maintained. The DON stated LVN 3 should have notified the physician following Resident 58's onset of acute confusion to obtain treatment orders and clinical direction to maintain safety. The DON stated the lack of physician notification and staff to staff communication placed Resident 58 at risk for an accident or fall. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, revised 4/2025, the P&P indicated the facility would ensure each resident received quality of care and services to attain and maintain the highest practicable physician mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. licensed nursing staff would ensure the physician would be notified based on the urgency of the situation. The P&P indicated the nurse would perform and document an assessment of the resident and identify need for additional interventions, through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. During a review of the facility's policy and procedure (P&P) titled, Fall Management System, revised 4/2025, the P&P indicated the facility would provide an environment that remained as free of accident hazards as possible. The P&P also indicated the facility was to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observation, interview and record review, the facility failed to ensure a resident received the volume of oxygen ordered by the physician for one of six sampled residents (Resident 61).This deficient practice resulted in Resident 61 receiving less oxygen than required and had the potential to negatively impact Resident 61's well-being.During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included hypoxia (when the body does not get enough oxygen) and cerebral infarction (a stroke caused by blocked blood flow to the brain). During a review of Resident 61's Physician Orders, dated 8/8/2024, the Physician Orders indicated to administer oxygen at 2 liters (L, a unit of volume measurement) per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen), continuously every shift for shortness of breath. During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 61's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 61 was dependent with toileting, bathing, and lower body dressing. The MDS indicated Resident 61 required oxygen therapy (a medical gas used to help with breathing).During a review of Resident 61's History and Physical (H&P), dated 2/19/2026, the H&P indicated Resident 61 had fluctuating (changing often) capacity to understand and make decisions.During an observation on 5/4/2026 at 8:27 a.m. and 5/4/2026 at 12:02 p.m., in Resident 61's room, Resident 61was observed lying in bed receiving 1L of oxygen via nasal cannula. Resident 61's oxygen nasal cannula was not attached properly in Resident 61's nostrils.During an interview on 4/5/2026 at 11:41 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 61 was on supplemental oxygen to prevent shortness of breath. RNS 1 stated that while Resident 61 was on oxygen therapy, the nasal cannula remains properly positioned in the nostrils to receive continuous oxygen therapy as ordered. RNS 1 stated that improper oxygen delivery may cause shortness of breath, low oxygen levels, and worsening respiratory status.During an interview on 5/6/2026 at 2:00 p.m., with the Director of Nursing (DON), the DON stated failure to provide the ordered 2L oxygen and an improperly positioned nasal cannula, may result in low oxygen levels, shortness of breath, respiratory decline, and risk for harm.During a review of the facility's Policy and Procedure (P&P) titled, Oxygen, Use of, revised 3/2023, the P&P indicated to promote safety in administering oxygen.

Based on observation, interview, and record review, the facility failed to ensure accurate and complete documentation on the Controlled Record for one of one sampled resident (Resident 110). This deficient practice resulted in the inaccurate count of medications remaining in the medication bubble pack (a card used to store medications for the resident) and had the potential to result in the administration of additional doses, drug diversion (the theft or misuse of prescription medications by health care providers for personal use), and/or medication errors.Findings:During a review of Resident 110's Face Sheet, the Face Sheet indicated Resident 110 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, peripheral vascular disease (a slow progressive narrowing of the blood flow to the arms and legs), and hypertension (high blood pressure.During a review of Resident 110's Physician Order, dated 5/2/2026, the Physician Order indicated to administer Resident 110 Norco (an opioid medication used to treat pain) 5-325 milligrams (mg, a unit of measurement), by mouth every four hours as needed for moderate to severe pain (pain rated four through ten on the pain scale).During a review of Resident 110's History and Physical (H&P), 5/5/2026, the H&P indicated Resident 110 had the capacity to understand and make decisions.During an observation on 5/5/2026 at 1:48 p.m., at the East Medication Cart, accompanied by Licensed Vocational Nurse (LVN) 1, Resident 110 had two bubble packs (a card used to store medications for the resident) containing Norco 5-325mg and had a total of 37 tablets left. During a concurrent interview and record review on 5/5/2026 at 1:51 p.m., with LVN 1, Resident 110's Controlled Record, dated 5/3/2026 through 5/4/2026, and Medication Administration Record (MAR), dated 5/1/2026 through 5/31/2026, were reviewed. The Controlled Record indicated 38 tablets of Norco 5-325mg should have remained in the bubble packs and the last administration to Resident 110 was on 5/4/2026 at 5:52 p.m. The MAR indicated Norco 5-325mg was administered to Resident 110 on 5/5/2026 at 9:45 a.m. LVN 1 stated there was a discrepancy between the tablets left in the bubble packs and the documentation on the Controlled Record. LVN 1 stated when administering controlled medication (medications heavily regulated due to their risk of addiction and misuse), he was responsible for removing the medication from the bubble pack, document on the Controlled Record, administer the medication, and finally, document on the MAR. LVN 1 stated he administered Norco 5-325mg to Resident 110 at 9:45 a.m. that day but he did not document it on the Controlled Sheet. LVN 1 stated Norco was a controlled medication which needed to be accounted for to ensure nothing was missing. LVN 1 stated without the accurate documentation of the Norco administration, Resident 110 was at risk for double dosing.During an interview on 5/7/2026 at 11:20 a.m., with the Director of Nursing (DON), the DON stated the licensed nurses were responsible for accurate documentation when administering controlled medications to the residents. The DON stated after LVN 1 removed the Norco 5-325mg tablet from the bubble pack, LVN 1 was responsible for documenting the date, time, quantity on hand, quantity used, and quantity remaining on the Controlled Record. The DON stated accurate documentation was necessary to prevent mishandling and theft. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration- Controlled Medications, revised 10/23/2021, the P&P indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: date and time of administration, amount administered, and signature of the nurse administering the dose completed after the medication is actually administered.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records for two out of twelve sampled residents (Resident 52 and Resident 58) by failing to: 1. Ensure nursing interventions and pertinent clinical details were documented after Resident 58 exhibited acute confusion and experienced an episode of partially sliding off the bed on 4/20/2026. 2. Ensure a skin assessment included bruising (occurs when small blood vessels near the skin's surface break from an injury) or discoloration to Resident 58's left arm on 4/22/2026. 2. Ensure a skin assessment was documented after Resident 52 sustained two wounds on her left lower leg on 4/29/2026. These deficient practices resulted in incomplete clinical communication regarding Resident 58 and a lack of a baseline skin assessment for Resident 52, which placed both residents at risk for delayed assessment, treatment, inappropriate clinical decision making and lack of continuity of care. Cross Reference F689 and F580. 1.During a review of Resident 58's admission Record, the admission Record indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 58's diagnoses included a displaced comminuted supracondylar fracture (a severe elbow injury where the humerus bone breaks into multiple pieces, with the bones separating), osteoarthrosis (a progressive disorder of the joints, caused by a gradual loss of cartilage), muscle weakness, and repeated falls. During a review of Resident 58's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 58 could make needs known but could not make medical decisions. During a review of Resident 58's care plan, titled, At risk for Bleeding or Bruising (occurs when small blood vessels near the skin's surface break from an injury) Related to Anticoagulant (blood thinning medication) Therapy, initiated 3/13/2026, the care plan interventions indicated to monitor, document, and report to the physician as needed for signs of bruising. During a review of Resident 58's care plan, titled, Fluid Deficit, initiated 3/24/2026, the care plan interventions indicated to monitor, document, and report to the physician as needed when signs and symptoms of dehydration like new onset confusion was present. During a review of Resident 58's Minimum Data Set ([MDS], a resident assessment tool), dated 4/30/2026, the MDS indicated Resident 's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 58 required maximal assistance (helper does more than half the effort) for bed mobility, showering, toileting, and upper body dressing. During a review of Resident 58's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 4/20/2026, timed at 7:00 a.m., and authored by the Director of Nursing (DON), the note indicated Resident 58 was caught in the process of sliding from the bed on 4/20/2026 at 7:00 a.m. During a review of Resident 58's SBAR Note, dated 4/20/2026, timed at 9:55 a.m., the SBAR note indicated Resident 58 complained of two out of ten acute pain to the left arm and Physician 1 ordered an in-house x-ray (a medical imaging test). During a review of Resident 58's SBAR Note, dated 4/23/2026, the note indicated Resident 58 was ordered to be transferred to the General Acute Care Hospital (GACH) for further evaluation and treatment for abnormal labs. During a review of Resident 58's GACH Physician Progress Notes, dated 4/24/2026, the notes indicated Resident 58 recently suffered a fall and had left arm swelling, bruising, mild redness, and pain with elbow range of motion. During a record review of Resident 58's GACH X-Ray (medical imaging technique) Results, dated 4/24/2026, the results indicated Resident 58's clinical history included a fall and the final impression indicated an impacted transverse comminuted left distal humeral supracondylar fracture with approximately 1.2 centimeters (a unit of measurement) of medial displacement (a significant shift of the bone fragments). During an observation and interview on 5/5/2026 at 8:10 a.m. with Resident 58, in Resident 58's room, Resident 58 was in her bed with a left arm sling (suspension device to immobilize the elbow) and demonstrated limited movement of the left arm secondary to pain. Resident 58 stated she believed she fell but she could not recall and stated that her granddaughter, Responsible Party (RP) 2, would be able to provide more details. During an interview on 5/5/2026 at 8:29 a.m. with RP 2, RP 2 stated Resident 58 sustained a left elbow fracture. RP 2 stated the DON contacted her on 4/20/2026 during the daytime hours but did not clearly explain what had occurred. RP 2 stated facility staff were unable to clearly explain what had occurred and informed her x-rays would be obtained. RP 2 stated she visited Resident 58 on 4/22/2026 and observed swelling and bruising to Resident 58's left arm. RP 2 stated, on 4/22/2026, she later learned Resident 58 had been found hanging off her bed during the early morning hours of 4/20/2026. RP 2 stated Resident 58 was not normally confused, did not typically attempt to get out of bed independently, and required assistance for mobility. During an interview on 5/5/2026 at 1:08 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 confirmed she was Resident 58's nurse on 4/20/2026 during the 11:00 p.m. to 7:00 a.m. shift. LVN 3 stated at approximately 2:00 a.m., Resident 58 exhibited acute confusion, repeatedly threatened to get up from bed, and stated she needed to go to an appointment. LVN 3 stated CNA 4 initiated one-to-one supervision due to Resident 58's confusion and attempts to get out of bed. LVN 3 stated CNA 4 later left for lunch and one-to-one supervision was not maintained. LVN 3 stated that during rounds at approximately 3:00 a.m., she heard Resident 58 moaning and observed Resident 58 in the act of sliding off the bed in an upside down 'L' position with the resident's legs dangling off the left side of her bed. LVN 3 confirmed Resident 58 exhibited increased confusion and experienced an episode of sliding from the bed. LVN 3 stated that she notified the DON regarding the incident; however, she did not complete documentation regarding Resident 58's acute confusion, nursing interventions, implementation of one-to-one supervision, or incident involving partially sliding from the bed. LVN 3 stated it was important to document all nursing intervention and changes in condition to ensure Resident 58's medical record remained complete and accurate for other healthcare providers involved in Resident 58's care. 2. During a concurrent interview and record review on 5/5/2026 at 3:03 p.m. with LVN 4, Resident 58's Nursing Progress Notes, SBAR Notes, and Changes in Condition Notes, dated 4/22/2026, were reviewed. The records did not indicate Resident 58 had bruising to the left arm. LVN 4 stated it was important to notify the physician of all changes of condition and ensure appropriate monitoring and treatment. LVN 4 stated Resident 58 developed left arm bruising on 4/22/2026, but did not document her assessment. LVN 4 further stated bruising should have been documented and reported to ensure complete clinical information was communicated to the physician for ongoing treatment decisions. During a concurrent interview and record review on 5/5/2026 at 3:56 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 Resident 58's Nursing Progress Notes, dated 4/22/2026, and SBAR Notes, dated 4/2026, were reviewed. There was no documentation to indicate, on 4/20/2026, at approximately 2:30 a.m. to 3:00 a.m. Resident 58 exhibited acute confusion, required one to one supervision, or experienced an incident involving partially sliding from the bed and being found in an abnormal position. There was no documentation to indicate complete nursing interventions, assessments, or physician notification related to Resident 58's change in condition and subsequent bruising. RNS 1 stated Resident 58's SBAR Note was not completed timely if the incident occurred during the early morning hours of 4/20/2026. RNS 1 stated incomplete or untimely documentation could result in health care providers being unaware of important clinical information necessary to guide Resident 58's plan of care and communicate significant findings to the physician. RNS 1 stated timely and complete documentation was important to ensure skin assessments and bruises were monitored, assessed, and communicated to the physician for treatment and orders. RNS 1 stated that it was especially important because Resident 58 was prescribed blood thinning medication. RNS 1 stated the lack of documentation placed Resident 58 at risk for unmonitored bleeding, delayed assessment, and delayed treatment. During a concurrent interview and record review on 5/6/2026 at 10:55 a.m. with the DON, Resident 58's Nursing Progress Notes, dated 4/22/2026, and SBAR Notes, dated 4/2026, were reviewed. The DON stated Resident 58's SBAR Note was not completed timely because she was made aware that the incident occurred approximately 2:30 a.m. to 3:00 a.m. on 4/20/2026. The DON confirmed that LVN 3 should have completed her own documentation. The DON stated all licensed nurses were responsible for documenting his or her own assessments and interventions pertinent to the clinical resident's clinical condition to ensure appropriate monitoring and treatment interventions for all residents. During a review of the facility's policy and procedure (P&P) titled, Documentation, revised 1/2023, the P&P indicated the facility was to ensure the following: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. 4. Nursing service personnel with a record of the physical and mental status of the resident. 5. Assistant in the development of a Plan of Care for each resident. 6. The elements of quality medical nursing care. 7. A legal record that protects the resident, physician, nurse and the facility. During a review of the facility's P&P titled, Change in Condition, revised 4/2025, the P&P indicated the licensed nursing staff would perform and document an assessment of the resident and identify need for additional interventions, through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. During a review of the facility's LVN Job Description (undated), the job description indicated the LVN was to chart nurses' notes in a professional and appropriate manner that timely, accurately and thoroughly reflected the care provided to the residents, as well as the resident's response to the care. The Job Description indicated to chart the following: All reports of accidents/incidents involving residents. All changes in resident condition and the response to those changes. Chart all communications with the residents attending physician regarding the resident, the residents treatment, or the response to that treatment. The Job Description indicated to perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations. 3. During a review of Resident 52's Face Sheet, the Face Sheet indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included generalized muscle weakness, Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 52's H&P, dated 3/24/2026, the H&P indicated Resident 52 did not have the capacity to understand and make decisions. During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52's cognition was severely impaired. The MDS indicated Resident 52 was dependent on staff's assistance with activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) such as toileting, bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 52 required maximal assistance with chair/bed-to-chair transfers. During a review of Resident 52's Change in Condition (COC), dated 4/29/2026, the COC indicated, on 4/29/2026, Resident 52 sustained an open ecchymosis (a bruise that opens, breaks, or tears) during transfer to the bed. The COC indicated Resident 52's wounds were located on the left lower posterior (area of the leg near the calf) and left lower lateral leg (outer side of the left shin, below the knee and above the ankle). During a review of Resident 52's Surgical Wound Consult Progress Note, dated 4/30/2026, the Progress Note indicated Resident 52 had a trauma wound (a sudden, severe physical wound caused by an external force requiring immediate medical attention) on the left lower lateral part of her leg. The Progress Note indicated the wound on the left lower lateral part of Resident 52's leg measured 5 centimeters (cm, a unit of measurement) in length, 6cm in width, and 1cm in depth. During an interview on 5/4/2026 at 12:22 p.m., with RP 1, RP 1 stated, on 4/29/2026, the facility notified her that Resident 52 sustained trauma injuries to her left leg. RP 1 stated Resident 52's injuries occurred when Resident 52 was transferred to the bed and Resident 52's leg got caught on something. During a review of Resident 52's Skin Issues Assessment, dated 5/1/2026, the Skin Issues Assessment indicated Resident 52's wound on the left lateral calf measured 3.5cm in length, 0.2cm in width, and 0.1cm in depth. The Skin Issues Assessment indicated Resident 52's wound on the left lateral lower leg measured 5cm in length, 6cm in width, and 1cm in depth. During a concurrent observation and interview on 5/4/2026 at 2:44 p.m., with Treatment Nurse (TN) 1, in Resident 52's room, Resident 52 was lying in bed and Registered Nurse (RN) 1 was at the bedside to assist TN 1 with Resident 52's wound treatment. Resident 52's dressings were removed from her left leg. Two wounds were observed on the lower left leg. The first wound was the shape of a half circle, with irregular edges along the rounded border, closest to the foot. The area of the wound closest to the foot was moist, with a pale pink wound bed, and a small amount of bright red bleeding. The second was located near the left calf. The area of the wound near the calf was covered by thin, pale, purplish-gray, flaps of skin that were fragile in appearance. The skin flaps were wrinkled and did not cover the entire wound. TN 1 stated Resident 52's wounds were classified as a trauma wound and Resident 52 sustained both wounds from the same accident, on 4/29/2026. During an interview on 5/6/2026 at 12:05 p.m., with LVN 1, LVN 1 stated, on 4/29/2026, Resident 52 received a shower and after Resident 52 was transferred to the bed, Certified Nursing Assistant (CNA) 2 noticed two wounds on Resident 52's leg. LVN 1 stated CNA 3 assisted CNA 2 with Resident 52's transfer back to bed. LVN 1 stated CNA 2 notified him and when he initially assessed Resident 52's leg, he saw open skin on the top part of Resident 52's leg and a skin flap on Resident 52's calf. LVN 1 stated upon assessing Resident 52's wounds, he called TN 1 to provide first-aid treatment (immediate, temporary care given). During a phone interview on 5/6/2026 at 12:55 p.m., with CNA 2, CNA 2 stated, on 4/29/2026, Resident 52 was scheduled to have a shower. CNA 2 stated she and CNA 3 assisted Resident 52 into a standing position from the shower chair to allow Resident 52 to sit at the edge of the bed. CNA 2 stated once Resident 52 was at the edge of the bed, she lifted Resident 52's legs and while supporting Resident 52's back and turned Resident 52 to her right and laid Resident 52 into the bed. CNA 2 stated when she attempted to put Resident 52's pants on, she noticed the injuries to Resident 52's legs and blood on Resident 52's bed frame. CNA 2 stated Resident 52 was injured during the transfer. During an interview on 5/7/2026 at 8:21 a.m., with TN 1, TN 1 stated, on 4/29/2026, LVN 1 notified him that Resident 52 sustained two wounds on her left lower leg after an accident during Resident 52's transfer from the shower chair to the bed. TN 1 stated when he entered Resident 52's room, he assessed Resident 52's wounds, cleansed the wounds, and applied a dry dressing. TN 1 stated he provided basic first aid wound treatment to the wounds until additional he received additional orders from the physician. TN 1 stated Resident 52's wounds were located on the left lateral lower leg and the left posterior lower leg. TN 1 stated the wound specialist classified the wounds as trauma wounds because they were not the typical skin tear (wound caused by friction or force that separates the top layer of the skin from the lower layer). TN 1 stated Resident 52 sustained new skin injuries and his assessment should be in Resident 52's medical record. During a concurrent interview and record review on 5/7/2026 at 8:29 a.m., with TN 1, Resident 52's Skin Issue Assessment, dated 4/29/2026, was reviewed. The Skin Issue Assessment indicated Resident 52 had a lower abdominal surgical wound. The Skin Issue Assessment did not indicate Resident 52 had two wounds on her lower left leg. TN 1 stated he should have documented his assessment on Resident 52's wounds because wounds could change very quickly. TN 1 stated the initial assessment would be used as a baseline to compare the healing process, whether the wounds were healing or declining. TN 1 stated without a detailed assessment of Resident 52's wounds, the facility was unable to determine if any changes occurred. TN 1 stated an assessment was documented by the wound specialist the following day and by the other treatment nurse two days later, however the wounds could have changed in the 24-to-48-hour time. TN 1 stated the facility had no way of determining if any changes occurred. During an interview on 5/7/2026 at 11:44 a.m., with the Director of Nursing (DON), the DON stated when Resident 52 sustained her wounds on the lower left leg, TN 1 should have documented the description and measurements of the wounds. The DON stated timely documentation would allow the facility and the wound specialists monitor the progress of Resident 52's wounds from the beginning. The DON stated without the documented assessment, the facility did not have a baseline of how big the wounds were or the wounds characteristics. During a review of the facility's Policy and Procedure (P&P) titled, Documentation, revised 1/2023, the P&P indicated the purpose of documentation was to provide a complete account of the resident's care, signs and symptoms, and the process of the resident's care. The P&P indicated nursing personnel would record the physical and mental status of the resident. The P&P indicated documentation was a source of all the resident's changes. During a review of the facility's P&P titled, Skin and Wound Monitoring and Management, revised 4/2025, the P&P indicated, Areas of breakdown, excoriation (skin that has been scraped, scratched, or worn away), discoloration, or other unusual findings (either initially identified at the time of admission or as a new finding) must be documented in the nursing notes or on the appropriate weekly assessment form.

Based on observation and interview, the facility failed to ensure that Resident 65's bedroom was equipped with a privacy curtain to ensure full visual privacy for one of six sampled residents (Resident 65). This deficient practice had the potential to violate the resident's right to visual privacy and dignity during personal care and activities of daily living. Findings:During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 65's diagnoses included spinal stenosis (is when the spaces in the spine become narrow and press on the nerves) and muscle weakness.During a review of Resident 65's Minimum Data Set (MDS- a resident assessment tool), dated 2/3/2026, the MDS indicated Resident 65's cognition (process of thinking) was intact. The MDS indicated Resident 65 was independent with toileting, bathing, and lower body dressing. During a review of Resident 65's History and Physical (H&P), dated 4/11/2026, the H&P indicated Resident 65 had the capacity to understand and make decisions.During an observation on 5/4/2026 at 10:52 a.m., a wrong size privacy curtain was observed on the horizontal track along the foot of Resident 65's bed. The privacy curtains provided full visual privacy for two of the room's three occupants.During an interview on 5/5/2026 at 10:22 a.m., with Resident 65, Resident 65 stated, the incomplete privacy curtain does not bother him.During an interview on 5/6/2026 at 10:01 a.m., with the Housekeeper (HK), the HK stated the privacy curtain along Resident 65's bed was the wrong size and may affect the resident's visual privacy and dignity (feeling respected).During an interview on 5/6/2026 at 2:45 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated privacy curtains are important to protect the resident's privacy and dignity during care and may cause the resident to feel uncomfortable. During a review of the facility's policy and procedure (P&P) titled Resident Rights, revised 4/2025, the P&P indicated employees were to treat all residents with respect and dignity. The P&P indicated all facility residents and staff are continually informed and aware of resident rights.

