Every finding on record at Foothill Regional Medical Center D/P SNF

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for January 2025. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. The facility failed to ensure the residents exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications were included in the facility's infection control surveillance log, and in the monthly infection surveillance report. * LVN 2 failed to perform hand hygiene prior to donning gloves when administering medications. These failures posed the risk for not identifying resident infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other residents in the facility, and had the potential to spread infection in the facility.Findings: 1. Review of the facility's P&P titled Pediatric Sub-Acute Infection Prevention and Control Program Plan revised 2/2025 showed an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Peds Sub-Acute Infection Prevention Program Plan uses sound epidemiologic principles to implement, evaluate, and improve infection prevention and control strategies. Surveillance, epidemiological investigation, consultation, and education are critical components of the program. Prevention and control efforts will include, but are not limited to: - Identifying, managing, and reporting persons with transmissible diseases as mandated by the state communicable disease regulations. - Identifying infections in patients present on admission or occurring thereafter and infections present in staff upon initial employment or arising from an exposure event. - Measuring, monitoring, evaluating, and reporting program effectiveness. - Expanding activities as needed in response to unusual events or to control disease outbreaks promptly. On 2/5/26 at 1136 hours, a concurrent interview, medical record review, and facility document review was conducted with the IP. The IP was asked to show the facility's infection control surveillance program for January to December 2025. Review of the Infection Prevention and Control Surveillance Log for January 2025 showed the infection control surveillance was only conducted for residents prescribed with antimicrobials. There was no documented evidence of surveillance for the residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications, such as the residents who were tested for COVID-19 were included in the surveillance log. Review of the facility's document showed there were three residents diagnosed with Influenza and were prescribed Antiviral medication. However, these three residents were tested with COVID-19 but not included in the surveillance log. When the IP was asked to describe the facility's infection surveillance program, the IP stated she would initially do an order listing of the report. The IP stated she would then manually enter the information of the residents prescribed with antibiotics to the surveillance log. The IP stated she conducted surveillance only on the residents with infections who were prescribed antimicrobial medications. When asked if the residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications were included in the surveillance, the IP stated she did not include the residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications such as those residents with Influenza. On 2/5/26 at 1431 hours, an interview was conducted with the CNO. The CNO was informed and verified the above findings. 2. Review of the facility's P&P titled Hand Hygiene revised 7/2025 showed hand hygiene is the single most important strategy to prevent the spread of infection. The indications for handwashing with alcohol based hand rub included before and after direct contact with patients, before handling patient medication, and before donning gloves. a. On 1/29/26 at 0938 hours, a medication administration observation for Resident 4 was conducted with LVN 2. Resident 4 was on EBP. LVN 2 was observed preparing the following medications:- one packet of polyethylene glycol (laxative medication) 17 gm;- one tablet of multivitamin (supplement);- one tablet of phenobarbital (anti-convulsant medication) 60 mg;- one tablet of lactobacillus acidophilus (probiotic) 0.2 mg;- one tablet of trihexyphenidyl hydrocholoride (anticholinergic medication) 2 mg;- one tablet of baclofen (muscle relaxant medication) 10 mg;- one tablet of baclofen 20 mg;- 2.125 ml of oral solution of sodium chloride (electrolyte) 23.4%; and- 0.6 ml of simethicone (antiflatulent medication) oral drops 40 mg / 0.6 ml. LVN 2 was observed donning gloves and a gown when she entered Resident 4's room to administer the medications. LVN 2 did not perform hand hygiene prior to donning PPE. LVN 2 then administered Resident 4's GT medications. b. On 1/29/26 at 1004 hours, a medication administration observation for Resident 17 was conducted with LVN 2. Resident 17 was on EBP. LVN 2 was observed preparing the following medications:- one packet of polyethylene glycol 17 gm;- 3 ml of glycopyrrolate (anticholinergic medication) 0.2 mg / ml;- 10 ml of docusate sodium (laxative medication) 100 mg / 10 ml;- one packet of esomeprazole (proton pump inhibitor) delayed release oral suspension 10 mg;- half tablet of propranolol hydrocholoride (blood pressure medication) 10 mg;- two capsules of gabapentin (anti-convulsant medication) 100 mg;- half tablet of tizanidine (muscle relaxant medication) 2 mg;- 1.5 ml of cholecalciferol (supplement) solution 400 units / ml; and- 0.6 ml of simethicone oral drops 40mg / 0.6 ml. LVN 2 was observed donning gloves and a gown when she entered Resident 17's room to administer the medications. LVN 2 did not perform hand hygiene prior to donning PPE. LVN 2 then administered Resident 17's GT medications. On 1/29/26 at 1046 hours, an interview was conducted with LVN 2. LVN 2 stated the purpose of hand hygiene was to ensure the safety of the patient and nurses and to promote infection control. LVN 2 verified she did not perform hand hygiene prior to donning gloves during the medication administration observation for Residents 4 and 17. On 2/5/26 at 1423 hours, an interview was conducted with the CNO and RN Manager. The CNO and RN Manager were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure food was properly labeled in the refrigerator. * The facility failed to ensure items in the kitchen were discarded after the use-by/expiration date. * The facility failed to ensure the kitchen equipment was stored or kept in sanitary conditions. * The facility failed to ensure the kitchen equipment was air-dried. * The facility failed to ensure the microwave was kept in clean and sanitary condition. * The facility failed to ensure the food preparation sinks had an air gap. These failures had the potential for exposure to food-borne illnesses for a medically vulnerable population.Findings: On 1/29/26 at 0840 hours, an interview was conducted with the DSS. The DSS stated there were two of 15 residents who consumed food from the kitchen. 1. Review of the facility's P&P titled Food and Supply Storage revised 1/2025 showed all food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. To cover, label, and date unused portions and open packaged. Use the Medvantage/Fresh date labeling system or complete all sections on a [NAME] orange label. Products are good through the close of business on the date noted on the label. On 1/29/26 at 0840 hours, during the initial tour of the kitchen with the DSS and the House Supervisor, a container was observed with an orange-colored liquid inside of Refrigerator 1. The container did not have a label to identify what the liquid was or the date the container of liquid entered the refrigerator. The DSS verified the above findings and stated when the items entered the refrigerator, it should be labeled with the content of the item, the date, and the use-by date. 2. Review of the facility's P&P titled Food and Supply Storage revised 1/2025 showed most but not all products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date. Foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded. To date and rotate items; first in, first out. Discard food past the use-by or expiration date. a. On 1/29/26 at 0840 hours, during the initial tour of the kitchen with the DSS and the House Supervisor, the following was observed:- 16 bottles of Glucerna with the use by date of 1/1/26 in Refrigerator 1,- Two 1/2-gallon cartons of Silk Vanilla Soy Milk with the expiration date of 1/15/26 in Refrigerator 1; and- one metal pan containing two bags of thawed chicken in Refrigerator 2. The label showed good through 1/27/26. The DSS verified the above findings and stated the items should have been discarded. The DSS further stated the refrigerators were checked by the diet clerks daily and the diet clerks were responsible for removing the expired items from the refrigerator. b. On 1/29/26 at 0858 hours, during the initial tour of the kitchen with the CDM, the following were observed in the dry storage room:- one container of Vanilla Creme Icing with the expiration date of 6/25/25; and- one box of chocolate brownie mix with the expiration date of 12/18/25. The CDM verified the above findings. 3. According to the USFDA Food Code 2022 (undated), 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Cleaning of Food and Nonfood Contact Surfaces revised 1/2025 showed the food-contact surface of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. On 1/29/26 at 0840 hours, during the initial tour of the kitchen with the DSS and the House Supervisor, the following was observed:- one metal spatula was observed with dry food particles;- one yellow lemon squeezer was observed with brownish dry residue; and- one peeler was observed with dry, crusted residue on the blade. The DSS verified the above findings and stated the kitchen utensils should be clean. 