Every finding on record at Emmanuel Post Acute Care - Hayward

Based on interview and record review, the facility failed to protect one of five sampled residents(Resident 1), from abuse when Resident 2 hit Resident 1 on the head with a folding chair. This failure resulted in Resident 1 sustaining a laceration, (traumatic injury that involves rips or tears to body tissue), to the forehead requiring sutures, (medical thread that holds the edges of wounds together after injury), and a broken neck bone.During a review of admission Record for Resident 1, undated, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including candidal sepsis, (a life-threatening medical emergency that happens when the body has an extreme, harmful response to an infection), diabetes, (a long-term illness in which the body cannot regulate the level of sugar in the blood), dementia, (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), depression, (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world.) anxiety, (common emotional state characterized by feelings of unease, such as worry or fear, that can range from mild to severe), and substance abuse related psychosis, (a mental state where a person loses touch with reality).During a review of MDS Section GG Functional Status for Resident 1, dated 5/27/26, the record indicated Resident 1 was fully dependent on staff for feeding, bathing, changing position in bed, and toileting.During a review of Collaborative Care for Hospice Patients in a Facility for Resident 1, dated 5/21/26, the record indicated Resident 1 was enrolled in hospice care, (a medical specialty focusing on comfort and dignity at the end of life), with a primary diagnosis of unspecified degenerative disease of the nervous system, (progressive, worsening loss of nerve cells, but the exact specific disorder has not been identified or finalized). During a review of admission Record for Resident 2, undated, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, anxiety, diabetes and immunodeficiency, (the body's immune system, [a complex network of cells, tissues, organs, and proteins that work together to defend the body against harmful germs] does not work correctly), and general body weakness.During a review of MDS Section C Cognitive Patterns for Resident 2, dated 4/6/26, the record indicated Resident 2 has a BIMS score of 8 indicating moderate cognitive impairment, (pronounced changes in thinking that interfere with daily activities such as memory loss, language issues, skewed judgment, and decreased problem-solving abilities are observed).During a telephone interview on 8/5/26 at 10:34 a.m. with Certified Nursing Assistant 1, (CNA1) CNA1 stated on the evening shift of 6/12/26, CNA1 was on a break and coming down the hall when CNA1 heard noise coming from the room shared by Resident 1 and Resident 2. CNA1 saw Resident 2 sitting in a wheelchair, yelling and holding a folding chair. CNA1 stated CNA1 saw Resident 2 hit Resident 1 across Resident 1's head with the chair. CNA1 stated CNA1 removed Resident 2 from the room and took Resident 2 to the nurse's station for observation. CNA1 stated the nurse was immediately notified.During a telephone interview on 8/5/26 at 12:00 p.m. with Licensed Vocational Nurse 1 (LVN1), LVN1 stated LVN1 was called to the room occupied by Resident 1 and Resident 2 by CNA1 after Resident 2 hit Resident 1. LVN1 stated upon entering the room LVN1 observed Resident 1 had a bleeding forehead laceration. LVN1 stated she assessed Resident 1 and applied pressure and a dressing, (a clean pad or material applied directly onto an injury to protect it, absorb blood or fluid, and help the skin heal), to the wound. LVN2 stated Resident 2 was taken to the nurse's station for observation and medication for agitation. LVN1 stated LVN1 notified Hospice and was advised by Hospice to transfer Resident 1 to the acute care hospital for evaluation and treatment. LVN1 stated Resident 2's behavior has been unpredictable, and Resident 2 is currently on antipsychotic medications, (a prescription drug used to treat severe mental health conditions by calming brain chemicals like dopamine, [a chemical in the brain that helps nerves work] and serotonin, [a chemical in the brain that carries signals between nerve cells in your brain and body] to manage loss of touch with reality, confused thinking, and severe mood swings]), with lorazepam, (a short acting medication used to relieve anxiety), as needed for agitation (a state of nervous excitement, worry, or physical shaking). LVN1 stated Resident 2 received the ordered dose of lorazepam after the incident, but Resident 2 threatened to harm others and was subsequently placed on a 5150-Psychiatric Hold, (document that allows authorized law enforcement or mental health professions to take and hold a person who is a danger to themselves and/or others in the hospital against their will for up to 72 hours for mental health evaluation and treatment). LVN1 stated Resident 2 was transported to the hospital by ambulance. During an interview on 8/8/26 at 9:45 a.m. with Hospice Nurse 1 (HN1, a licensed nurse that provides end-of-life care to those with terminal illness), HN1 stated HN1 responded to a call from the facility during the evening shift on 6/12/26 stating there had been an altercation at the facility involving a hospice patient (Resident 1). HN1 stated upon arrival at the facility HN1 observed Resident 2 was in a wheelchair by the nurse's station and Resident 1 was lying in Resident 1's bed. HN1 stated HN1 assessed Resident 1 and noted a 3-centimeter (metric unit of measure for length), laceration to the right forehead that was still bleeding. HN1 stated he observed blood on Resident 1's face, gown and bedding. HN1 stated HN1 controlled the bleeding and notified the Nurse Practitioner, (NP an advanced practice nurse that holds a master's degree or doctoral degree), at the hospice. HN1 stated the NP advised HN1 that Resident 1 needed to go to the acute hospital for assessment and treatment. HN1 stated Resident 1 left the facility by ambulance.During a telephone interview on 8/11/26 at 5:30 p.m. with Police Officer 1 (PO1), PO1 stated Resident 2 met the criteria for a 5150 hold because of a mental health history, demonstrated behavior, (aggression, agitation and threatening), and Resident 2 being unaware of Resident 2's actions that injured Resident 1. PO1 stated the facility staff called an ambulance. When the ambulance arrived PO1 restrained Resident 2 to the ambulance stretcher with soft restraints, (padded, fabric-based medical devices-such as wrist or ankle cuffs-used in healthcare settings to limit a patient's movement.), and Resident 2 was taken to the hospital.During a telephone interview on 8/6/26 at 8:50 a.m. with Family Member 1 (FM1) for Resident 1 1, FM1 stated FM1 was notified by the facility on 6/12/26 in the evening that Resident 1 was assaulted by another resident and was on the way to the hospital. FM1 stated FM1 was initially shocked at hearing about the assault but then became scared and upset.During a review of acute care hospital emergency department records for Resident 1, dated 6/12/26, the record indicated Resident 1 was brought to the emergency department by ambulance. The record indicated Resident 1 had been hit in the head with a chair inflicting a 4-centimeter laceration on the right side of Resident 1's forehead. The record stated due to Resident 1's advanced age, mechanism of injury and dementia, Resident 1 was evaluated by a trauma surgeon, (a physician who performs operations on patients with severe, life-threatening physical injuries). Resident 1 was diagnosed with a 4-centimeter laceration requiring stitches, to the right forehead and sustained a closed, nondisplaced fracture, (broken bone where pieces stay lined up properly), of the 6th (sixth) cervical, (neck), vertebral body, (thick, round part of the spinal bone), and was admitted to the hospital for observation. During a review of Care Plan Report for Resident 2, dated 4/1/26, the record indicated Resident 2 has a mood problem related to unspecified psychosis. The report indicated nursing staff would monitor/record/report to the physician if the resident was as at risk for harming others, demonstrated increased anger, labile, (emotionally unstable), mood or agitation, (state of physical and mental unrest), if the resident feels threatened by others or expresses thoughts of harming someone, and if the resident is in possession of weapons or objects that would be used as weapons. The record indicated nursing staff were to observe for signs and symptoms of mania, (persistent state of abnormally elevated mood with extreme energy and high activity levels), or hypomania, (mental state with high energy and low need for sleep), racing thoughts, euphoria, (feelings of happiness, excitement and wellbeing), increased irritability, frequent mood changes, pressured speech, (rapid, intense uninterrupted way of talking), flight of ideas, (rapid fire speech and thought pattern where someone jumps quickly from one topic to another), marked changes in need for sleep, agitation or hyperactivity. A Review of the Electronic Medication Administration Record May 2026, undated, for Resident 2, the record indicated quetiapine had been discontinued and the last dose of quetiapine was given to Resident 2 on 5/11/26. During a review of Order Summary Report June 2026 for Resident 2, undated, the report indicated Resident 2 was started sertraline, (prescription antidepressant), 25 mg every day for depression manifested by expression of sadness beginning on 5/25/26. The record also indicated on 5/30/26 sertraline increased to 50 mg daily for depression manifested by intrusive verbal behavior, threatening other residents. During a review of Electronic Medication Administration Record for May 2026 and for June 2026 for Resident 2, undated, the record indicated Resident 2 received sertraline 25mg by mouth every day from 5/29/26 until 6/11/26. The record indicated Resident 2 began receiving sertraline 50 mg by mouth on 6/12/26. During a review of Progress Note for Resident 2, dated 5/27/26, the record indicated Resident 2 had an episode of yelling at the staff. The record indicated Resident 2 was not receptive to redirection and received lorazepam 0.5 milligrams by mouth for agitation with good effect. During a review of Progress Note for Resident 2, dated 5/29/26, the record indicated Resident 2 was experiencing increased yelling. The record indicated Resident 2 decreased yelling after redirection but remained irritable resulting in an order to increase the sertraline to 100mg every day pending medication delivery. During a review of Progress Notes for Resident 2, dated 5/30/26, the record indicated Resident 2 was noted to be yelling loudly, using threatening language perceived as intimidating toward staff. During a review of Situation, Background, Assessment, Recommendation, Communication Tool (SBAR), for Resident 2, dated 6/12/26, the record indicated Resident 2 was observed in a wheelchair pacing up and down the hallway prior to the incident with Resident 1. The record indicated Resident 2 was redirected back to the nurse's station for safety.During a review of Progress Notes for Resident 2, dated 6/12/26 at 2:40 p.m., the record indicated Resident 2 was observed sitting in a wheelchair in the hallway yelling at the CNAs saying Resident 2 would fire the CNAs because they work for Resident 2. The record indicated Resident 2 was yelling Get out of my company. During a review of Situation, Background, Assessment, Recommendation, (SBAR, communication tool used in healthcare settings) Physician, Nurse Practitioner, (NP, advanced practice registered nurse who has completed a master's or doctoral degree (/Pysician's Assistant, (PA, a licensed medical professional who practices medicine on a healthcare team with physicians), Communication Tool for Resident 2, dated 6/12/26 at 10:00 p.m., the record indicated at approximately 7:35 p.m., CNA1 observed Resident 2 strike Resident 1 with a chair. The record indicated Resident 2 attempted to strike Resident 1 again but CNA1 intervened and Resident 2 was removed from the resident room, escorted to the nurse's station for observation and medicated with lorazepam 0.5 milligrams by mouth for agitation. During an interview on 8/6/26 at 2:00 p.m. with the Director of Nursing (DON), the DON stated the DON became aware of the incident between Resident 1 and Resident 2 when the chargenurse called the DON on the same day the incident occurred, and that Resident 1 and Resident 2 had been transported to the acute hospital. The DON stated the staff reported Resident 1 was taken to the hospital at the direction of hospice for evaluation and treatment of the injury and that Resident 2 had been placed on a 5150 hold and directed to the hospital for psychiatric evaluation by the police for being a threat to others. The DON reported Resident 2 showed unpredictable behavior when Resident 2 would go from calm to aggressive and became agitated with staff very quickly and the DON stated Resident 2 should have been placed in a private room. The DON stated by putting Resident 2 in a room with vulnerable, bedbound hospice resident (Resident 1), the facility put Resident 1 at risk for abuse. During a review of the facility's policy and procedure titled Resident Rights, dated 1/16/26, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include.to be free from abuse neglect, misappropriation of property and exploitation.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality in one of three sampled residents, (Resident 3), when Resident 3 was placed in a bed too small for Resident 3's body mass index, (BMI, tool using height and weight to estimate body fat and screen for potential health risks), and when the facility failed to provide adequate translation services to allow Resident 3 to communicate with the caregivers.These failures resulted in the potential for Resident 3's pressure injury to escalate in severity and left Resident 3 unable to effectively communicate needs to staff. As a result, Resident 3 reported feeling frustrated, humiliated, and unsafe.During a review of Resident 3's admission Record, printed on 8/4/26, the record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including encephalopathy, (any disease, damage or disorder that affects the structure or function of the brain), renal osteodystrophy, (a disease of the bone affecting those with chronic kidney disease), dysphasia, (difficulty or discomfort swallowing),pressure injury, diabetes, (a long-term illness in which the body cannot regulate the amount of sugar in the blood), anxiety, (common emotional state characterized by feelings of unease, such as worry or fear, that can range from mild to severe), dependence on renal, (kidney), dialysis, (a life-saving medical treatment that replaces core kidney function), and morbid obesity, ( a category indicating a BMI greater than 40). During a review of Minimum Data Set, (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) Section C-Cognitive Patterns for Resident 3, dated 7/8/26, the record indicated Resident 3 has a Brief Interview for Mental Status, (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information), score of 11 out of 15 indicating moderate cognitive impairment, (pronounced changes in thinking that interfere with daily activities such as memory loss, language issues, skewed judgment, and decreased problem-solving abilities are observed).During an interview on 8/5/26 at 9:00a.m., with Resident 3, in Resident 3's room, Resident 3 stated the staff would get frustrated with Resident 3 because Resident 3 did not speak English. Resident 3 stated they would speak to him in a rude tone and Resident 3 felt disrespected, frustrated and uncertain that the care being provided was correct. Resident 3 stated the bed provided is very small and Resident 3 does not have enough room on either side to turn over effectively. Resident 3 stated when Resident 3 needed to be on his side for care, the front of Resident 3's body was jammed into the side rail with the staff pushing on his back to allow access for wound and incontinent care causing Resident 3 to feel humiliated.During an interview on 8/4/26 at 1:40 p.m. with Certified Nursing Assistant 1 (CNA1), CNA1 stated resident 3 required two CNAs to provide any care that involved turning Resident 3 in the bed. CNA1 stated it required force to hold Resident 3 on Resident 3's side to provide care. CNA1 stated Resident 3 would be pushed up against the siderail on the bed during care because the bed was too small. CNA1 stated there are a limited number of staff that speak Spanish and most are on the day shift and the staff uses family members for translation when they are available. CNA1 stated other times staff used hand gestures and sometimes translations applications on cell phones to communicate with Resident 3. CNA1 stated there are no translation services available for the staff to use.During an interview on 8/4/26 at 12:15 p.m. with LVN2, LVN2 stated Resident 3 requires at least two people to turn him. LVN2 stated LVN2 would not be able treat Resident 3's sacral pressure injury without the assistance of two people to roll Resident 3 to a side position and to keep Resident 3 in position for injury care. LVN2 stated the factors that make moving Resident 3 in bed challenging are Resident 3' BMI and the bed Resident 3 occupied was not large enough to allow Resident 3 to move without substantial assistance.During a concurrent interview and record review on 8/6/26 at 1:15 p.m. with Registered Nurse 1, (RN1), Care Plan Report for Resident 3, printed o 8/4/26 was reviewed. RN1 stated the Care Plan Report for Resident 3 did not include care planning for Resident 3's language needs. RN1 stated it is very important for Resident 3 to communicate effectively with the care team so the Resident 3 can participate in the plan of care and so staff can assure care needs are being met. RN1 stated it would be difficult and very frustrating for Resident 3 to verbalize daily needs or alert staff to a change of condition. RN1 stated that could cause feelings of frustration and fear for Resident 3.During a concurrent observation and interview on 8/5/26 at 10:00 a.m. with the Director of Nurses (DON), at Resident 3's bedside, Resident 3 was observed to be in a bed with a low air loss mattress, (specialized bed surface that uses a continuous stream of air pushed through tiny laser made holes in the fabric providing constant gentle airflow keeping skin cool and dry which prevents pressure injuries), that were too small for Resident 3. The DON stated Resident 3 was in a bariatric bed but stated there was not enough room for Resident 3 to effectively turn while in the current bed and if Resident 3 could feel the bed frame under Resident 3's back the size of the low air loss mattress was also too small. The DON stated if a resident with a high BMI is assigned to a bed and a low air loss mattress that are too small such that the resident cannot reposition or be repositioned it can compromise the resident's ability to heal existing pressure injuries and/or prevent future pressure injuries. The DON also stated when bariatric residents are required to use equipment that does not fit properly it can cause feelings of frustration and humiliation. During a concurrent observation and interview on 8/5/26 at 10:05 a.m. with the Director of Nurses (DON), at Resident 3's bedside, The DON also stated there are a few staff members that speak Spanish in the facility, but they are not available on all shifts. DON stated the staff relies on family when available, use of gestures and some broken Spanish between staff and Resident 3. The DON stated there are no telephonic or electronic translation services available to assist the staff in caring for non-English speaking residents.During a record review of Order Summary Report for Resident 3, dated 8/4/26, the report indicated on 7/9/26 a physician's order for a low air loss mattress for wound healing was issued for Resident 3.During a review of the facility's policy and procedure titled, Resident Rights, dated 1/16/26, indicated residents have the right to a dignified existence and to be treated with respect, kindness and dignity.

BBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after an allegation was made for 1 of 4 sampled residents (Resident 1), when Resident 2 hit Resident 1 in the head with a chair on 6/12/26, resulting in Resident 1 sustaining a laceration, (traumatic injury that involves rips or tears to body tissue), to the forehead requiring sutures, (medical thread that holds the edges of wounds together after injury), and a broken neck bone.This failure resulted in the California Department of Public Health not being notified timely and unable to initiate an investigation to ensure the safety of vulnerable residents who cannot always advocate for themselves.During a review of admission Record for Resident 1, undated, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including candidal sepsis, (a life-threatening medical emergency that happens when the body has an extreme, harmful response to an infection), diabetes, (a long-term illness in which the body cannot regulate the level of sugar in the blood), dementia, (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), depression, (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world.) anxiety, (common emotional state characterized by feelings of unease, such as worry or fear, that can range from mild to severe), and substance abuse related psychosis, (a mental state where a person loses touch with reality).During a review of MDS Section GG Functional Status for Resident 1, dated 5/27/26, the record indicated Resident 1 was fully dependent on staff for feeding, bathing, changing position in bed, and toileting.During a review of Collaborative Care for Hospice Patients in a Facility for Resident 1, dated 5/21/26, the record indicated Resident 1 was enrolled in hospice care, (a medical specialty focusing on comfort and dignity at the end of life), with a primary diagnosis of unspecified degenerative disease of the nervous system, (progressive, worsening loss of nerve cells, but the exact specific disorder has not been identified or finalized). During a review of admission Record for Resident 2, undated, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including unspecified psychosis, anxiety, diabetes and immunodeficiency, (the body's immune system, [a complex network of cells, tissues, organs, and proteins that work together to defend the body against harmful germs] does not work correctly), and general body weakness.During a review of MDS Section C Cognitive Patterns for Resident 2, dated 4/6/26, the record indicated Resident 2 has a BIMS score of 8 indicating moderate cognitive impairment, (pronounced changes in thinking that interfere with daily activities such as memory loss, language issues, skewed judgment, and decreased problem-solving abilities are observed).During a telephone interview on 8/5/26 at 10:34 a.m. with Certified Nursing Assistant 1, (CNA1) CNA1 stated on the evening shift of 6/12/26, CNA1 was on a break and coming down the hall when CNA1 heard noise coming from the room shared by Resident 1 and Resident 2. CNA1 saw Resident 2 sitting in a wheelchair, yelling and holding a folding chair. CNA1 stated CNA1 saw Resident 2 hit Resident 1 across Resident 1's head with the chair. CNA1 stated CNA1 removed Resident 2 from the room and took Resident 2 to the nurse's station for observation. CNA1 stated the nurse was immediately notified.During a telephone interview on 8/5/26 at 12:00 p.m. with Licensed Vocational Nurse 1 (LVN1), LVN1 stated LVN1 was called to the room occupied by Resident 1 and Resident 2 by CNA1 after Resident 2 hit Resident 1. LVN1 stated upon entering the room LVN1 observed Resident 1 had a bleeding forehead laceration. LVN1 stated she assessed Resident 1 and applied pressure and a dressing, (a clean pad or material applied directly onto an injury to protect it, absorb blood or fluid, and help the skin heal), to the wound. LVN2 stated Resident 2 was taken to the nurse's station for observation and medication for agitation. LVN1 stated LVN1 notified Hospice and was advised by Hospice to transfer Resident 1 to the acute care hospital for evaluation and treatment. During an interview on 8/3/26 at 2:00 p.m. with the Director of Nursing (DON), the DON stated no reports of the abuse allegation involving Resident 1 and Resident 2 occurring on 6/12/26 were filed with the California Department of Public Health within two hours of the incident.During a review of Report of Suspected Dependent Adult/Elder Abuse-SOC 341 for Resident 1, dated 8/10/26, the report indicated the altercation between Resident 1 and Resident 2 occurred on 6/12/26. The submission date of the report to the California Department of Public health was 8/10/26.During a review of the facility's policy and procedure titled Policy and Procedure on Patient Abuse and Prevention, dated 5/2023, indicated, The facility share ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required.within 24 hours of knowledge of such incident.Facility shall report the incident by calling the.Department of Health-Licensing and Certification, (California Department of Public Health) .

Based on observation, interview, and record review, the facility had a 17.39 % error rate when four medication errors out of 23 opportunities were observed during a medication pass for one of nine residents (Resident 2).These failures resulted in medications not given in accordance with the Physician's Orders and may affect Resident 2's health conditions. During a medication pass observation on 3/6/26 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed to give Resident 2 six medications, including 1. Docusate Sodium 250 milligrams (mg. a form of measurement) capsule, 2. Hydrochlorothiazide 12.5 mg tablet, 3. Metoprolol Tartrate 25 mg tablet, 4. Multiple Vitamins tablet, 5. Senna 8.6 mg tablet and 6. Vitamin B12, 2000 micrograms (mcg. is a form of measurement) tablet to Resident 2 (Docusate Sodium and Senna are medications that prevent constipation, Hydrochlorothiazide and Metoprolol Tartrate are medications that lower blood pressure and Vitamin B 12 is a vitamin the body uses to make and support healthy nerve cells).A review of Resident 2's Physician Orders dated 3/5/26 revealed that four scheduled 9:00 a.m. medications were not administered by LVN 1 when she was observed giving medications to the resident. The following medications which were not given: 1. Aspirin 81 Tablet delayed release 81 mg (Aspirin), give one tablet by mouth one time a day for CVA prophylaxis, 2. Folic Acid oral tablet 1 mg (folic acid), give one tablet by mouth one time a day for supplement, 3. Vitamin C tablet 250 mg. ( Ascorbic acid), give one tablet by mouth one time a day for supplement and 4. Vitamin D3 oral tablet 25 mcg (Cholecalciferol), give one tablet by mouth one time a day for supplementation (CVA is cerebrovascular accident or stroke. Prophylaxis means preventive care. Aspirin is a medication given to prevent stroke. Folic Acid is a supplement that helps body create new cells, Vitamin C or Ascorbic Acid is a supplement that can help the body fight infections and Cholecalciferol is a supplement to build strong bones).During a joint interview and record review on 3/5/26 at 12:00 p.m. with LVN 1, and the Director of Nursing (DON), Resident 2's Physician's Orders and Medication Administration Record (MAR) were reviewed. The MAR indicated that LVN 1 signed the following medications as given to the resident at 9:00 a.m. : 1. Aspirin 81 Tablet delayed release 81 mg, give one tablet by mouth one time a day, 2. Folic Acid oral tablet 1 mg (folic acid), give one tablet by mouth one time a day for supplement, 3. Vitamin C tablet 250 mg ( Ascorbic acid), give one tablet by mouth one time a day for supplement, and 4. Vitamin D3 oral tablet 25 mcg (Cholecalciferol), give one tablet by mouth one time a day. When questioned by the DON, LVN 1 admitted to falsely signing the MAR for these medications without actually administering them. During an interview on 3/5/26 at 1:19 p.m. with the DON, the DON stated LVN 1's actions were unacceptable and stated that the nurse failed to administer ordered medications and falsified the MAR. Furthermore, the DON stated that this omission placed Resident 2 at risk for poor bone health and nutritional deficiencies. A review of the facility's policy and procedure (P&P) titled, (Administering medications), the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed.19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication .

Based on interview and record review, the facility failed to implement Resident 3's oncology referral ordered by the General Acute Care Hospital (GACH) upon the resident's discharge to the facility (oncology is a specialized branch of medicine dedicated to the diagnosis, treatment, and prevention of cancer).This failure resulted in Resident 3 having a delay in the referral for her cancer treatment. During a phone interview on 3/5/26, at 9:37 a.m., with Resident 3's Family Member (FM) 1, FM 1 stated, the facility failed to timely refer the resident to an oncologist. FM 1 stated that this caused a referral delay until she intervened on 1/14/26. FM 1 also stated that the facility referral to oncologist was only made due to FM 1's follow-up (an oncologist is a doctor who diagnoses and treats cancer).During a review of Resident 3's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE].During a review of Resident 3's Nurse Practitioner Progress Notes dated 1/16/26 , it indicated that Resident was transferred from the facility to the GACH on 12/25/25 due to unresponsiveness and was readmitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities), and malignant pleural effusion (defined as an abnormal accumulation of fluid containing cancer cells within the pleural space). During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/17/26, it indicated that the resident's cognition was severely impaired.During a concurrent interview and record review on 3/5/26 at 3:23 p.m. with Social Services Assistant (SSA), Resident 3's Hospitalist Discharge Summary and Transfer Instruction (HDSTI) to the facility dated 1/6/26 was reviewed. HDSTI indicated an order to refer the resident to oncology. SSA further stated that on 1/14/26, FM 1 approached her and pointed out in the HDSTI the order to refer Resident 3 to oncology. SSA stated that on 1/14/26, the facility did not know of the resident needing to be referred to oncology.During a review of Resident 3's Physician's Orders (PO) dated 1/7/26, the PO did not indicate an order to refer the resident to oncology. During a concurrent interview and record review on 3/6/26 at 12:00 p.m. with the Director of Nursing (DON), Resident 3's HDSTI dated 1/6/26 and the facility's PO dated 1/7/26 were reviewed. The DON acknowledged that while the HDSTI ordered a referral to oncology, the facility's PO did not. She stated it was the reviewing nurse's responsibility to follow up with the facility physician regarding the oncology referral. Furthermore, the DON acknowledged that the failure to act on this referral could cause a worsening of Resident 3's malignant pleural effusion.During a review of the facility's policy and procedure (P&P) titled, Transportation schedule, Updated 5/2023, the P&P indicated, . Procedures.1 Licensed nurse shall check physician order sheet for any existing orders for medical appointments, consults or procedures provided outside of the facility .

Based on interviews, and record review, the facility failed to protect Resident 1 from hitting his right foot and toes during care on two separate occasionsThis resulted in Resident 1 sustaining right foot and toes pain and swelling. During a review of Resident 1's Facesheet ( information containing contact details, brief medical history at-a-glance) dated 3/5/26 indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis caused by stroke ( hemiplegia is a form of paralysis that affects one side of the body, usually due to a brain injury and hemiparesis is weakness on one side of the body). During an interview on 3/5/26 at 10:21 a.m., Resident 1 stated that the staff repeatedly accidentally hit his right foot and toes in the door and bathroom wall while being transported in the shower chair and commode. The resident stated this caused pain and swelling to his right foot and toes. Resident 2 requested that staff take more care during transfers. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/2/26, indicated a Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 15, reflective of Resident 1 being cognitively intact. The MDS Section GG titled, Functional Abilities and Goals scored Resident 1as being unable to walk and was dependent for mobility and toileting, meaning helper does all the effort; the resident does none of the effort to complete the activity, thereby needing the assistance of two or more helpers to complete the activity.During a review of Resident 1's nurses' notes dated 12/1/26 at 6:47 p.m. showed: resident had his toe accidentally struck by the bathroom door while he was being assisted out of the restroom. At that time, he stated the toe was painful.During an interview on 3/6/26 at 10:04 a.m. with Certified Nursing Assistant (CNA)1, CNA 1 stated that on 12/1/25 at around 6:15 p.m., while maneuvering Resident 1 on the commode to exit the bathroom, the resident's right foot toes accidentally struck the edge of the bathroom door frame. CNA 1 acknowledged she should have been more careful and could have prevented the incident.During a review of Resident 1's Situation, Background, Assessment, and Recommendation notes (SBAR, is a structured communication framework that can help teams share information about the condition of a resident) dated 12/4/25, it reflected: Resident 1 complained of pain to his right foot following a bump during a shower. Assessment revealed swelling on the right foot. During an interview and concurrent record review on 3/6/26 at 10:31 a.m. with LVN 2, Resident 2's clinical records were reviewed. LVN 2 stated that on 12/4/25 at 5:00 p.m., Resident 1 bumped his right foot while he was being maneuvered in the shower chair in the shower room. LVN 2 further stated that on her assessment, the resident's right foot was swelling. LVN 2 confirmed that no care plan was made or was in place to prevent this recurring injury.During a concurrent interview and record review on 3/6/26 at 12:00 p.m., with the Director of Nursing (DON), Resident 1's clinical records were reviewed. DON acknowledged the lack of a care plan for Resident 1 in preventing his right foot and toes injuries. Furthermore, the DON stated that these incidents were preventable had an appropriate care plan been in place. A review of the facility's policy and procedure (P&P) titled, (Protocol for Prevention, Monitoring and Recording of Accidents and Incidents), the P&P indicated, Policy. It is the policy of this facility to implement and enforce all safety procedures and rules to ensure the safety and well-being of residents, staff and visitors. Facility shall implement measures to prevent, monitor and record accidents and incidents whenever applicable .6. Immediate corrective actions should be taken to prevent accidents or incidents.