Based on observation, interview and record review, the facility failed to meet professional standards of quality, for one of three residents (Resident 2), by failing to:1). Ensure timely documentation was performed when Resident 2 was assessed and administered pain medication on 3/11/2026. 2). Ensure Resident 2, who had a foley catheter (catheter that drains urine from bladder into a bag outside the body), was provided a securing device (to keep the catheter from being pulled away), as indicated in the resident's care plan titled Resident with an episode of blood in the urine.These failures had the potential for poor quality care and placed Resident 2 at risk for unintentional drug overdose (taking more than what is safely prescribed) and further catheter-associated trauma (like bleeding), pain and discomforts, leading to complications and hospitalization.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included metabolic encephalopathy (a change in the how the brain works due to an underlying condition), muscle weakness, and end stage renal disease ([ESRD], irreversible kidney failure). During a review of Resident 2's History and Physical (H&P) dated 2/15/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a resident assessment tool), dated 3/6/2026, the MDS indicated Resident 2 had severe (extreme) cognitive impairment (problems with the ability to think, remember, and solve problems). The MDS indicated Resident 2 was dependent (helper does less than half the effort) with Activities of Daily Living (ADLs) such as toileting hygiene and required substantial/maximal assistance (helper does more than half the effort) to perform movements such as rolling left and right. 1). During an observation on 3/11/2026 at 1:25 p.m., at Resident 2's bedside, Licensed Vocational Nurse (LVN) 1 was observed telling Resident 2 that he had just received his pain medication (unspecified). During a concurrent interview and record review on 3/11/2026 at 2:13 p.m., with LVN 1, Resident 2's Medication Administration Record (MAR), for the month of 3/2026, was reviewed. LVN 1 stated on 3/11/2026 at 12:30 p.m., Resident 2 was given Tylenol 325 milligrams ([mg], metric unit of measurement, used for medication dosage and/or amount) for the resident's 2/10 pain ([site not specified] a numerical pain scale used in a facility with 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible). LVN 1 stated the Tylenol administered was not documented right away in the MAR because she had to attend to another resident. LVN 1 stated that the Tylenol administered, the assessments and reassessments performed, should have been documented right away to ensure Resident 2 was given the correct dose and documented an accurate record. During an interview on 3/13/2026 at 11:38 a.m., with LVN 3, LVN 3 stated late documentation of the medication administered had the potential for licensed nurses to administer another dose when the resident needs it and placed Resident 3 at risk to receive too much medication. 2). During a concurrent observation on 3/11/2026 at 3:58 p.m., with LVN 2, LVN 2 stated Resident 2 has a foley catheter, and did not have a statlock (a device to secure the foley catheter in place on the skin to prevent from moving or being pulled) in place. During a concurrent interview and record review on 3/13/2026 at 11:38 a.m., with LVN 3, Resident 2's care plan titled, Resident with an episode of blood in the urine, dated 2/27/2026, and the picture taken during the observation on 3/11/2026 at 3:58 p.m., were reviewed LVN 3 stated the facility did not follow Resident 2's care plan to address residents' problem and the standard of care when Resident 2 did not have a statlock securing the foley catheter. During a review of Resident 2's care plan titled, Resident with an episode of blood in the urine, dated 2/27/2026, one of the interventions indicated to secure catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal. During an interview on 3/13/2026 at 12:38 p.m., with the Director of Nursing (DON), the DON stated staff should always document assessments performed and medications administered in real time to prevent staff from forgetting the care given. The DON stated Resident 2 was at risk for penile trauma for having the foley catheter for a long period of time and needed the statlock to prevent trauma and irritation to the skin. During a review of facility's policy and procedure (P&P) titled, Medication Administration, dated 10/2019, the P&P indicated, the individual who administers the medication dose records the administration on the resident's MAR after the medication pass is completed. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. During a review of facility's P&P titled, Indwelling Urinary Catheter, dated 4/2025, the P& indicated, it is the policy for this facility that each resident with an indwelling urinary catheter will receive catheter care daily and as needed (PRN) to promote comfort and decrease risk of infection. The P&P indicated that staff, may secure the tubing with a securement device, PRN to prevent migration, friction, or tension of the catheter. During a review of facility's P&P titled, Comprehensive Care Planning, dated 4/2025, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop and implement a comprehensive person-centered care plan for each resident.

Based on interview and record review, the facility failed to ensure a resident-centered care plan, for one of three residents (Resident 1), who was incontinent (no control) of bowel and bladder functions and who developed a Moisture-Associated Skin Damage (moisture associated skin damage caused from prolonged exposure to moisture) on 11/3/2025, was created, with interventions, to keep the resident's skin clean and dry. This failure resulted in delayed interventions and had resulted in the development of further MASDs, placing the resident at risk for wound complications and further skin breakdown.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and discharged on 11/24/2025. The admission Record indicated Resident 1 had a history of muscle weakness, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and subarachnoid hemorrhage (bleeding in the brain) with loss of consciousness. Resident 1 was discharged from the facility on 11/24/2025. During a review of Resident 1's Progress Note, dated 10/11/2025, the Progress Notes indicated Resident 1's skin was warm and dry with normal skin color. The progress notes did not indicate Resident 1 had MASD. During a review of Resident 1's Braden Scale (a standardized tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers, or bedsores) for Predicting Pressure Ulcer Risk Evaluation, dated 10/11/2025, the evaluation indicated Resident 1 had very limited sensory perception, was constantly moist, and completely immobile. The evaluation indicated Resident 1 was at high risk of skin breakdown. During a review of Resident 1's History and Physical (H&P), dated 10/14/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make medical decisions. During a review of Resident 1's Bowel and Bladder Evaluation, dated 10/14/2025, the evaluation indicated Resident 1 was not continent (no control) of bowel and bladder for an unknown length of time. The evaluation indicated Resident 1's incontinence was related to an old cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), other debilitating disease over 2 years. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/17/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was dependent (helper does all of the effort) for toileting hygiene (the ability to maintain perineal hygiene) and rolling left and right (ability to roll from lying on back to left and right side). During a review of Resident 1's care plan titled, Has potential for impairment to skin integrity related to (r/t) a Braden scale score of 12, high risk for pressure ulcer, dated 10/18/2025, the interventions indicated to administer treatments as ordered, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, identify/document potential causative factors and eliminate/resolve where possible, reposition at least every 2 hours or as needed, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. During a review of Resident 1's Plan of Care (POC) Response History for Bowel movement/Bowel incontinence, dated 10/28/2025-11/24/2025, the response history indicated Resident 1 had 2-7 bowel movements per day. During a review of Resident 1's Surgical Consult, dated 11/3/2025, the consult indicated Resident 1 had MASD on the peri wound (the surrounding area of the wound) of his coccyx (tailbone) wound and right ischium (curve bone at the pelvis) wounds with mild and serous (bloody) exudate (drainage). During a review of Resident 1's Physical Therapy (PT) Progress Report, dated 11/19/2025, the PT Progress Report indicated Resident 1 required moderate assistance and required consistent cuing for safety to roll left and right while in bed with weight shifting. During a review of Resident 1's Surgical Consult, the consultation indicated the following:1). On 11/3/2025, Resident 1's coccyx peri wound area had MASD.2). On 11/10/2025, Resident 1's right ischium wound was classified as MASD. 2). On 11/10/2025, Resident 1's coccyx peri wound area had MASD.3). On 11/17/2025, Resident 1 developed MASD on the peri wound of his coccyx. During a review of Resident 1's care plan titled Has MASD to right ischium., dated 11/11/2025, the interventions indicated nursing staff to administer treatment as ordered, identify/document potential causative factors and eliminate/resolve where possible. During a concurrent interview and record review on 11/25/2025 at 9:40 a.m. with Licensed Vocational Nurse 2 (LVN 2), Resident 1's Nursing Notes dated 10/11/2025, POC Response History for Bowel movement/Bowel incontinence dated 10/28/2025-11/24/2025, and Resident 1's Braden Skin assessment dated [DATE], were reviewed. LVN 2 stated the Nursing Notes indicated Resident 1 did not have MASD upon admission to the facility. LVN 2 stated the Braden Scale indicated Resident 1 was at high risk of skin breakdown due to high levels of moisture, limited mobility, and limited perception. LVN 2 stated the POC Response History indicated Resident 1 required frequent monitoring and cleaning to keep him clean and dry of his frequent bowel movements. During an interview on 11/25/2025 at 2:35 p.m., with Resident 1, Resident 1 stated he developed a red, painful, stinging rash while at the facility. Resident 1 stated he poops 3-10 times per day, due to a gunshot wound and surgical procedure over 30 years ago. Resident 1 stated staff would not respond to his call light for 2-3 hours every night, forcing him to urinate and have bowel movements in his bed, and sit in his urine and feces for up to three hours. Resident 1 stated he felt dreaded (fearful), dehumanized (deprived), and frustrated because of his rash. During a concurrent interview and record review on 11/25/2025 at 10:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1's Surgical Consult, dated 11/3/2025, and Care Plan titled Resident has MASD . dated 11/11/2025, were reviewed. LVN 1 stated Resident 1 was constantly soiled, contributing to MASD on his skin of his perineum, buttocks, and coccyx. LVN 1 stated the nursing notes indicated Resident 1 did not have MASD when he was admitted . LVN 1 stated the MASD was first identified on 11/3/2025, but the care plan to address the MASD was not started until 11/11/2025. LVN 1 stated the care plan should have been created and implemented to address Resident 1's MASD for healing and to prevent it from worsening. LVN 1 stated the care plan indicated that Resident 1 should have been kept clean of urine and stool. LVN 1 stated Resident 1 was constantly soiled and the care plan for Resident 1's incontinence was not enough to prevent skin breakdown and MASD. During a concurrent interview and record review on 11/26/2025 at 10:05 a.m. with Medical Doctor 1 (MD 1), Resident 1's Surgical Consults, dated 11/3/2025, 11/10/2025, 11/17/2025, and 11/24/2025, were reviewed. MD 1 stated Resident 1 had MASD on his buttocks and perineum since 11/3/2025. MD 1 stated Resident 1's MASD on the right ischium and peri wound was definitely caused by Resident 1's incontinence. MD 1 stated Resident 1's wound edges, perineum, and buttock area was reddened due to MASD during his consultation on 11/24/2025. MD 1 stated MASD was due to Resident 1's incontinence of bowel and bladder and placed Resident 1 at high risk of skin breakdown and wound infection. During a concurrent interview and record review on 11/26/2025 at 4:26 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P), titled Comprehensive Person-Centered Care Planning, dated 4/2025, was reviewed. The DON stated the care planning P&P indicated care plans should have been created to address Resident 1's needs after the MASD developed on 11/3/2025, especially that Resident 1 was constantly soiled. The DON stated the P&P indicated staff should have provided the treatments and services to maintain and improve Resident 1's skin. During a review of the facility's P&P, titled Comprehensive Person-Centered Care Planning, dated 4/2025, the P&P indicated the Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) should develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs. The P&P indicated care plans must include interventions, planned services and treatment, and resident's goals.

Based on interview and record review, the facility failed to provide supervision during toilet use to one of six sampled Residents (Resident 1), who was assessed as high risk for falls. This failure resulted in Resident 1 falling from the toilet and sustaining a forehead laceration (a deep cut in the skin), which required five sutures (used to close wounds and hold tissues together) at a general acute care hospital (GACH). Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Face Sheet indicated Resident 1 had diagnoses that included right femur fracture (a broken thighbone, a serious injury often requiring surgery and extensive rehabilitation, typically caused by high-impact trauma like falls), Alzheimer's (a disease characterized by a progressive decline in mental abilities), and osteoporosis (weak and brittle bones due to a lack of calcium and Vitamin D).During a review of Resident 1's Minimum Data Set (MDS, a Resident assessment tool), dated 9/18/2025, the MDS indicated Resident 1 had severely impaired cognition (the process of thinking). The MDS indicated Resident 1 required moderate assistance (the helper did less than half the effort) with eating and oral hygiene. The MDS indicated Resident 1 required maximal assistance (the helper did more than half the effort) with toileting hygiene. The MDS indicated Resident 1 was dependent (the helper did all the effort) on staff with toilet transferring.During a review of Resident 1's History and Physical (H&P), dated 9/13/2025, Resident 1's H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Fall Risk Evaluation, dated 9/12/2025, the evaluation indicated Resident 1 was at high risk for falls.During a review of Resident 1's Post-Event Interdisciplinary Team (IDT, a group of healthcare professionals from different fields who worked together to plan and provide coordinated care for a Resident) Review, dated 10/7/2025, the IDT record indicated on 10/6/2025 Resident 1 had an unwitnessed fall in the room. The IDT record indicated Resident 1 was sitting on the toilet when Certified Nursing Assistant (CNA) 1 turned to inform another resident that she (CNA 1) was helping Resident 1. The IDT record indicated Resident 1 stood up from the toilet, fell on the floor, and sustained a cut on the forehead. The IDT record indicated Resident 1 had a history of a fall on 9/8/2025 which resulted in a right femur fracture.During a review of Resident 1's General Acute Care Hospital (GACH) records, dated 10/6/2025, the GACH records indicated Resident 1 was brought in by ambulance for an unwitnessed fall resulting in a head laceration and bruising on right side of the face. The GACH records indicated Resident 1 was awake, alert and oriented, and expressed experiencing pain to her right leg and head. The GACH records indicated Resident 1 stated she had fallen from the toilet and hit her head. The GACH records indicated Resident 1 was administered lidocaine (pain medication) and the resident's forehead laceration was repaired with five sutures (used to close wounds and hold tissues together).During a telephone interview on 10/16/2025 at 10:42 a.m. with CNA 1, CNA 1 stated that on 10/16/2025 around 10 a.m., Resident 1 was sitting on the toilet in the restroom. CNA 1 stated she left the restroom and informed another resident that she was assisting Resident 1. CNA 1 stated as soon as she reached the other resident, she heard Resident 1 screaming I fell in Spanish. CNA 1 stated Resident 1 was on the floor in the restroom with blood to the forehead. CNA 1 stated Resident 1 did not provide details on the fall. CNA 1 stated Resident 1 was confused and unaware of her surroundings. CNA 1 stated it was not safe to leave Resident 1 alone in the restroom because of fall risks. CNA 1 stated she should have asked another staff to stay with Resident 1 in the restroom to prevent falls.During an interview on 10/17/2025 at 10:44 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated for safety purposes staff should provide more supervision to high fall risk residents. LVN 1 stated supervision meant the staff should have residents within their visual field. LVN 1 stated it was standard nursing care to provide supervision and monitoring to residents as needed. LVN 1 stated he determined the level and type of supervision residents needed by collecting information from previous shifts, admission assessments, MDS assessments, and the plan of care. LVN 1 stated that he was not aware if the facility had any nursing manual or guidelines regarding resident supervision.During a concurrent interview and record review on 10/17/2025 at 10:44 a.m. with LVN 1, Resident 1's Care Plan titled Activities of Daily Living (ADL) self-care performance deficit related to right femur fracture and a history of falls, revised on 9/22/2025, was reviewed. The Care Plan indicated staff were to safely perform transfers and toilet use. The Care Plan interventions indicated staff were to participate with toilet use and transferring. LVN 1 stated the care plan interventions did not specify the types of assistance Resident 1 needed. LVN 1 stated the care plan interventions should be more specific so it would be clearer to communicate among staff. LVN 1 stated the non-specific care plan could increase the risks of avoidable mistakes and negatively impact on the quality of resident care.During an interview on 10/17/2025 at 12:04 p.m. with Registered Nurse (RN)1, RN 1 stated it was not safe to leave Resident 1 alone on the toilet due to the resident's history of falls and confusion. RN 1 stated CNA 1 should have stayed with Resident 1 for safety. RN 1 stated CNA 1 should have used the call light and asked for someone to supervise Resident 1 on the toilet before leaving to assist another resident.During an interview on 10/17/2025 at 1:34 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 1 was to be toe touch weight bearing (lightly touching the toes to the ground while walking or standing) on the right side after her fall on 9/8/2025. The DOR stated Resident 1 was not aware of safety measures and it was not safe to leave the resident lone in the restroom because of Resident 1's cognitive deficit and poor understanding of weight-bearing status and safety. The DOR stated Resident 1 was at risk of injury and possible worsening of the right femur fracture. The DOR stated Resident 1 needed cuing and redirection for activities. The DOR stated Resident 1 required assistance from two people with any kind of transfer due to the weight-bearing status. The DOR stated for safety staff had to stay and monitor Resident 1 while on the toilet. The DOR stated staff needed to make sure Resident 1 did not put weight on the right lower extremity.During an interview on 10/17/2025 at 2:18 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 1's fall on 10/6/2025 was preventable and due to a lack of staff supervision. The ADON stated if CNA 1 asked for help when she needed to attend the other resident or should have just stayed with Resident 1. The ADON stated staff should have kept Resident 1 safe and should not have left the resident unattended, especially residents who were at high risk for falls. The ADON stated she determined the level of supervision the residents required based on the fall risk assessments. The ADON stated residents at high risk for falls required more supervision. The ADON stated the facility did not have a nursing manual regarding resident supervision. The ADON stated the facility did not set guidelines for resident supervision and monitoring.During a review of the facility's policy and procedure (P&P) titled, Fall Management System, dated 4/2025, the P&P indicated the facility should provide an environment that remained as free of accident hazards as possible. The P&P indicated the facility should provide each resident with appropriate assessment and interventions to prevent falls and minimize the complications of falls. The P&P indicated high fall risk residents would have an individualized care plan developed. The P&P further indicated the care plan interventions would be developed to prevent falls by addressing the risk factors and would consider the particular elements of the evaluation that put the resident at risk.

During an observation, interview, and record review the facility failed to practice pressure related injury preventive practices for three out of seven residents (Resident 1, 2, and Resident 3): 1. Nursing staff did not follow doctor's order for a low air loss mattress ([LALM], a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, treat pressure sores and prevents pressure sores) for Resident 1, 2, and 3. 2. Nursing staff did not follow up on LALM order status. 3. Nursing staff did not ensure Resident 1, 2, and 3 had LALM to prevent pressure injuries (localized area of tissue damage that develops when prolonged pressure or shear forces are applied to the skin and underlying tissues). These deficient practices placed Resident 1,2, and 3 at risk for further skin damage and it placed residents at risk for developing pressure injuries. Findings: During an observation on 7/24/2025 at 1146 a.m. Resident 1, 2, and 3 did not have a LALM on their bed. 1. A review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included diabetes mellitus ([DM]a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension ([HTN]high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 7/21/2025, the H&P indicated Resident 1 could make his needs known but could not make medical decisions. During a review of Resident 1's electronic record, unable to locate Minimum Data Set ([MDS] a resident assessment tool) due to Resident 1's recent admission to the facility. During a review of Resident 1's Doctor Orders, dated 7/21/2025, the orders indicated Resident 1 had an order for a LALM for skin maintenance. During a review of Resident 1's Interdisciplinary Team (IDT) Skin Review Notes, dated 7/23/2025, the IDT notes indicated Resident 1 would use a LALM as a pressure redistributing device. IDT notes indicated a LALM was recommended for Resident 1 due to wounds and immobility. The IDT notes indicated Resident 1 had a wound on his coccyx (last bone at the bottom (base) of the spine) extending to left buttock (either of the two round fleshy parts that form the lower rear area of a human trunk) and wound was noted with 100% necrosis (death of cells or tissues in the body, occurs when cells are deprived of blood supply (ischemia) or injury). IDT notes indicated Resident 1 was at risk for wound decline or slow healing due to his comorbidities (simultaneous presence of two or more diseases or medical conditions) and limited mobility. 2. A review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2's diagnosis included pressure ulcer (a localized injury to the skin and underlying tissues that occurs due to prolonged pressure or pressure combined with shear and/or friction) of sacral region (located at the base of the spine), stage 2 (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed) and dementia (the loss of cognitive functioning [ability to think and reason], thinking, remembering, and reasoning). During a review of Resident 2's H&P dated 7/22/2025, the H&P indicated Resident 2 had fluctuating ability to make medical decisions.During a review of Resident 2's Doctor Orders, dated 7/22/2025, the orders indicated Resident 2 had an order for LALM for skin maintenance. During a review of Resident 2's IDT Skin Review Notes, dated 7/23/2025, the IDT notes indicated Resident 2 would use a LALM as a pressure redistributing device. IDT notes indicated a LALM was recommended for Resident 2 due to wounds and immobility. The IDT notes indicated Resident 1 had a coccyx pressure injury stage 2. IDT notes indicated Resident 2 was at risk for wound decline or slow healing due to his comorbidities and limited mobility. During a review of Resident 2's electronic record, unable to locate MDS due to Resident 2's recent admission to the facility. 3. A review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnosis included fracture (a break or discontinuity in a bone) of left humerus (bone of the upper arm) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 3's H&P dated 7/7/2025, the H&P indicated Resident 3 could make needs known but could not make medical decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was intact. The MDS indicated Resident 3 needed maximal assistance (helper does more than the effort) for toileting hygiene, shower/bathing, and dressing. The MDS indicated Resident 3 needed supervision for eating and oral hygiene. The MDS indicated Residents 3's skin and ulcer/injury treatment was a pressure reducing device for bed. During a review of Resident 3's Skin Evaluation, dated 7/18/2025, skin evaluation indicated Resident 3 had bilateral buttock redness and redness to bilateral heels. During a review of Resident 3's Doctor Orders, dated 7/22/2025, the orders indicated Resident 2 had an order for LALM for skin maintenance During an interview on 7/24/2025 at 1:11 p.m. with Treatment Nurse (TN), TN stated a resident with a risk in developing a pressure injury would benefit from having a LALM. TN stated a LALM is recommended for wound management because it helped alleviate pressure on skin. TN stated a doctor must order a LALM, nurse puts order in computer and LALM arrives the next day. TN stated all nursing staff were responsible on checking on LALM order status. During a concurrent interview and record review on 7/24/2025 at 1:39 p.m. with TN, Resident 1's Doctor Orders, dated 7/21/2025, were reviewed. The doctor's orders indicated Resident 1 had an order for LALM. TN stated if a resident has an order for a LALM that resident should have a LALM. TN stated Resident 1 had a pressure injury and redness on his buttocks and would benefit from using a LALM as a preventive measure. During a concurrent interview and record review on 7/24/2025 at 1:50 p.m. with TN, Resident 2's Doctor Orders, dated 7/22/2025, were reviewed. Doctor orders indicated Resident 2 had an order for a LALM. TN stated she did not know a LALM was ordered for Resident 2 and she did not know why he did not have a LALM. TN stated Resident 2 needed a LALM because he had skin issues and it would prevent his skin from getting worse. During a concurrent interview and record review on 7/24/2025 at 2:02 p.m. with TN, Resident 3's Doctor Orders, dated 7/21/2025, were reviewed. The doctor's orders indicated Resident 3 had an order for a LALM. TN stated Resident 3 had a stage 1 pressure injury (redness, intact skin, typically over a bony prominence) and needed LALM for preventive measures. During an interview on 7/24/2025 at 2: 10 p.m. with TN, TN stated she did not know why the residents did not have a LALM. TN stated she did not know a LALM was ordered for Resident 1, 2, and 3. TN stated the person that ordered the LALM should have notified her. TN stated if there was an order, nursing must follow the order. During an interview on 7/24/2025 at 2:17 p.m. with Maintenance Supervisor (MS), MS stated he ordered LALM when the TN or Director of Nursing (DON) notified him of a resident that needed one. MS stated he usually had extra LALM's that are kept in-house and he currently had 3 available. MS stated nursing had only notified him Resident 1 needed a LALM and he ordered it. MS stated Resident 1 had not received the LALM and he forgot to follow up on the LALM order. MS stated he was not aware of other residents waiting for LALM because no one notified him. During an interview on 7/24/2025 at 3:34 p.m. with the DON, the DON stated the purpose of using a LALM is to help relieve skin pressure, help with wound healing and prevent pressure injuries. The DON stated it was important for residents that need a LALM used a LALM for wound prevention and comfort. The DON stated if a resident did not receive a LALM resident can potentially develop a pressure injury, pressure injury can get worse and it can create a slow healing process. The DON stated she did not know why Resident 1, 2, and 3 did not have a LALM. The DON stated TN should have noticed the LALM order during her treatment rounds with those residents and followed up on the order. The DON stated after a LALM got ordered it took 1 day for a resident to receive a LALM. The DON stated Resident 1, 2, and 3 had an order for a LALM and nursing should have provided a LALM to those residents. During a review of facility's Policy and Procedure (P&P) titled Skin and Wound Monitoring and Management, dated 4/2025, the P&P indicated it was the facility's policy for residents with pressure injuries to receive necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The P&P indicated to prevent the development of skin breakdown or prevent existing pressure injuries from worsening a pressure relieving/reducing and redistributing device (low air loss mattress) would be provided to residents.