4. According to the USFDA Food Code 2022 (undated), Section 4-901.11, Equipment and Utensils, Air-Drying Required (undated) showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. Review of the facility's P&P titled Storage of Pots, Dishes, Flatware, Utensils revised 1/2023 showed to air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet. On 1/29/26 at 0840 hours, during the initial tour of the kitchen with the DSS and the House Supervisor, a blender was observed on the blender base, ready for use. The blender was wet with water residue on the inner walls and the blender blade. The blender lid was also observed wet. The DSS verified the above findings and stated the kitchen equipment should be completely air-dry prior to use. 5. According to USFDA Food Code 2022, 4-602.13, Non-Food Contact Surfaces (undated) showed the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility's P&P titled Cleaning of Food and Nonfood Contact Surfaces revised 1/2025, showed nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and their debris. On 1/29/26 at 0840 hours, during the initial tour of the kitchen with the DSS and the House Supervisor, the microwave was observed with dry food particles and residue on the top inner compartment. The DSS verified the above findings and stated the microwave was used to heat up soups for the patients. The DSS stated the microwave should be cleaned after every use. 6. According to USFDA Food Code 2022 (undated), 5-202.13 - Backflow prevention, Air Gap, showed an air gap between the water supply inlet and the food level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (one inch). According to USFDA Food Code 2022 (undated), 5-202.14 - Backflow Prevention Device, Design Standard, a backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device. On 1/29/26 at 0840 hours, during the initial tour of the kitchen with the DSS and the House Supervisor, the food preparation sinks to the left and the right of Refrigerator 2 were not observed with an air gap. The DSS verified the sinks were used for food preparation. On 2/5/26 at 0830 hours, an interview was conducted with the Maintenance Mechanic. The Maintenance Mechanic stated the purpose of an air gap was to prevent the backflow of water back into the sink compartment. The Maintenance Mechanic verified the food preparation sinks to the left and the right of Refrigerator 2 did not have an air gap and the drains were connected and led to the mainline. On 2/5/26 at 1443 hours, an interview and concurrent observation of the food preparation sinks was conducted with the Maintenance Mechanic, CDM, and Regional Consultant. The Maintenance Mechanic stated the drains from the food preparation sinks had a contraption called the P-trap, and the purpose of the contraption was to prevent the backflow of water. Inspection of the drain contraption showed a U-shaped design, with all the drains connected. The mechanism to show how the contraption prevented the backflow of water was unable to be visualized and the facility was unable to provide any documentation on the specific design of the contraption and how or where it prevented the backflow of contaminated water. On 2/5/26 at 1445 hours, an interview was conducted with the Nurse Manager. The Nurse Manager was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs for five of nine final sampled residents (Residents 1, 5, 6, 9, and 15). * The facility failed to develop a care plan for Resident 15's use of lorazepam (antianxiety medication) and diazepam (antianxiety medication). * The facility failed to develop a care plan for Resident 1's GT feeding and use of insulin lispro (medication to lower blood sugar). * The facility failed to develop a care plan to address the use of GJ tube feeding for Resident 5. * The facility failed to develop a care plan for Resident 6's use of the duloxetine (antidepressant medication) and trazadone (antidepressant medication). * The facility failed to develop a care plan for Resident 9's use and management of the GT. These failures had the potential for the residents to not be provided with appropriate, consistent, and individualized care.Findings: Review of the facility's P&P titled Care Plan Resident (undated) showed all residents admitted to the pediatric sub-acute facility will have a plan of care developed and implemented based on the individual resident care needs. 1. Review of the facility' P&P titled Psychotropic Drugs dated 7/2025 showed the resident's plan of care shall include the specific behavior(s) for which the medication is being used, the goal of therapy, and common side effects of the medication. Medical record review for Resident 15 was initiated on 2/5/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 2/4/26, showed Resident 15 had diagnoses including spasticity. Review of Resident 15's Physician's Orders, showed the following physician's orders: - dated 9/1/25, to administer diazepam 2 mg, one tablet via GT every six hours for muscle spasms and neurological irritability; and - dated 12/17/25, to administer lorazepam 1 mg, one tablet via GT every six hours as needed for increased toning and neuro-irritability as evidenced by heart rate greater than 140 bpm. Review of Resident 15's plan of care failed to show a care plan problem was developed for Resident 15's use of diazepam and lorazepam medications. On 2/5/26 at 1037 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 3. RN 3 reviewed Resident 15's medical records and verified a care plan was not developed for Resident 15's use of diazepam and lorazepam medications. On 2/5/26 at 1423 hours, an interview was conducted with the CNO and RN Manager. The CNO and RN Manager were informed and acknowledged the above findings. 2. Medical record review for Resident 1 was initiated on 1/29/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 2/3/26, showed Resident 1 had diagnoses including a GT and Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control). a. On 1/29/26 at 0828 hours, during the initial tour of the facility, Resident 1 was observed lying in bed. Resident 1 was observed with Glucerna 1.2 (enteral feeding formula) infusing at 173 ml/hr via the GT. Review of Resident 1's Physician's Orders showed a physician's order dated 1/27/26, to administer Glucerna 1.2 at 173 ml/hr via the GT every four hours. Review of Resident 1's plan of care failed to show a care plan problem was developed to address Resident 1's use and management of the GT. b. Review of Resident 1's Physician's Orders showed a physician's order dated 10/31/25, to administer insulin lispro injection per sliding scale subcutaneously as needed before meals with the following medication parameters: - to inject 0 units of insulin for the blood glucose level of 60 to 150 mg/dL, - to inject 1 unit of insulin for the blood glucose level of 151 to 200 mg/dL, - to inject 2 units of insulin for the blood glucose level of 201 to 250 mg/dL, - to inject 3 units of insulin for the blood glucose level of 251 to 300 mg/dL, - to inject 4 units of insulin for the blood glucose level of 301 to 350 mg/dL, - to inject 5 units of insulin for the blood glucose level of 351 to 400 mg/dL, - to inject 6 units of insulin for the blood glucose level of 401 to 450 mg/dL, - to inject 7 units of insulin for the blood glucose level of 451 to 500 mg/dL, - if the blood glucose level was above 400 mg/dL, to call the physician and Resident 1 would need an endocrine consult. Review of Resident 1's plan of care failed to show a care plan problem was developed for Resident 1's use of insulin lispro medication. On 2/2/26 at 1106 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 reviewed Resident 1's medical records and verified the above findings. On 2/5/26 at 1423 hours, an interview was conducted with the CNO and RN Manager. The CNO and RN Manager were informed and acknowledged the above findings. 3. On 1/29/26 at 1032 hours, an observation was conducted in Resident 5's room. Resident 5 was observed with Pedia Sure Peptide 1.5 (enteral feeding formula) infusing at 23 ml/hr. The label on the formula showed it was hung on 1/29/26 at 0600 hours. Medical record review for Resident 5 was initiated on 2/2/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 2/2/26, showed the resident did not have the capacity to understand and make decisions. Reviewed of Resident 5's Physician's Orders showed the following physician's orders: - dated 1/8/26, for J-tube feeding with Pedia Sure Peptide 1.5 at 23 ml/hr for 20 hours; - dated 1/9/26, may use J-tube for all meds and flushes until further evaluation ordered; and - dated 1/28/26, water flush 60 ml GT and 50 ml every four hours. Review of Resident 5's plan of care failed to show a care plan problem was developed for Resident 5's use of the GJ tube. On 2/2/26 at 0808 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 2. RN 2 reviewed Resident 5's medical record and verified the facility failed to develop a care plan specific to the use GJ tube feeding for Resident 5. On 2/5/26 at 1355 hours, an interview with the CNO was conducted. The CNO was informed and acknowledged the above finding. 4. According to DailyMed- National Library of Medicine, the black box warning for the duloxetine and trazodone medications showed a warning for suicidal thoughts and behaviors- antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. In patients of all ages who are started on antidepressant therapy, monitor closely for worsening, and the emergence of suicidal thoughts and behaviors. Review of the facility' P&P titled Psychotropic Drugs dated 7/2025, showed the resident's plan of care shall include the specific behavior(s) for which the medication is being used, the goal of therapy, and common side effects of the medication. Medical record review for Resident 6 was initiated on 1/29/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 12/12/25, showed Resident 6 had diagnoses including depression and anxiety. Review of Resident 6's Physician's Orders, showed the following physician's orders: - dated 12/21/25, to administer duloxetine delayed-release 30 mg daily via GT for depression; and - dated 1/7/26, to administer trazodone 200 mg via GT at bedtime. Review of Resident 6's plan of care failed to show a care plan problem was developed for Resident 6's use of the duloxetine and trazodone antidepressant medications. On 2/5/26 at 0942 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 3. RN 3 reviewed Resident 6's medical records and verified a care plan was not developed for Resident 6's use of the trazodone and duloxetine antidepressant medications. On 2/5/26 at 1148 hours, an interview was conducted with the Nurse Manager. The Nurse manager stated for the residents who were administered the antidepressant medications, there should be a care plan developed and implemented specific to the antidepressant medications and the monitoring of the medications' side effects. 5. On 1/29/26 at 0910 hours, during the initial tour of the facility, Resident 9 was observed lying in bed. Resident 9 was observed with Jevity 1.2 (enteral feeding formula) infusing at 52 ml/hr via the GT. Medical record review for Resident 9 was initiated on 1/29/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 12/7/25, showed Resident 9 was GT feed dependent. Review of Resident 9's Physician's Orders showed a physician's order dated 1/6/26, to administer Jevity 1.2 at 52 ml/hr via the GT. Review of Resident 9's plan of care failed to show a care plan problem was developed to address Resident 9's use and management of the GT. On 2/2/26 at 0946 hours, an interview and concurrent medical record review for Resident 9 was conducted with RN 2. RN 2 verified the above findings. RN 2 stated there should be a care plan developed specific to the use of the enteral feeding via the GT to ensure the residents plan of care was addressed and the goals met. On 2/5/26 at 1147 hours, an interview was conducted with the Nurse Manager. The Nurse Manager stated for the residents receiving the enteral feedings via the GT, a care plan should be developed for the GT management including the interventions to meet the goals and prevent complications. On 2/5/26 at 1417 hours, an interview was conducted with the Nurse Manager and CNO. The Nurse Manager and CNO were informed and acknowledged the above findings.