Based on observation, interview and record review, the facility failed to ensure proper labeling and storage of medications according to the facility policy and procedures (P&P) and/or manufacturer specifications in two of two medication carts and two of two medication rooms when:Three unopen bottles of latanoprost (a medication for glaucoma) eye drops and an unopened insulin lispro (a pre-filled insulin pen containing a short-acting insulin called insulin lispro, used to treat high blood sugar) pen were found stored at room temperature.Two opened containers of glucose test strips and an opened vial of tuberculin purified protein derivative (PPD, protein substance used to diagnosis tuberculosis (TB), an infection in the lungs) were not dated with an open date.An opened bottle of fluticasone (an over-the-counter nasal spray, used for seasonal allergies) was without a label to indicate whom it was for.An opened, Advair (an inhaler containing medication to manage long-term breathing problems) for Resident 12, and a vial of PPD were found expired.These failures had the potential for medication errors and/or medications given beyond their effective dates, which would be ineffective for the residents. 1. During an inspection of 1B Medication Cart on 8/25/25 at 9:43 a.m., the following were identified and confirmed with registered nurse (RN) 2: a. Three unopened bottles of latanoprost eye solution bottles for Residents 36, 38 and 2 were stored at room temperature in the cart. The pharmacy labels indicated, Refrigerate. There was no date indicating when they were left at room temperature.During a review of the manufacturer's prescribing information for latanoprost, revised 9/24, indicated, Storage.store unopened bottle(s) under refrigeration at 36 to 46 degrees Fahrenheit (F) (temperature scale) .the bottle may be maintained at temperatures up to 104 degrees F for a period not exceeding 8 days. Once a bottle is opened for use, it may be stored at room temperature (77 degrees F) for 6 weeks.b. One unopen insulin lispro pen for Resident 36, stored at room temperature in the cart. There was no date indicating when it was left at room temperature. The pharmacy label indicated, refrigerate until used. Once in use, store at room temperatureDuring a review of the manufacturer's instructions for use for insulin lispro pen, revised 7/23, indicated, Storing your pen, Unused Pens, Store unused pens in the refrigerator at 36 degrees F to 46 degrees F.Unused pens may be used until the expiration date printed on the label if the pen has been kept in the refrigerator. In-use pens, store.at room temperature.throw away the .pen.after 28 days, even if it still has insulin left in it.c. One open bottle of glucose test strips (strips used to measure blood sugar level). There was no date indicating when the bottle was opened. A review of the manufacturer's label printed on the label with RN 2 indicated to use within 6 months after first opening. d. One open bottle of fluticasone nasal spray without any patient identifiers or labeling. RN 2 confirmed he did not know to whom the medication belonged. A review of the facility's P&P titled Medication Labels, effective 4/2014, indicated Nonprescription medications not labeled by the pharmacy are kept in the manufacturer's original container and identified with the resident's name. 2. During an inspection of the 2A Medication Cart on 8/25/25 at 10:54 a.m. with LVN 6, one Advair Diskus for Resident 12 was identified with the date open of 7/21/25. A review of the product labeling from the manufacturer with LVN 6 indicated to discard inhaler one month after opening the foil pouch. LVN 6 verified this finding and acknowledged the medication expired on 8/21/25. The inspection with LVN 6 also identified an open glucose test strip vial without open date. A review of the manufacturer's patient information for Advair Diskus, revised 6/2023, indicated, .throw away Advair Diskus.1 month after you open the foil pouch or when the counter reads 0, whichever comes first. 3. During an inspection of Station 1 Medication Room on 8/25/25 at 2:18 p.m. with the Director of Nursing (DON), an open PPD vial with an open date of 7/24/25 was identified in the refrigerator. A review of the product labeling with the DON indicated, Once entered, vial should be discarded after 30 days. The DON verified the PPD vial was expired. 4. During an inspection of Station 2 Medication Room on 8/25/25 at 4:18 p.m. with the DON, an open PPD vial without the open date was identified in the refrigerator. The DON confirmed the finding and acknowledged it should have an open date. A review of the facility's P&P titled Storage of Medications, updated 5/2023, indicated in part, 2. The nursing staff shall be responsible for medication storage. in a.safe.manner. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use.outdated.drugs. Medications requiring refrigeration must be stored in a refrigerator.

Based on observation, interview, record review, the facility failed to maintain walk in freezer temperature below zero degrees Fahrenheit. This failure had the potential to spread foodborne illnesses to all residents. During an interview and observation on 08/26/2025 at 10:04 AM the walk-in freezer in kitchen thermometer read 10 F. Dietary Manager (DM) placed a new thermometer. DM stated staff use the largest thermometer to document onto temperature log. Largest thermometer read 10 F. Touch tested ice cream, broccoli, donuts, chicken, fries, diced carrots, meat patties, all items frozen hard/solid. During an observation on 08/26/2025 at 10:10 AM walk-in freezer thermometer read 8 F on two separate thermometers. During an observation on 08/26/2025 at 11:34 AM the walk-in freezer temperature read 8 F on two separate thermometers. During an observation and interview on 08/26/2025 at 11:50 AM the Maintenance Director (MTD) stated freezer temperature felt fine. MD stated walk-in freezer temperature should be below zero to keep food frozen and keep food safe. The walk-in freezer temperature read 10 F on two separate thermometers. During an interview on 08/28/2025 at 8:46 AM MTD stated walk-in freezer in kitchen was serviced (perform routine maintenance) monthly but has not been serviced since February 2025 due to change in Maintenance Director.During an observation on 08/28/2025 at 8:51 AM walk-in freezer temperature was 8 F.During an observation on 08/28/2025 at 5:16 PM walk-in freezer temperature was 8 F on two thermometers and 2 F on one thermometer. DM stated MTD is aware and working on freezer temperature.During a review of facility's undated policy and procedure (P&P) titled, Refrigerators and Freezers, the P&P indicated, The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperature will be recorded on the tracking sheet, including the repair personnel and/or department contacted.During a review of facility's undated policy and procedure (P&P) titled, Refrigerators and Freezers, the P&P indicated, Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled ad followed.

Based on interview and record review, the facility failed to ensure the nursing practices that met professional standards for 3 out of 31 sampled residents (Resident 49, 57, and 74) when:1.There was no blood pressure (BP) assessment prior to Lasix (a medication to treat high BP and other conditions) administration for Resident 49.2. Pain medication orders were not followed as prescribed for Residents 57 and 74.3. Elevated ammonia level (toxic waste product produced by the body's metabolism of protein) was not communicated with the physician for Resident 57.The failures resulted in medications not being given as ordered, and inadequately monitored or untreated medical conditions for the residents.1. A review of Resident 49's clinical record indicated he was admitted to the facility with diagnoses including congestive heart failure (CHF, long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply).A review of his physician's orders included an order for: Lasix 20 milligrams (mg, unit of measurement), give 1 tablet by mouth one time a day for CHF HOLD FOR SBP [systolic BP] <100. This indicated to hold the Lasix if the SBP was below 100 (normal SBP is 120).A review of Resident 49's August 2025 Medication Administration Record (MAR) indicated the nursing staff has been giving the medication daily; however, there was no corresponding BP each time they administered it.A review of the Vital Signs section in Resident 49's clinical record indicated the nursing staff only documented BP assessment 7 times from 6/8/25 to 8/18/25 (a period over 2 months): on 6/8/25, 6/11/25, 6/29/25, 7/6/25, 7/27/25, and 8/18/25.During an interview with Resident 49 on 8/27/25 at 4:31 p.m., when asked whether the nursing staff take his BP on a daily basis, Resident 49 stated, Yes. He further stated he would not take Lasix unless his BP was above 100.During a concurrent interview and record review with the Director of Nursing (DON) and the Infection Preventionist (IP 1) on 08/28/25 at 1:20 p.m., they verified there was no documentation that Resident 49's BP was obtained before Lasix administration. IP 1 explained that the order was not entered correctly for the BP to be input in the computer system. They acknowledged the computer system must require the input for staff to remember to take the BP before administering the medications, especially for those residents who could not speak for themselves.A review of the facility's policy and procedures (P&P) titled Medication and Treatment Administration, updated 5/2023, indicated, Licensed nurse shall perform tests and taking of vital signs, as indicated or required by specific medication administration or treatment administration. Results of test and taking of vital signs shall be recorded in the resident's clinical record.2a. A review of Resident 74's physician's orders indicated an order for morphine sulfate (a potent narcotic for pain) 20 mg/milliliters (mL, unit of volume), give 0.25 mL by mouth every 6 hours as needed for severe/breakthrough pain, dated 8/8/25.A review of Resident 74's August 2025 MAR indicated, on 5 occasions, the nursing staff administered the morphine when the resident's pain score was zero (scoring range, 0-10; 0 = no pain, 10 = worst pain possible).During a concurrent interview and record review with IP 1 on 8/27/25 at 12:02 p.m., she stated severe pain scale is from 7 to 10. She reviewed Resident 74's August 2025 MAR and confirmed the staff administered the morphine while the resident had zero pain, inconsistent with the physician's order.2b. A review of Resident 57's clinical record indicated he had a physician's order for Ultram (a controlled medication for pain) 50 mg, give 1 tablet every 6 hours as needed for moderate to severe pain, dated 7/2/25.A review of Resident 57's July 2025 MAR indicated the nursing staff administered the Ultram dose 15 times during this month. Of the 15 times, 9 had the pain score of zero and 1 had pain score of NA (not applicable). During a concurrent interview and record review with the DON and IP 1 on 8/28/25 at 12:57 p.m., both staff verified this finding and stated that the Ultram should not be given for a pain score of zero. They acknowledged the medication was not given as ordered.A review of the facility's P&P titled Medication and Treatment Administration, updated 5/2023, indicated, Medications and treatments shall be administered as prescribed.3. A review of Resident 57's clinical record indicated a physician's order for lactulose (medication for liver disease, to reduce ammonia level in the blood) 10 grams (gm, unit of measurement)/15 mL, give 45 mL by mouth three times a day, dated 11/17/24.Further review of Resident 57's clinical record indicated he had a physician's order to obtain an ammonia level on 5/27/25 and 6/23/25.During a concurrent interview and record review on 8/28/25 at 12:57 p.m. with the DON and IP 1, they were asked to show the ammonia laboratory results as per order. IP 1 reviewed Resident 57's clinical record and stated the ammonia level was 65 (normal value: 9-37) on 6/23/25. When asked whether the physician was notified of the elevated ammonia level, both the DON and IP 1 could not find any documentation the physician was notified. They acknowledged it should have been communicated with the physician.A review of the facility's P&P titled Reporting of Lab and X-ray Results, updated 5/2023, indicated, Licensed nurse in charge of resident's care must notify physician of results of laboratory.tests within reasonable amount of time or PROMPTLY if test results are abnormal.

Based on interviews and record review, the facility failed to ensure 3 out of 5 sampled residents (Residents 8, 9, and 51) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when all three residents received psychotropic medications without documented evidence of behavioral (or non-pharmacological) interventions attempted.The employment of non-pharmacological/non-drug interventions allows the facility to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. 1. A review of Resident 8's clinical record indicated he was admitted to the facility with diagnoses including schizoaffective disorder (mental illness that can affect your thoughts, mood and behavior) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).A review of Resident 8's physician's orders indicated the following psychotropic medications:a. Lexapro (an antidepressant) 10 milligrams (mg, unit of measurement), give 1 tablet one time a day for depression manifested by sudden angry outbursts such as throwing meal tray, verbal aggressiveness towards staff and others, dated 7/11/25. b. Depakote (a medication for mood disorder) 125 mg, give 2 capsules by mouth three times a day related to bipolar disorder, dated 6/25/25. c. Seroquel (an antipsychotic medication) 300 mg, give 1 tablet by mouth at bedtime related to schizoaffective disorder manifested by inappropriate sexual behavior to female staff, dated 6/25/25.A review of Resident 8's clinical record indicated no documented evidence of non-drug interventions (such as redirection, activities, music therapy, emotional support, pain assessment, etc.) being implemented/attempted for the resident, or that they were contraindicated.During a concurrent interview and record review with the Infection Preventionist (IP 1) on 8/27/2025 at 1:06 p.m., she reviewed Resident 8's clinical record and stated, It's not there. She explained that the staff used to document these interventions on the medication administration record, but the previous director of nursing (DON) cleaned up the documentation and removed all these requirements.2. A review of Resident 9's clinical record indicated she was admitted to the facility with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and depression.A review of Resident 9's physician's orders included an order, dated 5/29/25, for mirtazapine (an antidepressant medication) 15 milligrams (mg, unit of measurement), 0.5 tablet at bedtime for depression manifested by poor meal intake.A review of Resident 9's clinical record indicated there was no documented evidence the facility implemented behavioral (or non-pharmacological) interventions (such as offering appetizing food or regular meal intervals, protein shakes, staff encouragement, emotional health support, etc.) before or during the use of mirtazapine.During a concurrent interview and record review with the DON and IP 1 on 8/28/25 at 1:16 p.m., IP 1 confirmed there was no documented evidence the facility implemented the non-drug interventions prior to today.3. A review of Resident 51's clinical record indicated she was admitted to the facility with diagnoses including anxiety and schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others).A review of Resident 51's physician's orders included the following:a. Risperidone (an antipsychotic) 1mg, give 1.5 tablet two times a day for schizophrenia manifested by screaming/yelling and seeing people not present that causing fear, dated 8/20/2025.b. Depakote 125 mg, give 6 capsules by mouth two times a day related to major depressive disorder, dated 8/15/25.A review of Resident 51's clinical record indicated there was no documented evidence that the facility employed non-drug interventions before or while the resident was receiving these medications or that they were contraindicated.During a concurrent interview and record review with the DON and IP 1 on 8/28/25 at 1:29 p.m., IP 1 stated the staff employed non-drug interventions such as getting the resident up on the chair, taking her to activities, leaving her be, assessing for pain, etc. whenever she exhibited behaviors, but acknowledged there was no documented evidence of any of these interventions by the staff.A review of the facility's policy and procedures titled Psychotropic Medication Use, dated June 2021, indicated: The facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Facility staff should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions. a. Facility should involve the resident or the resident's representative(s) in the discussion of potential non-drug and medication interventions to address management of behaviors and the involvement should be documented in the resident's medical record. b. Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use.