Based on interview and record review, the facility did not ensure Braden scale assessment (tool used in Skilled Nursing Facilities to assess a patient's risk of developing pressure injuries [localized area of tissue damage that develops when prolonged pressure] or shear forces [horizontal force that causes the bony prominence to move across the tissue as the skin is held in place] are applied to the skin and underlying tissues) was accurately performed for one resident (Resident 1) out of 4 sampled residents. 1. Facility did not ensure Resident 1 was correctly assessed during Braden Scale assessment. 2. Facility did not ensure Nursing staff had the knowledge of scoring resident during the Braden Scale assessment. This deficient practice placed Resident 1 at a low risk of developing pressure injuries and potentially caused Resident 1 not to receive the preventive measures in developing pressure injuries. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis included pressure ulcer of sacral region (located at the base of the spine), stage 4 (full-thickness skin and tissue loss) and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P) dated 11/4/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), the MDS indicated Resident 1's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for toileting hygiene. The MDS indicated Resident 1 required supervision for oral hygiene. The MDS indicated Resident 1 required set up assistance for eating. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 11/8/2024, the Braden scale indicated Resident 1 had a score of 15 (Scores: 15 and above - low risk, 13-14 moderate risk, 10-12 high risk, and less than 9 severe risk). The Braden scale indicated Resident 1 had a low risk of developing a pressure injury. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 10/22/2024, the Braden scale indicated Resident 1 had a score of 15. The Braden scale indicated Resident 1 had a low risk of developing a pressure injury During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 10/15/2024, the Braden scale indicated Resident 1 had a score of 15. The Braden scale indicated Resident 1 had a low risk of developing a pressure injury. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 9/18/2024, the Braden scale indicated Resident 1 had a score of 15. The Braden scale indicated Resident 1 had a low risk of developing a pressure injury. During a review of Resident 1's Weights and Vitals Summary, dated 10/9/2024 - 11/09/2024, the Summary indicated Resident 1 lost 16 pounds in 1 month. The summary indicated Resident 1 weighed 113 pounds on 10/9/2024 and weighed 97 pounds on 11/9/2024. During a review of Resident 1's Interdisciplinary Team (IDT) Skin Review Notes, dated 10/18/2024, the IDT notes indicated Resident 1 had a sacrococcyx (fused bone formed by the sacrum and coccyx [tailbone]) pressure injury that was unstageable (a type of pressure ulcer where the wound bed is completely obscured by slough [dead tissue] or eschar [dead tissue that forms over healthy skin and over time falls off]. The IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown. During a review of Resident 1's Interdisciplinary Team (IDT) Skin Review Notes, dated 10/18/2024, the IDT notes indicated Resident 1 had a sacrococcyx pressure injury that was unstageable. IDT notes indicated Resident 1's health conditions were incontinence, compromised nutritional status and decreased sensory perception (ability to understand and interact with the environment using senses of sight, smell, hearing, taste, touch). IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown. During a review of Resident 1's IDT Skin Review Notes, dated 10/24/2024, the IDT notes indicated Resident 1 had a sacrococcyx pressure injury that was unstageable. The IDT notes indicated Resident 1's health conditions were incontinence, declining condition (a gradual decrease or deterioration in health or physical condition), compromised nutritional status and decreased sensory perception. The IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown During a review of Resident 1's IDT Skin Review Notes, dated 11/7/2024, the IDT notes indicated Resident 1 had a sacrococcyx pressure injury that was unstageable. The IDT notes indicated Resident 1's health conditions were incontinence, declining condition (a gradual decrease or deterioration in health or physical condition), compromised nutritional status and decreased sensory perception. The IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown. During a review of Resident 1's IDT Skin Review Notes, dated 11/14/2024, the IDT notes indicated Resident 1 had a sacrococcyx pressure injury that was unstageable. The IDT notes indicated Resident 1's health conditions were immobility, incontinence, malnutrition, declining condition, compromised nutritional status and decreased sensory perception. The IDT notes indicated Resident 1 was at risk for slow healing or worsening of wound due to poor oral intake and fragile appearance. The IDT notes indicated Resident 1 was at high risk for skin integrity breakdown. During an interview on 7/24/2025 at 1:29 p.m. with Treatment Nurse (TN), TN stated a Braden Scale was used to predict which resident had had a risk of developing pressure injuries. TN stated if a resident had a high Braden score it meant the resident had a low risk of developing a pressure injury. TN stated if a resident had a low Braden score nursing would implement interventions to prevent pressure injuries. TN stated if a resident was not eating and lost weight, the resident would get a lower Braden score and would put that resident at risk for developing a pressure injury. TN stated it was important to accurately assess residents to provide the correct care and identify residents that are at risk at developing pressure injuries. TN stated a resident with a pressure injury should not receive a low-risk Braden score, they should at least have a score of moderate risk. TN stated a resident with a low-risk Braden score should not have any pressure injuries. During an interview on 7/24/25 at 3:10 p.m. with the Director of Nursing (DON), the DON stated a Braden Scale was used to know if a resident was at risk of developing skin wounds. The DON stated she used the Braden Scale score to implement changes for residents at risk of developing skin breakdown. The DON stated if a resident sits on a wet diaper, they are at risk of developing a pressure injury. The DON stated it was important to accurately assess residents so they can get the care they need. The DON stated if a resident did not get a correct Braden Scale score, the resident had potential to develop a pressure injury or their pressure injury could get worse. The DON stated if a resident scored low, they had a low risk of developing a pressure injury and if they scored a high, they had a high risk of developing a pressure injury. The DON stated if a resident did not eat and was incontinent that would be a moderate risk of developing a pressure injury. The DON stated Resident 1 should not have a low risk of developing a pressure injury because she was incontinent, had weight loss, and was skinny. The DON stated resident 1's Braden Scale should have not been marked as rarely moist because she was incontinent and could be sitting on a wet diaper. During a review of facility's Policy and Procedure (P&P) titled Skin and Wound Monitoring and Management, dated 4/2025, the P&P indicated nursing staff would complete a Braden Scale to identify risks and to identify any alterations in skin integrity noted at that time.

Based on observation, interview, and record review, the facility failed to develop a care plan (a document that outlines a person's health needs and the care they required) for four out of four sampled residents (Resident 27, 71, 78, and 62) by failing to: 1. Ensure Resident 27 received a magic cup (a nutritious frozen supplement designed to enhance nutritional intake for individuals experiencing involuntary weight loss) on his lunch meal tray as indicated in Resident 27's physician orders and in his nutritional care plan. 2. Ensure a resident centered care plan was developed for Resident 71's vision impairment. 3. Ensure a care plan was developed for Resident 78's vision impairment. 4. Ensure the facility developed a care plan for Resident 62's medication refusal. This deficient practice had the potential to delay and negatively affect the delivery of care for Resident 71 and 78's vision impairment, Resident 27's nutritional intake, and Resident 62's overall health. Findings: 1. During a review of Resident 27's Admission Record, the Admission Record indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 27's diagnoses included dysphagia (difficulty swallowing), cerebral infarction (stroke, loss of blood flow to a part of the brain), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 27's Minimum Data Set ([MDS], a resident assessment tool), dated 2/27/2025, the MDS indicated Resident 27's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 27 was entirely dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 27's Nutritional Care Plan Interventions, initiated 3/6/2025, the Care Plan indicated Resident 27 was to receive magic cup with lunch [meals]. During a review of Resident 27's Physician Orders, dated 3/5/2025, the orders indicated Resident 27 was to receive magic cup one time a day for nourishment with lunch. During a concurrent interview and observation on 3/24/2025 at 12:46 p.m. with Certified Nursing Assistant (CNA) 1, while in Resident 27's room, Resident 27's food tray was observed. There was no magic cup on the tray. CNA 1 stated that she was not sure what a magic cup was. During a concurrent interview and record review on 3/24/2025 at 12:46 p.m. with CNA 1, Resident 27's meal slip, dated 3/24/2025, was reviewed. The meal slip indicated Resident 27 was to receive one magic cup on his meal tray. During a concurrent interview and observation on 3/26/2025 at 1:11 p.m. with the Dietary Supervisor (DS), a photo of Resident 27's lunch meal tray, dated 3/24/2025, timed at 12:44 p.m., was reviewed. The photo indicated Resident 27 received a plate of vegetables, ground meat, potatoes and a bread roll. The photo indicated there was an apple dessert and a glass of milk served on the side. The DS stated there was no magic cup on Resident 27's lunch meal tray on 3/24/2025. During a concurrent interview and record review on 3/26/2025 at 1:11 p.m. with the DS, Resident 27's Physician Orders, dated 3/2025, were reviewed. The Physician Orders indicated Resident 27 was to receive a magic cup once a day with his lunch meal. The DS stated the kitchen staff were to ensure all magic cups were placed on the meal tray. The DS stated that if the tray was missing a magic cup, the CNA staff would ask the kitchen staff to provide one. The DS stated if the magic cup was missing from Resident 27's lunch tray, then there was a possibility that Resident 27 did not get all his recommended nutrients for the meal. During an interview on 3/26/2025 at 2:43 p.m. with CNA 1, CNA 1 stated Resident 27's lunch meal tray did not have a magic cup, and she did not ask the kitchen for a magic cup because she did not know what a magic cup was. 2. During a review of Resident 71's Admission Record, the admission record indicated Resident 71 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and diabetic retinopathy (leading cause of vision loss in diabetic people. Diabetes damages blood vessels in the retina and the light sensitive tissue at the back of the eye). During a review of Resident 71's MDS, dated [DATE], the MDS indicated Resident 71's vision was moderately impaired (limited vision, not able to see newspaper headlines) The MDS indicated Resident 71's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 71 required moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Resident 71 required supervision for oral hygiene. During a review of Resident 71's History and Physical (H&P) dated 7/14/2025, the H&P indicated Resident 71 had fluctuating capacity to understand and make decisions. The H&P indicated Resident 71was legally blind. During a review of Resident 71's Care Plan for impaired vision, dated 7/19/2024, the care pan indicated Resident 71's goals was to attend activities of choice. The care plan interventions included playing cards, cooking and gardening. During an interview on 3/26/2025 at 3:22 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was important to develop a care plan for a resident that is vision impaired. LVN 1 stated a care plan should include interventions such as talking to the resident, playing music, reading to the resident and provide things for the resident to touch. During a concurrent interview on 3/27/2025 at 10:48 a.m. with the Assistant Director of Nursing (ADON), Resident 71's Care Plan, dated 7/19/2024, was reviewed. The ADON stated an intervention of playing cards was not an ideal intervention for a person with a vision impairment because they cannot see the cards. The ADON stated an intervention of gardening was not an appropriate intervention for a resident with a vision impairment because they could not see what they were doing. The ADON stated an intervention of cooking was not an appropriate intervention for a resident with a vision impairment because it placed the resident's safety at risk. The ADON stated these interventions were not resident centered because vision was important to carry out these interventions. The ADON stated it was important to develop a care plan that was resident centered for it to be beneficial to the resident. 3. During a review of Resident 78's Admission Record, the admission record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses of DM and left below the knee amputation (removal of limb). During a review of Resident 78's H&P, dated 12/19/2024, the H&P indicated Resident 78 had the capacity to understand and make decisions. During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78's cognitive skills for daily decision making were intact. The MDS indicated Resident 78 required moderate assistance for toileting hygiene, showering/bathing, and lower body dressing. The MDS indicated Resident 78 required setup assistance for eating, oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 78's Optometry Consultation Notes, dated 3/3/2025, the Optometry Consultation Notes indicated Resident 78 had a diagnosis of cataracts (condition where the lens of the eye became progressively opaque, resulting in blurred vision) on the left and right eyes. The Optometry Consultation Notes indicated Bifocal glasses (eyeglasses with two distinct optical powers correcting vision at both long and short distances) were recommended for Resident 78. During a review of Resident 78's electronic medical record there was no care plan located for Resident 78's vision impairment. During an interview on 3/27/2025 at 10:55 a.m. with the ADON, the ADON stated a care plan is a resident's plan of care that nursing staff must follow. The ADON stated residents' diagnosis are included in the resident's care plan. The ADON stated it was important to develop a care plan to provide goals and interventions for resident's medical condition. The ADON stated if there was no care plan it could affect the resident's quality of life, and their needs could possibly not be met. 4. During a review of Resident 62's Admission Record, the Admission Record indicated Resident 62 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 62's diagnoses included End Stage Renal Disease (ESRD- irreversible kidney failure), peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), and DM. During a review of Resident 62's MDS, dated [DATE], the MDS indicated Resident 62 had intact cognitive skills for daily decision making. The MDS indicated Resident 62 was independent (resident completed the activity by himself without assistance from a helper) with eating; required supervision with oral hygiene, toileting hygiene, and personal hygiene; and required moderate assistance with showering/ bathing self and transferring in-and-out of bed/ chair. The MDS indicated Resident 62 used a walker for mobility devices. During a review of Resident 62's H&P, dated 5/2/2024, the H&P indicated Resident 62 had fluctuating capacity to understand and make decisions. During a review of Resident 62's March Medication Administration Record (MAR), the MAR indicated Resident 62 refused auryxia (medication to treat high phosphorus levels for ESRD adults), clopidogrel (medication to prevent blood clots in PVD), and Rena Vite (a combination of B vitamins used to treat or prevent low vitamin due to poor diet and certain illnesses) at 5 p.m. on 4/12/2025, 4/19/2025, and 4/25/2025. The MAR indicated Resident 62 refused atorvastatin (medication to decrease the amount of fat that might build up on the walls of the arteries and block blood flow to the heart, brain, and other parts of the body) at 9 p.m. on 4/12/2025, 4/19/2025, and 4/25/2025. During an interview on 3/27/2025 at 1:25 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the assigned licensed nurse for the resident should develop the care plan when made aware of the resident's condition. LVN 2 stated the purpose of a care plan was to address the resident's condition and provide proper care. LVN 2 stated it would delay necessary care for the resident without a care plan. During a concurrent interview and record review on 3/27/2025 at 10:23 a.m. with the ADON, all Resident 62's Care Plans were reviewed. The ADON stated there was no Care Plan for Resident 62's medication refusal, and there should have been a Care Plan for medication refusal. The ADON stated it was the standard of practice for a licensed nurse to develop a care plan for Resident 62's medication refusal upon acknowledgment. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 12/2023, the P&P indicated the facility will implement a comprehensive person-centered care plan for each resident and will include resident's needs identified in the comprehensive assessment, and resident's goals and desired outcomes, and preferences for future discharge and discharge plan. The P&P indicated In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from a wheelchair to the bed. This deficient practice caused Resident 1 to fall, sustain a right distal femur fracture (thigh broken bone), was admitted to a general acute care hospital (GACH), and had an open reduction internal fixation ([ORIF]-surgical procedure to stabilize and heal a broken bone). Findings: During an interview on 8/12/2024 at 10:50 a.m., with Resident 1, Resident 1 stated on 8/2/2024 around 3:00 p.m., CNA 1 transferred her from the wheelchair to the bed using a Hoyer lift. Resident 1 stated the Hoyer lift sling broke and she fell . Resident 1 stated she had right femur surgery. Resident 1 stated she was unable to perform her bicycle exercises, was very upset, and was in pain. During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (abnormal blood sugar), hypertension (high blood pressure), and muscle weakness (decrease in muscle strength). During a review of Resident 1 ' s History and Physical (H&P), dated 7/9/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/11/2024, the MDS indicated Resident 1 had the ability to express ideas and wants, and had clear comprehension (capability of understanding something). The MDS indicated Resident 1 was totally dependent (full staff performance) with two persons physical assist for transfer (how the resident moves between surfaces including to or from bed, chair, wheelchair, or standing position). During a review of Resident 1 ' s Fall report dated 8/2/2024 timed at 3:45 p.m., the report indicated Resident 1 required a Hoyer lift for transfer. The report indicated on 8/2/2024, Resident 1 was being transferred from the wheelchair to the bed. The report indicated during the transfer, the Hoyer lift sling broke and Resident 1 fell on the floor. The report indicated Resident 1 ' s right leg was noted with slight swelling. The report indicated Resident 1 was assisted back to bed and reported 10 out of 10 pain on a pain scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain) to her right leg. During a review of Resident 1 ' s Situation, Background, Appearance, Review (SBAR) Communication Form, dated 8/2/2024, timed at 3:55 p.m., the SBAR indicated on 8/2/2024, at 3:50PM, Resident 1 slid off the Hoyer lift on to her right leg, when the lift ' s sling snapped (broke). The SBAR indicated Resident 1 ' s right leg was noted with slight swelling and the resident reported a level of 10 out of 10 pain. During a review of Resident 1 ' s Order Summary, dated 8/2/2024, the order summary indicated X-ray (a photographic image of a part of the body) of the right knee, and right hip. During a review of Resident 1 ' s X-ray result dated 8/2/2024, the X- ray result indicated acute (sudden) comminuted supracondylar (broken bone into more than two pieces) fracture of the right distal femur. During a review of Resident 1 ' s Progress Note dated 8/3/2024 timed at 9:30 a.m., the progress note indicated Resident 1 was transferred to the GACH for further evaluation and treatment due to a fall. During a review of Resident 1 ' s GACH Admission Record, dated 8/3/2024, the GACH admission record indicated Resident 1 was admitted to the GACH on 8/3/2024 with a diagnosis of acute right femoral fracture. During a review of Resident 1 ' s GACH Computed Tomography ([CT] a procedure that uses a computer linked to a machine to make a series of detailed picture of areas inside the body) Report, dated 8/3/2024 timed 4:05 p.m., the CT report indicated comminuted fracture of the right distal femur. During a review of Resident 1 ' s GACH Physician Daily Progress Note dated 8/5/2024, the GACH physician daily progress note indicated Resident 1 had an ORIF surgery for right distal femur fracture. During a review of Resident 1 ' s GACH Discharge Note, dated 8/8/2024, the discharge note indicated Resident 1 was discharged back to the facility. During a review of Resident 1 ' s Progress Note dated 8/8/2024 timed 3:07 p.m., the progress note indicated Resident 1 returned to the facility from the GACH with a diagnoses of status post (after) right knee ORIF. During an interview on 8/12/2024 at 3:00 p.m., with CNA 3, CNA 3 stated, on 8/2/2024 around 3:30 p.m., the Director of Nursing (DON) notified her that Resident 1 fell from the Hoyer lift, was on the floor, and the DON needed assistance to transfer Resident 1 back to bed. CNA 3 stated she went to Resident 1 ' s room and observed Resident 1 on the floor. CNA 3 stated the Hoyer lift strap was broken. CNA 3 stated the laundry aid ([LA] person who works in a facility washing and folding laundry) was responsible for checking the Hoyer lift straps for torn pieces and tears every wash. CNA 3 stated CNAs were responsible for checking the Hoyer lift prior to use. During an interview on 8/12/2024 at 3:38 p.m., with LA 1, LA 1 stated she was responsible for checking the Hoyer lift sling for any damages prior to washing and before folding. LA 1 stated after the sling was checked and good for use, she signed and initialed the facility ' s sling log. LA 1 stated reported to the maintenance supervisor ([MS] person responsible for repairs and keeping the facility safe and functional) for damaged and broken slings. LA 1 stated the MS was responsible for replacing damaged the slings. During a concurrent interview and record review on 8/12/2024 at 4:10 p.m., with MS 1, the facility ' s sling log dated 7/2024, and 8/2024 was reviewed. MS 1 stated the sling log indicated there was no entry on the log from 7/31/2024 through 8/8/2024. MS 1 stated he and other laundry staff were supposed to check the slings daily to ensure it was in good condition. MS 1 stated he was also responsible for the Hoyer lift ' s maintenance and replacement when damaged. MS 1 stated the facility ' s staff failed to check the sling and placed residents at risk for falls and injuries. During an interview on 8/12/2024 at 4:25 p.m., with the DON, the DON stated on 8/2/2024 at 3:30 p.m., CNA 1 notified her that while CNA 1 was transferring Resident 1 from the wheelchair to the bed with the Hoyer lift, the Hoyer lift ' s sling strap broke. The DON stated she immediately went to Resident 1 ' s room and observed Resident 1 on the floor next to her bed. The DON stated she (DON) and six other staff assisted Resident 1 into bed. The DON stated Resident 1 complained of right leg pain. The DON stated Resident 1 was dependent and required two persons assist for transfer. The DON stated CNA 1 should have asked for assistance from another staff to transfer Resident 1 via the Hoyer lift. The DON stated CNAs were responsible for checking the Hoyer lift sling for tears and torn pieces prior to resident use. During an interview on 8/12/2024 at 4:35 p.m., with the Director of Staff Development (DSD), the DSD stated there should have been a two person physical assist when operating the Hoyer lift. The DSD stated staff should assess the Hoyer lift sling(s) prior to each use for the residents ' safety and to prevent falls and injuries. During an interview on 8/13/2024 at 10:53 a.m., with CNA 1, CNA 1 stated on 8/2/2024 around 3:15 p.m., she was assisting Resident 1 with a Hoyer lift transfer from the wheelchair to bed. CNA 1 stated Resident 1 was seated in the wheelchair and the Hoyer lift sling was under Resident 1. CNA 1 stated there were four straps, two in front of Resident 1 and two on the back of Resident 1. CNA 1 stated she attached the four sling straps to the Hoyer lift. CNA 1 stated she was standing behind Resident 1 and while she started to lift Resident 1 with the Hoyer lift from the wheelchair, she (CNA 1) heard a loud noise. CNA 1 stated Resident 1 immediately fell to the floor. CNA 1 stated she noted that the right front sling strap was broken. CNA 1 stated she notified the DON right way. CNA 1 stated she was aware that Resident 1 was a two persons physical assist for transfer, and she should have asked another staff for assistance before transferring Resident 1 with the Hoyer lift. CNA 1 stated she was busy rushing to get her other assigned residents ' care done, did not ask for assistance, and did not assess the Hoyer lift prior to use. CNA 1 stated Resident 1 ' s fall could had been avoided if she asked for assistance and assessed the Hoyer lift prior to use. During a concurrent observation and interview on 8/13/2014 at 11:31 a.m., with the Administrator (ADM), in the ADM ' s office, the Hoyer lift sling used during Resident 1 ' s transfer on 8/2/2024 was observed. The ADM stated the front right strap of the sling was broken, and the other three straps (front left side, and two on the back side) were torn, worn, and ragged. The ADM stated the sling was unsafe for use and should have been thrown out. During a review of the facility ' s policy and procedure (P&P) tilted Fall Management System, revised 12/2023, the P&P indicated the facility will provide an environment free of accident hazards. The P&P indicated the facility will provide each resident with appropriate assessment and interventions to prevent falls. During a review of an undated Manufacturer ' s User Manual titled Invacare ([Invacare] manufacture of long-term care medical products), Manual/Electric Portable Patient Lift, the manual indicated staff will read the manual before using the Lift. The manual indicated a recommendation to use two persons assist for lifting and transferring procedures. The manual also indicated a one-person assist could be used based on the evaluation of the health care professional for each individual case. During a review of an undated Manufacturer ' s Operations and Maintenance Manual titled, Patient Slings, the manual indicated staff will read the manual before using the slings. The manual indicated staff will inspect the sling(s) for wear, tears, loose stitching, or broken sling(s)and immediately discard any damaged slings to prevent injury.