Based on interview, facility document review, medical record review and facility P&P review, the facility failed to ensure the antibiotic stewardship program monitored and addressed the use of the antibiotics for one of nine final sampled residents (Resident 10) and one nonsampled resident (Resident 16) . * The facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria. This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled Antibiotic Stewardship Program dated 9/2022 showed the facility should optimize clinical outcomes while minimizing unintended consequences of antimicrobial appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). The members of the Antibiotic Stewardship Program included to discuss antimicrobial order changes with the physician or prescriber and monitor antimicrobial therapy to evaluate the appropriateness of use. Review of the facility's P&P titled McGeer Criteria undated showed healthcare personnel will utilize the McGeer Criteria to identify and classify infections occurring among patients. Effective communication of infection classification and corresponding control measures will occur among healthcare teams to ensure a coordinated approach to patient care. Data on infections classified according to the McGeer Criteria will be collected regularly to monitor trends, evaluate the effectiveness of infection control interventions, and facilitate quality improvement initiatives. Based on the classification of infections using the McGeer Criteria, appropriate infection prevention and control measures will be implemented. The classification of infections according to the McGeer Criteria and corresponding infection prevention measures will be documented accurately and maintained in accordance with organizational policies and regulatory requirements. Review of the facility's Infection Control Surveillance Log dated February 2025 showed Resident 16 was prescribed an antibiotic for a respiratory tract infection but did not meet McGeer's Criteria. Review of the facility's Infection Control Surveillance Log dated August 2025 showed Resident 10 was prescribed an antibiotic for a respiratory tract infection but did not meet McGeer's Criteria. Medical record review for Residents 10 and 16 were initiated on 2/5/26. Resident 10 was admitted to the facility on [DATE] and Resident 16 was admitted to the facility on [DATE]. Review of Residents 10 and 16's medical records failed to show documented evidence the physician was notified of the infections that did not meet McGeer's Criteria. On 2/5/26 at 1216 hours, an interview, medical record review and concurrent facility document review was conducted with the IP. The IP verified the above findings. The IP stated the facility used McGeer's Criteria as the facility's antibiotic stewardship program. The IP could not show documentation if the physicians were notified on when the infection criteria was not met for the above residents. On 2/5/26 at 1431 hours, an interview was conducted with the CNO. The CNO was informed and verified the above findings.

Based on interview and medical record review, the facility failed to ensure one of five sampled residents (Resident 6) reviewed for unnecessary medications was free from the unnecessary medications. * The facility failed to ensure Resident 6 was monitored for signs and symptoms of bleeding related to the use of the enoxaparin (anticoagulant) therapy. This failure had the potential for Resident 6 to receive unnecessary medications and develop significant adverse effects.Findings: According to DailyMed- National Library of Medicine (undated) showed the following adverse reactions listed for the enoxaparin medication: spinal/epidural hematoma, increased risk of hemorrhage, and thrombocytopenia. Medical record review for Resident 6 was initiated on 1/29/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 12/12/25, showed Resident 6 had diagnoses including quadriplegia. Review of Resident 6's Physician's Orders showed a physician's order dated 12/11/25, to administer enoxaparin 30 mg subcutaneous every 12 hours for anticoagulation, prophylaxis of VTE/PE; high alert medication; black box warning. The physician's orders for the enoxaparin medication did not include the monitoring for side effects. Review of Resident 6's care plan for risk for bleeding dated 2/2/26, showed interventions including to assess Resident 6 for signs and symptoms of bleeding. Review of Resident 6's medical record failed to show documented evidence Resident 6 was monitored for signs and symptoms of bleeding. On 2/2/26 at 1011 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 2. RN 2 stated for the residents who were on the anticoagulation therapy, the residents should be monitored for signs and symptoms of bleeding and bruising by the licensed nurses every shift. RN 2 reviewed Resident 6's medical record and verified the above findings. RN 2 stated there was no documentation that Resident 6 was assessed or monitored for signs and symptoms of bleeding. On 2/5/26 at 1148 hours, an interview was conducted with the Nurse Manager. The Nurse Manager stated for the use of anticoagulation therapy, the residents should be monitored for bleeding. The Nurse Manager further stated the licensed nurses were expected to assess for signs and symptoms of bleeding and document the assessments in the nursing progress notes. On 2/5/26 at 1417 hours, an interview was conducted with the Nurse Manager and CNO. The Nurse Manager and CNO were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of GT for one of nine final sampled residents (Resident 9) reviewed for tube feedings. * The facility failed to ensure Resident 9's HOB was elevated 30 degrees or greater during the enteral feeding to reduce the risk of aspiration. These failures posed the risk for complications related to use of the GT for Resident 9.Findings: Review of the facility's P&P titled Gastrostomy Tube Feedings dated 7/2025 showed under the section Mechanical Pump Feedings, to explain the procedure to the resident and elevate the HOB to high or semi-Fowler's, if possible. On 1/29/26 at 0910 hours, during the initial tour of the facility, Resident 9 was observed lying in bed with Jevity 1.2 (enteral feeding formula) infusing at 52 ml/hr via the GT. The indicator on Resident 9's side rail showed the HOB was less than 30 degrees. Medical record review for Resident 9 was initiated on 1/29/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 12/7/25, showed Resident 9 was GT feed dependent. Review of Resident 9's Physician's Orders showed an order dated 1/6/26, to administer Jevity 1.2 at 52 ml/hr via the GT. On 1/29/26 at 0917 hours, an observation of Resident 9 and concurrent interview was conducted with LVN 1. LVN 1 stated when the enteral feeding was infusing, the HOB should be elevated at 30 degrees or more to prevent aspiration. LVN 1 verified the above findings. LVN 1 further stated Resident 9 becomes agitated when the HOB was greater than 30 degrees. On 2/2/26 at 0811 hours, during an observation, Resident 9 was lying in bed with the enteral feeding formula infusing at 52 ml/hr. The HOB indicator on Resident 9's side rail showed the HOB was less than 30 degrees. On 2/2/26 at 0946 hours, an interview and concurrent medical record review for Resident 9 was conducted with RN 2. RN 2 stated the indicator on the resident's side rail showed the angle of the HOB. RN 2 stated when the enteral feeding formula was infusing, the resident's HOB should be 30 degrees or more to prevent aspiration. RN 2 reviewed Resident 9's medical record and verified Resident 9 did not have a physician's order for Resident 9's HOB to be less than 30 degrees during the enteral feedings. Review of Resident 9's Physician's Orders showed an order dated 2/2/26, may have the head flat per the family's request. On 2/5/26 at 1147 hours, an interview and concurrent medical record review for Resident 9 was conducted with the Nurse Manager. The Nurse Manager stated for residents with the enteral feedings, the HOB should be at least 30 degrees or more to prevent complications like aspiration when the enteral feeding was infusing. The Nurse Manager stated for the residents whose family requested for the resident's HOB to be less than 30 degrees when the enteral feeding was infusing, there should be a physician's order for it to be okay to lay the resident flat. The Nurse Manager further stated if there was a physician's order to lay the resident flat or less than 30 degrees when the enteral feedings were infusing, then there should be nursing documentation in the resident's medical record to show the licensed nurses assessed the resident for aspiration and documented the presenting symptoms and interventions the licensed nurse attempted prior to lowering the resident's head of bed below 30 degrees while the enteral feeding was infusing. When asked about a physician's order for Resident 9 HOB, the Nurse Manager verified Resident 9's physician's order showed the resident could have the head flat per the family's request. The Nurse Manager verified the order was not specific to include during the enteral feedings. On 2/5/26 at 1417 hours, an interview was conducted with the Nurse Manager and CNO. The Nurse Manager and CNO were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 6 and 15) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure the physician's order for the duloxetine (antidepressant medication) and trazodone (antidepressant medication) had the specific behavior manifestations for Resident 6. Additionally, the facility failed to ensure Resident 6 was monitored for the specific behaviors and side effects/adverse reactions related to the use of the duloxetine and trazodone medications. * The facility failed to ensure Resident 15 was monitored for the specific behaviors and side effects/adverse reactions related to the use of the lorazepam (antianxiety medication) and diazepam (antianxiety medication). Additionally, the facility failed to ensure the physician documented the rationale for extending the PRN lorazepam medication for Resident 15. These failures had the potential for the residents to experience potential harm from the adverse consequences from the use of psychotropic medications and the potential for not providing the physician with the accurate data of the residents' behavior occurrences each month, in an effort to discontinue the use of psychotropic medications.Findings: Review of the facility's P&P titled Psychotropic Drugs dated 7/2025 showed all residents receiving routine and as needed medication(s) prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness and side effects. Therapeutic and toxic data will be reported to the physician. A physician's order is required with the following information included: Purpose of treatment, Drug, frequency, route, duration, Probable duration: a. temporary, b. long term Possible side effects or significant risks commonly known by health professionals, Reasonable alternative treatment Further review of the P&P showed the staff shall monitor and record the occurrence of aberrant behavior on the behavior sheet, nurse's notes effects on the behavior summary sheet. The staff shall observe and document the occurrence of medication side effects in the nurse's notes. Monthly, the staff shall summarize the incidence of behavior episodes and side effects on the behavior summary sheet. 1. According to DailyMed- National Library of Medicine (undated), the black box warning for the duloxetine and trazodone antidepressant medications showed a warning for suicidal thoughts and behaviors. Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. In patients of all ages who are started on antidepressant therapy, monitor closely for worsening, and the emergence of suicidal thoughts and behaviors. Medical record review for Resident 6 was initiated on 1/29/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 12/12/25, showed Resident 6 had diagnoses including depression and anxiety. Review of Resident 6's Physician's Orders showed the following physician's orders: - dated 12/21/25, to administer duloxetine delayed release 30 mg daily via GT for depression; and - dated 1/7/26, to administer trazodone 200 mg via GT at bedtime. Further review of the physician's orders failed to show the purpose of treatment for the psychotropic medications, the specific manifesting behaviors, and the side effects related to the use of the antidepressant medications. Review of Resident 6's Physician's Consultation Note dated 12/20/25, showed Resident 6 reported having increased depression and denied any suicidal thoughts. Review of Resident 6's medical record failed to show documented evidence Resident 6 was monitored for the specific behaviors and side effects related to the use of the duloxetine and trazodone medications. On 2/5/26 at 0942 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 3. RN 3 stated the physician's orders for the administration of the psychotropic medications should include the diagnosis and the specific behaviors related to the use of the psychotropic medication. RN 3 stated for the residents administered the psychotropic medications, the specific manifesting behaviors should be monitored every shift to track and determine if the medication was effective. RN 3 reviewed Resident 6's medical records and verified the above findings. RN 3 verified there were no documentation of the monitoring Resident 6 for the specific behaviors and side effects related to the use of the duloxetine and trazodone psychotropic medications. On 2/5/26 at 1148 hours, an interview was conducted with the Nurse Manager. The Nurse Manager stated the physician's order for the administration of the psychotropic medications should include the medication name, dose, route, frequency, and the indication of use and the specific manifesting behavior. The Nurse Manger stated the resident should be monitored for the effectiveness of the psychotropic medication by monitoring for the occurrence of the specific behavior. The Nurse Manager further stated the licensed nurses were expected to monitor the resident for the specific behaviors and the side effects related to the use of the psychotropic medications and document in the nurse's progress notes. On 2/5/26 at 1417 hours, an interview was conducted with the Nurse Manager and CNO. The Nurse Manager and CNO were informed and acknowledged the above findings. 2. Medical record review for Resident 15 was initiated on 2/5/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 2/4/26, showed Resident 15 had the diagnosis of spasticity (a neurological motor disorder characterized by increase in muscle tone, stiffness, and exaggerated reflexes). Review of Resident 15's Physician's Orders, showed the following physician's orders: - dated 9/1/25, to administer diazepam 2 mg, one tablet via GT every six hours for muscle spasms and neurological irritability; and - dated 12/17/25, to administer lorazepam 1 mg, one tablet via GT every six hours as needed for increased toning and neuro-irritability (state of persistent, often unexplainable, crying, agitation) as evidenced by heart rate greater than 140 bpm. In addition, the PRN lorazepam medication had a stop date of 12/17/26. There was no documented evidence of the rationale to extend the PRN lorazepam medication and the side effects related to the use of the psychotropic medications in the physician's orders. Review of Resident 15's MAR for January and February 2026 showed the following: - Resident 15 was administered the diazepam medication from 1/1 to 2/4/26. - Resident 15 was administered the lorazepam medication on 1/20/26 at 0827 hours. Further review of Resident 15's medical record failed to show documented evidence Resident 1 was monitored for the specific behaviors and side effects related to the use of the diazepam and lorazepam medications. On 2/5/26 at 1037 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 3. RN 3 stated if a medication was routinely administered to the resident, the licensed nurses did not need to document the resident's behavior. RN 3 stated there was no documentation of the monitoring for Resident 15's specific behaviors and side effects related to the use of the diazepam and lorazepam medications RN 3 verified the above findings. On 2/5/26 at 1417 hours, an interview was conducted with the CNO and RN Manager. The CNO and RN Manager were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to fully inform the resident or responsible party and obtain a completed informed consent prior to the use of the psychotropic medications for one of five final sampled residents (Resident 15) reviewed for unnecessary psychotropic medications. *The facility failed to ensure the informed consent was obtained from Resident 15's representative prior to the use of lorazepam (antianxiety medication) and diazepam (antianxiety medication). This failure had the potential for Resident 15 and their responsible party to be unaware of the risks associated with psychotropic medications and the potential side effects.Findings: Review of the facility's P&P titled Psychotropic Drugs revised 7/2025 showed a signed consent is required for administration of psychotropic drugs. Medical record review for Resident 15 was initiated on 2/5/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's Physician's Orders, showed the following physician's orders:- dated 9/1/25, to administer diazepam 2 mg, one tablet via GT every six hours for muscle spasms and neurological irritability; and- dated 12/17/25, to administer lorazepam 1 mg, one tablet via GT every six hours as needed for increased toning and neuro-irritability (state of persistent, often unexplainable, crying, agitation) as evidenced by heart rate greater than 140 bpm. Review of Resident 15's MAR for January and February 2026 showed the following:- Resident 15 was administered the diazepam medication from 1/1 to 2/4/26.- Resident 15 was administered the lorazepam medication on 1/20/26 at 0827 hours. Review of Resident 15's H&P examination dated 2/4/26, showed Resident 15 was neurologically devastated (describes a condition where a patient has suffered severe, often irreversible damage to the brain). Review of Resident 15's medical record failed to show an informed consent was obtained from Resident 15's representative prior to the resident receiving the diazepam and lorazepam medications. On 2/5/26 at 1037 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 3. RN 3 stated the facility obtained consent for psychotropic medications, however, Resident 15 did not have a consent form for diazepam and lorazepam because the medications were used for Resident 15's increased toning (the continuous and passive partial contraction of muscles, or the resting tension in a muscle that helps maintain posture and stability) and neuro-irritability. RN 3 verified the above findings. On 2/5/26 at 1417 hours, an interview was conducted with the CNO and RN Manager. The RN Manager stated the licensed nursing staff would obtain consent for psychotropic medications. Furthermore, the RN Manager stated Resident 15 did not have a consent form for diazepam and lorazepam because the facility did not use the medications for psychoactive indications. The CNO and RN Manager were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure staff provided care and promoted dignity and respect for two of nine final sampled residents (Residents 10 and 18). * The facility failed to ensure the privacy curtain was drawn for Resident 10 when CNA 1 was changing and providing care to the resident. * The facility failed to ensure the privacy curtain was drawn for Resident 18 when RT 1 was suctioning the resident. These failures had the potential to negatively impact the residents' feelings of self-worth and well-being.Findings: Review of the facility's P&P titled Resident Rights dated 7/2025 showed the residents have the right to be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 1. Review of the facility's P&P titled Bath-In Bed dated 9/2025 showed all pediatric residents will be bathed daily following the assigned schedule. To identify the resident, explain the procedure to the resident and bring the equipment to the bedside, and to provide the resident with privacy. Medical record review for Resident 10 was initiated on 1/29/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 2/2/23, showed Resident 10 had hypoxic ischemic encephalopathy with persistent vegetative state. On 1/29/26 at 0920 hours, an observation and concurrent interview was conducted with LVN 1. Resident 10 was lying in bed and CNA 1 was providing care to the resident. Resident 10's abdomen was exposed. The privacy curtain was on the left side of Resident 10's bed and not drawn to provide privacy between Resident 10 and his roommate. LVN 1 verified the above finding. LVN 1 stated when the care was provided to the residents, the privacy curtain should be drawn to provide the residents with privacy and dignity. On 1/29/26 at 0927 hours, an interview was conducted with CNA 1. CNA 1 stated she was giving Resident 10 a partial bed bath and changing his clothes. CNA 1 verified she did not pull the curtain to provide Resident 10 with privacy, and stated she should have pulled the curtain. On 2/5/26 at 1147 hours, an interview was conducted with the Nurse Manager. The Nurse Manager stated the staff should ensure the residents were covered and the curtains should be pulled to provide the residents with privacy and dignity when changing the resident or providing care in the bed. On 2/5/26 at 1417 hours, an interview was conducted with the Nurse Manager and CNO. The Nurse Manager and CNO were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Suctioning Airway Pediatric dated 9/2025 showed suctioning the airway of the resident was performed by an RN or RT. The procedures in performing suctioning the residents include the provision of privacy. Medical record review for Resident 18 was initiated on 1/29/26. Resident 18 was admitted to the facility on [DATE]. On 2/2/26 at 1047 hours, during an interview with CNA 2 inside Resident 18's bedroom, RT 1 entered the room and stated he would suction Resident 18. RT 1 donned PPE and proceeded to suction Resident 18. The privacy curtain was not drawn and other staff in the hallway were able to see and talk to RT 1. On 2/2/26 at 1055 hours, an interview was conducted with RT 1. RT 1 stated he prepared everything needed before suctioning the resident. RT 1 was informed of the observation and verified there was another staff asking him a question from the hallway while he was suctioning Resident 18. RT 1 verified the findings. On 2/5/26 at 1013 hours, an interview was conducted with the CNO. The CNO was informed and verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the POLST for one of nine final sampled residents (Resident 1) was completed. * Resident 1's POLST was incomplete. This failure had the potential for Resident 1's care needs to not be met as their medical information was not complete.Findings: Review of the facility's P&P titled Life Sustaining Treatment Physician Orders (POLST) revised 7/2025 showed the POLST is a document that describes the patient's specific wishes for end of life treatment. The POLST clarifies the patient's treatment intentions, minimizes confusion about patient preferences, and complements the patient's advance health directive. Medical record review for Resident 1 was initiated on 1/29/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's POLST dated 12/1/22, showed Section D for the advance directive was not completed. On 2/2/26 at 1106 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 verified the above findings. On 2/5/26 at 1423 hours, an interview was conducted with the CNO and RN Manager. The CNO and RN Manager were informed and acknowledged the above findings.