Based on observation, interview, and record review, the facility failed to provide necessary one to one (1:1; one staff to one resident) feeding assistance to seven out of 42 sampled residents (Residents 19,66, 67, 85, 62, 29 and 58). This failure resulted in Resident 19, 66, 67, 85, 62, 29 and 58 to be fed more than 15 minutes after meal trays were delivered to bed side.During record review of Resident 19's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper extremity, and Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) regarding eating. During record review of Resident 66's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper and lower extremity, and Substantial/maximal assistance (Helper does MORE THAN HALF the effort, Helper lifts or holds trunk or limbs and provides more than half the effort) regarding eating. During record review of Resident 67's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment to both sides to lower extremity, and Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) regarding eating.During record review of Resident 85's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment to both sides to upper and lower extremity, and Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) regarding eating.During record review of Resident 62's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment to both sides to upper and lower extremity, and Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) regarding eating.During record review of Resident 29's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment to both sides to upper and lower extremity, and Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) regarding eating.During record review of Resident 58's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment to both sides to lower extremity, and Substantial/maximal assistance (Helper does MORE THAN HALF the effort, Helper lifts or holds trunk or limbs and provides more than half the effort) regarding eating.During an observation on 08/27/2025 at 12:26 PM Station two (2B; rooms 214-221) meal trays were delivered on the floor. Certified Nursing Assistant (CNA) 4 was passing meal trays to Station 2B.During an observation on 08/27/2025 at 12:33 CNA 4 placed Resident 85 meal tray at bedside but did not set-up Resident to eat.During an observation and interview on 08/27/2025 at 12:38 PM CNA 4 was delivering Station 2B Resident meal trays alone. CNA 4 stated was waiting for another CNA to return from the dining room to assist in delivering meal trays to Station 2B. CNA 4 stated Station 2B has 6 1:1 feeding Residents. CNA 4 stated she will begin 1:1 feeding with each Resident after delivering all Station 2B meal trays.During an observation on 08/27/2025 at 12:41 PM Resident 67 meal tray was placed at bedside, but Resident 67 not set up to eat. During an observation and interview on 08/27/2025 at 12:47 PM CNA 4 was feeding Resident 85. CNA stated will feed remaining five other dependent residents when complete with Resident 85.During an observation on 08/27/2025 at 12:51 PM Resident 29 was sitting up in bed with meal tray at bedside. Resident stated he was unable to feed himself and awaiting CNA assistance. CNA 4 stated resident is a 1:1 feeder. During an observation on 08/27/2025 at 12:53 PM Resident 19 meal tray was at bedside, but Resident 19 not set up to eat. During an interview on 08/27/2025 at 12:53 PM Licensed Vocational Nurse (LVN) 3 stated CNA are responsible to feed residents, and nurses assist when needed. LVN 3 stated dependent, 1:1 feeding Residents should be fed 10 minutes after their meal tray is delivered. LVN 3 Stated it is important to feed residents to help with healing.During record review of facility's policy and procedure (P&P) titled, Assistance with Meals, dated 5/2023, it indicated, Nursing staff and/or Feeding Assistants will feed those resident needing full assistance within 15 minutes of the delivery of food trays.During record review of facility's policy and procedure (P&P) titled, Assistance with Meals, dated 5/2023, it indicated, Residents who cannot feed themselves will be fed with attention to safety effort and dignity, for example.avoiding the use of labels when referring to residents, (e.g. 'feeders').During record review of facility's policy and procedure (P&P) titled, Providing Assistance with ADL Care, dated 5/2023, it indicated, Provide assistance with activities of daily living depending on the level of assistance needed and the number of person(s) needed to assist resident.

Based on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services that included availability of medications, accurate administration of medications, safe medication storage, and accurate accountability of controlled substances (that can be easily abused and are under strict government control) when:1. Lovenox (an anticoagulant to treat blood clots) was not available for administration for Resident 34 on 6 occasions since May 2025. This had the potential for the resident to develop blood clots.2. Glipizide (a medication for diabetes) as not accurately administered as per manufacturer's specifications for 2 residents (Residents 9 and 51). This resulted in the residents not receiving the optimized therapeutic effect of the medication.3. Controlled medications were not reconciled when they were signed out of the controlled drug record (CDR, an accountability sheet of controlled medications) but not documented on the medication administration record (MAR) for 4 out of 5 residents (Residents 74, 65, 81, and 23). This resulted in facility not having accurate accountability and the potential for abuse/loss of controlled medications.4. Discontinued controlled substance medications for residents (Residents 41,74, 56 and 18) were not removed timely in 2 of 2 medication carts inspected. This failure had the potential for medication errors and abuse/loss of controlled medications.5. There were duplicate narcotic emergency drug kits (E-kit, containing scheduled II medications-controlled substance) in Station 1 Medication Room. This failure had the potential for drugs to be diverted.6. A total of 9 discontinued controlled medications for residents (Residents 6, 76, 53, 35, and 8) were stored in Station 1 Medication Room where they were accessible to multiple staff members. This failure had the potential for medication errors and loss/abuse of controlled substances. 7. Nursing staff did not consistently document E-kit checks between nursing shift changes. This failure had the potential for emergency medications to be unavailable to residents in need, and/or narcotic e-kits to be lost or diverted.8. An oral medication E-kit was opened but not replaced timely. This failure had the potential for medications not to be available to meet the needs of residents. 1. During a medication observation on 8/25/25 at 5:00 p.m., LVN 5 checked her medication cart and stated she did not have the Lovenox syringes for Resident 34; she stated it was last administered the day before, on 8/24/25. A review of Resident 34's clinical record indicated an order, dated 4/17/25, for Lovenox injection solution 40 milligrams (mg, unit of measurement), inject 1 time a day for long term deep vein thrombosis (blood clot in the deep vein) prevention. It was scheduled to be given daily at 9 a.m. On 8/26/25, a review of Resident 34's August 2025 MAR indicated the nursing staff placed a code 9 (meaning Other/See progress notes) in the entry for Lovenox administration on 8/25/25 and 8/26/25 at 9 a.m. A review of the corresponding progress notes, dated 8/26/25 at 10:31 a.m., indicated Medication in order. Another progress notes, dated 8/26/25 at 1:24 p.m., indicated in part, Resident missed Lovenox 40 mg Scheduled dose on 8/25/25 due to pharmacy delivery delay. During an interview with Resident 34 on 8/26/25 at 2:05 p.m., she stated she has not had the Lovenox injection for 2 days. She stated this has happened in the past, and it would take 2 days for the facility to order it. A review of Resident 34's May 2025 MAR indicated the staff placed a 9 in the entry for Lovenox injection administration on 4 occasions: on 5/3/25, 5/6/25, 5/7/25, and 5/8/25. The corresponding progress notes on those days indicated: f/u [follow up] with pharm[[NAME]], f/u with pharm, no notes, and Not available, respectively. During a concurrent interview and record review with the Infection Preventionist (IP 1) on 8/27/25 at 11:47 a.m., she reviewed Resident 34's May and August 2025 MARs and stated a 9 code means not administered. She confirmed Resident 34's Lovenox was not available for administration on 6 occasions since May 2025 (as indicated above). A review of the facility's policy and procedures (P&P) titled Preparation and General Guidelines, dated 10/2017, indicated, Medications are administered in accordance with written orders of the attending physician. 2a. A review of Resident 9's clinical record indicated she had a physician's order, dated 5/28/25, for glipizide 5 mg, give 1 tablet two times a day before meals for diabetes. A review of Resident 9's August 2025 MAR indicated glipizide was scheduled to be administered at 8 a.m. and at 4 p.m. A review of the facility's meal schedule indicated breakfast was scheduled at 7:15 a.m. and dinner is at 5 p.m. Thus, the morning dose of glipizide was schedule after breakfast, not before meal, as ordered. During a concurrent interview and record review with the DON on 8/28/25 at 2:08 p.m., she stated glipizide is supposed to be given 30 minutes before a meal. She stated breakfast is between 7 a.m. to 7:30 a.m. She confirmed Resident 9's morning glipizide dose was scheduled after breakfast, contrary to the physician's order. A review of the 7-day administration history for Resident 9's morning glipizide dose indicated it was administered at the following times and days, all of which was after breakfast time: 9:03 a.m. on 8/28/25 8:10 a.m. on 8/27/25 8:26 a.m. on 8/26/25 8:19 a.m. on 8/25/25 8:44 a.m. on 8/24/25 8:35 a.m. on 8/23/25 8:14 a.m. on 8/22/25 2b. A review of Resident 51's clinical record indicated she had a physician's order, dated 2/16/24, for glipizide 10 mg, 1 tablet by mouth one time a day with meals for diabetes. It was scheduled daily at 7:30 a.m. since 2/16/24 (1.5 years ago). During a concurrent interview and record review with the DON on 8/28/25 at 2:08 p.m., she confirmed glipizide was not to be given with meals, but 30 minutes before a meal. She stated that the nurse who entered the order must have mistaken it for metformin (another antidiabetic medication). A review of the Package Insert (information about a drug and its use) for glipizide, dated 9/2008, indicated glipizide should be given approximately 30 minutes before a meal to achieve the greatest reduction in postprandial hyperglycemia [rise in blood sugar after meal]. A review of the 7-day administration history for Resident 51's glipizide indicated it was administered at the following times and days, all of which was after breakfast: 11:09 a.m. on 8/28/25 9:34 a.m. on 8/27/25 11:56 a.m. on 8/26/25 9:38 a.m. on 8/25/25 9:10 a.m. on 8/24/25 10:09 a.m. on 8/23/25 10:57 a.m. on 8/22/25 A review of the facility's P&P titled Medication and Treatment Administration, updated 5/2023, indicated, It is the policy of this facility to administer medication or treatment. within the scope of professional standards of practice. 3. During the survey, the controlled drug record (CDR, an accountability sheet of controlled medications) for 5 residents receiving as-needed medications were requested for review. During a concurrent interview and record review with IP 1 on 8/27/25 at 11:59 a.m., she stated any time a resident requests an as-needed medication, the nursing staff assesses the resident; reviews the medication order, and if within administration time frame, removes the medication from the medication cart; administers the medication; and documents the administration on the MAR. 3a. A review of Resident 74's clinical record indicated an order for morphine sulfate (a potent narcotic for pain) 20 mg/milliliters (mL, unit of volume), give 0.25 mL by mouth every 6 hours as needed for severe/breakthrough pain, dated 8/8/25. On 8/27/25 at 12:02 p.m., a review of Resident 74's CDR for morphine and August 2025 MAR with IP 1 indicated, on 6 occasions, the nursing staff signed out the morphine doses on the CDR but did not document the administration on the MAR: on 8/8/25 at 9 a.m.; 8/12/25 at 5 a.m.; 8/13/25 at 5 a.m.; 8/19/25 at 4 a.m.; 8/22/25 at 5 a.m.; and on 8/22/25 at 9 p.m. During the review, IP 1 confirmed this finding. - 3b. A review of resident 65's clinical record indicated she had a physician's order, dated 8/26/25, for lorazepam (a controlled medication for anxiety) 0.5 mg, 1 tablet every 4 hours as needed for anxiety for 14 days. On 8/27/25 at 12:15 p.m., a review of Resident 65's CDR for lorazepam and July 2025 MAR with IP 1 indicated, on 2 occasions, the nursing staff signed 1 tablet out of the CDR but did not document the administration on the MAR: on 7/7/25 at 4 a.m. and 7/24/25 at 4 a.m. IP 1 reviewed the records and confirmed the finding. 3c. A review of Resident 81's clinical record indicated a physician's order, dated 4/11/25, for lorazepam 0.5 mg, 1 tablet every 2 hours as needed for anxiety. On 8/27/25 at 12:25 p.m., a review of Resident 81's CDR for lorazepam and April and May 2025 MARs with IP 1 indicated, on 4 occasions, the nursing staff signed the medication out of the CDR but did not document the medication administration on the MARs: 4/12/25 at 5 p.m.; 5/1/25 at 5 p.m.; 5/9/25 at 4:30 p.m.; and on 5/24/25 at 5 p.m. During the review, IP 1 confirmed this finding. 3d. A review of Resident 23's clinical record indicated a physician's order, dated 5/8/25, for Dilaudid (a potent narcotic for pain) 1 mg/milliLiter (mL, unit of measurement), give 1 mL by mouth every 4 hours as needed for pain. On 8/27/25 at 12:29 p.m., a review of Resident 23's CDR for Dilaudid and August 2025 MAR with IP 1 indicated the nursing staff removed 1 dose on 8/9/25 at 5:34 p.m. without documenting the medication administration on the MAR. On 8/27/25 at 12:36 p.m., IP 1 confirmed the lack of documentation for all four residents above and stated the nursing staff need to document the medication administration on the MAR to account for these controlled medications. A review of the facility's policy and procedures (P&P) titled Controlled Medications in the Preparation and General Guidelines, dated 4/2008, indicated: When a controlled medication is administered, the licensed nurse administering the mediation immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration. 2) Amount administered. 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. 4) Initials of the nurse administering the dose on the MAR after the medication is administered. 4a. During an inspection of the 1B Medication Cart at 8/25/25 at 10:22 a.m. with Registered Nurse 2 (RN 2), the following 2 discontinued or expired controlled medications were found: 8 oral syringes (syringes containing, liquid medication for oral use) containing 0.125 milliliters (mL) of Morphine (a medication to relieve severe pain) 100 milligram (mg)/ 5 mL (unit of measure) for Resident 41. The pharmacy prescription label indicated, Drug Exp. (Expired) 5/21/25. 20 oral syringes containing 0.5 mL of Lorazepam (a medication commonly used for anxiety) 2 mg/ mL for Resident 41. The pharmacy prescription label indicated, Drug Exp. 6/01/25 RN 2 confirmed the finding and stated the nursing staff does not count them during shift changes, and they should have been given to the Director of Nursing (DON) right away. A review of the facility's P&P, titled Discarding and Destroying Medication updated 5/2023, indicated, .Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. A review of the facility's P&P, titled Controlled Substances updated 5/2023, indicated, .Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. 4b. During an inspection of 2A Medication Cart on 8/25/25 at 11:10 a.m. with Licensed Vocational Nurse 6 (LVN 6), the following 5 discontinued and/or expired controlled medications were found: - Two bottles of Lorazepam Intensol (liquid) 2 mg/mL, for Resident 74. One punch card containing 54 half-tablets (1/2) of Tramadol (a medication for severe pain) 50 mg, for Resident 56. A review of the pharmacy label, indicated, the medication expired (exp) 8/21/25 . One punch card containing 2 tablets of Lorazepam 0.5 mg tablets for Resident 74. . One punch card containing 20 tablets of Hydrocodone 5 mg-Acetaminophen, 325 mg (a combination medication to treat severe pain) for Resident 18. A review of the pharmacy label, indicated, the medication expired (exp.), 6/21/25. During the inspection, LVN 6 confirmed the findings. She acknowledged the controlled medications have been in the bin for a while and are to be surrendered to the DON at the end of the shift. 5. During an inspection of the Station 1 Medication Room with the DON on 8/25/25 at 2:33 p.m., two narcotic E-kits were identified in a locked drawer: one had two red seals, indicating it was unopened; the other had two yellow seals, indicating it was previously opened. The DON opened the yellow sealed kit which contained a log that indicated: One tablet of hydromorphone was removed 8/3/25 for Resident 53 One tablet of hydrocodone 5 mg/acetaminophen 325 mg was removed 8/13/25 for Resident 79. During this inspection, the DON stated that only one narcotic kit should be stocked. She stated when the pharmacy brought a new E-kit, they did not pick up the used one. The DON stated nursing staff do not count the E-kits during shift change and acknowledged the potential for a lost/ diverted narcotic kit to go unnoticed. A review of the facility's P&P, titled Emergency Pharmacy Service and Emergency Kits, revised 1/2025, indicated, .An emergency supply of medications including emergency drugs. controlled substances.is supplied by the provider pharmacy.in limited quantities. and M. If exchanging kits, when the replacement kit arrives, the receiving nurse gives the used it to the courier for return to the pharmacy. N. If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. 6. During an inspection of Station 1 Medication Room with the DON on 8/25/25 at 2:44 p.m., the following 9 expired or discontinued controlled substances were in the locked drawer, co-mingled with the narcotic E-kits: One medication card containing 19 tablets of oxycodone (a medication to treat severe pain) 5 mg for Resident 6; A review of the prescription label, indicated the medication expired (exp.) 8/7/25. One medication card containing 30 tablets of hydrocodone 5mg/acetaminophen 325 mg for Resident 76. One medication card containing 28 tablets of Morphine ER (extended release) 15 mg tablets for resident 53. One bottle of Morphine oral liquid for Resident 35. One 15 mL bottle of lorazepam 2 mg/mL oral liquid for Resident 8. Pharmacy label indicated, medication expired: 6/10/25. One prescription bottle containing 9 tablets of hydromorphone 4 mg tablets for Resident 53. A total of three (3) medication cards containing half-tablets of hydromorphone (medication to treat severe pain) 2 mg for Resident 53; (1) card with 14 half-tablets (1) card with 30 half-tablets and (1) card with 25 half-tablets. During an interview with RN 3 in the presence of the DON, in Station 1 Medication Room, on 8/25/25 at 2:45 p.m., when asked if nurses count the discontinued controlled medications stored in the medication room drawer, RN 3 stated, No, we do not. During an interview with the DON on 8/25/25 at 2:51 p.m., she verified a total of 9 medication cards and bottles of controlled substances were in the locked medication room drawer. The DON stated the medications should have been given to her to store separately and not stored in the drawer where multiple staff had access and do not keep count. 7. During an interview on 8/25/25 at 4:02 p.m. with LVN 7 in the presence of the DON, in the Station 1 Medication Room, LVN 7 stated, During shift change we check if it [E-kit] is sealed, she added it is documented in the narcotic binder. A review of the July and August 2025 logs in the station 1 medication room with the DON and LVN7, indicated some entries had circled (S) for sealed or (O) for opened and during many shift changes there were no circles, documenting the status of the kits. in July, there were 44 times where the staff did not check the E-kit during shift changes. In August 2025, there were 17 times the staff did not check whether the E-kits were opened or sealed. The DON confirmed the finding. 8. During a follow-up inspection of the station 1 medication room on 8/25/25 at 4:11 p.m. with the DON, one oral E-kit with a yellow seal, indicated the E-kit was opened. A review of the emergency kit pharmacy log (a log documenting, opened date, medication and quantity, obtained, name of the resident and provider ordering the medication) indicated the oral E-kit was opened 8/12/25 for a new order of Augmentin (an antibiotic) for Resident 101; and on 8/13/25 for a new order of doxycycline (an antibiotic) for resident 90. The DON stated the kit should have been replaced already. A review of the facility's P&P, titled Emergency Pharmacy Service and Emergency Kits, revised 1/2025, indicated, .the used sealed kits are replaced with the new sealed kits within 72 hours of opening.