Based on interview and record review, the facility's staff failed to ensure a resident who exhibited high elopement (an act of leaving a safe area or safe premises unsupervised and undetected without permission) risk was provided with close supervision (an intervention and a means of mitigating accident risk) to prevent elopement for one of six sampled residents (Resident 1). Resident 1, who had wandering behavior (aimlessly move about within the building or grounds without appreciation of their personal safety) and was preoccupied with leaving the facility was not supervised and eloped from the facility twice within three hours (5 a.m. and 8:25 a.m.) on the same day (8/10/2021) after the facility failed to: 1. Implement appropriate interventions to closely supervise Resident 1 after being assessed as a high risk for elopement on admission (8/2/2021) and after the first episode of elopement on 8/10/2021 at 5 a.m. to prevent further elopements. 2. Re-assess Resident 1's risk for elopement after the resident eloped from the facility on 8/10/2021 at 5 a.m. and document the outcome of the re-assessment in the resident's medical records. 3. Communicate to all staff, including to the Director of Staff development (DSD) and the Admission Assistant (AA) Resident 1's first episode of elopement on 8/10/2021 at 5 a.m., so the DSD and AA will not take the resident outside the facility's entrance door and create an opportunity for the resident to elope again on 8/10/2021 at 8:25 a.m. These deficient practices resulted in Resident 1 leaving the facility without permission and running into oncoming traffic on a high traffic street in front of the facility while being chased by the facility's staff. This placed Resident 1 at risk for serious injury and/or death. On 8/12/2021 at 4:54 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared for lack of supervision of Resident 1. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the resident's health and safety being threatened. The facility submitted a Plan of Action (POA) for the correction of the IJ which included: 1. Resident 1 was sent to the hospital for further evaluation on 8/10/2021. If the resident was referred back to the facility, prior to his return, the facility would review his updated medical information to ensure the facility was able to meet his needs and will consult with the resident's attending physician. 2. All residents with high-risk scores for elopement were immediately identified and their care plans reviewed on 8/11/2021. Residents with wandering and or exit seeking behavior were closely monitored. There were six residents identified. On 8/11/2021, the care plan intervention for each of the six residents included frequent visual monitoring. 3. The elopement binder at each nurse's station were updated on 8/11/2021 with the current six residents at risk for elopement added, including their photos, emergency contacts, the residents' description, and any pertinent medical condition. 4. Licensed Nurses, Certified Nursing Assistants (CNAs), admissions staff, business office staff, housekeeping staff, therapy, activities staff, dietary, social services staff, receptionist, and maintenance staff were in-serviced on 8/11/2021 on 8/12/2021 regarding the six residents at high risk for elopement and the processes put in place to ensure their safety. 5. As of 8/13/2021, there were currently four residents with high-risk scores for elopements. The Care plan interventions included frequent visual monitoring, at least hourly, by the nursing staff. 6. All staff, including staff on vacation will receive training the processes put in place to ensure the safety of the residents identified as at high risk for elopement prior to their next scheduled shift for work. 7. The Minimum Data Set (MDS), (a standardized resident assessment and care planning tool) nurses re-evaluated all residents for their elopement risk utilizing the Elopement/Wandering Evaluation on 8/12/2021 to ensure all residents at risk for elopement have been properly identified. The elopement binder will be updated by nursing staff as soon as someone is identified as a high risk for elopement. The Interdisciplinary Team ([IDT] involves team members from different disciplines working collaboratively with a common purpose, to set goals, make decisions and share resources and responsibilities) will review the care plans for any newly identified high risk residents. 8. The Director of Staff Development (DSD) will provide nursing staff with re-training on facility's Policy and Procedure (P/P) on physician notification of any resident incident while in the facility, including but not limited to any unusual occurrence; prompt documentation and importance of ensuring accuracy of the resident medical record; the IDT will review the incident documentation each morning during stand-up meeting, and facility's P/P for Elopement and documentation. 9. The Clinical Resource/Governing Body Representative in-serviced the Administrator and the DON on 8/12/2021 regarding the facility's P/P for elopement and documentation. 10. The DON reviewed and updated the elopement binder on 8/12/2021 with all current high-risk residents to include photo of the resident, emergency contact, resident description, any pertinent medical conditions. 11. The facility will review the Unusual Occurrence Policy and policies related to timeliness of documentation at the next Quality Assurance & Assessment ([QAA] a program that identifies quality deficiencies and requires facilities to have a system for monitoring departmental performance data routinely to identify deviations in performance and adverse events) meeting. 12. The Resident Safety Committee will review all High risk residents weekly for four weeks and then quarterly to ensure the above plan is effective and followed. 13. The Maintenance Director will conduct elopement drills every month for six months. Results of these will be taken to our Monthly QAA for trending and recommendations. 14. Ongoing education will continue with evaluation of staff's understanding (of elopement procedures) with focus on monitoring and supervision of residents that are at risk for elopement and unsafe wandering. 15. The DON/Designee will review all new resident admissions within 24 hours to identify any risk factors for elopement or unsafe wandering to ensure that all interventions to mitigate those risk factors have been care-planned and communicated. 16. The DON/Designee will ensure employees receive education related to elopement risk and management of high-risk residents upon hire and annually. 17. The Administrator will present a summary of all elopement related interventions and share a summary to the Quality Assurance Performance Improvement ([QAPI] a program to improve the quality of life and quality of care and services delivered in nursing homes) Committee for review and recommendations monthly. During an interview with the ADM on 8/14/2021 at 4:07 p.m., the IJ was lifted after the team verified and confirmed on-site via observations, interviews, and record reviews that the POA was implemented. Findings: During a review of Resident 1's general acute care hospital (GACH 1), records, prior to the resident's admission to the skilled nursing facility (SNF), dated 8/2/2021, GACH 1 records indicated Resident 1 was alert and oriented, had history of homelessness, [CONDITION(S)] (the habitual misuse of alcohol), and [CONDITION(S)] (a late stage of fibrosis [scarring] of the liver caused by excessive alcohol consumption). During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated the facility admitted Resident 1 on 8/2/2021. Resident 1's diagnoses included difficulty in walking, [CONDITION(S)], metabolic [CONDITION(S)] (an alteration of brain function, due to a chemical imbalance in the blood), and a lack of coordination. During a review of Resident 1's Elopement /Wandering Evaluation, dated 8/2/2021, upon admission, the evaluation indicated Resident 1 was in the high-risk category for elopement and there was no updated evaluation after the resident eloped. During a review of Resident 1's care plans indicated there were no care plans created to address Resident 1's elopement and wandering behavior with preoccupation of leaving the facility until after the resident eloped twice on 8/10/2021 (at 5 a.m. and 8:25 a.m.). During a review of an email, dated 8/10/2021 and timed at 1:49 p.m., a complainant wrote Resident 1 was observed on 8/10/2021 at 8:25 a.m., running into oncoming traffic almost being struck by cars on a high traffic main street located in front of the facility, while being chased by numerous facility's staff members. Surveyor 1 confirmed the elopement of Resident 1 after viewing the facility's video surveillance camera (a system of monitoring activity in an area or building using a television system). During a review of Resident 1's late entry (L/E) Change of Condition (COC) evaluation, written by Licensed Vocational Nurse 2 (LVN 2), dated 8/10/2021 and timed at 3:26 p.m., the COC indicated Resident 1 was exit seeking on 8/10/2021 (no time specified). The COC indicated there were no changes observed for Resident 1's behavioral evaluation. The COC indicated Resident 1's assigned physician (Physician 1) was notified at 8 a.m. [sic] During a review of Resident 1's L/E Licensed Progress Notes (LPN) written by LVN 2, dated 8/11/2021 and timed at 3:39 p.m., the LPN indicated Resident 1 was observed exiting the facility, at an unspecific date and time, with staff behind him, monitoring him closely for safety. Resident 1 stopped and sat down on sidewalk. The LPN indicated the staff was able to talk Resident 1 into returning inside the facility. Resident 1 verbalized he wanted to go back to the place (school) he previously lived before coming to the facility. During a review of Resident 1's L/E LPN written by LVN 2, dated 8/11/2021 and timed at 3:43 p.m., for Resident 1's elopement that happened on 8/10/2021 indicated an order was received from Physician 1 (on 8/10/2021) to transfer Resident 1 to GACH 2 for a psychiatric evaluation (process of gathering information about a person with a psychiatric [specialist in the treatment of mental illness] service, with a purpose of making a diagnosis) and evaluation for substance abuse (type of substance was not identified). The LPN indicated the physician order was noted, carried out, and Resident 1 was notified of the new order. During an interview on 8/11/2021 at 2:57 p.m., LVN 1 stated he had to chase Resident 1 in the streets (on 8/10/2021 at 8:25 a.m.) because Resident 1 left the facility. LVN 1 stated he overheard the staff yelling Resident 1 was running away from the facility, and he (LVN 1) immediately went outside to help the other staff members chase Resident 1. LVN 1 stated he crossed the main street to get Resident 1, who stopped running, once he crossed the busy street, due to being tired. LVN 1 stated when he reached Resident 1, he was sitting on the street curb. During the interview on 8/11/2021 at 2:57 p.m., LVN 1 stated he asked Resident 1 why he ran away, and Resident 1 stated he did not want to be in the facility anymore. LVN 1 stated he then assisted Resident 1 back to the facility and notified the resident's assigned nurse, LVN 2, about Resident 1 eloping from the facility and wanting to leave the facility. LVN 1 stated he did not personally notify the Administrator (ADM) or the DON of Resident 1's elopement because he notified LVN 2, the assigned nurse. LVN 1 stated he did not physically assess Resident 1 once he was returned to the facility. LVN 1 stated he should have assessed the resident and document in Resident 1's clinical record about the elopement. During an interview with LVN 2 on 8/11/2021 at 3:08 p.m., LVN 2 stated LVN 1 notified her Resident 1 ran away from the facility (on 8/10/2021 at 8:25 a.m.). LVN 2 stated she was busy passing medication when Resident 1 ran away from the facility. LVN 2 stated LVN 1, along with other staff members, brought Resident 1 back to the facility. LVN 2 stated Resident 1 would wander around the facility frequently and stated she (LVN 2) was not monitoring Resident 1 for elopement. LVN 2 stated she did not physically assess Resident 1, after he eloped from the facility because he was fine and took all his morning medications. During the interview with LVN 2 on 8/11/2021 at 3:08 p.m., LVN 2 stated Resident 1 was transferred to GACH 2 on 8/10/2021 (no time specified) for a psychiatric evaluation and evaluation for substance abuse. LVN 2 stated she received an order for Resident 1 to have a psychiatric evaluation because the resident left the facility. LVN 2 acknowledged not documenting Resident 1's assessment after the elopement and documenting the physician order for the transfer to GACH 2. LVN 2 stated she did not document Resident 1's elopement because the resident was fine, but she did notify the ADM and DON. During an interview on 8/11/2021 at 3:46 p.m., LVN 3 stated she was passing the morning medications on 8/10/2021 (time not specified) during the day shift (7 a.m. to 3 p.m.), when she heard the receptionist mentioned Resident 1 ran away from the facility. LVN 3 stated Resident 1 wanders and pace back and forth in the facility's hallways. LVN 3 stated the staff should have closely monitored Resident 1, because he displayed behaviors of trying to leave the facility. LVN 3 stated during the change of shift (on the day shift [7 a.m. -3:30 p.m.]) huddle (communication), the nurses discussed the incident of Resident 1 eloping from the facility on 8/10/2021 and the DON was present. During an interview with the ADM and DON on 8/11/2021 at 5:27 p.m., the DON stated she was aware Resident 1 left the facility (on 8/10/2021 at 5 a.m. and 8:25 a.m.). The DON stated she arrived late for work on 8/10/2021 and was informed about Resident 1 leaving the facility. The DON stated she was informed by the (day shift) staff (not identified) Resident 1 needed fresh air and the DSD took Resident 1 outside, at the front of the facility. The DON stated the DSD had the Admissions Assistant (AA) relieve her while she (the DSD) went to the restroom and AA took over watching Resident 1. The DON stated Resident 1 was at the facility's front entrance outside near the busy street with the AA when the resident started running away from the facility while the AA called for help. The DON stated Resident 1 was ambulatory (able to walk unassisted), had exit seeking behavior and verbalized to the nursing staff on multiple occasions that he wanted to go home referring to the grounds of a school where he slept, while he was homeless. During the interview with the ADM and DON on 8/11/2021 at 5:27 p.m., the DON stated the nursing staff did not document or create a care plan of Resident 1's exit seeking behavior prior to Resident 1's elopement incidents. The DON stated the nurse (LVN 2) contacted Physician 1 on 8/10/2021 (time not specified) to notify him of Resident 1's exit seeking behavior which was considered a change of condition. The physician determined Resident 1 needed to be sent out due to his history of substance abuse and a need for a psychiatric evaluation. During the interview with the ADM and DON on 8/11/2021 at 5:27 p.m., the DON stated LVN 2 did not document Resident 1's elopement on 8/10/2021 and should have documented it at the time she received the order. The DON stated LVN 2 did not document the order for Resident 1's transfer or the details of the elopement because LVN 2 forgot. The DON stated LVN 2 documented Resident 1's transfer order (to GACH 2) more than 24 hours after receiving the physician order and after being interviewed by Surveyor 2 as a L/E. The DON stated it was not the facility's normal practice not to document residents' elopements, physician orders, and/or COCs with transfer details. During a subsequent interview with the ADM on 8/11/2021 at 5:46 p.m., in the presence of the DON, the ADM stated he was aware of Resident 1 leaving the facility on 8/10/2021(at 5 a.m. or 8:25 a.m.), as he arrived for work that morning and the staff were bringing Resident 1 back into the building. The ADM stated he had informal conversations with the staff about Resident 1 leaving the facility. During an interview on 8/13/2021 at 8:42 a.m., Resident 1, who is Spanish speaking only was interviewed and a translator used to interpreter, stated he left the facility twice on 8/10/2021 at 5 a.m. and 8:25 a.m. because he did not want to be there. Resident 1 stated on those two occasions he left the facility, a staff member brought him back. Resident 1 stated the last time he left (on 8/10/2021 at 8:25 a.m.) he was sent out to the hospital on the same day because the facility's staff did not want him to try to leave again. Resident 1 stated he told the nursing staff he wanted to go back to where he used to sleep. During an interview with the Activities Director (AD) on 8/13/2021 at 11:19 a.m., the AD stated she arrived for work on 8/10/2021 on the day shift (7 a.m.-3:30 p.m. [no time specified]) and just as she was putting down her belongings, she overheard the AA ask for help and she looked up and saw Resident 1 running from the facility. The AD stated she and LVN 1 chased after Resident 1. The AD stated Resident 1 ran across the busy street in front of the facility and then the resident sat down on the other side of the street sidewalk after becoming tired. The AD stated LVN 1, who was Spanish speaking, spoke with Resident 1 and kept him calm. During an interview with the DSD on 8/13/2021 at 11:25 a.m., the DSD stated Resident 1 wanted to go outside and get fresh air, so on 8/10/2021 (no time specified), she accompanied him to see how he was doing. The DSD stated after a few minutes of being outside with Resident 1, she asked the AA to relieve her and to stay with Resident 1 outside the facility. The DSD stated she was not present to witness Resident 1 run away from the facility. The DSD stated she saw staff bringing Resident 1 back to the facility and she notified the ADM and the DON. The DSD stated it was the licensed nurses' responsibility to document any unusual occurrence by the end of their shift. During a review of the facility's P/P titled, Elopement and Unsafe Wandering, dated 6/2018 indicated it was the facility's P/P to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Elopement is when a resident leaves the facility premises or a safe area without authorization and/or necessary supervision to do so. When the resident returns to the facility an assessment of the resident will be completed to determine if medical attention is required and provide interventions as indicated. Document relevant information in the resident's medical record. Notification to the appropriate state agency will be made within twenty-four (24) hours of the serious accident/incident. During a review of the facility's policy and procedure (P/P) titled, Documentation and Charting, dated 5/2009 indicated it was the facility's P/P to provide documentation pertaining to accidents/incidents involving residents which should include where the accident/ incident took place, the date and time the incident occurred, name of witnesses and their account of the accident/incident, the resident's account of the accident/incident, the time the physician was notified as well as the time the physician responded, the disposition of the resident such as transferred to hospital, and all pertinent observations.

Based on interview and record review, the facility failed to provide close supervision while a resident was ambulating (walking) as per the resident's plan of care and the facility's policy and procedure for one of three sampled residents (Resident 1). Resident 1, who had a recent fracture (broken bone), weakness, and risks for falling, was allowed to walk to the restroom without the assistance of the staff, use of a gait belt (device use for residents who have mobility problems to assist in stabilization and fall prevention by caregivers prior to moving residents) and/or use of Close Guard Assist ([CGA] to assist a resident and have one or two hands on the resident's body) as per Resident 1's care plan, felt dizzy and fell to the floor. These failures resulted in Resident 1 falling and injuring a previous fracture to the right lower leg tibia (inner and larger bone) and fibula (outer and narrower bone) and a new right distal femur (thighbone) fracture requiring a transfer to a general acute care hospital (GACH) and underwent an open reduction internal fixation ([ORIF] type of surgery used to stabilize and heal a broken bone) to the right leg. Findings: During a review of Resident 1's Admission Face sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included generalized muscle weakness, displaced (out of alignment) [NAME] fracture (break that occurs at the bottom of the tibia [shinbone] and involves the weight-bearing surface of the ankle joint) of right tibia and difficulty walking. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 5/18/2020, the MDS indicated Resident 1 had the ability to understand other and made herself understood. The MDS indicated Resident 1 required extensive assistance of a one-person physical assist for transferring (moving between surfaces including to or from: bed, chair, wheelchair, standing position) and toilet use. The MDS indicated Resident 1 was not steady for moving on and off toilet unless stabilized by staff assistance and had impairment on one side (not indicated) of the lower extremities (everything between the hip to the toes). During a review of Resident 1's care plan titled, ADL (activities of daily living) self-care Performance Deficit Related to Non-Weight Bearing ([NWB] no weight/pressure) to Right Leg, revised on 6/2/2020, the care plan indicated Resident 1 would safely perform toilet transfer with CGA. The staffs' interventions included to assist Resident 1 with a one-person physical assist for transfers on and off the toilet. During a review of Resident 1's Fall Risk Evaluation, dated 6/9/2020, the evaluation indicated Resident 1 was at medium risk for fall with a score of 10. According to the Fall Risk Evaluation Grid 0-5=low risk, 6-10=medium risk and 11-35=high risk. During a review of Resident 1's History and Physical (H/P), dated 7/7/2020 and timed at 2:40 p.m., the H/P indicated Resident 1 was seen by the Nurse Practitioner ([NP] an advanced practice registered nurse trained to assess resident's needs, order interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe treatment/medications) and indicated Resident 1 required CGA for transfers. During a review of Resident 1's Change in Condition (COC) evaluation, dated 7/7/2020, the COC indicated on 7/7/2020 at 10:10 p.m. CNA 1 caught Resident 1 while the resident was falling when ambulating (walking) to the restroom. The COC indicated Resident 1 cried in pain and was yelling, I think I broke my leg again. The COC indicated Resident 1 had declined in her abilities in ambulation (walking), mobility and transferring. The COC also indicated Resident 1 was noted with bruising (discoloration), swelling and pain on her right knee, front side of the right lower leg, and outer side of the right ankle. According to the COC, the Nurse Practitioner ([NP] advanced practice registered nurse trained to assess residents' needs, interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe treatment plan) was notified and gave orders for a STAT (immediate) x-ray of the right leg. During a review of Resident 1's Fall Committee Interdisciplinary Team ([IDT] group of health care professionals with various areas of expertise who work together toward the goals of the residents) notes, dated 7/8/2020 and timed at 10:14 a.m., the IDT note indicated upon ambulating to the restroom, Resident 1 had a fall. The IDT note indicated on 7/7/2020 at 10:10 p.m., Resident 1 was asking for help, but the staff was not able to understand the resident because of a language barrier. During a review of Resident 1's x-ray results of the right leg done on 7/8/2020 and timed at 11:33 a.m., the results indicated Resident 1 had a right knee acute displaced distal (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) femoral supracondylar (thigh bone break at the knee) fracture and acute displaced fractures of the right distal tibia (inner and larger bone) and fibula (outer and narrower bone). During a review of Resident 1's nurses Progress Note (NPN), dated 7/8/2020 and timed at 8:46 p.m., the NPN indicated an untimed late entry for 7/7/2020 written by Licensed Vocational Nurse 1 (LVN 1), which indicated LVN 1 ran into Resident 1's room after hearing CNA 1 yelling out for help. The NPN indicated upon LVN 1 entering the room Resident 1 was leaning forward holding on to her walker and CNA 1 behind the resident. The NPN indicated Resident 1's right leg was noted in an irregular position during assessment and was then transferred by LVN 1, and CNAs 1 and 2 to a raised shower chair located near the resident. During a review of the facility's internal investigation interview report, dated 7/8/2020, the investigation report indicated Resident 1 stated she asked CNA 1 to walk behind her as the other CNAs does. The report indicated the day of the fall on 7/7/2020, CNA 1 walked in front of Resident 1 and the resident fell . During an interview on 9/18/2020 at 1:57 p.m., Resident 1 stated on 7/7/2020 she asked CNA 1 to assist her to the restroom. Resident 1 stated she asked CNA 1 to walk behind her as the other nurses did, but CNA 1 refused and walked in front of her. Resident 1 stated CNA 1 was not able to assist her while inside the restroom when she asked for help after she felt dizzy. Resident 1 stated CNA 1 moved her head side-to-side saying No Spanish, and then shortly after remembered hearing a pop sound and her weight shifting to the right as she was falling to the ground. During a concurrent interview and review on 9/18/2020 at 3:06 p.m., of the physical therapy ([PT] the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) assessments, Occupational Therapist ([OT] health care professionals who promote independence, meaningful occupations, and residents' functional ability to fulfill their daily routines and roles) indicated Resident 1 required one-person physical assist to transfer from wheelchair (w/c) to toilet and back to w/c. The OT stated Resident 1 was assessed as a non-weight bearing as tolerated to the right lower leg due to an external fixator (surgical treatment wherein rods are screwed into bone and exit the body to be attached to a stabilizing structure on the outside of the body). The OT stated on 6/22/2020, the order for NWB as tolerated (by the resident) was given by the orthopedic doctor (specialized in care and treatment of bones, joints, ligaments, nerves, and tendons [the tissue that connects bones and joints]) and meant weight bearing as tolerated by Resident 1. During a concurrent interview and record review on 9/28/2020 at 4:02 p.m., of all Resident 1's care plans and interview statement, and in the presence of the Administrator (ADM), Interim Director of Nursing (IDON) stated during the investigation Resident 1 stated CNA 1 was walking in-front of her when the resident fell to the ground. The IDON stated and confirmed a care plan created on 2/17/2020 indicated Resident 1 required a one-person physical assist to transfer onto toilet. The IDON stated the staff had received in-service on how to transfer residents with fractures and utilizing a gait belt. During an interview on 9/29/2020 at 3:30 p.m., CNA 1 stated on 7/7/2020 at approximately at 11 p.m. she got Resident 1 up from bed utilizing the walker and walking resident to the restroom. CNA 1 stated she did not utilize a gait belt to assist Resident 1 during ambulation or transfer to the toilet, instead she was holding Resident 1 from the back of her gown while ambulating and walking the resident. CNA 1 stated she was in-serviced on the use of a gait belt when ambulating residents but did not utilize the gait belt on the night Resident 1 fell . CNA 1 stated she left Resident 1 in the restroom and allowed her privacy, but Resident 1 slid leaning backwards and CNA 1 able to hold her and prevent her from falling [sic]. CNA 1 stated she was sorry or what happened to Resident 1 and for her not utilizing a gait belt to assist the resident. During an interview on 9/29/2020 at 7:39 p.m., CNA 3 stated being in-service on the use of a gait belt when transferring or ambulating a resident. CNA 3 stated gait belts are helpful during transfers and help prevent falls when ambulating a resident. During an interview on 9/29/2020 at 7:47 p.m., Director of Staff Development (DSD) stated staff was in-serviced on the use of a gait belt when ambulating or transferring a resident and each carries their own gait belt. During an interview on 9/30/2020 at 11:41 a.m., Resident 2 stated not witnessing how Resident 1 fell but does remember hearing Resident 1 yelling out for help. Resident 2 stated she did not see any staff CNA assisting Resident 1 to the toilet or walking behind her. Resident 1 stated from her bed, she was only able to see Resident 1's hands holding on to the walker. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to understand and understood others. During an interview on 10/6/2020 at 11:40 a.m., the Physical Therapist Aide ([PTA] aides perform nonmedical tasks, such as setting up and cleaning treatment rooms and transporting patients to different areas of a health care facility) stated gait belts are used depending on the status of each resident. The PTA stated it was always recommended to use a gait belt when transferring or ambulating residents. During a review of the facility's undated policy and procedures (P/P) titled, Gait Belt/Transfer, the P/P indicated it was the policy of the facility to prevent injuries to employees and residents (back strain or potential for chronic disability, resident falls or fractures) by the use of the gait belt allowing the resident and aide to feel more secure during a transfer. The P/P indicated for staff to place gait belt around resident's waist, grasp from the back and walk on resident's weakside and a little to the back. The P/P indicated to place gait belt around a resident's waist for a one-person transfer and a resident that can bear weight.