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment addressed or included the following: active involvement of required individuals in developing facility assessment, resources necessary to care for residents including weekends, include a plan to maximize recruitment and retention of direct care staff and include a contingency plan for staffing needs. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan. Review of the Facility's Assessment for 2025 did not show the direct care staff members, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment. Additionally the Facility Assessment did not show resources necessary to care for residents including weekends, a plan to maximize recruitment and retention of the direct care staff and a contingency plan for staffing needs. On 2/2/26 at 1124 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with the CNO. The CNO reviewed the Facility Assessment for 2025 and verified the above findings. The CNO further verified there were no resources necessary to care for residents including weekends, and no documentation of a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs in the Facility Assessment. The CNO verified the Facility Assessment for 2025 was not updated based on the latest guidance from the CMS.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented. * The facility failed to record all the residents with infection on the facility's infection surveillance tool. The facility's infection surveillance tool did not include all the residents identified with infections. Only the residents with positive culture results were identified as having infection and were listed on the surveillance list. * The facility failed to ensure Resident 8's water pitcher was clean. * LVN 1 failed to disinfect the stethoscope after use on Resident 9 and prior to exiting the room. * LVN 4 failed to disinfect the stethoscope after use on Resident 12 and prior to exiting the room; additionally, LVN 4 failed to don proper PPE during the administration of the medications to Resident 12 via the GT. * The facility failed to ensure RCP 2 wore proper PPE when providing suctioning through tracheostomy for Resident 7. * The facility failed to ensure LVN 2 wore proper PPE when administering medication through the GT for Resident 14. These failures posed a risk for transmission of disease-causing microorganisms and infections and incorrect notification of infection control practices. Findings: 1. Review of the facility's P&P titled Pediatric Sub-Acute Infection Prevention Program Plan revised 1/2023 showed the Peds Subacute Infection Control plan covers the care, treatment, and services for the facility subacute care. The Peds Sub-Acute Infection Prevention Program Plan uses sound epidemiologic principles to implement, evaluate, and improve infection prevention and control strategies. Surveillance, epidemiological investigation, consultation, and education are critical components of the program. Prevention and control efforts will include, but are not limited to: * Identifying, managing, and reporting persons with transmissible diseases as mandated by the state communicable disease regulations * Identifying infections in patients present on admission or occurring thereafter, and infections present in staff upon initial employment or occurring as a result of an exposure * Measuring, monitoring, evaluating, and reporting program effectiveness Review of the facility's infection surveillance list did not show a record of all the residents with infection. Only the residents with positive culture results were listed on the surveillance list. On 1/30/25 at 1018 hours, an interview and concurrent record review was conducted with the Director of Infection Prevention. The Director of Infection Prevention stated he was responsible for the infection control surveillance in the Subacute unit. When asked if the facility included on their infection surveillance form the residents with identified infections who met the McGeer's criteria but did not have a positive culture, the Director of Infection Prevention stated they were only tracking the residents with positive culture results and listed on the surveillance list. The Director of Infection Prevention verified the surveillance forms did not include all the residents identified with infection and only the residents with positive culture results were listed on the infection surveillance form. The Director of Infection Prevention stated he followed the NHSN guidelines to see if it met the true infection of HAI. 2. Review of the facility's P&P titled Pediatric Sub-Acute Infection Prevention Program Plan revised 1/2023 showed the Pediatric Sub-Acute Infection Prevention Program Plan established by the facility provides a multidisciplinary systemic approach to promoting quality patient care, emphasizing risk reduction of disease transmission in the healthcare environment. During the initial facility tour on 1/29/25 at 0829 hours, Resident 8's water pitcher was observed on top of the side table. The cover of Resident 8's water pitcher was dirty and had yellowish powder and stain. Medical record review for Resident 8 was initiated on 1/29/25. Resident 8 was admitted to the facility on [DATE]. Review of the Physician H&P General dated 10/16/24, showed Resident 8 had global developmental delay (a significant delay in two or more domains of development, including activities of daily living as well as motor, cognitive, speech/language, and personal/social skills). On 1/29/25 at 1114 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the cover of Resident 8's water pitcher was dirty and had yellowish powder and stain. LVN 2 stated the staff member used the water from the water pitcher during the medication administration. LVN 2 stated the staff member should have changed Resident 8's water pitcher for infection control. On 1/31/25 at 1621 hours, an interview was conducted with the CNO and Director of Quality and Risk. The DON and Director of Quality and Risk were informed and acknowledged the above findings. 48882 3. On 1/30/25 at 1524 hours, during the medication administration observation for Resident 9, LVN 1 was observed using a stethoscope and syringe to check for the GT placement and then placing the stethoscope around her neck. After completing Resident 9's medication administration, LVN 1 was observed performing hand hygiene and exited Resident 9's room. LVN 1 did not disinfect the stethoscope prior to exiting Resident 9's room. On 1/30/25 at 1540 hours, an interview and concurrent observation was conducted with LVN 1 in the hallway. LVN 1 stated the stethoscope should be disinfected after each use and prior to exiting the resident's room. LVN 1 verified she did not disinfect her stethoscope after using the stethoscope to check Resident 9's GT placement, and prior to exiting Resident 9's room. 4.a. On 2/3/25 at 0928 hours, during the medication administration observation for Resident 12, LVN 4 was observed using a stethoscope and syringe to check for the GT placement and then placing the stethoscope around her neck. After completing Resident 12's medication administration, LVN 4 removed her gloves, washed her hands, and exited Resident 12's room. LVN 4 did not disinfect the stethoscope prior to exiting Resident 12's room. On 2/3/35 at 0955 hours, an interview was conducted with LVN 3. LVN 3 stated after using the stethoscope to check for GT placement, the stethoscope should be disinfected prior to exiting the resident's room to prevent the transmission of organisms to other residents. LVN 3 verified she did not disinfect her stethoscope after using the stethoscope to check Resident 12's GT placement and prior to exiting Resident 12's room. On 2/3/25 at 1024 hours, an interview was conducted with the Infection Control Coordinator. The Infection Control Coordinator stated the licensed staff are expected to disinfect the stethoscope after each use on the resident and the stethoscope should be disinfected before leaving the resident's room to prevent cross contamination and the transmission of organisms to others. On 2/3/25 at 1409 hours, an interview was conducted with the CNO. The CNO stated the stethoscope should be disinfected with the appropriate disinfectant after each use and before leaving the resident's room to prevent the cross contamination and transmission of infections. The CNO was informed and acknowledged the above findings. b. Review of the CDC'S Long-Term Care Facilities: Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug- resistant Organisms (MDROs), dated 4/2/24, showed multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: - Wounds or indwelling medical devices, regardless of MDRO colonization status - Infection or colonization with an MDRO. Review of the CDC's Enhanced Barrier Precaution sign showed providers and staff must also: wear glove and gown for the following high- contact resident care activities: - dressing - bathing/showering - transferring - changing linens - providing hygiene - changing briefs or assisting with toileting - device care or use: central line, urinary catheter, feeding tube, tracheostomy - wound care: any skin opening requiring a dressing. Medical record review for Resident 12 was initiated on 2/3/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 4/28/21, showed Resident 12 was a GT dependent. Review of Resident 12's MDS dated [DATE], showed Resident 12 had a feeding tube. On 2/3/25 at 0928 hours, during a medication administration observation with LVN 3. LVN 3 was observed administering Resident 12's medication via GT. LVN 3 was not observed wearing a gown during the medication administration. On 2/3/25 at 0955 hours, an interview was conducted with LVN 3. LVN 3 was asked about the proper PPE during the administration of medications to a resident with a GT. LVN 3 stated for the residents who did not have an active infection, and have a GT, she did not don a gown during the medication administration. LVN 3 further stated Resident 12 was not under any isolation. LVN 3 verified she did not don a gown during the medication administration observation. LVN 3 was asked about the enhanced barrier precautions and LVN 3 stated she was not familiar with the precautions. On 2/3/25 at 1024 hours, an interview was conducted with the Infection Control Coordinator. The Infection Control Coordinator was asked about her understanding of the enhanced barrier precautions. The Infection Control Coordinator stated when the staff member were providing care for a resident with a GT, the staff member must don a gown and gloves. The Infection Control Coordinator further stated a gown and gloves were required when providing a direct resident care and when administering medications via the GT. The Infection Control Coordinator was asked if the licensed nursed were aware of the enhanced barrier precautions guidelines, the Infection Control Coordinator stated the facility practice was that the residents who did not have an order for isolation and did not have an active infection, the licensed nurses were using standard precautions during the medication administration via the GT and when providing care. On 2/3/25 at 1409 hours, an interview was conducted with the CNO and Director of Quality and Risk. The CNO was informed and acknowledged the above findings. 