Based on observation, interview, and record review, the facility had a medication error rate of 15.15% when five medication errors occurred out of 33 opportunities during the medication administration for three out of eight residents (Residents 62, 70 and 1).Resident 62 received an insulin (medication to lower blood sugar) dose via insulin pen without the pen being primed prior to administration. Resident 70 did not receive two medications as scheduled; and Resident 1 did not receive two medications as prescribed.The failures resulted in the residents not receiving medications as prescribed and had the potential for complications of their medical conditions (such as high/low blood sugar, breathing problems or blood clots). 1. During a medication observation on 8/25/25 at 4:38 p.m. with Licensed Vocational Nurse (LVN) 4, she was observed removing Resident 62's Humalog Kwikpen (a pre-filled insulin pen containing a short-acting insulin called insulin lispro, used to treat high blood sugar) from the medication cart. LVN B stated she will give 6 units of insulin lispro for a blood sugar reading of 256.On 8/25/25 at 4:41 p.m. at Resident 62's bedside, LVN 4 dialed the pen to 6 units and injected the Humalog into the resident's right abdomen. LVN 4 did not prime the pen prior to administering the insulin dose to the resident.During an interview on 8/25/25 at 4:54 p.m., when asked about priming the insulin pen, LVN 4 stated she did not know how and had not done it before.A review of Resident 62's clinical record indicated a physician order, dated 6/25/25, for insulin lispro solution, to inject per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings), to give 6 units for blood sugar between 250 - 299.During an interview on 8/26/25 at 12:07 p.m. conducted with the Director of Nursing (DON) regarding the priming of insulin pens, she stated to prime the needle first, pushing the liquid out before administering the pen. A review of the drug manufacturer's INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) KwikPen, dated 7/2023, indicated the following instructions for priming the pen:Prime before each injection, priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.To prime you Pen, turn the Dose Knob to select 2 units .Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top .Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window .Turn the Dose Knob to select the number of units you need to inject .A review of the facility's policy and procedures (P&P) titled Use of Prefilled Insulin, updated 2025, indicated, Attach a new, sterile needle for each use .Prime the pen (usually 2 units) to ensure proper insulin flow.2. During a medication pass observation on 8/25/25 at 5:02 p.m., LVN 5 was at the medication cart preparing six medications for Resident 70. LVN 5 stated the resident's Flovent inhaler (an inhaled steroid to reduce lung inflammation) and Xarelto (an anticoagulant) were unavailable at this time. She stated she will check the medication room later.On 8/25/25 at 5:30 p.m. in the medication room, LVN 5 looked for the medications and stated they are not here. A review of Resident 70's medical record indicated Resident 70 had the following physician orders:- Xarelto oral tablet 10 milligram (mg, unit of measurement), give one tablet by mouth for CVA (cerebral vascular accident, also known as stroke)/ DVT (deep vein thrombosis, also known as blood clots), dated 2/11/23. It was scheduled daily at 5 p.m. - Flovent HFA 110 microgram/actuation (mcg unit of measurement), 1 puff inhale orally two times a day for COPD (chronic obstructive pulmonary disease, damage to the lungs), dated 5/2/22. It was scheduled daily at 9 a.m. and 5 p.m.On 8/26/25 at 10:45 a.m., a review of Resident 70's August 2025 Medication Administration Record indicated LVN 5 placed a 9 (meaning the medication was not administered and other/ see progress notes) in the entry for 8/25/25 at 5 p.m. administration for Xarelto and Flovent HFA. A review of the nursing progress notes, written by the Infection Preventionist (IP 1) on 8/25/25 at 7:12 p.m., indicated Xarelto 10 mg and Flovent HFA . will be delivered to the facility between 7:30 to 9:30 tonight. Nurse Practitioner notified.During an interview with the DON on 8/26/25 at 12:07 p.m., the DON acknowledged Resident 70's Flovent HFA and Xarelto were not given on 8/25/25 at 5 p.m. as scheduled.3. During a medication pass observation on 8/26/25 at 8:55 a.m., Registered Nurse (RN) 1 was observed preparing 7 medications for Resident 1. The 7 medications were an inhalation unit dose for breathing treatment, a tablet of cholecalciferol 25 micrograms (mcg) (Vitamin D supplement), a tablet of docusate (a stool softener) 100 mg and four other medications in tablet form. RN 1 crushed each tablet form medication and put them in individual medication cups. During the preparation, RN 1 was unable to locate one medication, placed the prepared medications in the locked medication cart, and went to look for the missing medication. On 8/26/25 at 9:09 a.m., RN 1 returned to the medication cart and was unable to find the missing medication. She then prepared 6 additional medications for Resident 1. The 6 medications were one tablet of cholecalciferol 25 mcg, one tablet of docusate 100 mg, 1 other medication in tablet form, a Miralax powder (for regular bowel movement), 2 capsules of a probiotic (to balance the gut flora) and an eye medication. RN 1 crushed each tablet form medication and put them in individual medication cups. Likewise, she opened the probiotic capsules and put the contents into a medication cup.On 8/26/25 at 9:28 a.m. in the resident's room, RN 1 confirmed there were a total of 13 medications: 11 medication cups, 1 inhalation, and 1 eye drop, to be administered to Resident 1. She administered the medications to the resident via the gastrostomy tube (a tube inserted into the stomach to deliver nutrition and medications).During an interview with RN 1 on 8/26/25 at 10:03 a.m., RN 1 acknowledged Resident 1 had a total of eleven medications due this morning, and thirteen medications were prepared and administered as the cholecalciferol and the docusate were prepared and administered twice.A review of Resident 1's clinical record indicated 11 medications were due during the morning medication pass. The physician orders included:-docusate sodium oral tablet 100 mg, give 2.5 tablets one time a day for bowel regularity hold for loose stools, dated 4/3/25.-cholecalciferol oral tablet 25 mcg, give 1 tablet one time a day for daily supplement, dated 4/3/25.During a follow-up interview and concurrent record review of Resident 1's MAR on 8/26/25 at 12:03 p.m. with RN 1, RN 1 confirmed that two docusate100 mg tablets were administered instead of the two and one-half (2.5) tablets as ordered by the physician.During a review of the facility's P&P, titled Medication and Treatment Administration updated 5/2023, indicated, 2. Medications and treatments shall be administered as prescribed. 16. Before administering medication or treatment, check every medication/treatment against the physician order and transcription in the Medication Administration or Treatment Record.During a review of the facility's P&P, titled Medication Administration-General Guidelines, effective 10/2017, indicated, Medications are administered in accordance with written orders of the attending physician.

Based on interview and record review, the facility's consultant pharmacist (CP) failed to identify and report irregularities during the monthly drug regimen review (MRR) for 3 out of 31 sampled residents (Residents 9, 51, and 57) when Resident 57 received lactulose (medication to treat constipation and liver disease) for a wrong indication; and Residents 9 and 51 did not receive glipizide (medication for diabetes) as per manufacturer's specifications.The failure resulted in inadequate monitoring for effectiveness and adverse effects for Resident 57's lactulose; and Residents 9 and 51 not receiving the optimized therapeutic effect of glipizide.1. A review of Resident 57's medical record indicated Resident 57 was admitted to the facility with diagnoses that include: alcoholic liver disease (a condition of liver damage) and portal hypertension (elevated pressure in the portal vein, commonly caused by liver disease). Resident 57's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/29/25, indicated Resident 57 has no cognitive impairment.A review of Resident 57's medical record indicated Resident 57 had the following physician order: - Lactulose 10 grams (gm, unit of measurement)/ 15 milliliters (mL, unit of volume), give 45 mL by mouth three times a day for constipation Hold if more than 3 bowel movements daily, dated 11/17/24 (9 months ago).During an interview on 8/27/25 at 9:27 a.m. with Resident 57, when asked about the lactulose medication, Resident 57 said, Oh, that is for my liver. The resident added he has been on the medication for four years.During an interview and record review with the MDS Coordinator (MDS C) on 8/27/25 at 1:15 p.m., when asked about indication for Resident 57's lactulose, MDS C stated it is for constipation. Upon further review of Resident 57 's clinical record, the MDSC stated the hospital Discharge summary, dated [DATE], indicated the lactulose was used for alcoholic cirrhosis with portal hypertension. She confirmed the facility had the wrong indication for Resident 57's lactulose. During a concurrent interview and record review on 8/28/25 at 12:57 p.m. with the DON and the Infection Preventionist (IP 1), when asked about the medication monitoring for lactulose (such as labs and liver disease), IP 1 stated monitoring had not been done as the lactulose had the wrong indication.During a telephone interview with the CP on 8/28/25 at 2:40 p.m., the CP stated the dose of 45 mL three times a day, is higher than usual for constipation; the medication is for hepatic encephalophagy (a condition of liver damage, associated with a buildup of toxins). When asked whether she identified this wrong indication as an irregularity and reported to the facility, she stated, No. She stated she just started servicing the facility in June this year, and her focus was on psychotropic medications and not on this.2. A review of the Package Insert (information about a drug and its use) for glipizide, dated 9/2008, indicated glipizide should be given approximately 30 minutes before a meal to achieve the greatest reduction in postprandial hyperglycemia [rise in blood sugar after a meal].A review of Resident 9's clinical record indicated she had a physician's order, dated 5/28/25, for glipizide 5 mg, give 1 tablet two times a day before meals for diabetes. A review of Resident 9's August 2025 MAR indicated glipizide was scheduled to be administered at 8 a.m. and at 4 p.m.A review of the facility's meal schedule indicated breakfast was scheduled at 7:15 a.m. and dinner is at 5 p.m. Thus, the morning dose of glipizide was schedule after breakfast, not before meal, as ordered.During a concurrent interview and record review with the DON on 8/28/25 at 2:08 p.m., she stated glipizide is supposed to be given 30 minutes before a meal. She stated breakfast is between 7 a.m. to 7:30 a.m. She confirmed Resident 9's morning glipizide dose was scheduled after breakfast, contrary to the physician's order.A review of the 7-day administration history, from 8/23/25 to 8/28/25, for Resident 9's morning glipizide dose indicated it was administered from 8:14 a.m. to 9:03 a.m. during these days, after breakfast time. A review of Resident 51's clinical record indicated she had a physician's order, dated 2/16/24, for glipizide 10 mg, 1 tablet by mouth one time a day with meals for diabetes. It was scheduled daily at 7:30 a.m. since 2/16/24 (1.5 years ago).During a concurrent interview and record review with the DON on 8/28/25 at 2:08 p.m., she confirmed glipizide was not to be given with meals, but 30 minutes before a meal. A review of the 7-day administration history, from 8/22/25 to 8/28/25, for Resident 51's glipizide indicated the earliest it was administered was 9:10 a.m. and latest at 11:09 a.m.During a telephone interview with the CP on 8/28/25 at 2:40 p.m., when asked whether she identified the wrong scheduled administration time for Resident 9's and Resident 51's glipizide as irregularities in her monthly MRR for the residents, the CP stated, It's something I would have caught this month, but haven't caught yet. It hasn't been the focus of my recommendations.A review of the facility's policy and procedures (P&P) titled Consultant Pharmacist Services Provider Requirements, dated 10/2017, indicated: The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. Consultant pharmacist helps identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This includes, but is not limited to. 3) Assisting the facility in the identification and evaluation of medication-related issues. 6) Assisting facility in defining schedules for administering medication to maximize effectiveness. The P&P also indicated the CP conducts monthly review of the residents' medication regimen to avoid unnecessary drugs such as those without adequate monitoring or without adequate indication for use.

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled Resident's (Resident 21) Responsible Party (RP; the party responsible for making health care decisions when the principal party is unable to make said health care decisions for him or herself) choice in Resident's hair cut was considered. This failure resulted in Resident 21 receiving an unwanted haircut and feeling terrible. During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE].During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. During record review of Resident 21's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper and lower extremity, and Substantial/maximal assistance (Helper does MORE THAN HALF the effort, Helper lifts or holds trunk or limbs and provides more than half the effort) regarding personal hygiene (i.e. combing hair, shaving, applying makeup, washing and drying face and hands). During an observation on 08/25/2025 at 10:15 A.M. Resident 21 had knotted hair while laying on her back in bed.During an observation and interview on 08/27/2025 at 10:34 A.M. Resident 21 stated the facility cut her hair about 1 month ago against her wishes. Stated short hair makes her feel terrible because it is a cultural preference to have very long hair. Resident 21 stated she expressed to staff she did not want her hair cut and facility staff cursed at her and stated she had to cut her hair because it was too long, and she could not care for it herself. Resident 21 stated was unable to comb and maintain long hair due to right sided weakness. During an interview on 08/27/2025 at 2:11 P.M. Social Services Director (SS) 1 stated facility had a resident hair care stylist that comes on a regular basis to cut and color hair, which is extra. SS 1 stated activities check to see which residents need haircuts. SS 1 stated women haircuts depend on what they want, stated residents had the right to call outside stylist to come in and style how resident and family wish. SS 1 stated activities had a list of residents who gets/needs haircut. SS 1 stated residents can refuse haircuts and can have long hair if desired. During record review of document titled, Barber/ Beauty Invoice, it indicated Resident 21 had a haircut on 10/10/24 for $25 in facility.During record review of document titled, Beautician Services, it indicated Resident 21 was signed up for appointment dated 10/10/24.During record review of facility's policy and procedure (P&P) titled, Resident Rights, dated 5/2023, it indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence.be supported by the facility in exercising his or her rights.exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.During record review of facility's policy and procedure (P&P) titled, Dignity, dated 5/2023, it indicated, Residents shall be groomed as they wish to be groomed ( hair styles, nails, facial hair, etc.).