Based on interview and record review, the facility's nursing staff failed to provide cardiopulmonary resuscitation ([CPR] chest compression and artificial breathing used to maintain blood circulation to the brain) immediately upon confirming there was no pulse (heart rate) for one of three sampled residents (Resident 1), as per the facility's policy to commence CPR and according to the American Heart Association (AHA) and the nursing standards of practice to provide immediate CPR and delegate assignments to unlicensed staff. Resident 1 was found unresponsive (unable to respond or wake-up) without vital signs (clinical measurements such as pulse rate, temperature, respiration rate, and blood pressure, indicating the state of a resident's essential body functions) and two (2) CPR certified facility's staff members, Certified Nurse Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) observed Resident 1 unresponsive and left the resident unattended (unspecified amount of time) without initiating CPR immediately. This deficient practice resulted in a delay in life sustaining measures for Resident 1, who was found unresponsive without vital signs on [DATE] at approximately 9:50 a.m. Resident 1 was pronounced deceased in the facility on [DATE] at 10:10 a.m., approximately 20 minutes after being found unresponsive. On [DATE] at 2:45 p.m., the Administrator (ADM) and the Director of Nursing (DON), were notified of the Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called for the facility's failure to provide the necessary care and emergency services immediately by not performing CPR on Resident 1 (F678). The facility's ADM and DON were notified of the immediacy and seriousness of the residents' health and safety being threatened. On [DATE] at 6:30 p.m., the ADM, and DON submitted an acceptable Plan of Action (POA) for the correction of the IJ which included: 1. The DON and Registered Nurse (RN) Clinical Resource conducted and in-service regarding the updated guidance and practices for CPR from the American Heart Association and the facility's Policy on CPR. The training was assigned to all Licensed Nurses and CNA's. 2. The DON and RN Clinical Resource conducted a review of the nursing personnel employee file for their CPR certifications. Licensed Nurses and CNAs who are on the work schedule would have current CPR Certification on file. 3. The DON and Director of Staff Development (DSD) were CPR re-certified on [DATE]. 4. A certified CPR instructor conducted two mock Code-Blue (simulation exercise to practice CPR skills) exercises on [DATE]. 5. The DON and RN Clinical Resource reviewed all resident's records for their Code Status on [DATE] and 34 residents out of 57 were identified as Full Code (request heroic measures, such as CPR for resuscitation). 6. The staff were in-service on the facility's CPR policy was initiated on [DATE] by the RN Clinical Resource and the DON on providing basic life support and CPR to a resident who requires emergency life support and/or resuscitative care; availability of staff who can provide CPR; directing staff when to initiate basic life support; confirming resident's code status in an emergency and maintaining current CPR certification for healthcare providers through a CPR provider whose training included hands on practice and in-person skills assessment. Including documentation during the Code Clue and return demonstration. 7. Licensed Nurses and CNAs will receive a CPR refresher in-service quarterly for one year by the DON or designee. 8. The DON and RN clinical Resource will conduct a review of each Code Blue for three months. Any concerns will be brought to the quality assessment and performance improvement ([QAPI] team for by various members, such as doctors, nurses, therapist, administrator, working together to achieve and perfume quality care assessments to deliver a resident-center care) committee for further review and follow-up. On [DATE] at 5:46 p.m., during a concurrent observation, interview and record review, while onsite, the RN Clinical Resource, DON and ADM were notified the IJ was lifted, after the team verified the Plan of Action (POA) was followed and implemented. Findings: A review of Resident 1's general acute care hospital (GACH) Transfer Report, dated [DATE] and timed at 11:45 a.m. indicated Resident 1 to be transfer to a Skill Nursing Facility (SNF) for intravenous ([IV] into the vein) antibiotic (medication to treat infections) therapy for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The transfer report indicated Resident 1 had history of infection in the urine with urine retention (unable to void voluntarily). The report indicated to not remove Resident 1's urinary catheter (thin flexible plastic tube inserted into the bladder to provide continuous urinary drainage). A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the Skilled Nursing Facility from the GACH on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and Physical (H/P), dated [DATE] and timed at 4:30 p.m. indicated Resident 1 did not have the mental capacity to understand and make medical decisions. The H/P indicated Resident 1 was a full code (if a resident's heart stopped beating and/or stopped breathing, all resuscitation procedures such as chest compressions, intubation (tube inserted through the residents throat to deliver air to the lungs), and CPR would be provided to keep the resident alive). The H/P indicated Resident 1's [CONDITION(S)] had clinically improved and was not expected to die within six (6) months. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Licensed Progress Notes, dated [DATE] and created at 5:16 p.m., indicated a timeline of the events occurring on [DATE]: At 8 a.m., Resident 1 was in bed awake and refused to eat. At 8:45 a.m., Restorative Nurse Assistant ([RNA] acquires special knowledge, skills, and techniques in therapeutic rehabilitation) provided range of motion (ROM) exercise and oral care. At 9:30 a.m., LVN 2 went to assess Resident 1, resident breathing with mouth opened and warm to touch. At 9:50 a.m., CNA 1 stated upon entering Resident 1's room to perform morning care (bed bath, linen change, oral care, clothing change, and hair combing), Resident 1's chest was not rising and reported to LVN 1, who was near the room. The licensed progress note indicated Resident 1 was a full code and CPR was initiated by LVN 1. At 9:55 a.m., paramedics were called to the facility while CPR was in progress. At 10 a.m., Resident 1's Responsible Party (RP) notified. At 10:05 a.m., paramedics arrived to the SNF while CPR was in progress and then resumed by paramedics [sic]. At 10:10 a.m., paramedics pronounced Resident 1 deceased . A review of Resident 1's Vital Signs Record for [DATE] indicated Resident 1's vital signs were not taken on the morning of [DATE]. A review of a Prehospital Care Report Summary, documented by the 911 paramedics emergency services, dated [DATE] indicated a call was received from the facility at 10:01 a.m., and the paramedics were assisting Resident 1 at 10:08 a.m. The report indicated Resident 1 was pulseless, unresponsive, with pupils fix and dilated (pupils may become fixed and dilated before the heart and respiration stops, or it may occur after), pale, cold, and apneic (stop breathing). The Report Summary indicated Resident 1 was last seen well at 9:30 a.m., and unresponsive [sic]. The report indicated paramedics found Resident 1 supine (lying face upward) positioned in bed with rigor mortis (stiffening of the joints and muscles of a body that usually occurs a few hours after death) to her chin and lividity (reddish to purplish discoloration of the skin due to settling and pooling of blood) to her back. The resident had a blood pressure of 0 ([B/P] ,d+[DATE]-,d+[DATE] normal reference ranges [NRR]), respirations of 0 (NRR is ,d+[DATE] breaths per minutes [bpm]), pulse of 0 beats per minute 0 ([bpm] NRR ,d+[DATE] bpm) and oxygen saturation (oxygen in the blood) at 0 percent (%) room air ([NRR] ,d+[DATE]%). The Report Summary indicated Resident 1 was pronounced deceased at 10:10 a.m. with no CPR attempted by the paramedics. A review of the Center for Medicare & Medicaid Services (CMS) All Facility Letter Reference S & C ,d+[DATE]-NH, revised on [DATE] indicated that prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including CPR, to a resident who experiences [CONDITION(S)] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a DNR order. The L&C Letter indicated that CPR-certified staff must always be available. A review of Resident 1's death certificate indicated the resident expired on [DATE] at 10:10 a.m., with the immediate cause of death listed as cardiopulmonary failure (sudden loss of blood flow), [CONDITION(S)] and [CONDITION(S)] (abnormal movement of the body such as tremors and impaired speech), and dementia. On [DATE] at 4:44 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated the facility neglected (failure to care for properly) the resident by not providing adequate care and not notifying him of Resident 1's declining condition. Resident 1's RP stated, the facility killed her. On [DATE] at 3:10 p.m., during a telephone interview, CNA 1 stated while she was providing morning care to Resident 1's roommate on [DATE], she noticed Resident 1 was not moaning like she normally did. CNA 1 stated she checked Resident 1's wrist for pulse and was unable to attain one. On [DATE] at 12:42 p.m., during a subsequent telephone interview, CNA 1 stated on [DATE] she found Resident 1 unresponsive and did not initiate CPR. CNA 1 stated she did not initiate CPR because, I didn't know how to do it, I have a CPR card but didn't feel comfortable and I have never been in-service by the facility to do CPR and I am new. CNA 1 stated she ran out of the room to call for help after finding Resident 1 pulseless. On [DATE] at 3:07 p.m., during a telephone interview, CNA 2 stated on [DATE] CNA 1 had notified LVN 2 Resident 1 was not feeling well and was refusing to eat but LVN 2 did not check on Resident 1. CNA 2 stated multiple Licensed Nurses were notified for several days of Resident 1 not feeling well and not eating but they would say it was fine. CNA 2 stated it was not the first time a CNA reported to LVN 2 of a resident's change of condition (COC) and LVN 2 not follow-up and assess the resident. CNA 2 stated the supervisors had been made aware of LVN 2's disregard to assess residents when there was a COC reported by the CNAs. CNA 2 stated CNA 1 asked her to help provide postmortem (after death) care for Resident 1. CNA 2 stated Resident 1's body was cold to touch and had discolored bruising on her legs. On [DATE] at 3:38 p.m., during a telephone interview, LVN 2 stated she did not remember going into Resident 1's room after she was notified by CNA 1 of the resident not eating. LVN 2 stated, I did rounds upon the start of my shift ([DATE]), after that, I did not go back to see the residents. LVN 2 stated she did not go see Resident 1 because she was passing medications. On [DATE] at 5:09 p.m. during a telephone interview, LVN 1 stated on [DATE] at approximately 10 a.m., CNA 1 reported Resident 1 was unresponsive with no pulse. LVN 1 stated after checking for a pulse and identifying Resident 1 was pulseless, she ran out of the room to call a Code Blue and grab the crash cart. LVN 1 stated she left CNA 1 in the room with Resident 1. LVN 1 stated CNA 1 did not initiate CPR on Resident 1. LVN 1 stated per the facility's policy, the staff are supposed to initiate CPR immediately to provide oxygen to the brain upon finding a resident pulseless. LVN 1 stated she did not initiate CPR on Resident 1 because she left the room to call for help. LVN 1 stated she should have had CNA 1 call for help, while she initiated CPR but she did not. On [DATE] at 11:55 a.m., during a telephone interview, physician (Physician 1) stated he was informed Resident 1 had a change of condition. Physician 1 stated rigor mortis meant the joints and muscles of Resident 1 were stiff and usually occurred two hours or more after death. Physician 1 stated lividity (bruising appearance) was the pulling of the blood and usually took between six to eight hours to start showing. Physician 1 stated if the paramedics identified lividity and rigor mortis, it meant Resident 1 was dead for a while. On [DATE] at 2:14 p.m., during an interview, the DSD stated when a resident was found unresponsive, the responsibility of the staff was check airway, breathing, circulation and last chest compressions. The DSD stated Resident 1 should not have been left alone. On [DATE] at 2:33 p.m. during an interview, the DON stated CPR should be initiated upon identifying a resident was pulseless. The DON stated LVN 1 should have stayed with Resident 1 and have CNA 1 call for help. On [DATE] at 2:45 p.m., during an interview, CNA 3 stated when a resident was found pulseless, first check airways, respirations, pulse and finally start chest compressions. CNA 3 stated chest compressions are initiated after the airway was check for obstruction [sic]. A review of the AHA article dated, 2020 indicated Cardiopulmonary Resuscitation was an emergency lifesaving procedure performed when the heart stops beating. The AHA article indicated immediate CPR can double or triple chances of survival after [CONDITION(S)] by keeping blood flow active. The article indicated for healthcare providers and those trained to first ask loudly if she/he is ok, if no reaction check breathing If the resident is not breathing or is only gasping, administer CPR. The AHA indicated to give CPR hard and fast by pushing down at least two inches at a rate of 100 to 120 pushes a minute in the center of the chest, allowing the chest to come back up to its normal position after each push and continue pushing until the person starts to breathe or move, or until someone with more advanced training takes over, such as an EMS team member. https://cpr.heart.org/en/resources/what-is-cpr A review of the facility's policy and procedure (P/P) titled, Cardiopulmonary Resuscitation last revised on ,d+[DATE] indicated cardiopulmonary resuscitation (CPR) is instituted in cases of recognized cardiac and/or pulmonary arrest until medical emergency personnel are available to take over the resuscitation efforts. Cardiopulmonary resuscitation is instituted on all residents except those designated as No Code or No CPR. The P/P indicated the staff would check for unresponsiveness, call out for help, call 911, position the resident on a flat surface and start chest compressions.

Based on interview and record review, the facility failed to implement a resident's plan of care and the facility's policy and procedures (P/P) to report to the physician several Change of Condition ([COC] a sudden clinically deviation from a resident's baseline in physical, cognitive [thought process], behavioral, or functional domains) for one of three sampled residents (Resident 1). Resident 1, who exhibited several COCs that included refusal to eat and drink adequate amount of fluid, high and low blood sugar levels, weight loss and abnormal laboratory results, were not reported to the physician as stipulated Resident 1's care plan and the facility's P/P (crossed referenced to F692). These deficient practices resulted in the physician not being able to accurately assess, diagnose and provide adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of the general acute care hospital (GACH) Transfer Report, dated [DATE] and timed at 11:45 a.m., indicated Resident 1 to be transfer to a Skill Nursing Facility (SNF) for Intravenous ([IV] into the vein) antibiotic (medication to treat infections) therapy for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The transfer report indicated Resident 1 had history of infection in the urine with urine retention (unable to void voluntarily). The report indicated to not remove Resident 1's indwelling urinary catheter (thin flexible plastic tube inserted into the bladder to provide continuous urinary drainage). A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical (H/P), dated [DATE] and timed at 4:30 p.m. indicated Resident 1 did not have the mental capacity to understand and make medical decisions. The H/P indicated Resident 1 was a Full code (if a resident's heart stopped beating and/or stopped breathing, all resuscitation procedures such as chest compressions, intubation, and CPR would be provided to keep the resident alive. The H/P indicated Resident 1's [CONDITION(S)] had clinically improved and Resident 1 was not expected to die within six (6) months. A review of Resident 1's care plan titled, Nutritional Problem or Potential Nutritional Problem related to Diabetes (high blood sugar levels), created on [DATE] indicated the resident will not experience weight loss/gain of three (3) pounds and will not experience signs and symptoms of malnutrition. The staffs' interventions included to offer meal replacement if the resident ate less than 50 percent (%), monitor and report to physician as needed for any signs and symptoms of decreased appetite, unexpected wight loss, monitor laboratory results, and monitor intake. A review of Resident 1's Nutritional/Hydration Risk Evaluation, dated [DATE] indicated Resident 1 indicated a score of 10. The Risk Evaluation indicated any scores above 10 required the staff to initiate a protocol immediately and documented in the care plan (no other specifications were indicated). The Risk Evaluation indicated Resident 1 had a fluid intake of 1000 to 2000 milliliters (ml) a day [sic]. A review of Resident 1's Activities of Daily Living (ADL) report indicated Resident 1 consumed the following fluid: On [DATE] consumed 120 ml On [DATE] through [DATE] (5 days), no fluids were documented as received the staff documented N/A (which indicated not applicable) On [DATE] consumed 360 ml On [DATE] consumed N/A On [DATE] consumed 220 ml On [DATE] consumed 120 ml On [DATE] consumed 600 ml On [DATE] consumed 100 ml On [DATE] consumed 410 ml On [DATE] consumed 120 ml On [DATE] consumed 600 ml On [DATE] consumed 503 ml On [DATE] consumed 120 ml On [DATE] consumed N/A A review of Resident 1's Activities of Daily Living (ADL) report indicated Resident 1 consumed the following amount of food percentage (%): On [DATE] Resident 1 consumed 0% On [DATE] consumed ,d+[DATE]% of dinner On [DATE] through [DATE] consumed 0% On [DATE] consumed ,d+[DATE]% of dinner On [DATE] consumed 25% of alternative dinner On [DATE] consumed ,d+[DATE]% of dinner On [DATE] consumed ,d+[DATE]% of dinner On [DATE] consumed ,d+[DATE]% of dinner On [DATE] consumed ,d+[DATE]% of breakfast On [DATE] consumed ,d+[DATE]% of breakfast On [DATE] consumed 0% consumed A review of Resident 1's Weight and Vitals Summary sheets, dated [DATE] through [DATE] indicated Resident 1 lost seven (7) pounds, 6.5 percent (%) of weight in 15 days as follow: [DATE], 108 pounds, a day after admission [DATE], 106 pounds [DATE], 101 pounds A review of Resident 1's laboratory results collected on [DATE] and received on [DATE] at 11:12 a.m., indicated sodium was 137 (helps maintain normal blood pressure, supports the work of nerves and muscles, and regulates body's fluid balance [normal reference range [NRR ,d+[DATE] milliEquivalents per liter [mEq/L]), Blood Urea Nitrogen was 14 ([BUN] test measures the amount of nitrogen in the blood that comes from the waste product [NRR 7.,d+[DATE].0]), potassium was 4.3 ([NRR is 3.5 to 5.0 millimoles] electrolyte that the body needs to work properly by helping the nerves and muscles to contract) and creatinine was 0.6 (supplies energy to muscles) were within normal range. A review of Resident 1's laboratory results collected on [DATE] at 3:20 a.m. and received on [DATE] at 7:03 a.m., indicated the sodium was elevated at 156 mmol/L, BUN/Creatinine was elevated at 42.2 mg/dl, potassium was borderline low at 3.9 mEq/L, and the white blood cells ([WBC] cells of the immune system that protect the body against both infectious disease and foreign invaders) were high at 16.68 There was no documented evidence to indicate Resident 1's abnormal lab results were reported to the physician. A review of Resident 1's ADLs report from [DATE] through [DATE] indicated Resident 1 had no urine out-put documented by the CNAs. A review of Resident 1's physician order, dated [DATE] indicated to administer 100 units/ml of regular [MEDICATION(S)] (intermediate-acting insulin with a slower onset of action than regular insulin and a longer duration of activity up to 24 hours) insulin injected subcutaneously (under the skin) as per sliding scale: for blood sugars of 401 to 999 administer 12 units of insulin and call physician. A review of Resident 1's Order Summary Report with an order date of [DATE] indicated to report blood sugar checks to the physician if above 400 milligrams (mg)/deciliters (dl) or below 70 mg/dl before meals and at bedtime. A review of Resident 1's Weight and Vitals Summary sheet for the month of ,d+[DATE] indicated on [DATE] at 1:20 p.m. Resident 1 had a high blood sugar level of 475 mg/dl. The summary sheet did not indicate insulin (protein hormone used as a medication to treat high blood sugar) was administered and the blood sugar levels rechecked 15 minutes after as indicated per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Licensed Progress Note and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (medication use to increase blood sugar levels) 1 milligram intramuscularly (into the muscle) for [CONDITION(S)] (low blood sugar) of 70. The order indicated to administer and wait 15 minutes and recheck blood sugar and notify physician immediately. A review of Resident 1's Weight and Vitals Summary sheet for the month of ,d+[DATE] indicated Resident 1 had a low blood sugar of 49 mg/dl (normal reference range [NRR],d+[DATE] mg/dl) on [DATE] at 3:50 p.m. and at 4 p.m. it was 122 mg/dl. There was no documented evidence to indicate Resident 1's physician was notified of the low blood sugar. A review of Resident 1's Licensed Progress Notes and the MAR, dated [DATE] did not indicate Resident 1 received [MEDICATION(S)] as indicated per physician orders. There was no documented evidence to indicate Resident 1's physician was notified of the COC. A review of Resident 1's Licensed Progress Note, dated [DATE] through [DATE] there was no documentation the physician was notified Resident 1 was not eating, refusing to drink and losing weight. A review of Resident 1's Vital Signs (clinical measurement of pulse rate, temperature, respiration rate, and blood pressure the indicate the state of a resident's essential body function) for [DATE], indicated no vital signs were taken for the morning of [DATE]. A review of a Prehospital Care Report Summary, documented by the 911 paramedics emergency services, dated [DATE] indicated a call was received from the facility at 10:01 a.m., and the paramedics were assisting Resident 1 at 10:08 a.m. The report indicated Resident 1 was pulseless, unresponsive, with pupils fix and dilated (pupils may become fixed and dilated before the heart and respiration stops, or it may occur after), pale, cold, and apneic (stop breathing). The resident had a blood pressure of 0 ([B/P] ,d+[DATE]-,d+[DATE] normal reference ranges [NRR]), respirations of 0 (NRR is ,d+[DATE] breaths per minutes [bpm]), pulse of 0 beats per minute 0 ([bpm] NRR ,d+[DATE] bpm) and oxygen saturation (oxygen in the blood) at 0 percent (%) room air ([NRR] ,d+[DATE]%). The Report Summary indicated Resident 1 was pronounced deceased at 10:10 a.m. with no CPR attempted by the paramedics. On [DATE] at 4:44 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated the facility neglected (failure to care for properly) the resident, did not provide adequate care and did not notify him of Resident 1's declining condition. Resident 1's RP stated while crying, The facility killed her. The RP stated the facility was not feeding or providing fluid to Resident 1. On [DATE] at 3:07 p.m., during a telephone interview, CNA 2 stated on [DATE] CNA 1 notified LVN 2 Resident 1 was not feeling well and was refusing to eat but LVN 2 did not check on Resident 1. CNA 2 stated multiple Licensed Nurses were notified Resident 1 had several days of not feeling well and not eating but they would say it was fine. CNA 2 stated it was not the first time the CNAs reported to LVN 2 of a resident's change in condition (COC) and LVN 2 not assessing the residents. CNA 2 stated the supervisors had been made aware of LVN 2's disregarding to attend when resident's COC was reported by the CNAs. On [DATE] at 3:38 p.m., during a telephone interview, LVN 2 stated not remembering going into Resident 1's room after she was notified by CNA 1 of the resident not eating. LVN 2 stated, I did rounds upon the start of my shift, after that, I did not go back to see the residents. LVN 2 stated not being able to go see Resident 1 because she was passing medications. On [DATE] at 11:55 a.m., during a telephone interview, physician (Physician 1) stated not being informed by the facility's staff of Resident 1 having changes in conditions. On [DATE] at 2:33 p.m., during a concurrent interview and record review of Resident 1's MARs, Licensed Progress Notes, Vital Signs Sheets and the Order Summary, in the presence of the MRD (medical records director), the DON stated there was no documentation of Physician 1 being notified of Resident 1's elevated blood sugar of 475 mg/dl on [DATE] and the administration of insulin, as indicated per the resident's care plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:31 a.m., during a telephone interview, Resident 1's Nurse Practitioner ([NP] nurse qualified to treat certain medical conditions without the direct supervision of a doctor) stated the facility did not notify her regarding Resident 1 not eating, drinking or of the high/low blood sugars levels. The NP stated the facility had orders to notify the physician when Resident 1 had abnormal blood sugar levels and the facility's staff should have contacted her if the resident was having a COC. The NP stated Resident 1 was not a hospice (end of life care) resident and was not expected to die soon. On [DATE] at 6:08 p.m., during a concurrent interview and review of Resident 1's MARs, Licensed Progress Notes, Vital Signs sheet and the Order Summary, in the presence of the MRD, the DON stated and confirmed the facility's staff failed to notify Resident 1's physician and document the following: a. Resident 1's seven (7) pound weight loss from [DATE] through [DATE] (15 days). b. Resident 1's blood sugar levels of 475 mg/dl on [DATE] without receiving insulin and rechecking 15 minutes after blood sugar levels as indicated per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] c. Resident 1's low blood sugar level of 49 mg/dl on [DATE] without documentation and administration of [MEDICATION(S)] as ordered by the physician. d. Resident 1's refusal to eat and drink fluids. On [DATE] at 5:11 p.m., during a concurrent interview and record review, the DON stated the facility's staff was not documenting Resident 1's urine output. The DON stated Resident 1 was admitted to the facility with an indwelling urinary catheter (thin flexible tube that collects urine from the bladder and leads to a drainage bag) and staff members should have been monitoring the urine output. On [DATE] at 1:10 p.m., during a telephone interview, the NP stated the facility has protocols for catheter output and they should have followed it. The NP stated per nursing standards of practice, the staff should have documented the urine output to make sure Resident 1 was having output since she had chronic urinary retention. The NP stated the staff should have monitored the urine output for sediment (particles that make urine look cloudy), color and amount and report to physician. A review of the facility's undated policy and procedures (P/P) titled, Change in Condition, indicated all COCs would be communicated to the resident's physician. The P/P indicated the staff would notify the physician of the resident's status as soon as possible before, during or after the COC and document the information in the clinical chart. The P/P indicated any sudden or serious change in physical or mental status will be communicated to the physician with request for a physician visit promptly. The P/P indicated a comprehensive care plan would be completed. A review of the facility's undated P/P titled, Intake and Output, indicated the facility staff was to maintain a record of the urine output to monitor residents' adequate fluid balance. The policy indicated at the end of each 24-hour cycle, the staff would document on the resident's chart the total input and output.