44175 5. Review of the CMS's QSO-24-08-NH Enhanced Barrier Precautions in Nursing Homes dated 3/20/24 and effective 4/1/24, showed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The QSO further showed EBP recommendations now include use of EBP for the residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. On 1/31/25 at 0848 hours, RCP 2 was observed entering the room and performing hand hygiene donned gloves. RCP 2 proceeded to suction the Resident 7 through the tracheostomy tube. RCP 2 was not observed wearing gown while performing suctioning of the Resident 7 through the tracheostomy tube. No EBP sign was observed outside the room. On 1/31/25 at 0850 hours, an interview was conducted with RCP 2. RCP 2 verified the observation and stated Resident 7 was not on any isolation precautions, so he was not required to wear gown while performing suctioning to the resident through tracheostomy. When asked RCP 2 if he was aware about the EBP, he stated he did not know about EBP and had not received any training on EBP. Medical record review for Resident 7 was initiated on 1/29/25. Resident 7 was admitted to the facility on [DATE]. Review of the H&P examination dated 6/2/24, showed Resident 7 was dependent on tracheostomy (an opening surgically created through the neck into the trachea {windpipe} to allow air to fill the lungs), gastrotomy tube (a thin, flexible tube inserted through the abdominal wall and into the stomach), and mechanical ventilator ( A mechanical ventilator is a machine that takes over the work of breathing when a person is not able to breathe enough on their own). Review of the Resident 7's Patient Orders, showed the following orders: - dated 7/12/24, for Promote with fiber tube feeding to give 118 ml per hour via GT. - dated 7/1/24, for tracheostomy tube change and mechanical ventilation. 6. On 1/31/25 at 0904 hours, LVN 2 was observed performing hand hygiene, donning gloves and entering the room of Resident 14 with the medication on her hand. LVN 2 was observed administering the medication through the GT. LVN 2 was not observed wearing gown before entering the room and administering the medication through the GT. On 1/31/25 at 0909 hours, an interview was conducted with LVN 2. LVN 2 verified the observation and stated Resident 14 was not on any isolation precautions, so she was not required to wear gown while administering medication through the GT. LVN 2 was asked if she was aware about the EBP, she stated she did not know about EBP and had not received any training on EBP. Medical record review for Resident 14 was initiated on 1/31/25. Resident 14 was admitted to the facility on [DATE]. Review of the Resident 14's Patient Orders showed an order dated 1/12/25, for tube feeding, Nutramigen (children's formula feeding) at 90 ml per hour via GT for nine hours from 2000 to 0500 hours. On 1/31/24 at 1448 hours, an interview was conducted with the Infection Control Coordinator. The Infection Control Coordinator stated EBP was not practiced in the facility, and she recently became aware about the residents with tracheostomy, GT, indwelling urinary catheters, central lines, colostomy, wounds needed the standard EBP precautions, including the use of gown and gloves during direct care,and medication administration for the residents with GT. The Infection Control Coordinator was informed of the above findings and stated the staff member should have wore gown in addition to the gloves while providing suctioning to Resident 7, and while administering medication through the GT for Resident 14. On 2/3/25 at 1410 hours, the CNO and Director of Quality and Risk were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services for the use of a GT for two of nine final sampled residents (Residents 7 and 12) and two nonsampled residents (Residents 1 and 9). * The facility failed to ensure LVN 1 elevated Resident 9's HOB at a 30 degree angle or above prior to the administration of medication via the GT, to reduce the risk of aspiration. * The facility failed to ensure LVN 3 elevated Resident 12's HOB at a 30 degree angle or above prior to the administration of the medication via the GT, to reduce the risk of aspiration. * The facility failed to ensure Resident 1's HOB was elevated at a 30 degree angle or above during the enteral feeding via the GT. * The facility failed to ensure Resident 7's HOB was elevated at a 30 degree angle or above when Resident 7 was receiving the enteral feeding via the GT. These failures posed the risk for complications related to use of the GT for Residents 1, 7, 9, and 12. Findings: Review of the facility's P&P titled Enteral Nutrition and Medication Administration revised 2/2018 showed during enteral feeding, keep the patient's head of the bed at a 30 degree angle to promote optimal flow of feeding. 1. Medical record review for Resident 9 was initiated on 1/30/25. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's H&P examination dated 2/10/23, showed Resident 9 was a GT dependent. Review of Resident 9's MDS dated [DATE], showed Resident 9 had a feeding tube. On 1/30/25 at 1532 hours, during a medication administration observation with LVN 1, LVN 1 was observed administering Resident 9's medication with the HOB at a 20 degree angle. On 1/30/25 at 1538 hours, an interview and concurrent observation was conducted with LVN 1. LVN 1 stated for the administration of the medications via the GT, the HOB should be elevated at a 30 degree angle or more. LVN 1 was asked how she checked to ensure the HOB was at an appropriate angle, LVN 1 stated the beds had a leveler which indicated the angle of the HOB. LVN 1 checked the leveler on Resident 9's bed and verified the HOB was at a 20 degree angle. LVN 1 was then observed raising Resident 9's HOB. 2. Medical record review for Resident 12 was initiated on 2/3/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 4/28/21, showed Resident 12 was a GT dependent. Review of Resident 12's MDS dated [DATE], showed Resident 12 had a feeding tube. On 2/3/25 at 0928 hours, during a medication administration observation with LVN 3, LVN 3 was observed elevating the HOB of Resident 12's bed before administering the medications. However, the indicator on Resident 12's bed showed the HOB was between 15 and 30 degree angle. On 2/3/25 at 0954 hours, an interview and concurrent observation was conducted with LVN 3. LVN 3 was asked about the facility's practice for the administration of medications via the GT. LVN 3 stated for the administration of medication via the GT, the HOB should be at a 45 to 60 degree angle, to prevent the risk of aspiration. When asked how LVN 3 determined the appropriate angle for the HOB during the medication administration, LVN 3 stated it was per her visual judgement. When asked about the HOB indicator on Resident 12's bed, LVN 3 stated she did not use the indicator and was not aware of its function. LVN 3 verified the indicator showed the angle was less than 30 degrees. On 2/3/25 at 1321 hours, an interview was conducted with the DSD/MDS Coordinator. The DSD/MDS Coordinator stated for the administration of medications via the GT, the HOB should be maintained above a 30 degree angle. The DSD/MDS Coordinator stated some of the beds had indicators to show the angle of the HOB. The DSD/MDS Coordinator further stated if the beds had the indicators on them, the licensed nurses should check the indicator to ensure the HOB was at the appropriate angle prior to the administration of the medication via the GT, to prevent aspiration. On 2/3/25 at 1409 hours, an interview was conducted with the CNO and Director of Quality and Risk. The CNO stated the facility's practice for the administration of the medications via the GT, was for the HOB to be at a 30 degree angle or more, to prevent aspiration. The CNO stated the indicators/levelers on the beds indicated the angle of the HOB. The CNO further stated, the nurses should check the indicator prior to the administration of the medications via the GT, to ensure the HOB was at the appropriate level. The CNO was informed and acknowledged the above findings. 49644 3. Review of the Foundations and Adult Health Nursing published 2023 showed when administering medication through the nasogastric tubing, place the patient in high Fowler's position (upper body elevated at a 60-90 degree angle). On 1/29/25 at 0940 hours, during the initial facility tour, Resident 1 was observed lying in bed with the HOB elevated less than 30 degrees and receiving tube feeding. Medical record review for Resident 1 was initiated on 1/29/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 12/10/22, showed Resident 1 had hypoxic ischemic encephalopathy (a disorder in which clinical manifestations indicate brain dysfunction). Review of Resident 1's Patient Orders (displayed orders) dated 1/30/25, showed a physician's order dated 7/18/24, to administer Jevity (enteral feeding) 1.2 calorie tube feeding at 105 ml/hour via GT every day. On 1/29/25 at 1050 hours, an observation and concurrent interview was conducted with LVN 1. The HOB angle indicator on Resident 1's bed showed Resident 1's HOB was at a 20 degree angle, while the tube feeding was infusing. LVN 1 verified Resident 1's HOB was at a 20 degree angle. LVN 1 stated the HOB should have been at a 30 degree angle, to prevent aspiration pneumonia (an infection caused by inhaling something other than air into the lungs). On 1/31/25 at 1621 hours, an interview was conducted with the CNO and Director of Quality and Risk. The DON and Director of Quality and Risk were informed and acknowledged the above findings. 44175 4. On 1/29/25 at 0842 hours, Resident 7 was observed lying in bed. Resident 7's tube feeding was observed running at 118 ml per hour. Resident 7's HOB was not observed elevated at a 30 degree angle. The indicator on the bed showed the angle of the HOB was at a 15 degree angle. Medical record review for Resident 7 was initiated on 1/29/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 6/2/24, showed Resident 7 was dependent on tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), gastrotomy tube. Review of the Resident 7's Patient Orders, showed a physician's order dated 7/12/24, to promote with fiber tube feeding at 118 ml per hour via the GT. On 1/29/25 at 0853 hours, a concurrent observation and interview was conducted with RN 4. RN 4 stated the HOB of the resident who was receiving the enteral feeding should be elevated at least at a 30 degree angle, to prevent complications of the tube feeding, including aspiration pneumonia. RN 4 verified the above observation and stated the HOB for Resident 7 should have been elevated to at least a 30 degree angle when the resident was receiving the enteral feeding. RN 4 was observed elevating the HOB for Resident 7 to a 30 degree angle. On 1/31/25 at 1621 hours, the CNO and Director of Quality and Risk were informed and acknowledged the above findings.