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled Resident's (Resident 21) Responsible Party (the party responsible for making health care decisions when the principal party is unable to make said health care decisions for him or herself) choice in Resident's hair cut was considered. This failure resulted in Resident 21 receiving an unwanted haircut and feeling terrible. During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE].During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. During record review of Resident 21's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper and lower extremity, and Substantial/maximal assistance (Helper does MORE THAN HALF the effort, Helper lifts or holds trunk or limbs and provides more than half the effort) regarding personal hygiene (i.e. combing hair, shaving, applying makeup, washing and drying face and hands). During an observation on 08/25/2025 at 10:15 A.M. Resident 21 had knotted hair while laying on her back in bed.During an observation and interview on 08/27/2025 at 10:34 A.M. Resident 21 stated the facility cut her hair about 1 month ago against her wishes. Stated short hair makes her feel terrible because it is a cultural preference to have very long hair. Resident 21 stated she expressed to staff she did not want her hair cut and facility staff cursed at her and stated she had to cut her hair because it was too long, and she could not care for it herself. Resident 21 stated was unable to comb and maintain long hair due to right sided weakness. During an interview on 08/27/2025 at 2:11 P.M. Social Services Director (SS) 1 stated facility had a resident hair care stylist that comes on a regular basis to cut and color hair, which is extra. SS 1 stated activities check to see which residents need haircuts. SS 1 stated women haircuts depend on what they want, stated residents had the right to call outside stylist to come in and style how resident and family wish. SS 1 stated activities had a list of residents who gets/needs haircut. SS 1 stated residents can refuse haircuts and can have long hair if desired. During an interview on 08/27/2025 at 3:11 p.m. Activity Co-Director (ACD) stated knew who needed haircut by asking each Resident during Resident rounds, and the family decides for resident who are dependent. Stated Resident 21 never requested a haircut, has been offered and refuses hair cut when offered. During an interview on 08/28/2025 at 8:26 A.M. Responsible Party (RP) 1 stated was not informed of Resident 21 haircut before haircut and found out about hair cut when came to visit that weekend. RP 1 stated Resident 21 probably did not want her hair cut, as Resident 21 typically prefers her hair long. RP 1 stated when visits hair is sometimes tangled, unbrushed, and unwashed. RP 1 stated if facility would have considered her opinion before Resident 21's haircut she would have refused facility offered haircut treatment and/or services. RP 1 stated she maintains Resident 21 hair and color dye treatment on weekend visits.During an interview on 08/28/2025 at 9:34 A.M. Activities Staff Assistant (ACT 1) stated if Resident's cannot make decisions or cannot talk, activities staff will call Resident's Responsible Party or ask nurse if able to provide hair cut or nail care treatment (medical care, nursing care, and interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms). During an interview on 08/28/2025 at 9:38 A.M. ACD stated asked Resident 21 if wanted haircut on today and Resident 21 refused. ACD stated she will ask Resident 21 later or will ask charge nurse and family if she can get a haircut. ACD stated Resident 21 had to get a haircut because her hair is long and had not had a hair cut in a long time. ACD stated Resident 21 had not had a haircut since 2024. ACD stated facility policy is Resident had right to have haircut, if Resident does not want a haircut, I won't cut it anymore. ACD stated should ask RP 1 for a second opinion from family, because sometimes Resident 21 is forgetful. ACD stated Resident 21 can make decisions for herself. ACD stated did not call Resident 21's to consent to haircut in October 2024, or after haircut. ACD stated it is important to contact Resident's RP about beautician treatments and services to make sure facility staff do the right thing.During record review of document titled, Barber/ Beauty Invoice, it indicated Resident 21 had a haircut on 10/10/24 for $25 in facility.During record review of document titled, Beautician Services, it indicated Resident 21 was signed up for appointment dated 10/10/24.During record review of facility's policy and procedure (P&P) titled, Consents, dated 5/2023, it indicated, In accordance with state and federal regulations, and in adherence with patient's bill of rights, facility shall obtain consent, whereby applicable and indicated, from resident and /or responsible party and/or family member for administration of treatment and/or procedure.During record review of facility's policy and procedure (P&P) titled, Consents, dated 5/2023, it indicated, If Resident or known representative refuses treatment and/or procedures, Director of Nursing Services and/or designee and members of interdisciplinary team shall make an attempt to determine reason(s) for refusal of treatment and/or procedures. This shall include, at least, consideration of adequacy of information provided to resident or representative, as such, reasons for treatment, risks and benefits, etc.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to one of eight Residents (Resident 21) to increase and/or prevent a further decrease in range of motion (ROM; the full movement potential of a joint.). This failure resulted in Resident 21 not receiving physician ordered passive range of motion (PROM; the movement of a joint through the range of motion with no effort from the patient) exercises for two months and feeling weak.During record review of admission record, printed on 8/28/25, Resident 21 was admitted on [DATE].During record review of Resident 21's Minimum Data Set (MDS, an assessment used to guide care) dated 5/25/25, indicated Resident 21's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 12 out of 15, indicated Resident was mildly impaired. During record review of Resident 21's MDS, dated [DATE], section 'GG-Functional Abilities' indicated, Impairment on one side to upper and lower extremity, and Substantial/maximal assistance (Helper does MORE THAN HALF the effort, Helper lifts or holds trunk or limbs and provides more than half the effort) regarding personal hygiene (i.e. combing hair, shaving, applying makeup, washing and drying face and hands). During an observation and interview on 8/25/2025 at 10:15 AM Resident 21 stated wants rehab, has not had it. Resident 21 stated felt weak laying in bed.During a record review of Resident 21 'Order Summary Report', dated 8/22/25, indicated RNA (restorative nursing assistance) PROGRAM for Active and Passive ROM (range of motion) on Bilateral UE/LE in all planes of motion 3x/week x 3 months to maintain CLOF and contraction prevention, dated 8/22/25. and PHYSICAL THERAPY EVALUATION AND TREATMENT AS INDICATED, dated 3/13/2025. During a record review of progress notes titled, RNA Progress Notes, dated from 06/23/25-08/25/25, indicated Resident 21 did not receive or refuse passive range of motion exercises to right extremity.During a record review of Resident 21' untitled care plan dated 08/22/25 indicated, RNA program for Active and Passive ROM on bilateral UE/LE in all planes of motion 3x/wk x 3 months to maintain contraction (structural changes to your soft and connective tissues that cause them to stiffen, tighten and contract) prevention.During an interview on 08/27/2025 at 1:27 PM Restorative Nursing Aide (RNA) stated placed Resident 21 right hand splint every day for 6-8 hour wear, and completed active ROM (the performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint) to left hand. RNA stated does not complete PROM exercises because Resident 21 cannot raise right hand. RNA stated she was aware Resident 21 had physician orders, dated 8/21/25, for active and passive ROM in all plane of motion three times per week for three months. RNA stated PROM exercises are important to help keep Resident's strength and prevent contractures. RNA stated Resident 21 never refused RNA or PROM. During record review of facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, dated 7/2017, it indicated, Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.

Based on observation, interview and record review, the facility failed to prepare one out of 42 (Resident 60) Resident meal tray according to resident preferences. This failure resulted in Resident 60 receiving lunch tray without double portion of protein, per Resident preferences. During record review of Resident 60's Minimum Data Set (MDS, an assessment used to guide care) dated 05/17/25, indicated Resident 60's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 00 out of 15, indicated Resident 60 had severe cognitive impairment. During an observation on 08/26/2025 at 12:32 PM Resident 60 tray was prepared and placed on meal tray cart for delivery but was not given extra protein as listed on meal tray card. During an observation and interview on 08/26/2025 at 12:39 PM, the Registered Dietitian (RD) and Dietary Manager (DM) stated Resident 60 was not given double protein, per photo, as listed in Resident's preferences. DM stated it is important for Residents to receive meals they prefer because it is their right. During record review of Resident 60 meal tray card, it indicated Resident 60's 'likes' included, Extra protein, pickles, crackers and soup.During record review of facility's undated policy and procedure (P&P) titled, Resident Food Preferences, it indicated, The dietitian and nursing staff, assisted by the physician, will identify any nutritional issues or dietary restrictions that might affect the facility's efforts to accommodate resident preferences. Whenever possible, the staff and physicians will strive to minimize dietary restrictions in order to accommodate those preferences. In conjunction with the physician, the Dietitian or nursing staff will document reasons why restrictions are necessary and/or why the facility cannot accommodate resident preferences.

Based on observation, interview, and record review, the facility failed to provide care according to the facility's policy and procedures (P&P) for one of one resident (Resident 1) receiving medications via the gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The nursing staff did not verify tube placement and check residual volume (the amount of fluid contents remaining in the stomach) prior to administering medications. In addition, the nursing staff administered the medications by pushing through the tube instead of allowing them to go down by gravity.The failures posed a risk for complications associated with enteral feeding, including aspiration (inhalation of foreign material into the lungs) due to undetected tube displacement, tube dislodgement from improper medication administration, and potential for gastrointestinal symptoms such as nausea, vomiting, and abdominal pain.During a medication pass observation on 8/26/25 at 8:55 a.m., Registered Nurse (RN) 1 was observed preparing 11 medications for Resident 1. The medications included 1 eye drop, 1 inhalation medication, 1 powder medication, and 8 solid medications that were prepared 10 cups. After finished, she brought all 11 medications along with 3 large cups of water and to Resident 1's bedside. On 8/26/25 at 9:31 a.m. at the resident's bedside, RN 1 was observed adding water to each medication cup to dilute the medications. She turned off Resident's 1's tube feeding pump, attached a 60-mililiter (mL, unit of measurement) syringe to the resident's G-tube, and started administering the medications. First, by filling the syringe with about 30 mL of water, she pushed it into the tube to flush the tubing, then she drew up each diluted medication into the syringe and pushed it into the tube with flushing of water in between the medications. RN 1 did a final flushing of the tube by pushing about 50 mL of water. During the process, water and medication liquid was observed seeping out of the tube and onto the resident's abdomen. RN 1 wiped the excess fluid off the resident's abdomen several times with tissues.During an interview on 8/26/25 at 10:03 a.m. with RN 1, when asked about checking tube placement and residual volume prior to medication administration, RN 1 responded, We have to check tube placement first, yes and check the placement with the stethoscope. She stated, I forgot. When questioned about the seeping of liquid from the G-tube and pushing water and diluted medications through the tube, RN 1 acknowledged she needed to pour in the fluids and diluted medications by gravity. During an interview with the Director of Nursing (DON) on 8/26/25 at 12:18 p.m., she stated nurses need flush and administer the medication via gravity. She added, If [the medications are] not prepared properly the tube may clog. The DON stated the nurses are to check tube placement with the stethoscope and check if there is residual volume before administering medications through the feeding tube.A review of Resident's 1, Medication Administration Record (MAR), on 8/26/25, indicated a physician's order, dated 4/2/25: Enteral Feed Order every shift verify tube placement before and after feeding and before administration of medications.A review of the facility's policy and procedure titled Administering Medications through an Enteral Tube, updated 5/2023, indicated, 8. This procedure is contraindicated if the tube is obstructed or improperly positioned, . or if bowel sounds are absent. The Steps in the Procedure are: 17. Confirm placement of the feeding tube. 18. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. 19. Check gastric residual volume (GRV) to assess for tolerance of enteral feeding. 20. When correct tube placement and acceptable GRV have been verified, flush tubing with 15-20 mL warm sterile water (or prescribed amount.) . 23. Reattach syringe (without plunger) to the end of the tubing. 24. Administer medication by gravity flow.a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion.b. Open the clamp and deliver medication slowly.c. Clamp tubing (or begin flush) before the tubing drains completely.

Based on interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 57) was free from unnecessary medications. Resident 57 received lactulose (a medication commonly used for liver disease) for a wrong indication for use.This failure resulted in an inadequate treatment plan and insufficient monitoring for medication effectiveness and adverse outcomes related to liver disease.A review of Resident 57's medical record indicated Resident 57 was admitted to the facility with diagnoses that include: alcoholic liver disease (a condition of liver damage) and portal hypertension (elevated pressure in the portal vein, commonly caused by liver disease). Resident 57's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/29/25, indicated Resident 57 has no cognitive impairment.A review of Resident 57's medical record indicated Resident 57 had the following physician order:Lactulose 10 gram (gm, unit of measurement)/ 15 milliliters (mL, unit of volume), give 45 mL by mouth three times a day for Constipation Hold if more than 3 bowel movements daily, dated 11/17/24.During an interview on 8/27/25 at 9:27 a.m. with Resident 57, when asked about the lactulose medication, Resident 57 said, Oh, that is for my liver. The resident added he has been on the medication for four years.During an interview and record review on 8/27/25 at 1:15 p.m. with the MDS Coordinator (MDS C) when asked about indication for Resident 57's lactulose, MDS C stated, it is for constipation. Upon further review of Resident 57 's clinical record, the MDSC stated the hospital Discharge summary, dated [DATE], indicated the lactulose was used for alcoholic cirrhosis with portal hypertension. She confirmed the facility had the wrong indication for Resident 57's lactulose.During a concurrent interview and record review on 8/28/25 at 12:57 p.m. with the DON and the Infection Preventionist (IP 1), when asked about the medication monitoring for lactulose, IP 1 stated monitoring had not been done, as the lactulose had the wrong indication.During a telephone interview on 8/28/25 at 2:40 p.m. with the Consultant Pharmacist (CP), when asked about the lactulose indication for Resident 57, the CP stated the dose 45 mL three times a day, is higher than usual for constipation; the medication is for hepatic encephalophagy (a condition of liver damage, associated with a buildup of toxins). A review of the facility's Policy and Procedure titled Medication Administration-General Guidelines, effective date 10/17, indicated,.If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or conditions, the nurse calls the provider pharmacy for clarification prior to administration of the medication, or if necessary contacts the prescriber for clarification.