Based on interview and record review, the facility failed to ensure nutritional and hydration (the absorption of or combination with water) care and services were provided to prevent weight loss and dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake) for one of three sampled residents (Resident 1). Resident 1, who required assistance from the staff with eating and drinking fluids, was not provided enough fluid and food as per the resident's plan of care and the facility's policy and procedure. This deficient practice of the staff not ensuring Resident 1 received adequate food and fluids resulted in Resident 1 losing 6.75 percent (%) of body weight in 15 days and had abnormal laboratory results due to inadequate hydration. Resident 1's death certificate indicated the resident expired on [DATE] at 10:10 a.m., with the immediate cause of death listed as cardiopulmonary failure (sudden loss of blood flow) and [CONDITION(S)] (infection in the blood). Findings: A review of Resident 1's general acute care hospital (GACH) Transfer Report, dated [DATE] and timed at 11:45 a.m. indicated for Resident 1 to be transfer to a Skill Nursing Facility (SNF) for Intravenous ([IV] into the vein) antibiotic (medication to treat infections) therapy for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The transfer report indicated Resident 1 had history of infection in the urine with urine retention (unable to void voluntarily). The report indicated to not remove Resident 1's indwelling catheter (thin flexible plastic tube inserted into the bladder to provide continuous urinary drainage). A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's history and physical (H/P), dated [DATE] and timed at 4:30 p.m. indicated Resident 1 did not have the mental capacity to understand and make medical decisions. The H/P indicated Resident 1's [CONDITION(S)] had clinically improved and to continue monitoring. The H/P indicated Resident 1, was not expected to die within the next six (6) months. A review of Resident 1's care plan titled, Nutritional Problem or Potential Nutritional Problem related to Diabetes (high blood sugar levels), created on [DATE] indicated the resident will not experience weight loss/gain of three (3) pounds and will not experience signs and symptoms of malnutrition. The staffs' interventions included to offer meal replacement if the resident ate less than 50 percent (%), monitor and report to physician as needed for any signs and symptoms of decreased appetite, unexpected wight loss, monitor laboratory results, and monitor intake. A review of Resident 1's Nutritional/Hydration Risk Evaluation, dated [DATE] indicated Resident 1 indicated a score of 10. The Risk Evaluation indicated any scores above 10 required the staff to initiate a protocol immediately and documented in the care plan (no other specifications were indicated). The Risk Evaluation indicated Resident 1 had a fluid intake of 1000 to 2000 milliliters (ml) a day [sic]. A review of Resident 1's Activities of Daily Living (ADL) report indicated Resident 1 consumed the following: On [DATE] consumed 120 ml On [DATE] through [DATE] (5 days), no fluids were documented as received the staff documented N/A (which indicated not applicable) On [DATE] consumed 360 ml On [DATE] consumed N/A On [DATE] consumed 220 ml On [DATE] consumed 120 ml On [DATE] consumed 600 ml On [DATE] consumed 100 ml On [DATE] consumed 410 ml On [DATE] consumed 120 ml On [DATE] consumed 600 ml On [DATE] consumed 503 ml On [DATE] consumed 120 ml On [DATE] consumed N/A A review of Resident 1's Activities of Daily Living (ADL) report indicated Resident 1 consumed the following amount of food percentage (%): On [DATE] Resident 1 consumed 0% On [DATE] consumed ,d+[DATE]% of dinner On [DATE] through [DATE] consumed 0% On [DATE] consumed ,d+[DATE]% of dinner On [DATE] consumed 25% of alternative dinner On [DATE] consumed ,d+[DATE]% of dinner On [DATE] consumed ,d+[DATE]% of dinner On [DATE] consumed ,d+[DATE]% of dinner On [DATE] consumed ,d+[DATE]% of breakfast On [DATE] consumed ,d+[DATE]% of breakfast On [DATE] consumed 0% consumed A review of Resident 1's Weight and Vitals Summary sheets, dated [DATE] through [DATE] indicated Resident 1 lost seven (7) pounds, 6.5 percent (%) of weight in 15 days as follow: [DATE], 108 pounds, a day after admission [DATE], 106 pounds [DATE], 101 pounds A review of Resident 1's laboratory results collected on [DATE] and received on [DATE] at 11:12 a.m., indicated sodium was 137 (helps maintain normal blood pressure, supports the work of nerves and muscles, and regulates body's fluid balance [normal reference range [NRR ,d+[DATE] milliEquivalents per liter [mEq/L]), Blood Urea Nitrogen was 14 ([BUN] test measures the amount of nitrogen in the blood that comes from the waste product [NRR 7.,d+[DATE].0]), potassium was 4.3 ([NRR is 3.5 to 5.0 millimoles] electrolyte that the body needs to work properly by helping the nerves and muscles to contract) and creatinine was 0.6 (supplies energy to muscles) were within normal range. A review of Resident 1's laboratory results collected on [DATE] at 3:20 a.m. and received on [DATE] at 7:03 a.m., indicated the sodium was elevated at 156 mmol/L, BUN/Creatinine was elevated at 42.2 mg/dl, potassium was borderline low at 3.9 mEq/L, and the white blood cells ([WBC] cells of the immune system that protect the body against both infectious disease and foreign invaders) were high at 16.68 There was no documented evidence to indicate Resident 1's abnormal lab results were reported to the physician. A review of Resident 1's Licensed Progress Note, dated [DATE] through [DATE] there was no documentation the physician and/or NP were notified Resident 1 was not eating, refusing to drink and losing weight. A review of Resident 1's Licensed Progress Note, dated [DATE] and timed at 5:16 p.m. indicated at 8 a.m., Resident 1 was in bed awake and refused to eat. On [DATE] at 4:44 p.m., during a telephone interview, Resident 1's Responsible Party (RP) stated the facility's staff neglected (failure to care for properly) the resident. The RP stated the staff did not provide adequate care, which included feeding and providing fluid to Resident 1 and did not notify him of Resident 1's declining condition and he attempted to meet and/or communicate with the staff on several occasions to no avail. The RP stated on one occasion, while visiting the facility the staff was giving Resident 1 the wrong diet of regular texture food when she was supposed to have a pureed diet (consists of foods with a smooth pudding-like consistency, without chunks or different textures). The RP stated Resident 1 was not receiving the IV medications that were ordered and when he would complain nothing was done. The RP stated while crying, the facility killed her. On [DATE] at 3:07 p.m., during a telephone interview, Certified Nurse Assistant 2 (CNA 2) stated on [DATE] CNA 1 notified Licensed Vocational Nurse 2 (LVN 2) Resident 1 was not feeling well and was refusing to eat but LVN 2 did not check on Resident 1. CNA 2 stated multiple Licensed Nurses were notified Resident 1 had several days not feeling well and not eating but they would say it was fine. CNA 2 stated it was not the first time the CNAs reported to LVN 2 of a resident's change in condition (COC) and LVN 2 not assessing the residents. On [DATE] at 3:38 p.m., during a telephone interview, LVN 2 stated not remembering going into Resident 1's room after she was notified by CNA 1 of the resident not eating. LVN 2 stated, I did rounds upon the start of my shift, after that, did not go back to see the residents. LVN 2 stated not being able to go see Resident 1 because she was passing medications. On [DATE] at 1:52 p.m., during an interview and record review, the Medical Records Director (MRD) stated there was no notes from the Registered Dietitian ([RD] trained nutrition professional) visit. On [DATE] at 9:31 a.m., during a telephone interview, Resident 1's Nurse Practitioner ([NP] nurse qualified to treat certain medical conditions without the direct supervision of a doctor) stated the facility did notify her regarding Resident 1 not eating or drinking. The NP stated the facility had orders to notify the physician when Resident 1 had a COC. The NP stated it was assumed the facility staff would contact her if a resident was having a COC. The NP stated Resident was not a hospice (end of life care) resident and was not expected to die soon. On [DATE] at 6:08 p.m., during a concurrent interview and record review of the Medication Administration Records (MAR), Licensed Progress Notes, Vital Signs sheet and the Order Summary from [DATE] through [DATE] and in the presence of MRD, the Director of Nursing (DON) stated and confirmed the facility staff failed to notify Resident 1's physician (Physician 1) and document in the clinical chart Resident 1's seven (7) pound weight loss from [DATE] through [DATE] (15 days) and resident's refusal to eat and drink fluids. The DON stated the staff should had been notifying the physician of Resident 1's COCs. A review of the undated facility's policy and procedure titled Hydration, indicated it was the policy of the facility to provide each resident with enough fluid intake to maintain proper hydration and health. The policy indicated abnormal laboratory values (elevated hemoglobin and hematrocrit, potassium, chloride, sodium, [MEDICATION(S)], blood urea nitrogen (BUN), or urine specific gravity) were indicative of dehydration and fluids will be offered with each resident contact. The policy indicated the staff's interventions included to offer fluids at a minimum of every two (2) hours for the dependent resident, unless contraindicated and for the residents who refuse fluids, have propensity for dehydration or evidence a need for increased fluids, will be placed on a fixed schedule for monitoring intake. Results will be appropriately recorded on the Intake and Output form.

Based on interviews and record review, the facility failed to follow its policy and procedures to ensure a resident's transfer/discharge was appropriate for one of one sampled resident (Resident 1). Resident 1, who was not independent in care and required physical assistance with all activities of daily living ((ADLs) grooming, toileting, walking. etc.) was discharged to a general acute care hospital (GACH) to be placed in a different nursing facility (SNF). This deficient practice resulted in Resident 1, who required a SNF care, being inappropriately discharged on [DATE] to the (GACH) Emergency Department (ED) for them to obtain placement for the resident. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 4/3/2020 indicated Resident 1's cognitive skills (ability to reason and think) for daily decision-making were intact and was able to understand and be understood by others. The MDS indicated Resident 1 required limited assistance of a one-person physical assist for transfer, locomotion, eating and dressing. According to the MDS, Resident 1 was unsteady in walking and transferring from surface to surface and was dependent of a walker and wheelchair for ambulation. A review of Resident 1's document titled, Social Services-Discharge evaluation, dated 4/3/2020 indicated under discharge plan, there was no definitive discharge plan. A review of Resident 1's document titled, Social Services Assessment/Evaluation, dated 4/4/2020 indicated Resident 1 required monitoring of [MEDICAL CONDITION] behavior and rehabilitation services of physical/occupational therapy. A review of Resident 1's care plans revealed a care plan for discharge was not created. A review of Resident 1's physician's orders, dated 4/20/2020 did not indicate an order for [REDACTED]. A review of Resident 1's Licensed Progress note, dated 4/20/2020 and timed at 4:06 p.m., indicated Resident 1 was transferred to the GACH on 4/20/2020 at 4 p.m. via public independent transportation service. A review of Resident 1's unsigned and undated Physician's Discharge Summary did not indicate a summary of Resident 1's final [DIAGNOSES REDACTED]. The policy indicated when the facility transfers or discharges a resident the record should have a physician documentation if the transfer or discharge was appropriate and a copy of the discharge summary should be completed. A review of Resident 1's Notice of Proposed Transfer/Discharge, dated 4/20/2020 indicated Resident 1 did not sign the transfer form as indicated in the facility's policy. A review of the Social Service Director (SSD) notes dated 4/20/2020 and timed at 4:06 p.m., indicated on 4/20/2020 at 4 p.m., Resident 1 was discharged to the GACH's ED. The progress note indicated to discharge Resident 1 to the ED for proper placement. On 5/28/2020 at 11:50 a.m., during a telephone interview, the GACH's Case Manager (GCM) stated on 4/20/2020 Resident 1 called her and said the nursing home was getting ready to discharge him from the facility without having a place to go. The GCM stated Resident 1 did not want to be discharge but was being forced by the facility's Social Services Director (SSD) to leave. The GCM stated the GACH did not have a placement for Resident 1. On 5/28/2020 at 1:52 p.m., during a telephone interview, GACHs Social Worker (SW) stated Resident 1 was sent to the GACHs ED to find placement. The GACHs SW stated the facility should have not sent Resident 1 alone because of his difficulty walking and aggressive and forgetfulness behavior. The SW stated Resident 1 tested positive for COVID (highly contagious virus) upon his arrival to the ED. The SW stated she did not understand why the facility discharge Resident 1 without a placement and with COVID-19 being on the rise. On 5/28/2020 at 2:15 p.m., during a telephone interview, Resident 1 stated how they got him out of the facility was horrible. Resident 1 stated nobody deserves to be treated the way he was, like a piece of s**t (expletive). Resident 1 stated he had informed the Social Service Director (SSD) he had no place to go or stay. Resident 1 stated he told the SSD he was not feeling safe out in the streets because of COVID-19. Resident 1 stated he was asked to leave the facility and no paperwork was given to him to sign upon leaving the facility. Resident 1 stated he felt angry because of the way he was thrown out of the facility and did not have anywhere to go. On 6/3/2020 at 1:36 p.m., during a telephone interview and a review of Resident 1's Discharge Summary, the Director of Nursing (DON) stated the discharge summary should include the physician's summary, address the resident was being transferred to, final diagnosis, physician's signature for approval of discharge and status of the resident. The DON stated after careful review of Resident 1's clinical record, there was no Notice of proposed Transfer/Discharge found. The DON stated there was no discharge order for Resident 1 or notification to the primary physician or Resident 1's discharge/transfer to the GACH. The DON stated the facility's SSD discharged Resident 1 to the GACH's ED without a physician's order. On 6/3/2020 at 3 p.m., during a telephone interview, Licensed Vocational Nurse 1 (LVN 1) stated she discharged Resident 1 because she was asked by the SSD to do so. LVN 1 stated, I would never discharge a resident via Uber, that is unsafe, it does not sound safe. On 6/3/2020 at 3:12 p.m., during a telephone interview the director of medical records (DMR) stated there was no discharge orders found in Resident 1's clinical record. On 6/4/2020 at 9:34 a.m., during a telephone interview, the SSD stated discharge of residents are done once a physician's order had been obtained. The SSD stated once an order was obtained, she would ensure the transfer and placement was safe for the resident. The SSD stated she was not aware of the facility's policy and procedures for discharging a resident. The SSD stated she believed Resident 1's discharge was safe and appropriate because the GACH was the resident's choice of discharge. The SSD stated on 4/20/2020 she ensured Resident 1 got into the Uber car and the driver had the correct address of the GACH. On 6/4/2020 at 4:01 p.m., during a telephone interview, LVN 2 stated on 4/20/2020 at approximately 3 p.m., the SSD requested for Resident 1 to be discharged to the GACH. LVN 2 stated he did not verify the physician's discharge order and the SSD was in a hurry to discharge Resident 1 from the facility because the Uber driver was waiting outside the facility. LVN 2 stated Resident 1 was not assessed by the physician prior to discharge and there was no physician order for [REDACTED].>A review of the facility's policy and procedures, revised on 11/2016 and titled, Admission, Transfer and Discharge, indicated when the facility transfers or discharge a resident, the resident's record should have a physician documentation if the transfer or discharge was appropriate and a copy of the discharge summary should be completed. A review of the facility's undated policy and procedure titled, Physician Orders-CA, indicated verbal orders must be recorded immediately in the resident's chart by the person receiving the order. A review of the facility's Social Services job description indicated the primary job of the SSD was to assist in planning, developing, organizing, implementing, evaluating, and directing social services programs in accordance with the Federal, State and local standards, establish policies and procedures, and participate in discharge planning.

Based on interview and record review, the facility failed to follow its policy and procedures and a resident's plan of care to ensure when a resident had a change of condition (C[NAME]), the physician was immediately notified for one of three sample residents (Resident 1). For Resident 1 who had vomiting episode on [DATE], the licensed nurse did not notify the resident's physician (cross refer F757). This deficient practice resulted in a delay of provision of care, delay of transfer, and Resident 1 being transferred to a general acute care hospital (GACH) with low blood pressure and being unresponsive. Resident 1 died within the first hour of arriving to the GACH on [DATE]. Findings: A review of Resident 1's Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. The Admission Record indicated Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment care screening tool), dated [DATE], indicated Resident 1 was independent in decision making with no memory problems. The MDS indicated Resident 1 needed supervision oversight of one-person physical assist for eating. The MDS indicated Resident 1 experienced frequent episodes of moderate pain. A review of Resident 1's care plan dated [DATE] titled, The Resident is at Risk for Pain Related to Weakness, Knee Replacement, and Femur Fracture, indicated the resident would be able to verbalize pain relief. The staff's intervention included to anticipate the resident's need for pain relief and respond immediately; evaluate its effectiveness, monitor/document the causes of each pain episode and observe for any signs/symptoms of constipation (inability to pass stool), nausea and vomiting (regurgitation of stomach contents) and record the resident's pain intensity and characteristics and report findings to the primary physician. A review of a Nurse's Progress Note, dated [DATE] and timed at 7:26 a.m., indicated that Certified Nurse Assistant 1 (CNA 1) reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had a vomiting episode. The progress note indicated that CNA 1 provided Resident 1 with a breakfast tray after cleaning up after vomiting. The progress note did not indicate that the physician was notified of the episode as per the plan of care. A review of a Nurses' Progress Note, dated [DATE] and timed at 4:22 p.m., indicated that milk of magnesium ((MOM) laxative-used for stool pass more easily) was given to Resident 1 due to complaints of constipation. On [DATE], at 8:26 p.m., a [MEDICATION NAME] (stool softener) suppository was inserted rectally due to the MOM being ineffective and the resident continued to complain of constipation. A review of a Situation/Background/Assessment/Recommendations ((SBAR) internal communication), dated [DATE] and timed at 2:20 p.m., indicated that on [DATE] at medication pass, Resident 1 was found unarousable (unable to wake up) with eyes opened, but not responsive to the staff. Resident 1's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) were obtained with the skin cold and clammy (wet or sweaty skin). The SBAR indicated that on [DATE] at 7:30 a.m., Resident 1 informed a Certified Nurse Assistant (CNA) that she was tired and closed her eyes back again. A review of Resident 1's Nurses' Notes, from [DATE] through [DATE] did not indicate that the physician was notified of Resident 1's episode of vomiting and constipation on [DATE]. On [DATE] at 10:17 a.m., during an interview, CNA 1 stated that on [DATE] approximately at 7:30 a.m., she went to the resident's room to wake up Resident 1 and to give resident her breakfast tray. Resident 1 opened her eyes and stated she felt tired and was going back to sleep. CNA 1 stated that on the morning that she transferred the resident to the bed, she did not notice anything wrong and did not remember if the vital signs were normal or not. On [DATE] at 12:15 p.m., during an interview and record review, Registered Nurse 1 (RN 1) stated and confirmed that vomiting was considered a C[NAME] and should have been reported to the resident's physician. RN 1 stated that when a C[NAME] was identified, the resident was placed on a 72-hour monitoring and the primary physician and responsible party were notified. RN 1 stated that there was no documentation found in Resident 1's clinical record that the physician was notified of the resident's C[NAME]. RN 1 stated, If it's not documented it means it wasn't done. On [DATE] at 2:10 p.m., during an interview and record review, the Director of Nursing (DON) stated the vomiting was considered a C[NAME] and the staff should had notified the physician. A review of the Paramedic Run Sheet, dated [DATE] and timed at 9:31 a.m., indicated that Resident 1 was found lying in bed unresponsive with a low blood pressure. A review of the GACH emergency department (ED) record, dated [DATE] and timed at 10:23 a.m., indicated Resident 1 arrived at the ED at 10 a.m., via ambulance, responsive to verbal stimuli, but slow to respond, non-verbal, lethargic (sluggish), pale, unable to attain blood pressure, heart rate of 80 beats per minute (bpm (NRR for pulse is ,[DATE] bpm)), 99 Fahrenheit (F) rectal temperature, oxygen saturation of ,[DATE] (NRR-Normal Reference Range is 95 to 100 percent (%)). A review of the ED report dated [DATE] and timed at 10:10 a.m., indicated Resident 1 became unresponsive had no pulse and was not breathing; chest compression initiated and was noted that coffee ground material came out from the resident's mouth, upon suctioning, 900 milliliters (ml) of the coffee ground material was positive for hematemesis (vomiting of blood), and positive guaiac (blood invisible in the feces) test was perform. At 10:11 a.m., on [DATE] a code blue (emergency announced when a patient was in cardiopulmonary arrest) initiated, [MEDICATION NAME] (used to treat low heart rate and severe low blood pressure) and [MEDICATION NAME] calcium (corrects metabolic acidosis during a [MEDICAL CONDITION]) was given. At 10:44 a.m., Resident 1 expired. A review of Resident 1's death certificate dated [DATE] and timed of death at 10:44 a.m., indicated the resident's first cause of death was [MEDICAL CONDITION] and hypertension (high blood pressure). A review of the facility's policy and procedures titled, Change of Condition, created on (YEAR), indicated that the facility staff would assess, document and communicate C[NAME] with findings to the physician. The P/P indicated that C[NAME]'s would be documented at least once a shift. A resident having a C[NAME] will be assessed and monitored as often as necessary and once each shift and the licensed nurse reports findings to physician.