Based on interview, and medical record review, the facility failed to ensure one of five final sampled residents (Resident 2) reviewed for unnecessary medications was free from the unnecessary psychotropic medication when: * The facility failed to monitor the behaviors specific to the use of clonidine (antihypertensive and sedative medication) for Resident 2. * The facility failed to ensure the informed consent was obtained from the resident representative for the use of the psychotropic medication (clonidine) when the route of administration, dose, and targeted behaviors were changed for Resident 2. These failures had the potential for the residents to receive unnecessary medications and not effectively evaluate the effectiveness of the psychotropic medications, and had the potential for Resident 2's representative not being informed of his clonidine medication and potential effects from the changed routes of administration, doses and targeted behavior. Findings: Review of the article published in National Library of Medicine titled Clonidine dated 7/17/23, showed clonidine is an antihypertensive medication and has multiple off labels uses which included treating anxiety. Medical record review for Resident 2 was initiated on 1/29/25. Resident 2 was admitted in the facility on 9/8/23. Review of the Resident 2's MDS dated [DATE], showed Resident 2 had a memory problem and severely impaired cognitive skills for daily decision making. Review of Resident 2's Patient Orders showed following orders: - dated 1/29/25, to administer clonidine hydrochloride 0.1 mg tablet via GT at bedtime at scheduled administration times. - dated 12/20/24, to administer clonidine hydrochloride 0.05 mg tablet via GT daily at scheduled administration times. Further review of the above Patient Orders showed the indication for the use of the clonidine medication was irritability. Further review of Resident 2's medical record failed to show if Resident 2's behavior of irritability was monitored. On 2/3/25 at 1035 hours, an interview was conducted with the Director of Pharmacy. The Director of Pharmacy stated if the clonidine was used to control the resident's behavior, then it was considered a psychotropic medication. The Director of Pharmacy further stated the effectiveness of the psychotropic medication and targeted behavior should be monitored. On 2/3/25 at 1250 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 2. RN 2 stated Resident 2 had a behavior of irritability. RN 2 stated when Resident 2 had the episodes of irritability, he would resist care, move his body, and his facial expression would change with an increase in his heart rate. When RN 2 was asked if the facility monitored the episodes of Resident 2's irritability behavior to monitor the effectiveness of the medications prescribed, RN 2 stated the behavior should be monitored. RN 2 reviewed Resident 2's medical record and stated she was not able to show the documented evidence Resident 2's behavior of irritability was monitored for the use of the clonidine medication. 2. Review of the Resident 2's Psychoactive Medication Consent dated 9/8/23, showed for clonidine patch 0.2 mg every seven days. Under the section specific targeted behavior, showed agitation. Further review of the document showed the informed consent was obtained via telephone and was signed by the physician. Further review of Resident 2's the medical record failed to show if the informed consent was obtained when the clonidine medication route of administration, dose (changed to tablet 0.1 mg at bedtime and 0.05 mg daily via GT) and the indication was changed to irritability. On 1/31/25 at 1326 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 verified the Psychoactive Medication Consent showed the clonidine patch 0.2 mg every seven days for agitation. RN 1 stated Resident 2 was currently on clonidine 0.1 mg at bedtime and 0.05 mg daily for irritability via GT. RN 1 was not able show if the informed consent was obtained when the clonidine medication dose, route of administration, and targeted behavior were changed. On 2/3/25 at 1009 hours, an interview was conducted with the Director of Quality and Risk. The Director of Quality and Risk stated the facility did not have the residents with psychiatric issues, so facility did not have the policy and procedures for the use of psychotropic medication. On 2/3/25 at 1410 hours, the CNO and Director of Quality and Risk were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of nine final sampled residents (Residents 7 and 18). * The facility failed to develop a comprehensive person-centered care plan to address Resident 18's nutritional oral gratification and GT feeding. In addition, the facility failed to develop a comprehensive care plan for the use of the abdominal binder. * The facility failed to develop a comprehensive person-centered care plan to address Resident 7's GT feeding. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Resident Care Plan revised 7/2024 showed all the residents will have an individualized comprehensive person-centered care plan developed and implemented based on residents individual care needs and includes all problems, goals, and interventions will be documented. 1a. On 1/29/25 at 0901 hours, Resident 18 was observed up in the baby chair and assisted by the family member with eating the baby food using a small rubberized spoon. Medical record review for Resident 18 was initiated on 1/30/25. Resident 18 was admitted to the facility on [DATE]. On 1/30/25 1011 hours, Resident 18 was observed on a wheelchair with the GT feeding infusing at 37 ml per hour. Review of Resident 18's physician's order dated 1/29/25, showed to provide a pureed diet with instructions for Resident 18 to eat baby food one to two times a day for oral gratification, to be fed by family member only, and to continue with routine Jejunostomy (surgical opening in the small intestine from the outside of the body) tube feeding. Another physician's order dated 1/21/25, showed to provide tube feeding with Elecare 26 kcal at 37 ml per hour for 22 hours and to stop for oral feeding. Review of Resident 18's plan of care did not show documented evidence a care plan was developed to address the nutritional problem of Resident 18. There was no documented evidence the care plan was formulated for the oral gratification and tube feeding. On 1/30/25 at 1058 hours, an interview for Resident 18 was conducted with CNA 3. CNA 3 verified Resident 18's family member assisted the resident with eating the baby food and Resident 18 was on tube feeding. b. Review of Resident 18's physician order dated 9/27/24, showed to apply the abdominal binder continuously for GT dislodgement prevention, and with instructions to use elastic bandage with self closure and cut to the appropriate size when resident was not wearing snappable clothing, and to check the skin every two hours. Review of Resident 18's plan of care did not show documented evidence a care plan was developed to address the use of the abdominal binder to prevent GT dislodgement for Resident 18. On 1/30/25 at 1058 hours, an interview for Resident 18 was conducted with CNA 3. CNA 3 verified Resident 18 had an abdominal binder on to prevent the resident from pulling out the tubes on her abdomen. On 2/03/25 at 0849 hours, and interview and concurrent medical record review for Resident 18 was conducted with RN 2. RN 2 verified Resident 18 was on oral feeding and the family member was able to assist the resident with eating. RN 2 verified Resident 18 moved a lot and the licensed nurses applied the elastic bandage as an abdominal binder. RN 2 verified Resident 18 had a physician's order for the elastic bandage to apply as an abdominal binder and to perform a skin checks every two hours. RN 2 stated the licensed nurses checked the placement of the elastic bandage. RN 2 was asked if there was a plan of care formulated for the GT feeding, oral feeding, and the use of the abdominal binder. RN 2 verified there was no care plan formulated for the the GT feeding, oral feeding and the use of the abdominal binder for Resident 18. On 2/03/25 at 1418 hours hours, an interview and concurrent medical record review for Resident 18 was conducted with the CNO. The CNO was informed and verified the above findings. 44175 2. On 1/29/25 at 0842 hours, Resident 7 was observed lying in bed. Resident 7's tube feeding was observed running at 118 ml per hour. Medical record review for Resident 7 was initiated on 1/29/25. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's H&P examination dated 6/2/24, showed Resident 7 was dependent on GT (a thin, flexible tube inserted through the abdominal wall and into the stomach) feeding. Review of the Resident 7's Patient Orders, showed a physician's order dated 7/12/24, to promote with fiber tube feeding at 118 ml per hour via the GT. Review of Resident 7's plan of care failed to show documented evidence a care plan addressing Resident 7's GT feeding was initiated. On 1/31/25 at 1345 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. RN 1 verified the above findings and stated the facility did not initiate a person centered care plan to address the resident's enteral feeding. RN 1 stated she used her standard professional practice to care for the residents with tube feeding. On 1/31/25 at 1621 hours, the CNO and Director of Quality and Risk was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to two of nine final sampled residents (Residents 4 and 12). * The facility failed to assess and check the skin of Residents 4 and 12 every two hours when the splint device was applied as ordered by the physician. In addition, the plans of care to address the function and mobility of Residents 4 and 12 were not included in the interventions for skin assessments every two hours when the splint device was applied. These failures had the potential to affect the residents well being while wearing the splint device. Findings: Review of the facility's P&P titled Splint Application revised 7/2024 showed the supportive devices will be applied to the resident as per physician's order. Prior and after application of the splint device, skin and site will be visually viewed for any changes. Document the application and removal of the splint device on the residents record. a. On 1/29/25 at 1234 hours and 1/30/25 at 0825 hours, Resident 4 was observed with contractures on both upper and lower extremities, no splint device was in place for the upper and lower extremities. Medical record review for Resident 4 was initiated on 1/30/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's physician's order dated 9/14/24, to apply the bilateral splint to both upper extremity WHFO for four to six hours or as tolerated with every two hours skin check during the day shift six times per week for 90 days. Another physician's order dated 12/27/24, to apply the bilateral splint AFO's as tolerated for six to 10 hours during the day shift, six times per week for 90 days and perform the skin checks every two hours. Review of Resident 4's plan of care showed a care plan problem dated 11/18/24, to address Resident 4's impaired physical mobility. However, there was no documented evidence in the interventions included to perform the skin assessments every two hours when the splint device was applied. On 1/30/25 at 1425 hours, an interview and concurrent medical record review was conducted for Resident 4 with RNA 1. RNA 1 verified Resident 4 had an RNA order and stated Resident 4 had a WHFO for the upper extremity and AFO for the lower extremity, to be applied for six to 10 hours or as tolerated. RNA 1 was asked for the documentation of the application of the splint device. RNA 1 reviewed Resident 4's treatment record flowsheet. RNA 1 documented the WHFO and AFO were applied and removed. RNA 1 verified she did not document the exact time because she had no time to check every two hours on all the resident who was wearing a splint device. On 1/30/25 at 1441 hours, an interview and concurrent medical record review for Resident 4 was conducted with LVN 1. LVN 1 stated she observed the RNA's provided the treatment to Resident 4 including the application of the splint device on both upper and lower extremity of Resident 4. LVN 1 stated the RNA document the treatment provided for Resident 4 on the treatment record flowsheet including the skin assessment of the resident every two hours. LVN 1 verified there was no documentation of the exact time the RNA's checked the skin of the resident when the splint devices were applied. b. On 1/29/25 at 0927 hours and 