Based on interview and record review, the facility failed to provide pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) care for one of three sampled residents (Resident 1), when staff: 1. did not notify the provider to obtain wound treatments for nine days, 2. did not provide Resident 1 with a low air loss mattress (LAL mattress, pressure relieving device to prevent skin and tissue breakdown) for four days and, 3. did not complete a care plan for Resident 1 ' s sacral pressure ulcer. This failure resulted in Resident 1 ' s sacral pressure ulcer growing from one by 1.5 centimeters (cm, a unit of measurement) to seven by six cm over nine days. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted on [DATE] to the facility for stroke (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain), hemiplegia (the loss of muscle function on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), type 2 diabetes (chronic disease in which the body cannot regulate the amount of sugar in the blood) and dysphagia (difficulty swallowing). During a record review of Resident 1 ' s admission minimum data set (MDS, an assessment tool to guide resident care), dated 10/20/24, the MDS indicated Resident 1 had upper and lower extremity impairment and was completely dependent on staff for bed mobility (turning and repositioning in bed) and activities of daily living such as toileting, eating and transferring out of bed. The MDS also indicated Resident 1 was at high risk of developing pressure ulcers and did not have any pressure ulcers. During a record review of Resident 1 ' s skin assessment record titled, Braden Scale (assessment score to predict risk of pressure sore development with a score of 13-14 indicating moderate risk for pressure ulcers) for Predicting Pressure Sore Risk, dated 10/16/24, the record indicated Resident 1 had a Braden Score of 13. During a record review of Resident 1 ' s physician order set titled, Order Summary Report, dated 12/30/24, the order set indicated Resident 1 had wound care orders for: Low air loss mattress, check for functionality every shift, dated 11/7/24, and Sacral-coccyx-cleanse with wound cleaner, pat dry, apply triad paste, leave it open to air every shift for 14 days, dated 11/12/24. The order set also indicated Resident 1 had an order to be transferred to another facility dated 11/13/24. During an interview on 12/24/24, at 8:15 a.m., with resident representative (RP), RP stated Resident 1 did not have a sacral wound on admission to the facility. RP stated, on 11/4/24, Registered Nurse 1 (RN 1) reported to her that Resident 1 had a wound on the tail bone. RP stated the facility did not perform sacral wound treatments until 11/12/24. RP stated when Medical Doctor 1 (MD 1) assessed Resident 1 on 11/11/24, MD 1 was upset because Resident 1 was not on a low air loss mattress. RP stated MD 1 had ordered a low air loss mattress the previous week, but the facility did not have one available. During a record review on 12/30/24, at 10:19 a.m., Resident 1 ' s progress note titled, Change of Condition, dated 11/3/24, by RN 1, the progress note indicated RN 1 assessed open wound as superficial stage 2 [pressure ulcer]. Wound measure 1.5 x 1.0 cm. During a concurrent interview and record review on 12/30/24, at 11:05 a.m., with treatment nurse (TR), a wound assessment note titled, Wound Assessment, dated 11/12/24, and a progress note, dated 11/3/24, by RN 1 was reviewed. TR stated on 11/12/24, Resident 1 had a sacral wound which TR measured seven by six cm. TR stated she was first aware of the pressure ulcer on 11/12/24 and communicated the findings to MD 1 who then ordered a sacral-coccyx wound treatment for Resident 1. After review of the progress note by RN 1, TR stated she was not informed by other nursing staff about the presence of the sacral wound prior to 11/12/24. After reviewing Resident 1 ' s order history and progress notes, TR was not able to find sacral wound treatment orders between 11/3/24 to 11/12/24. TR stated any residents with a wound would have provider assessment and treatments for the wound. During a concurrent phone interview and record review on 12/30/24, at 1:03 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 ' s progress note titled, Nurses Note, dated 11/10/24, was reviewed. LVN 1 stated Resident 1 had a recently developed sacral wound but did not recall any treatments ordered for the sacral wound. LVN 1 stated a LAL mattress was not available for Resident 1 and had endorsed to the next shift to obtain one. The progress note indicated resident ' s [family] are requesting LAL mattress at 8pm. They mentioned it has already been a week, and they are concerned because the resident has an open wound on his coccyx. The writer checked all rooms for an available [LAL mattress], but none were found. During a concurrent interview and record review on 12/30/24, at 1:20 p.m., with the Director of Nursing (DON), a record of a LAL mattress order ticket titled, [Vendor] Delivery Ticket, dated 11/11/24 was reviewed. The DON stated the ticket indicated an outside company had delivered the LAL mattress on 11/11/24. During a phone interview on 12/30/24, at 1:28 p.m., with RN 1, RN 1 stated he had completed a change of condition documentation for Resident 1 ' s sacral wound on 11/3/24. RN 1 could not recall if he had notified the provider about the wound or created a care plan for the wound. RN 1 did not recall starting any orders for Resident 1 regarding the sacral wound. During a concurrent interview and record review on 12/30/24, at 1:45 p.m., with MD 1, Resident 1 ' s physician note titled, SNF Rounding Note, dated 11/11/24, by MD 1 was reviewed. MD 1 could not recall if she was notified of the sacral wound before 11/11/24. After review of the physician note, MD 1 stated she had documented Resident 1 was still not on a LAL mattress for the open area over the sacrum, and she may have given a verbal order for the LAL mattress. MD 1 did not find any records of facility staff notifying any provider about Resident 1 ' s sacral wound between 11/3/24 and 11/11/24. During a concurrent interview and record review on 12/30/24, at 2:40 p.m., with the DON, Resident 1 ' s physician orders, care plans and RN 1 ' s change of condition progress note, dated 11/3/24, were reviewed. The DON stated after review of Resident 1 ' s physician orders for November 2024, orders for sacral wound treatment prior to 11/12/24 were not found. The DON stated after a review of Resident 1 ' s care plans, a care plan for the sacral wound was not completed. The DON stated the progress note by RN 1 did not indicate the provider was notified about the sacral wound. The DON stated provider notification was expected to be carried out and documented by the nurse who found the change of condition. During a concurrent interview and record review on 12/30/24, at 3:20 p.m., with RN 2 and the DON, a progress note titled, Nurses Note, dated 11/7/24, by RN 2 was reviewed. The progress note indicated, This note is a follow up to 11/3/24 9:05:00 Change of Condition [Author: [RN1]]. RN 2 stated she had measured and documented the size of Resident 1 ' s sacral wound at four by four cm. RN 2 did not recall updating the provider about the size of the sacral wound. RN 2 clarified she had corrected the documented location of the wound from the perineum to the sacrum. RN 2 recalled Resident 1 was not on a low-air loss mattress for that day and did not recall when the low- air loss mattress arrived. The DON stated the mattress would not be delivered during the weekend. During a record review of Resident 1 ' s transfer record titled, Admission/Discharge To/From Report, dated 12/30/24, the record indicated Resident 1 was transferred to another facility on 11/13/24. During a record review of receiving facility ' s admission skin assessment for Resident 1 titled, Skin Assessment, dated 11/13/24, the skin assessment indicated Resident 1 was admitted to the second facility with a sacral pressure ulcer and was placed on a LAL mattress. During a review of facility policy and procedure (P&P) titled, Policy and Procedure on Pressure Sore Risk Assessment, dated 5/2023, the P&P indicated, It shall be this facility ' s policy to assess .and provide necessary care and services that will meet patient needs and promote skin integrity .plans of care shall be developed to address risk factors to development or further development of pressure ulcer. During a review of facility P&P titled, Change in a Resident ' s Condition or Status, dated 5/2017, the P&P indicated, the nurse will notify the resident ' s Attending Physician or physician on call when there has been a .discovery of injuries of an unknown source .notifications will be made within twenty-four hours of a change occurring in the resident ' s medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent spread of infection in the facility during a novel Coronavirus Disease (COVID 19- a mild to severe respiratory (lung) illness) outbreak (an occurrence of disease greater than expected at a particular time and place) when the following was observed: 1. Facility failed to screen all healthcare personnel for COVID-19 signs and symptoms prior to entering the facility. 2. Certified Nursing Assistant (CNA) 3 and Licensed Vocational Nurse (LVN) 2 did not use Personal Protective Equipment (PPE) while providing care to a resident (Resident 38) who was exhibiting COVID-19 symptoms. CNA 3 and LVN 2 became positive for COVID-19. 3 . CNA 3 continued to provide care to 13 residents (Residents 2, 3, 11, 12, 14, 20, 22, 23, 24, 38, 39, 42, and 44) after exhibiting COVID 19-symptoms. Residents 2, 3, 11, 12, 14, 20, 22, 23, 24, 38, 39, 42, and 44 tested positive after exposure from CNA 3. 4. Facility did not assign dedicated direct care staff for COVID (+) and (-) residents. CNA 1, who tested positive for COVID-19, provided care to both COVID (+) and (-) residents. 5. The doors to 25 out of 25 residents' (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25) bedrooms, for COVID-19 positive residents were left open. 6. Assistant Director of Nursing (ADON) did not wear a face shield and N95 mask while feeding Resident 20 who was tested positive for COVID-19. ADON also wore a short-sleeved cloth hospital gown on top of a soiled isolation gown, while feeding Resident 20. 7. Licensed Vocational Nurse (LVN 1) failed to follow appropriate hand hygiene procedure, when she applied hand sanitizer on gloved hands; and did not follow appropriate use of gown and gloves when LVN 1 put on a short sleeved cloth hospital gown on top of a soiled isolation gown prior to entering a room of three (3) positive COVID-19 residents (Resident 20, 21, and 22). 8. Three facility staff including Housekeeper (HSKP 1), CNA 2 and Payroll Personnel (PP 1) did not follow six (6) feet social distancing and CNA 2 did not wear the facemask properly to cover the mouth and nose. These failures to follow transmission-based precautions, resulted in cross contamination and lead to a significant number of positive COVID-19 cases at the facility including 47 residents and 28 staff members who worked at the facility. 17 facility residents (6, 28, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, and 58) died due to COVID-19 related complications. The Administrator (ADM) was verbally notified of an Immediate Jeopardy (IJ) situation on [DATE] at 3:41 p.m. The facility failed to follow infection control practices to prevent the spread of infection. Findings: 1. During an interview on [DATE] at 10:47 a.m., CNA 1 stated she had an episode of Fever on [DATE] and [DATE], and Nausea on [DATE], followed by positive tested for COVID on [DATE]. Review of facility's untitled document used for screening for COVID-19 indicated to ask the following questions: 1. Check temperature 2. Signs and symptoms of cold, cough, runny nose, sore throat, body aches, fever. If Yes- Do not work. 3. Have you, family, or friend visited from any restricted county or country in last 14 days? If Yes-Do not work. 4. Have you had contact with anyone with or under investigation for COVID-19. If Yes- Do not work. Review of facility's untitled sign-in sheet dated [DATE] indicated at 6:45 a.m., CNA 1's temperature was 99.7 °F. Further review showed CNA 1 was not screened for Question 2, 3, and 4. Review of CNA assignment sheet dated [DATE] indicated CNA 1 provided direct care to Resident 9, 10, 28 and 41 on that day she was feverish. Review of an undated line listing showed Resident 9, 10, 28 and 41 were tested positive for COVID-19, and Resident 28 and 41 died due to COVID complications during the outbreak at the facility. During an onsite visit on [DATE] at 10:00 a.m., 16 facility staff (ADM, Social Worker (SW), ADON, Admissions Coordinator (AC), Staffing Coordinator (SC), PP 1, RN 1, LVN 1, LVN 4, LVN 5, CNA 1, CNA 2, HSKP 1. HSKP 2, HSKP 3, and Business Office Manager (BOM) were observed working at the facility. During a record review, facility's untitled document for COVID-19 screening, dated [DATE] was reviewed. The document indicated ten (ADM, SW, AC, PP 1, LVN 1, LVN 4, CNA 1, CNA 2, HSKP 1, and BOM) out of 16 facility staff were not screened for COVID-19 on [DATE]. Review of Centers of Medicare and Medicaid Services (CMS) released memo- Ref: QSO-,[DATE]-NH dated [DATE] indicated, Implement active screening of residents and staff for fever and respiratory symptoms. Screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and self-isolate at home. 2. During an interview with ADM on [DATE] at 12:10 p.m., ADM stated Resident 38 was the first resident tested positive for COVID-19 and was transferred to an Acute Care Hospital (ACH) on [DATE]. ADM stated Resident 38 passed away at ACH. Review of facility's undated document titled Line listing for COVID-19 outbreak showed, Resident 38 developed high temperature of 101 degrees Fahrenheit (°F) (normal body temperature 98.6 °F) on [DATE]. Further review showed two staff members (CNA 3 and LVN 2) also had high temperature of 99 and 100 °F respectively on [DATE]. Review of Resident 38's Progress notes dated [DATE] showed at 12:45 a.m., Resident 38 was noted with mild Short of Breath (SOB) and oral temperature of 101°F. At 1:20 a.m., Advice Nurse at ACH advised LVN 2 to follow droplet precautions and send Resident 38 to ACH. Then at 3:30 a.m., Resident 38 was having trouble breathing with oxygen saturation (which determines amount of oxygen saturated hemoglobin in relation to total hemoglobin in blood) of 77% (normal oxygen saturation level in human body is ,[DATE] %), and 911 was called. Resident 38 was sent to ACH at 3:45 a.m. During a phone interview with LVN 2 on [DATE] at 10:27 a.m., LVN 2 stated on [DATE], CNA 3 told her Resident 38's temperature was very high. LVN 2 stated she told CNA 3 to recheck Resident 38's temperature and it was 101 °F. LVN 2 stated she called ACH to get advice and ACH told her they would send a regular transport to pick Resident 38 from the facility. LVN 2 stated she could hear crackles when Resident 38 was (SOB), LVN 2 stated she offered [MEDICATION NAME] (breathing treatment), but Resident 38 refused. LVN 2 stated Resident 38 had history of [MEDICAL CONDITIONS] and was on continuous Oxygen (O2) 2 liters/min. LVN 2 stated Resident 38's condition was worsening and her oxygen saturation dropped to 70% before she was transferred to ACH. LVN 2 also stated staff was not using isolation precautions at that time. LVN 2 stated on [DATE] she also developed a temperature of 100.4 degrees °F, experienced body aches, chills, and cough and could not work after [DATE]. During a phone interview with CNA 3 on [DATE] at 5:15 p.m., CNA 3 stated Resident 38 was very sick and had a high temperature on [DATE]. CNA 3 stated CNA 3 and LVN 2 were only able to find two masks in the emergency cart that night which they wore to transfer Resident 38 to ACH. CNA 3 stated it was too late because she had already provided direct care to Resident 38 during toileting and providing a drink and did not wear full PPE except gloves. CNA 3 stated she developed signs of itchy throat, and tiredness on [DATE], [DATE] and was tested positive for COVID-19 afterwards. During a follow up phone interview on [DATE] at 11:41 a.m., CNA 3 stated, LVN 2 and CNA 3 continued to provide direct care to other assigned residents at nursing station 2 the whole night on [DATE]. Review of facility's undated document titled Line listing for Residents indicated 47 facility residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 33, 34, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 52, 53, 54, 55, 56 and 57) were tested positive for COVID-19 during a period from [DATE] to [DATE]. Review of facility's undated document titled Line listing for staff indicated 30 staff members who worked at the facility developed symptoms of COVID-19 during period of [DATE] through [DATE], and 28 staff were tested positive for COVID-19. 3. During a phone interview with CNA 3 on [DATE] at 5:15 p.m., CNA 3 stated Resident 38 was very sick and had a high temperature on [DATE]. CNA 3 stated she developed signs of itchy throat, and tiredness on [DATE], [DATE] and was tested positive for COVID-19 afterwards. During a follow up phone interview on [DATE] at 11:41 a.m., CNA 3 stated, she continued to provide direct care to her assigned residents at nursing station 2 the whole night on [DATE]. During a review of the Station 2 C.N.A Assignment Sheet for [DATE], indicated CNA 3 was assigned to take care of Residents 2, 3, 11, 12, 14, 20, 22, 23, 24, 38, 39, 42, and 44 Review of facility's undated document titled Line listing for Residents indicated 47 facility residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 33, 34, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 52, 53, 54, 55, 56 and 57) were tested positive for COVID-19 during a period from [DATE] to [DATE]. Review of facility's undated document titled Line listing for staff indicated 30 staff members who worked at the facility developed symptoms of COVID-19 during period of [DATE] through [DATE], and 28 staff were tested positive for COVID-19. Review of Centers of Medicare and Medicaid Services (CMS) released memo- Ref: QSO-,[DATE]-NH dated [DATE] indicated, Implement active screening of residents and staff for fever and respiratory symptoms. Screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and self-isolate at home. 4. During an interview with ADM on [DATE] at 10:10 a.m., ADM stated Nursing station 2 was designated as COVID positive (+) unit and Nursing Station 1 was designated as COVID negative (-) unit. ADM stated Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25 were tested (+) and 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37 were tested (-) for COVID. During a follow up interview on [DATE] at 2:30 p.m., ADM stated COVID (+) residents were separated from COVID (-) residents after [DATE]. ADM remained unable to state the exact date when (+) and (-) COVID units was separated. During an observation on [DATE] at 10:20 a.m., CNA 1 was observed in room [ROOM NUMBER], bedroom of Resident 34, 25, and 37, in COVID (-) unit. During an interview on [DATE] at 10:47 a.m., CNA 1 stated she was providing direct care to 12 residents (Resident 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37) that day. CNA 1 also stated she had been providing direct care to residents on both COVID (+) and (-) units. During an interview with ADM on [DATE], at 12:10 p.m., ADM stated he was not aware CNA 1 was tested (+) for COVID. ADM stated if he was aware, he would not have allowed CNA 1 to work with COVID (-) residents. During a follow up observation at nursing station 2, on [DATE], at 12:55 p.m., ADM instructed CNA 1 to come and provide direct care COVID (+) residents for rest of the morning shift for [DATE]. ADM then asked CNA 2, who worked with COVID (+) residents that morning, to provide direct care to COVID (-) residents at station 1. During a record review of laboratory results for the residents (Resident 28, 33, 34, and 37) in COVID (-) unit on [DATE], lab results dated [DATE] indicated they were tested positive for COVID-19 on [DATE]. A review of facility's document titled CNA assignment sheet dated [DATE] showed CNA 1 provided direct care to residents on COVID (+) and (-) residents during the same day shift. A review of CNA assignment sheet dated [DATE] showed LVN 3 also provided direct care to residents on COVID (+) and (-) residents at the same time during evening shift. Review of CDC guidance dated [DATE] indicated, As a measure to limit Health Care Personnel (HCP- which includes , but not limited to, emergency medical service personnel , nurses, nursing assistants, .) exposure .facilities could consider .dedicated HCP to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. 5. During an observation on [DATE] at 10:55 a.m., the doors on all COVID (+) residents' (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25) rooms were left wide open. During an interview on [DATE] at 10:57 a.m., Registered Nurse (RN 1), who was a charge nurse in COVID (+) unit, stated the staff closed the doors for COVID (+) resident's bedrooms only for first two-three days after the outbreak ([DATE]). RN 1 stated she did not know the protocol about keeping the doors closed to COVID (+) resident's bedrooms. Review of CDC guidance updated as of [DATE] indicated, for infection prevention and control in healthcare settings- place suspected or confirmed COVID-19 residents in private rooms with the door closed. 6. During an observation in the COVID (+) unit, on [DATE] at 12:40 p.m., ADON was feeding lunch to Resident 20. ADON had two surgical masks covering her face, and she was wearing a short-sleeved cloth hospital gown on top of an isolation gown. ADON had eyeglasses on and was not wearing an eye protection such as goggles or face shield on at that time. During an interview with ADON, accompanied by LVN 1, on [DATE] at 12:45 p.m., ADON stated the staff wore a dedicated isolation gowns all day to protect themselves, and they get hot in that isolation gown. ADON stated that was why she put on cloth hospital gown on top of the isolation gown to feed lunch to Resident 20. ADON then stated the facility had N95 masks available but she did not wear it, because she could not breathe in N95 masks. Review of CDC recommendations for Interim infection prevention and control for patients with suspected or confirmed COVID-19 in healthcare settings, dated [DATE], indicated to put on an N95 respirator (or higher level respirator) or facemask (if respirator is not available) before entering into patient room or care area . Further review of the document indicated, Put on eye protection (i.e. goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area .Personal eyeglasses and contact lenses are NOT considered adequate eye protection. 7. During a phone interview with Infection Preventionist (IP) on [DATE] at 12:09 p.m., IP stated each staff was provided a dedicated isolation gown for the whole day and were instructed to wear a cloth hospital gown on top of the dedicated gown to provide direct care to residents. During an observation in COVID (+) unit on [DATE] at 12:42 p.m., LVN 1 was observed in an isolation gown and a pair of gloves, sitting at nursing station 2. LVN 1 then walked to the hallway and put on a cloth hospital gown on top of the original isolation gown. LVN 1 put on another pair of gloves on top of already gloved hands. LVN 1 then asked ADON, who was feeding lunch to Resident 20, if she should feed Resident 21 or 22. During an interview with LVN 1 on [DATE] at 12:45 p.m., LVN 1 stated the isolation gown was to protect herself and the cloth hospital gown was to protect the residents. LVN 1 stated, I get hot in isolation gown, I am sweating already. During a follow up observation on [DATE] at 12:50 p.m., LVN 1 removed the cloth hospital gown, removed the top pair of gloves, sanitized her gloved hands and put on another pair of gloves and a new isolation gown on top of her original isolation gown. LVN 1 grabbed the meal tray and went inside the room of Resident 20, 21 and 22. LVN 1 did not have an eye protection. During a phone interview with IP on [DATE] at 12:09 p.m., IP stated never for sanitization of gloved hands. IP stated gloved hands could not be sanitized. Review of facility's undated policy and procedure titled Handwashing showed, .if gloves are worn for a procedure, hands are to be washed before putting gloves on and after removal and deposit of gloves in appropriate container. Review of CDC recommendations for Interim infection prevention and control for patients with suspected or confirmed COVID-19 in healthcare settings, dated [DATE], indicated, Healthcare personnel should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during removal process. Further review of the document indicated, The PPE recommended when caring for a patient with known or suspected COVID-19 includes: Respirator or Facemask, Eye protection: goggles or a disposable face shield, clean/nonsterile gloves, clean isolation gown. 8. During an observation on [DATE] at 11:04 a.m., HSKP 1, CNA 2 and PP 1 were talking and standing approximately two to three (2 to 3) feet apart from each other at nursing station 2, the designated unit for COVID (+) residents. CNA 2's mask was hanging around her neck and was not covering the mouth and nose. During an interview on [DATE] at 11:04 a.m., RN 1 stated the staff should not stand that close. Review of CDC recommendations document dated [DATE] indicated, Limiting face-to-face contact with others and to stay at least 6 feet (2 meters) from other people is the best way to reduce the spread of COVID-19. Further review showed, As part of source control efforts, Healthcare Personnel should wear a facemask at all times while they are in the healthcare facility.