Based on interview and record review, the facility failed to ensure that one of three-sampled resident (Resident 1) was free from receiving medications with the same drug therapy effects, without adequate monitoring of the effects and potential adverse consequences of the seven medications prescribed, and without pain rating scale of routine pain medications in accordance with the resident's care plan and facility policy. These deficient practices resulted in Resident 1 found unresponsive and requiring a transfer to the general acute care (GACH) where he was diagnosed with [REDACTED]. Resident 1 died on e hour after admission on [DATE]. Findings: A review of Resident 1's Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. The Admission Record indicated Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated [DATE], indicated Resident 1 was independent of decision consistency and reasonable with no memory problems. The MDS indicated Resident 1 needed supervision oversight of one-person physical assist for eating. The MDS indicated Resident 1 experienced frequent moderate pain. A review of Resident 1's Admission Nursing Assessment, dated [DATE] and timed at 8 p.m., indicated that Resident 1 was admitted for rehabilitation (process that helps a person in recovering from serious injury, illness or surgery) and skilled nursing care. Resident 1 had no pain present at time of assessment and all home medications reconciled (comparison of medications the patient is taking) with the facility's admission medications. A review of Resident 1's care plan titled, Admission Baseline, dated [DATE] indicated that resident's pain would be at a minimum and the resident would not experience medication adverse reaction (unexpected or dangerous reaction to a drug). The staff interventions included to administer medications as ordered by physician and monitor reactions of opioids (medications used to treat moderate to severe pain) and Black Box medications warnings (strictest warning put in the labeling of prescription drugs when there is evidence of a serious hazard with the drug). A review of Resident 1's care plan titled, The Resident is at Risk for Pain Related to Weakness, Knee Replacement, and Femur Fracture, dated [DATE] indicated that the resident would be able to verbalized pain relief. The staff intervention included to anticipate the resident's need for pain relief and respond immediately, evaluate its effectiveness, monitor/document causes of each pain episode and observe for any signs/symptoms of constipation, nausea, vomiting, agitation, hallucination, restlessness, confusion, dizziness, and record resident's pain intensity and characteristics. A review of Resident 1's Physician order [REDACTED]. 1) [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] drug) 15 milligrams (mg) one tablet by mouth (PO) every (q) morning for pain management, start date of [DATE]. 2) [MEDICATION NAME] (pain medication) ,[DATE] mg, give one tablet by PO q four (4) hours (hrs.) as needed (PRN) for pain start date of [DATE]. 3) [MEDICATION NAME] ,[DATE] mg, give one tablet PO q six (6) hrs. for pain management, start date of [DATE]. 4) [MEDICATION NAME] (use to treat muscle spasm) 10 mg, give one tablet by PO q day for muscle spasm, start date of [DATE]. 5) [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 600 mg, give one tablet by PO q three times a day (TID) for [MEDICAL CONDITION] (Weakness, numbness, and pain from nerve damage, usually in the hands and feet) pain, start date of [DATE]. 6) [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] drug) 600 mg, give one tablet by PO q six (6) hrs. for pain management, start date of [DATE]. 7) Aspirin (blood thinner and nonsteroidal anti-[MEDICAL CONDITION] drug) 81 mg, give one tablet by PO at bedtime, start date of [DATE]. A review of Resident 1's MAR for the month of [DATE] to [DATE] indicated the resident received the following medications: [REDACTED] Aspirin 81 mg q day, five (5) doses received [MEDICATION NAME] ,[DATE] mg q 6hrs. one (1) dose received [MEDICATION NAME] ,[DATE] mg q 4hrs. PRN two (2) doses received [MEDICATION NAME] 10 mg q day, five (5) doses received [MEDICATION NAME] 15 mg q day, two (2) doses received [MEDICATION NAME] 600 mg q TID, 11 doses received [MEDICATION NAME] 600 mg q six (6) hrs. 16 doses received Non-pharmacological interventions done, seven (7) in four days for repositioning limb Highest level of pain recorded ,[DATE] from pain (numerical scale) from [DATE] through [DATE] A review of the facility's document tiled, Controlled or Antibiotic Drug Record, dated ,[DATE] indicated Resident 1 received [MEDICATION NAME] ,[DATE] mg PO q six (6) hours for pain management (4 doses) on [DATE] at 1:25 p.m., [DATE] at 2:30 a.m., and 9:39 a.m., on [DATE] at 9:45 a.m. A review of Resident 1's Nurses Notes, dated [DATE] and timed at 9:15 a.m., indicated during the medication pass, Resident 1 was found unarousable with eyes open, respirations present, and unable to respond to the staff. At 9:18 a.m., blood pressure (BP) ,[DATE], heart rate 72, respirations 17 per minute. A review of a Situation/Background/Assessment/Recommendations ((SBAR) internal communication), dated [DATE] and timed at 2:20 p.m., indicated that on [DATE] at medication pass, Resident 1 was found unarousable (unable to wake up) with eyes opened, but not responsive to the staff. Resident 1's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) were obtained with the skin cold and clammy (wet or sweaty skin). The SBAR indicated that on [DATE] at 7:30 a.m., Resident 1 informed a Certified Nurse Assistant (CNA) that she was tired and closed her eyes back again. On [DATE] at 10:17 a.m., during an interview, CNA 1 stated that on [DATE] approximately at 7:30 a.m., she went to the resident's room to wake up Resident 1 to give resident her breakfast tray. CNA 1 stated that Resident 1 opened her eyes and said she felt tired and was going back to sleep. CNA 1 stated that on that morning she transferred the resident to the bed and did not notice anything wrong and did not remember if the vital signs were normal or not. On [DATE] at 12:15 p.m., Registered Nurse 1 (RN 1) stated that the admission nurse did the medication reconciliation after reviewing it with the physician. On [DATE] at 1:22 p.m., during an interview and record review, RN 2 stated and confirmed that resident was receiving multiple pain medications. On [DATE] at 2:10 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that staff should assess residents on a daily basis and every shift for pain management. The DON stated that the staff should assess resident's symptoms of regurgitation and adverse reactions such as stomach pain, nausea, vomiting, drowsiness, and constipation when nonsteroidal anti-[MEDICAL CONDITION] medications are taken in combination. A review of the paramedic run sheet dated [DATE] and timed at 9:31 a.m., indicated that Resident 1 was found lying in bed not awake or alert and low blood pressure ,[DATE], respirations 16, heart rate 109 ((NRR) for pulse is ,[DATE] bpm), and 95 (NRR-Normal Reference Range is 95 to 100 percent (%)) A review of the GACH emergency department (ED) record, dated [DATE] and timed at 10:23 a.m., indicated Resident 1 arrived at the ED at 10 a.m., via ambulance, responsive to verbal stimuli, but slow to respond, non-verbal, lethargic (sluggish), pale, unable to attain blood pressure, heart rate of 80 beats per minute 99 Fahrenheit (F) rectal temperature, oxygen saturation of ,[DATE]. The ED report indicated that at 10:10 a.m., Resident 1 became unresponsive, no pulse present, and not breathing; chest compression initiated and was noted that coffee ground material (blood) came out from the resident's mouth, 900 milliliters (ml) of dark hematemesis (vomiting of blood) was suction, positive guaiac (blood invisible in the feces) test. At 10:11 a.m., code blue (emergency announced in a hospital in which a patient is in cardiopulmonary arrest) initiated, [MEDICATION NAME] (used to treat low heart rate and severe low blood pressure) and [MEDICATION NAME] calcium (corrects metabolic acidosis during a [MEDICAL CONDITION]) was given. At 10:44 a.m., Resident 1 expired. A review of the facility's policy titled, Pain Management Process, dated ,[DATE] indicated that it was the responsibility of the licensed nurse to consistently assess, manage, and monitor pain for all residents. The results of assessments, effectiveness of the pain interventions, and monitoring of behaviors were necessary components within the documentation. The policy indicated that pain assessment and effectiveness for both routine and as needed medications utilizing a pain scale of ,[DATE] was a critical element of the pain management process. A review of Resident 1's death certificate dated [DATE] and timed of death at 10:44 a.m., indicated the resident's first cause of death was [MEDICAL CONDITION] and hypertension (high blood pressure).

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control system that identifies, track, and provide surveillance for the prevention of infections to ensure the cause of the residents' skin rashes were identified for seven of eight sampled residents (Residents 4, 5, 6, 8, 9, 12, and 13); and not following the physician's orders [REDACTED]. These deficient practices resulted in an ineffective scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite) identification and prevention of infection, that resulted in the spread of scabies, unnecessary pain, suffering and the inability to sleep for the residents with rashes. This lack of immediate actions for all the residents, staff and visitors in the facility, placed them at risk to acquire and be exposed to the scabies infection with the potential for secondary infections due to the severe scratching. On 1/24/18 at 7:28 p.m., an Immediate Jeopardy (IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared and the facility's administrator and the Director of Nursing (DON) were notified that an IJ was been called due to the facility inability to carry out a physician order [REDACTED]. The facility submitted a Plan of Action (POA) for the correction of the IJ, which included: 1. Resident 4 was transferred to the general acute care hospital (GACH) and was diagnosed with [REDACTED]. 2. Resident 5's physician was notified on 1/25/18 of the delay in obtaining a dermatology (a medical practitioner specializing in skin care and treatments) consult originally ordered on [DATE] and 1/8/18. The physician ordered [MEDICATION NAME] (an anti-parasitic used for treatment of [REDACTED]. 3. The Department of Health was notified on 1/25/18 of the scabies outbreak. 4. The nursing staff completed a facility-wide (head-to-toe) skin inspection on the residents on 1/25/18 to identify any new or suspicious skin rashes. The medical director examined all in-house residents and provided treatment by 1/25/18. The staff were screened to see if they were experiencing itching or rash-like conditions. 5. All residents discharged within six weeks will receive a letter advising them of the potential exposure to scabies and the actions to be taken. 6. The licensed nurses will be re-educated by the DON, or designee regarding timely physician notification of newly identified and or unresolved conditions and promptly obtain and follow physician orders [REDACTED]. 7. Certified Nurse Assistants (CNA) will be re-educated by Director of Staff Development (DSD) on the facility practices of completing a Stop and Watch tool to promptly record new skin conditions to licensed nurses. 8. [MEDICATION NAME] (to prevent) treatment will be offered to staff and residents as indicated and documented on the Medication Administration Sheet (MAR). 9. Nursing and laundry will be re-educated by the DSD, regarding the facility's policies for scabies management and preventing the spread of infection. On 1/28/18 at 7:04 p.m., the DON, Administrator, and the facility's consultant were notified that the IJ was lifted, after the team verified that the POA was implemented. Findings: a. A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission nursing assessment, dated 1/17/18, indicated Resident 4 had a lower back pinpoint rash. A review of a paramedic's notes dated 1/18/18 indicated Resident 4 was transferred to the general acute care hospital (GACH) for [MEDICAL CONDITION] (low blood pressure). On 1/23/18 at 11:15 a.m., during an interview while in the GACH, Resident 4 stated that he mention to the facility's staff that he had a body rash that was painful with itching. Resident 4 stated he told the staff that he could not sleep at night because of the severe itching, but the staff told him it was because of the injuries from the car accident. Resident 4 stated he did not have the rash when he arrived at the facility. A review of the GACH's physician progress notes [REDACTED]. A review of Resident 4's GACH pictures, taken by the GACH's staff, dated 1/23/18, showed the resident had scattered bright red and prickly spots with scratch marks on both upper and lower extremities, back, chest, and feet. b. On 1/24/18 at 10:45 a.m., during an observation and interview, Resident 5 was observed scratching bilateral upper extremities; Resident 5 stated that the rash was painful and was over the body, but stated he thought it was normal since he has been having it for a long time. Resident 5 stated that he scratches his back against the bed since he was not able to reach to scratch. A review of Resident 5's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 5's History and Physical (H/P), dated 5/30/17, indicated the resident had a rash under the area for skin physical examination. A review of Resident 5's Minimum Data Set (MDS), a standardized care screening and assessment tool), dated 10/3/17, indicated Resident 5 had adequate hearing, made self-understood and understands others. Resident 5's BIMS score was 13 (13-15=cognition (thought process) intact) and had no memory problems. The MDS indicated Resident 5 required an extensive assist of a one-person physical assist for personal hygiene and shower. On 1/24/18 at 10:51 a.m., during an observation and interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 5's rash was diffused throughout the body including the inguinal (groin) and perineal area (area between the anus and the scrotum or vulva) scattered swollen, red, dry, scabbed, and raised rash. A review of Resident 5's Skin Inspection Assessment, dated 5/30/17, indicated Resident 5 had a rash in the right outer knee. A review of the physician's orders [REDACTED]. A review of the Nurses Progress note, dated 9/12/17, and timed at 11:08 p.m., indicated Resident 5 was being monitored for generalized body rash. On 10/17/18 at 3:20 p.m., the note indicated an unresolved rash with new orders to apply [MEDICATION NAME] (Anti-parasite) with daily showers for one week. A review of the physician's orders [REDACTED]. A review of the Nurses Progress note, dated 1/3/18, and timed at 9:02 a.m., indicated a dermatologist consultation for complaints of itchy back. A review of the nurses' weekly summary for Resident 5 for the following dates: 10/16/17 thru 10/23/17 and 10/23/17 thru 10/30/17, indicated there was no documented skin assessment. On 1/24/18 at 4:18 p.m., during an interview and record review, LVN 2 stated she was not able to find the dermatologist consult for Resident 5. LVN 2 stated the Assistant Director of Nurses (ADON) should had followed-up with Resident 5's physician order [REDACTED].>A review of Resident 5's pictures showed generalized body rash, linear bumps, and scattered bright red with prickly spots and tracking observed. There were scratch marks observed on the lower extremities and back. A review of Resident 5's treatment records indicated the resident was treated for [REDACTED]. On 10/18/17 Resident 5 was treated with [MEDICATION NAME] for unresolved rash, and order for [MEDICATION NAME] (formulated for skin conditions caused by microorganisms and bacteria) daily starting on 8/8/17. On 1/25/18 at 1:47 p.m., during an interview, the Social Services Director (SSD) stated she did not follow-up with Resident 5's dermatologist consult after she had faxed the request on 10/24/17 and should have. On 1/25/18 at 3:04 p.m., during an observation and interview, in the presence of the DON and LVN 1, the facility's Medical Director stated Resident 5 had scabies and described it as maculopapular (rash characterized by a flat, red area on the skin that was covered with small confluent (flowing together or merging) bumps) generalized, with areas that are opened and some dry. The Medical director stated that she would prescribed [MEDICATION NAME] and Ivermectin (oral (Anti-parasite) and to apply the [MEDICATION NAME] to the residents' genital area. c. A review of Resident 6's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's [DIAGNOSES REDACTED]. A review of Resident 6's MDS, dated [DATE], indicated the resident had adequate hearing, was able to understand and be understood. Resident 6's BIMS score was 14 (13-15=cognition intact) no memory problems. The MDS indicated Resident 6 required extensive assist of a one-person physical assist for personal hygiene and was totally dependent on staff for showers. On 1/24/18 at 5:53 p.m., during an observation, interview and record review, Registered Nurse 1 (RN 1) stated Resident 6 had a generalized fungal rash and had no dermatologist consultation ordered. RN 1 described Resident 6's rash on the right hip as closed dry, clustered, and raised pink in color. During the concurrent interview, Resident 6 stated he has had the rash for a year. Resident 6 stated he wakes up at nighttime due to the pain caused by the severe itching. A review of the physician's orders [REDACTED]. A review of Resident 6's Skin Inspection Assessment, dated 9/26/17, indicated the resident had a rash on the abdomen, right hip, right and left hand, and under the pits of left and right under arms. A review of the nurse's progress notes from 11/3/17 thru 1/25/18, did not indicate that Resident 6 had a rash on the right hip. A review of Resident 6's right hip picture showed weeping patches of skin that were red, scaly and itchy and raised. d. On 1/24/18 at 6:47 p.m., during an observation, interview, and record review of residents chart, RN 1 stated Resident 8 has a generalized body rash that caused her to scratch. In the presence of RN 1, Resident 8 stated: It hurts you know, I'm constantly scratching all over, I do wake up at night to scratch 2 or 3 times. A review of Resident 8's Admission Record indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 8's MDS, dated [DATE], indicated the resident had adequate hearing, was able to self-understood and understands others. Resident 8's BIMS score was 04 (0-7: the resident is severely impaired) and had memory problems. The MDS indicated Resident 8 required extensive assist of one-person physical assist for all personal hygiene and showers. On 1/24/18 at 7:05 p.m., LVN 1 stated that Resident 8 had been using the same cream ([MEDICATION NAME]) for the rash since 8/2017 and did not have a dermatologist consultation ordered A review of the Skin Inspection Assessment, dated 9/26/17, indicated Resident 8 had a generalized body rash scattered throughout entire body accompanied with scratch marks that were dry and brown in color. On A review of Resident 8's Nursing Weekly Summary Review, dated from 9/4/17 thru 12/1/17, indicated Resident 8 did not have a body rash. The Nursing Weekly Summary Review from 12/4/17 thru 1/1/18 indicated Resident 8 had a generalized body rash. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. On 1/25/18 at 3:08 p.m., during an interview, Wound Care Specialist/Physician (WCS/MD) stated that she was going to performed skin inspections and no scraping was needed to [DIAGNOSES REDACTED]. The WCS/MD stated that she had asked the facility if they did not have scrapping kits to request them from a GACH. On 1/25/18 at 3:10 p.m., during an observation, interview and record review, in the presence of the DON, the WCS/MD diagnosed Resident 8 with generalized scabies. The WCS/MD stated that she did not need a scrapping kit for resident since her assessment indicated she had scabies all over body. The review of the WCS/MD assessment indicated Resident 8 had diffused generalized nodular/papular pink [MEDICAL CONDITION] with severe excoriation (repetitive and compulsive picking of skin, which resulted in tissue damage). e. On 1/24/18 at 10:38 a.m., during an observation of Resident 9's skin and interview, LVN 1 and LVN 3 stated that Resident 9 had a generalized body rash that was a dry red linear rash. Resident 9 stated in the presence of LVN 1 and LVN 3: It hurts all the time all over, sometimes I wake up. It itches, but I can't scratch my legs. A review of Resident 9's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 9's MDS, dated [DATE], indicated the resident had adequate hearing, had the ability to make self-understood and understands others. Resident 9's BIMS score was 03 (0-7: the resident was severely impaired) had memory problems. The MDS indicated Resident 9 required extensive assist of a one-person physical assist for personal hygiene and was totally dependent on staff for showers. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of Resident 9's pictures showed generalized body rash, linear bumps, and scattered bright red and prickly spots with weeping areas. There were scratch marks observed on the bilateral upper and lower extremities and back. On 1/24/18 at 10:55 a.m., during an interview, LVN 3 stated several residents have had on and off rashes and the dermatologists were not involved. LVN 3 stated that when a medication does not work within three weeks of being prescribed, the physician needed to be notified so that the medication could be changed. LVN 3 stated that when she notified the physicians regarding residents experiencing outburst of rashes, the physicians' orders were to follow the medication used by the facility for rash. f. On 1/25/18 at 1:18 p.m., during a concurrent observation and interview, Resident 12 was observed with bilateral lower extremities pin-point dry rash. The DON stated Resident 12 appeared to have scabies to the bilateral lower extremities. A review of Resident 12's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 12's MDS, dated [DATE], indicated Resident 12 was unable to hear and make self-understood and/or understand others. Resident 12's BIMS was 03 (0-7: the cognition was severely impaired) with memory problems. The MDS indicated Resident 12 required extensive assist of one-person physical assist for personal hygiene and for showers. A review of Resident 12's pictures showed linear bumps, scattered pink in color and dry on bilateral lower extremities. g. On 1/24/18 at 12:50 p.m., during an observation and interview, in the presence of the Administrator and DON, Resident 13 was observed scratching his legs. Resident 13 stated, They bite please take them off, It itches all the time and it hurts when I sit down, they are in my arm and my back. A review of Resident 13's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had adequate hearing, had the ability to understand and be understood. Resident 13's BIMS score was 15 (13-15=cognition intact) without memory problems. The MDS indicated Resident 13 required extensive assist of one-person physical assist for personal hygiene and showers. A review of Resident 13's Nursing Weekly Summary Review, dated from 9/7/17 thru 1/18/18 indicated Resident 13 did not have a body rash. On 1/25/18 at 8:15 a.m., during an interview, the Director of Staff Development (DSD) stated that a few months ago, she was notified regarding Resident 5's rash, but she was not responsible to assess the residents; she then stated that no line list or skin sweeping had been initiated because she was not aware that residents had a skin rash. The DSD stated that nurses are responsible to notify the physicians of the residents' skin rash. The DSD stated that a dermatologist (skin specialist) needed to be called to assess residents' when a skin rash has been identified. The DSD stated there have not been skin sweeping conducted because she was not aware that there was a current outbreak. The DSD stated the residents needed to be placed on isolation when scabies was suspected. A review of Resident 13's pictures showed linear bumps, scattered bright red and prickly spots with tracking observed on bilateral lower extremities with scratch marks; red dry scattered dots on bilateral upper extremities and on back with scratch marks. On 1/25/18 at 8:30 a.m., during an interview, the DON stated the skin sweep was initiated on 1/24/17, but was unable to provide documented evidence of the skin assessments. The DON stated the facility was not able to track were the scabies of Resident 4 came from since the facility had no surveillance and tracking system in place. On 1/25/18 at 2:42 p.m., during an interview, the central supplies manager (CSM) stated that the facility did not have enough personal protective equipment (PPEs) for the scabies outbreak. On 1/25/18 at 3:24 p.m., during an observation and interview, the WCS stated Resident 13 had 100 percent (%) epithelium (outer layer of body surface) generalized rash suspicious of scabies with nodules pale pink [MEDICAL CONDITION] measuring 1-2 centimeters (cm) and diffused excoriation. On 1/25/18 at 3:38 p.m., during an observation and interview, the WCS stated the chlorohexidine can irritate and burn the skin when [MEDICAL CONDITION] are open and the residents should not have been showered with the chlorohexidine. On 1/26/18 at 9:58 a.m., during an interview and record review, LVN 4 stated the only residents treated with [MEDICATION NAME] on 1/25/18 were residents in Rooms 1 thru 12. On 1/27/18 at 6:31 a.m., during an interview, the DON stated that she does not know why the staff waited so long to treat the residents for the rashes. On 1/28/17 at 3:12 p.m., during an interview, a family member (FM 3) stated she has been telling the staff regarding Resident 5's body rash, but the facility would ignore her complaints. A review of 50 physician progress notes [REDACTED]. A review of the pharmacy order form indicated that on 1/26/18 the facility ordered Ivermectin for 24 residents and on 1/27/18 Ivermectin was ordered for 8 residents. A total of 32 of 86 sampled residents received Ivermectin orally and Elemite topically and 54 of 86 sampled residents received [MEDICATION NAME]. On 1/28/18 at 6:05 p.m., during an interview and record review of residents (86 residents) MARs, RN Consultant (RNC) indicated that the orders indicated to apply [MEDICATION NAME] for all residents. RNC stated that [MEDICATION NAME] is used to treat scabies. A review of American Academy of Dermatology (AAD), dated 2009, indicated scabies among residents of nursing homes and extended care facilities had become a common problem due to delayed [DIAGNOSES REDACTED]. The delay allows time for scabies to spread to nursing home staff and other residents, because residents require assistance in activities of daily living , this exposure provides an opportunity for the scabies to spread. Getting rid of the mites is critical in the treatment of [REDACTED]. This included nursing homes. Bedding or clothing must be washed. Incubation is 6-8 weeks symptoms may not show up for a while. If you do not treat everyone, it is as if they were never treated. A review of the facility's policy titled, Change in Condition, dated (YEAR) indicated that the facility staff would appropriately assess, document and communicate changes of condition including diagnostic results to the primary care provider. The facility staff was to provide treatments and services to address changes in accordance with resident needs by notifying the physician of assessment findings and subsequent actions. On 1/26/18 at 7:39 a.m., during an interview with the ADM in the presence of the DON, the ADM stated the facility follows the Title 22 regulations for outbreaks management and does not have a written policy for management of Unusual Occurrences.