Based observation, interview, and record review, the facility failed to ensure resident received adequate supervision to prevent accidents for one of three sample residents (Resident 1) when Resident 1 was left in the bathroom without staff supervision, fell to the floor, and obtained multiple bruises and a Left hand fracture (broken bone). Findings: Review of Resident 1's Admission Record indicated, Resident 1 was admitted to the facility 11/28/14 with multiple [DIAGNOSES REDACTED]. During an observation on 9/19/18 at 10:30 a.m., Resident 1 was in her room, Resident 1 had multiple bruises on her face and a splint (a cast like devise supporting and immobilizing a broken bone) on her left hand. During an interview on 10/9/18 at 11:50 a.m., Certified Nurse Assistant (CNA) 1 stated that on the day of the accident, she took Resident 1 to the bathroom, put her on the toilet, went back to her bed to turn off the alarm then, went back to the restroom and saw Resident 1 on the floor. CNA 1 also stated that she knew Resident 1 needed assistance during the bathroom activities. CNA 1 stated she should not have left Resident 1 alone in the restroom. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 10/8/18 at 10:45 a.m., LVN 1 stated Resident 1 required supervision from the CNA's during activities of daily living. Review of Resident 1's MDS (Minimum Data Set) section G0110 (I) and G0300 (D), dated 6/8/18 indicated Resident 1 needed limited assistant with physical assist from the staff for toilet using. Review of section C0500, BIMS (Brief Interview for Mental Status) showed: 06 (which meant severely impaired cognition). Review of Resident 1's fall risk evaluation dated 3/8/18 indicated, Resident 1 had history of falls, balance problem, decrease muscular coordination and high risk for potential falls. During a review of Resident 1's falls care plan, dated 3/19/18 indicated, Resident 1 was at risk for falls, impaired balance and needs assistance due to the confusion. Goal was The resident will not sustain serious injury through the review date .The resident will be free of minor injury through the review date. Review of a progress notes dated 9/4/18 by Licensed Vocational Nurse 1 (LVN 1) indicated Resident 1 hit her head on the floor as witnessed by a CNA. Upon assessment, LVN 1 noted a raised area on the forehead measuring eight centimeters and Resident 1 complained of 10 out of 10 pain (worst pain possible on a scale of one to ten) on the left arm. Further review indicated Resident 1 was transported to the acute hospital. Review of the hospital document titled progress notes dated 9/6/18 indicated Resident 1's bones below the Left thumb and index finger were fractured. During an interview with Physical Therapist Supervisor (PTS) 1 on 9/19/18 at 11:00 a.m., PTS stated Resident 1 needed supervision from the staff for activities of daily living, also Resident 1 had the tendency to move from the toilet by herself because of dementia, PTS 1 also stated, supervision means constant supervision and not just checking on residents.

Based on observation, interview and record review the facility failed to follow the manufacturer's instructions for use of the facility's wander management system (a system which tracks the person by use of a wrist or ankle band and alarms if the resident moves outside a defined area without being accompanied).This failure resulted in one (Resident 1) of three sampled residents leaving the facility unsupervised and sustaining an injury. This fall resulted in Resident 1 being sent to the emergency room and being treated for [REDACTED].) Findings: On [DATE], a review of the facility's report of the incident, untitled and dated [DATE], and signed by the facility's administrator, indicated Resident 1 was found outside the facility at approximately 9 p.m., on [DATE], being attended to by paramedics. Resident 1 was transported to the local hospital's emergency room . The report also indicated Resident 1 was wearing a wander guard (departure alert device) when she left the facility unsupervised on [DATE]. Resident 1's wander guard was found to inconsistently alarm when checked by a technologist from the wander guard company, on [DATE], a day after the fall. According to the Departure Alert System policy, undated, the wander guard was wired to the doors in the lobby, back exit and side exit. The report also indicated that a staff member last saw Resident 1 in the facility at 8:45 p.m. Review of the paramedic's notes for Resident 1's incident on [DATE], indicated the resident was found at 9:11 p.m., sitting on the curb beside a wheelchair, being attended to by the fire department's personnel. The notes indicated Resident 1 fell out of her wheelchair when she hit a hole. Resident 1 had a hematoma (A swelling that is filled with blood caused by a break in the wall of a blood vessel. The breakage may be caused by trauma.) with a small laceration (deep cut in the skin) above her left eye. Review of the records from the emergency room , dated [DATE], showed Resident 1 was treated for [REDACTED]. The records also indicated that Resident 1 experienced throbbing pain on the left side of her forehead at a level 5 out of a possible 10 (pain assessment severity level with 1 being the least pain and 10 being the worst pain). Resident 1 was discharged from the emergency room to return to the facility on [DATE] at 12: 26 a.m. During a record review on [DATE] of Resident 1's history and physical indicated she was first admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) (a standardized assessment tool which guides care) for Resident 1 indicated the resident had moderately impaired mental abilities. The MDS also indicated that Resident 1 was unable to walk but could propel herself in her wheelchair using her feet. Review of the care plan dated [DATE] for Resident 1 indicated she was at risk for wandering and elopement (leaving the facility unsupervised). To reduce the risk of elopement, the care plan called for the use of a wander guard. The care plan also indicated the wander guard placement and functioning should be monitored. The care plan also indicated Resident 1's whereabouts should be monitored at frequent intervals and Resident 1 should be redirected and distracted if needed to prevent her reaching exit doors. A Behavioral Medicine's progress note dated [DATE] noted Resident 1 was yelling and threatening staff because she wanted to leave via the exit door and was intercepted. Resident 1's insight and judgement was rated poor by Behavioral Medicine. Review of the manufacture's information for the wander guard system used at the facility showed the system consisted of a transmitter that resembles a wristwatch that is worn by the resident on the wrist or ankle. The transmitter activates an alarm if the resident attempts to leave the facility through a monitored door. The manufacturer's user guide indicated that while in use transmitters must be tested weekly using the transmitter tester and the expiration date stamped on the transmitters must be checked weekly to verify it is not expired. The user guide also indicated the facility must keep records of the test and transmitter inspections. The undated facility's policy and procedure titled Departure Alert System, indicated that a departure alert device tester (transmitter tester) was to be used to monitor the door and code alert system monthly by the Maintenance Manager. The policy and procedure did not have instructions on the frequency for testing the transmitters worn by the residents. During an interview on [DATE] at 1:50 p.m., the facility's Administrator (Adm) stated Resident 1 was wearing a wander guard transmitter at the time she left the facility unsupervised on [DATE]. Resident 1 left the facility through the monitored front entrance door. The Adm stated the facility was not testing the transmitters used at the facility with a transmitter tester prior to Resident 1's elopement from the facility on [DATE]. The Adm further stated the facility did not have a transmitter tester available in the facility until [DATE]. The facility was not recording any checks of the wander guard transmitters used in the facility prior to Resident 1's elopement. During an interview on [DATE] at 2 p.m. the restorative nursing assistant 1 (RNA 1) confirmed that the facility was not checking the wander guard transmitters using a transmitter tester prior to [DATE]. RNA 1 also confirmed no staff member documented that weekly transmitter testing and expiration date checks were done. The undated facility's policy and procedure titled Departure Alert System, undated, had instructions to use a transmitter tester to check the wander guards. There were no instructions on how to perform the tests, nor on the frequency for testing the transmitters worn by the residents, nor on how to document that the wander guards worked. During an interview on [DATE] at 4:14 p.m., Registered Nurse 1 (RN 1) stated she was working at the facility at the time Resident 1 left the facility unsupervised. RN 1 stated the door did not alarm when Resident 1 left the faciity on [DATE]. RN 1 confirmed the facility was unaware that Resident 1 left the facility until staff noticed an ambulance and fire engine outside the facility. During an observation and concurrent interview on [DATE] at 4 p.m., Resident 1 was seated in a wheelchair. A small wound was noted on her left eyebrow and old bruising (golden brown discoloration) was noted on the left side of her face. Resident 1 was alert and able to move about in her wheelchair. Resident 1 stated she recalled falling in a hole outside the facility. Resident 1 also stated she continues to have some pain on the left side of her face.