Based on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 1) was not given a medication that would cause adverse consequence (an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in the resident's mental or physical condition or functional (treatments that focus on optimal functioning of the body and its organs)) especially when the administered medication had the potential to complicate the current state of the resident's disease process. Resident 1, who had a Stage 5 [MEDICAL CONDITION] ((CKD), end stage kidney disease or kidney failure), received seven doses (the amount of drug that should be taken at one time) of 1,000 milligrams ((mg), 1,000 milligrams is equal to 1 Gram) per dose of [MEDICATION NAME] (a medication used to help control blood sugar levels) from [DATE] to [DATE]. The [MEDICATION NAME] medication had a black box warning (a warning put in the labeling of prescription drugs by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard (danger or risk) with the drug) indicating that lactic acidosis (occurs when the blood becomes too acidic due to the presence of excess lactic acid (an acid that is produced when oxygen level in the body drops)) was more likely to result in certain medical conditions such as kidney disease. This deficient practice resulted in Resident 1 developing [MEDICAL CONDITION] (abnormally low blood pressure (the strength of the blood pushing against the sides of the blood vessels), normal reference range top number is between 90 and 120 millimeter mercury (mmHg), and the bottom number is between 60 and 80 mmHg) and somnolence (sleepiness) and was transferred to the hospital on [DATE]. Resident 1 was diagnosed to have lactic acidosis and died on [DATE] at 10:48 a.m. Cross reference to F425 Findings: A review of Resident 1's record titled, Admission Record, no date, indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. to use blood sugar resulting to high levels of sugar in the blood). A review of Resident 1's record titled, history and physical examination [REDACTED]. A review of Resident 1's record titled, Minimum Data Set (MDS, a resident assessment and care screening tool), dated [DATE], indicated that Resident 1 had no problem with cognitive skills (ability to reason and think) for daily decision-making, required extensive assistance (resident performed part of the activity; staff provided support with bearing weight and at times full staff performance of activity) from staff with transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), and could not walk. A review of Resident 1's record titled, Laboratory and Pathology Test Results, dated [DATE] indicated that, a high level of glycated Hemoglobin A1C (blood test for diabetes that reflects the average blood sugar levels for the past two to three months) of 7.5 percent (normal reference range 4XXX,[DATE].1 percent). A handwritten physician's orders [REDACTED].), dated and signed on [DATE]. A review of Resident 1's record titled, Medication Administration Record, for [DATE] indicated that Resident 1 received seven doses of 1000 mg per dose of [MEDICATION NAME] from [DATE] to [DATE] (1-dose on [DATE] and 2-doses each on [DATE], [DATE], and [DATE]). A review of Resident 1's record titled, Progress Notes, dated [DATE], at 4:05 a.m., indicated Transportation for [MEDICAL TREATMENT] here, resident is alert, sleeping most of the time, no respiratory distress (shortness of breath), able to verbalize needs, going in stable (within normal) condition. A review of Resident 1's record titled, [MEDICAL TREATMENT] Care Communication/Coordination, dated [DATE], (no time indicated) completed in the facility, indicated that Resident 1's blood pressure was ,[DATE] mm/Hg (millimeters of mercury- a measure of blood pressure). A review of Resident 1's [MEDICAL TREATMENT] record titled, [MEDICAL TREATMENT] Clinic/Treatment Report, dated [DATE] no time indicated indicated that, Resident 1's blood pressure pre (before) [MEDICAL TREATMENT] was ,[DATE] mm/Hg. Resident 1 was sent to the hospital by [DATE] (emergency number). A review of Resident 1's hospital record titled, Emergency Department (ED) Reports, dated [DATE], no time, indicated Resident 1 arrived in the hospital at 5:55 a.m. with altered mental status, acute (sudden) distress (physical or mental suffering), and was unable to verbalize what was wrong. The blood pressure reading was ,[DATE] mm/Hg, and temperature of 92.3 degrees Fahrenheit ((F) normal body temperature range from 97.8 degrees F to 99 degrees F). A review of Resident 1's hospital laboratory results, dated [DATE], at 7:05 a.m., indicated lactic acid level was 21.6 millimoles per liter ((mmol/L), reference range is 0XXX,[DATE].2 mmol/L), Resident 1's GFR (glomerular filtration rate- a calculation that determines how well the blood is filtered by the kidneys, which is one way to measure remaining kidney function) indicated Low 7 milliliters per minute (mL/min)/1.73m2. A review of Resident 1's hospital record titled, History and Physicals, dated [DATE], 5:34 p.m., indicated Resident 1, . began to have progressive [MEDICAL CONDITION] (abnormal slow heart rate below 60 beats per minute) and [MEDICAL CONDITION] despite maximal [MEDICATION NAME] (a medication used to treat life-threatening low blood pressure). Patient became asystolic ('flat line', no heart activity) and expired (died ). A review of Resident 1's hospital record titled, Discharge Summaries Notes, dated [DATE], at 4:17 p.m., indicated Resident 1 was pronounced dead on [DATE] at 10:48 a.m. and Cause of Death: Preliminary (initial) cause of death: Lactic acidosis. Due to: Septic shock (a life-threatening severe form of infection that usually results from the presence of bacteria and their toxins (a poisonous substance produced within living cells or organisms)) in the bloodstream characterized by persistent [MEDICAL CONDITION] with reduced blood flow to organs and tissues and organ dysfunction). During a telephone interview, on [DATE] at 12:40 p.m., the [MEDICAL TREATMENT] Registered Nurse (DRN 1) stated, Around 5:05 a.m. (on [DATE]), I saw the resident (Resident 1) looked 'drugged' and was sleepy. DRN 1 stated Resident 1 could not answer where she was (location). DRN 1 stated [DATE] was called immediately and came within five minutes and took Resident 1 to the hospital. During a telephone interview, on [DATE] at 1:15 p.m., the Patient Technician Care (PTC 2), who received Resident 1 from the facility on [DATE], stated, I received her (Resident 1) with a consistently low blood pressure. PTC 2 stated that upon Resident 1's arrival to the [MEDICAL TREATMENT] center, the resident was not alert, was confused, and was just making sounds, and could not speak very well and then would black out (to undergo a temporary loss of vision, consciousness, or memory). PTC 2 stated Resident 1's blood pressure was ,[DATE] mmHg when she arrived to the [MEDICAL TREATMENT] center around 5 a.m. PTC 2 stated that when [DATE] came, Resident 1 was able to say her name but could not answer any other questions. PTC 2 stated Resident 1 was so sleepy. During a telephone interview, on [DATE], at 2:40 p.m., the Registered Nurse (RN1) stated Resident 1's attending physician came to the facility on [DATE], and reviewed the resident's high HgbA1C laboratory result and ordered to start Resident 1 on [MEDICATION NAME] 1000 mg twice a day. RN 1 was asked if she knew the black box warning for [MEDICATION NAME], RN 1 was unable to answer. RN 1 stated she did not know how the facility addresses (to direct the attention of) the concerns or issues of black box warnings in a new medication order. RN 1 stated she did not check the pharmacy website for contraindications (to advise against or indicate the possible danger of) or side effects of [MEDICATION NAME] medication. A review of an educational reference material titled, Drug Information, revised ,[DATE] printed and provided by RN 1 from the facility's online pharmacy website subtitled, Warning, indicated, Rarely, too much [MEDICATION NAME] can build up in the body and cause a serious, sometimes fatal condition (cause to end someone's life) called lactic acidosis. Lactic acidosis is more likely to happen in certain medical conditions such as kidney disease, worsening heart failure. According to https://www.dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4a0166c[DATE]e4a-,[DATE]c9a60d08fc6, updated on [DATE], indicated: CONTRAINDICATIONS: [MEDICATION NAME] and [MEDICATION NAME] XR (extended-release tablets) are contraindicated in patients with: 1. Severe renal (kidney) impairment (eGFR (estimated glomerular filtration rate), a formula that uses age, race, gender (male or female), and serum creatinine (waste product in the blood) level to measure kidney function) below 30 mL/min/1.73 m2 (milliliters per minute per body surface area)). WARNING: LACTIC ACIDOSIS Postmarketing (the practice of monitoring the safety of a drug after it has been released on the market) cases of [MEDICATION NAME]-associated lactic acidosis have resulted in death, hypothermia (abnormally low body temperature), [MEDICAL CONDITION] (abnormally low blood pressure (the strength of the blood pushing against the sides of the blood vessels)), and resistant bradyarrhythmias (slow irregular heartbeat). The onset of [MEDICATION NAME]-associated lactic acidosis is often subtle (not obvious), accompanied only by nonspecific symptoms such as malaise (general feeling of discomfort), myalgias (muscle pain), respiratory distress (shortness of breath), somnolence (sleepiness), and abdominal pain. During a telephone interview on [DATE], at 3:15 p.m., the facility's Pharmacy Consultant (PharmD) stated the next scheduled medication regimen review for the month of [DATE] was due on [DATE]. PharmD stated that [MEDICATION NAME] was not recommended for residents who are renal-impaired and with creatinine clearance (GFR) below 30 mL/minute/1.73m2. PharmD stated that the physician should have known of the risks of this medication and should not have ordered it for Resident 1 without first obtaining a creatinine clearance. PharmD stated the facility should have a list of medications with black box warnings and should have reviewed new MEDICATION ORDERS FOR [REDACTED]. During a telephone interview, on [DATE], at 4:58 p.m., Resident 1's Physician (MD1) stated that he ordered the [MEDICATION NAME] to Resident 1 because he was presented by RN 1 with Resident 1's high HgbA1C and because [MEDICATION NAME] was the first line of medication for diabetes. MD 1 stated he was not near the computer (electronic medical record) during that time so he did not have all the information with him like laboratory results. MD 1 stated he did not know there was a black box warning for the [MEDICATION NAME] but if he had been told, I would not have prescribed it. During a telephone interview, on [DATE] at 8:35 a.m., the Director of Nursing (DON) stated the facility did not have a policy and procedures on how the licensed nurses identifies concerns/issues of black box warnings and notify a resident's physician or pharmacist. The DON stated the facility's pharmacy had the manual with the list of medications with black box warnings and the manual was located in the facility's nursing station. The DON stated that [MEDICATION NAME] medication was included in the list. A review of the educational reference material titled, Drugs with Boxed Warnings, copyright 2016, provided by the DON from the facility's pharmacy manual located in the facility's nursing station indicated [MEDICATION NAME] risk is increased with increasing age ., and conditions including renal impairment . Monitor malaise (general feeling of discomfort), myalgia (muscle pain) .and increasing somnolence (sleepiness), hypothermia (abnormally low body temperature), and [MEDICAL CONDITION] . If lactic acidosis is suspected, use should be discontinued, the prescriber should be notified immediately, and hospitalization should be considered. During a telephone interview, on [DATE] at 9:30 a.m., the Licensed Vocational Nurse (LVN 1) stated Resident 1 was normal as before prior to leaving the facility that morning on [DATE]. LVN 1 stated she refers to the facility's drug handbook located in the nursing station and the medication cart if she wanted to find out about side effects or contraindications of medications she was administering to residents. LVN 1 stated the electronic medical record system did not have the capacity to indicate if a medication had black box warnings. According to the article published by the American Journal of the Medical Sciences, Volume 349, Number 3, dated [DATE], titled, [MEDICATION NAME]-Associated Lactic Acidosis, indicated, Patients with diabetes are at increased risk of developing lactic acidosis if safety guidelines (warnings indicated by the FDA regarding use of the diabetes medicine [MEDICATION NAME]) are ignored and the drug is continued in the presence of contraindications. Impaired kidney function is the most important risk factor for [MEDICATION NAME]-associated lactic acidosis. The article indicated, The American Poison Association Control Centers reported that [MEDICATION NAME] and cases of lactic acidosis contributed to a number of fatalities and deaths between [DATE] and [DATE]. The pathogenesis (the manner of development of the disease) of [MEDICATION NAME]-associated lactic acidosis was caused by impaired [MEDICATION NAME] clearance (reduced ability to remove) in the body because of acute or chronic kidney failure that may lead to impaired tissue oxygenation (reduced oxygen supply in the body). A review of Resident 1's document titled, Certificate of Death, dated [DATE], indicated Resident 1's immediate cause of death on [DATE] at 10:48 a.m. was cardiopulmonary arrest (a sudden stop in effective and normal blood circulation due to failure of the heart to pump blood).

Based on interview and record review, the dispensing pharmacist failed to clarify medication orders that presented concerns for resident's safety prior to dispensing the medication to the facility for administration for one of two sampled residents (Resident 1). As a result, Resident 1 was diagnosed to have lactic acidosis (occurs when the blood becomes too acidic due to the presence of excess lactic acid (an acid that is produced when oxygen level in the body drops)) and died on [DATE] at 10:48 a.m. Findings: A review of Resident 1's Admission Record indicated that Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. to use blood sugar resulting to high levels of sugar in the blood). A review of Resident 1's record titled, history and physical examination [REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 1/13/17, indicated that Resident 1 had no problem with cognitive skills (ability to reason and think) for daily decision-making, required extensive assistance (resident performed part of the activity; staff provided support with bearing weight and at times full staff performance of activity) from staff with transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), and could not walk. A review of Resident 1's record titled, Laboratory and Pathology Test Results, dated 1/13/17, indicated that the resident had a high level of glycated Hemoglobin A1C (blood test for diabetes that reflects the average blood sugar levels for the past two to three months) of 7.5 percent (normal reference range 4.3-6.1 percent). A handwritten physician's orders [REDACTED].), dated and signed on 1/19/17. A review of Resident 1's Medication Administration Record, for January 2017 indicated that Resident 1 received seven doses (the amount of drug that should be taken at one time) of 1000 mg per dose of Glucophage from 1/19/17 to 1/22/17. (1-dose on 1/19/17 and 2-doses each on 1/20/17, 1/21/17, and 1/22/17) A review of Resident 1's clinical record titled Order Review Report for 1/1/2017 to 1/31/2017 indicated the resident was to receive hemodialysis treatments outside the facility three days a week at 5 a.m. and the scheduled transportation time was at 4 a.m. On 1/23/17, Resident 1 was present to the dialysis center by the transportation staff (TS1) to the patient technician care (PTC2) 2 at the dialysis center. TS1 informed PTC1 that he was worried about Resident 1's health condition because TS1 feared that Resident 1 did not look normal to him at the time of pick up from the facility. However, the Charge Nurse (LVN 1) the facility stated that Resident 1 was Okay to go for dialysis. A review of Resident 1's record titled, Dialysis Care Communication/Coordination, dated 1/23/17, (no time indicated) completed in the facility, indicated that Resident 1's blood pressure was 118/69 mm/Hg (millimeters of mercury- a measure of blood pressure). A review of Resident 1's dialysis record titled, Dialysis Clinic/Treatment Report, dated 1/23/17 no time indicated indicated that, Resident 1's blood pressure pre (before) dialysis was 57/72 mm/Hg. Resident 1 was sent to the hospital by 9-1-1 (emergency number). A review of the dialysis progress note report dated 1/23/17 indicated that Resident 1's condition worsened upon arrival at the Dialysis Center. The resident's level of consciousness was altered and the BP reading = 57/72 between the hour of 5:10 to 5:15 a.m. The resident was subsequently transferred to the acute hospital via 9-1-1. A review of Resident 1's hospital record titled, Emergency Department (ED) Reports, dated 1/23/17, no time, indicated Resident 1 arrived in the hospital at 5:55 a.m. with altered mental status, acute (sudden) distress (physical or mental suffering), and was unable to verbalize what was wrong. The blood pressure reading was 64/51 mm/Hg, and temperature of 92.3 degrees Fahrenheit ((F) normal body temperature range from 97.8 degrees F to 99 degrees F). A review of Resident 1's hospital laboratory results, dated 1/23/17, at 7:05 a.m., indicated lactic acid level was 21.6 millimoles per liter ((mmol/L), reference range is 0.5-2.2 mmol/L), Resident 1's GFR indicated, Low 7 mL/min/1.73m2. A review of Resident 1's hospital record titled, History and Physicals, dated 1/23/17, 5:34 p.m., indicated Resident 1, . began to have progressive bradycardia (abnormal slow heart rate below 60 beats per minute) and hypotension despite maximal Levophed (a medication used to treat life-threatening low blood pressure). Patient became asystolic ('flat line', no heart activity) and expired (died ). During a telephone interview, on 3/31/17 at 2:40 p.m., the Registered Nurse (RN1) stated that when she entered the Glucophage medication order electronically, RN 1 did not receive any call from the dispensing pharmacist clarifying the Glucophage medication order. RN 1 stated that if there were important warnings on the medication, the dispensing pharmacist should have notified the facility or the dispensing pharmacist would call the ordering physician directly to clarify the new medication (1000 mg per dose of Glucophage) order. During a telephone interview on 4/3/17, at 3:15 p.m., the facility's Pharmacy Consultant (PharmD) stated the next scheduled medication regimen review for the month of January 2017 was due on 1/27/17. PharmD stated that Glucophage was not recommended for residents who are renal-impaired (kidney failure) and with creatinine clearance (a test that helps determine whether the kidneys are functioning normally) (GFR- glomerular filtration rate) below 30 mL/minute/1.73m2. PharmD stated that the physician should have known of the risks of this medication and should not have ordered it for Resident 1 without first obtaining a creatinine clearance. PharmD stated, Unfortunately, the dispensing pharmacist did not have a direct link to the laboratory results of the residents in the facility and had no way of finding out the creatinine clearance of a resident. PharmD stated the facility staff (licensed nurses) should have checked the resident's laboratory result and notified the dispensing pharmacist. During a telephone interview, on 4/4/17, at 4:58 p.m., Resident 1's Physician (MD 1) stated that he ordered the Glucophage for Resident 1 because according to RN 1, Resident 1 had a high HgbA1C dated 1/13/17and because Glucophage was the first line of medication for diabetes. MD 1 stated he was not near the computer (electronic medical record) during that time so he did not have all the information/facts with him like laboratory results (e.g. creatinine clearance) before he prescribed the Glucophage. MD 1 stated he did not know there was a black box warning for the Glucophage but if he had been told, I would not have prescribed it. MD 1 stated that usually the dispensing pharmacist would call the physician or coordinate with the facility when there are issues like black box warnings or contraindications to medications. MD 1 stated he did not receive any call from the facility or the facility's pharmacist. MD 1 stated that the dispensing pharmacist was supposed to review medication when it is newly prescribed. A review of Resident 1's clinical record indicated a laboratory report from a previous hospitalization dated 1/2/17 indicated Resident 1's GFR was low at 13 mL/min/1.73m2 (reference range should be above 59 mL/min/1.73m2 (milliliters per minute per body surface area)). During a telephone interview, on 4/5/17 at 8:35 a.m., the Director of Nursing (DON) stated the facility did not have policy and procedures on how the licensed nurses identifies concerns/issues of black box warnings and notify a resident's physician or pharmacist. The DON stated the facility's pharmacy had the manual with the list of medications with black box warnings and the manual was located in the facility's nursing station. The DON stated that Glucophage medication was included in the list. A review of an educational reference material titled, Drug Information, revised 7/2016, printed and provided by RN 1 from the facility's online pharmacy website subtitled, Warning, indicated, Rarely, too much metformin can build up in the body and cause a serious, sometimes fatal condition (cause to end someone's life) called lactic acidosis. Lactic acidosis is more likely to happen in certain medical conditions such as kidney disease. According to https://www.dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4a0166c7-7097-4e4a-9036-6c9a60d08fc6, updated on 2/6/17, indicated: CONTRAINDICATIONS (should not be used): GLUCOPHAGE and GLUCOPHAGE XR (extended-release tablets) are contraindicated in patients with: 1. Severe renal (kidney) impairment (eGFR (estimated glomerular filtration rate), a formula that uses age, race, gender (male or female), and serum creatinine (waste product in the blood) level to measure kidney function) below 30 mL/min/1.73 m2 (milliliters per minute per body surface area)). WARNING: LACTIC ACIDOSIS Post-marketing (the practice of monitoring the safety of a drug after it has been released on the market) cases of metformin-associated lactic acidosis have resulted in death, hypothermia (abnormally low body temperature), hypotension (abnormally low blood pressure (the strength of the blood pushing against the sides of the blood vessels)), and resistant bradyarrhythmias (slow irregular heartbeat). According to the article published by the American Journal of the Medical Sciences, Volume 349, Number 3, dated March 2015, titled, Metformin-Associated Lactic Acidosis, indicated, Patients with diabetes are at increased risk of developing lactic acidosis if safety guidelines (warnings indicated by the FDA regarding use of the diabetes medicine metformin) are ignored and the drug is continued in the presence of contraindications. Impaired kidney function is the most important risk factor for metformin-associated lactic acidosis. The article indicated, The American Poison Association Control Centers reported that metformin and cases of lactic acidosis contributed to a number of fatalities and deaths between January 2005 and August 2010. The pathogenesis (the manner of development of the disease) of metformin-associated lactic acidosis was caused by impaired metformin clearance (reduced ability to remove) in the body because of acute or chronic kidney failure that may lead to impaired tissue oxygenation (reduced oxygen supply in the body). A review of the facility's agreement contract with the pharmacy titled, Master Pharmacy Products and Services Agreement, dated 1/7/15 indicated, Pharmacy and the facility will continue to work together in good faith in the development and implementation of hard stop and soft stop (provides warnings through the use of electronic medication warnings or stops geared towards medication safety) edits for particular pharmacy products.