1/30/25 at 0927 hours, Resident 12 was observed in bed asleep, and had contractures on both upper and lower extremities. No splint device was in place at this time. Medical record review for Resident 12 was initiated on 1/30/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's physician's order dated 1/17/25, to apply the bilateral splint to both upper extremity WHFO for four to six hours or as tolerated with every two hours skin check during the day shift, six times per week for 90 days. Review of Resident 12's plan of care showed a care plan problem dated 11/4/24, to address Resident 12's impaired physical mobility. However, there was no documented evidence in the interventions included to perform the skin assessment every two hours when the splint device was applied. On 1/30/25 at 1121 hours, an interview and concurrent medical record review for Resident 12 was conducted with RNA 1. RNA 1 verified Resident 12' use of splint device on upper extremities have the WHFO applied daily for four to six hours or as the resident tolerated. RNA 1 was asked for the documentation of the application of the splint device. RNA 1 reviewed Resident 12's treatment record flowsheet. RNA 1 documented the WHFO was applied and removed. RNA 1 verified she did not document the exact time because she had no time to check every two hours on all the resident who was wearing a splint device. On 1/30/25 at 1354 hours, an interview and concurrent medical record review for Resident 12 was conducted with LVN 4. LVN 4 verified Resident 12's physician's order for the RNA treatment and stated she had seen the RNA's providing treatment and application of the splint to Resident 12. LVN 4 stated she assisted the RNA on checking the resident's skin when providing care and also when the splint device was placed. LVN 4 was asked where did the RNA documented for the assessment of the skin every two hours while the splint device was applied. LVN 4 stated in the flowsheet, the LVN reviewed the flowsheet for the RNA and verified there was no documentation of Resident 12's skin was assessed every two hours by the RNA. In addition, LVN 4 was asked for the care plan of Resident 12's problem of function and mobility. LVN 4 was able to show the long term care plan of the resident, however, there was no intervention on applying the splint device on the resident and assessment of the skin every two hours when the splint device was applied. On 2/3/25 at 0916 hours, an interview and concurrent medical record review for Residents 4 and 12 was conducted with RN 2. RN 2 verified Residents 4 and 12 had an order for the splint device and was applied to the resident by the RNAs. RN 2 verified there was no documentation by the RNA for the skin assessment was performed on Residents 4 and 12 when the split devices were applied. RN 2 verified there was a care plan for Residents 4 and 12 to address the problem of function and mobility; however, the application of the splint device was not included in the interventions including the skin assessments every two hours. On 2/3/25 at 1418 hours, an interview and concurrent medical record review for Residents 4 and 12 was conducted with the CNO. The CNO informed of the findings and verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to obtain the informed consent for the use of side rails for one of three final sampled residents (Resident 11) reviewed for side rails. This failure posed the risk for Resident 11 and/or his representative to not be informed of his care and the risks for the padded bilateral upper and lower siderails. Findings: Review of the facility's P&P titled Side Rails revised 9/2023 showed all the residents shall have side rails in the full up position while in bed or crib. If the four siderails are required for the patient safety, a consent is required. Review of the Foundations and Adult Health Nursing published 2023 showed under Informed Consent, the Patient Care Partnership establishes the patient's right to make decisions regarding his or her health care. On 1/29/25 at 0823 hours, during the initial facility tour, Resident 11 was observed lying in bed with padded bilateral upper and lower siderails elevated. Medical record review for Resident 11 was initiated on 1/29/25. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 4/30/20, showed Resident 11 had encephalopathy (a disturbance of brain function). Review of Resident 11's Physician Order: Pediatric Subacute Restraints dated 1/25/25, showed a physician's order for padded siderails elevated times four. Further review of Resident 11's medical record did not show documented evidence the informed consent for the use of the padded bilateral upper and lower siderails was obtained from Resident 11's representative. On 1/30/25 at 1500 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 11's padded bilateral upper and lower siderails were elevated. CNA 1 stated Resident 11 moved in the bed and had side rails to prevent him from falling. On 1/31/25 at 1357 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no informed consent for the use of padded bilateral upper and lower side rails for Resident 11. RN 1 stated Resident 11's bed was changed to a bed with side rails last weekend and the informed consent was not done yet. RN 1 stated the licensed nurse should have obtained the informed consent prior to Resident 11 using the padded bilateral upper and lower side rails . On 1/31/25 at 1621 hours, an interview was conducted with the CNO and Director of Quality and Risk. The CNO and Director of Quality and Risk were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration and storage of the medications as evidenced by: * The facility's medication error rate was 3.85%. One of four licensed nurses (LVN 4) who were observed during the medication administration was found to have an error. LVN 4 failed to administer the complete dose of one of Resident 3's medications when significant residual of the medication was observed in the medication cup after administering the multivitamin (supplement) via GT to Resident 3. * The facility failed to ensure the electronic MAR for Resident 3 was not signed prior to the medication administration. These failures had the potential to negatively affect the resident's health conditions and posed the risk for possible complications or delay in interventions. Findings: Review of the facility's P&P titled Medication Administration, General Guidelines revised 3/2024 showed all medication orders must be ordered for a specific patient and include the name of the drug, exact dosage, route, and frequency. The five rights shall be observed in the administration of all medications: 1. Right patient; 2. Right drug; 3. Right dose; 4. Right route; and 5. Right time. Further review of the facility's P&P showed all the licensed nurses must administer and chart the medication prepared and given by them. The licensed nurse shall dispense the medication for one resident at a time and document immediately. Review of the facility's P&P titled Enteral Nutrition and Medication Administration revised 2/2018 showed when the medications are administered via the enteral routes, the tube will be checked for placement/residual, flushed with a minimum of 10 ml of water, the medication given and then another fluid flush to follow before the feeding is resumed. 1a. On 1/30/25 at 0931 hours, a medication administration observation for Resident 3 was conducted with LVN 4. LVN 4 prepared and administered Resident 3's medications which included the following: - one tablet of glycopyrrolate (anticholinergic medication, used for secretion control) 1 mg. - one tablet of multivitamin (supplement). - one 1/2 (half) tablet of famotidine (antacid) 10 mg. - one tablet of calcium carbonate (supplement) 500 mg. - one ml of cholecalciferol (vitamin D3) solution, equaling to 400 international units. - one ocular lubricant ophthalmic ointment to each eye. LVN 4 was observed administering the above medications to Resident 3 via the GT. After administering the medication, the medication cup labeled multivitamin was observed with significant amount of orange-colored medication residue. On 1/30/25 at 0954 hours, an interview and concurrent observation was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 was asked when there are noticeable medication residue in the medicine cup what should she do. LVN 4 stated she should add more water, stir the contents, and then administer the remaining residue. On 2/3/25 at 1409 hours, an interview was conducted with the CNO. The CNO stated medications should be administered as ordered by the physician, including the complete dose. The CNO stated for the administration of medication via the GT, if there was significant residue in the medicine cup, the nurse was expected to add water, mix the contents, and administer the dose. The CNO was informed and acknowledge the above findings. 1b. Review of the Resident 3's Patient Orders showed a physician's order dated 2/3/24, to administer saliva substitute oral gel 5 ml topically to the mouth every six hours for oral hygiene. On 1/30/25 at 1047 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 4. LVN 4 verified she did not administer the saliva substitute oral gel scheduled for 1000 hours during the medication administration observation. LVN 4 then stated she still had a one-hour window before and after the scheduled time to administer the medication. LVN 4 stated she would administer the medication now and was observed walking to her medication cart. On 1/30/25 at 1100 hours, an interview was conducted with LVN 4. LVN 4 stated her cart did not have the saliva substitute oral gel and she had requested and obtained a new tube of the saliva substitute oral gel medication for Resident 3. Review of Resident 3's Medication Administration History Visit showed the scheduled saliva substitute oral gel medication was documented as administered to Resident 3 on 1/30/25 at 1016 hours. On 1/30/25 at 1410 hours, an interview and concurrent medical record review for Resident 3 was conducted LVN 4. LVN 4 verified she signed the electronic MAR for the administration of the saliva substitute oral gel medication before she had administered the medication to Resident 3. On 2/3/25 at 1409 hours, an interview was conducted with the CNO and Director of Quality and Risk. The CNO stated the licensed nurses should sign the electronic MAR either during the administration of the medication in the resident's room, or right after administering and exiting the resident's room. The CNO further stated the licensed nurses should not sign the electronic MAR before actually administering the medication. The CNO and Director of Quality and Risk were informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to ensure one of nine final sampled residents (Resident 4) were free from the unnecessary medications. * The facility failed to ensure to document the monitoring of seizure activities and side effects related to Resident 4's use of clobazam, clonazepam, diazepam, lacosamide, lamotrigine, and levetiracetam (anticonvulsant medications to prevent seizure). This failure had the potential for Resident 4 to receive unnecessary medications and develop significant adverse effects, and risk for adverse effects from prolonged used of medications. Findings: Medical record review for Resident 4 was initiated on 1/30/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's physician's order showed the following orders: - dated 2/23/24, to administer clobazam 10 mg via GT every day for seizure. - dated 3/23/24, to administer clonazepam 0.5 mg via GT every eight hours for seizure. - dated 4/15/24, to administer diazepam 7.5 mg via GT every six hours as needed for seizure. - dated 3/23/24, to administer lacosamide 100 mg via GT three times a day for seizure. - dated 3/23/24, to administer lamotrigine 100 mg via GT every eight hours for seizure. - dated 11/1/24, to administer levetiracetam 1000 mg via GT every eight hours for seizure. Further review of Resident 4's physician's orders failed to show documented evidence a physician's order to monitor for seizure activities and side effects of the anti-seizure medications were obtained. On 2/03/25 at 1300 hours, an interview and concurrent medical record review for Resident 4 was conducted with RN 2. RN 2 verified Resident 4 had a seizure diagnosis and was on prescribed anti-seizure medications. RN 2 was asked to show the monitoring of the seizure episodes of Resident 4. RN 2 accessed the electronic medical record and stated 11/8/24 was the last recorded seizure activity for Resident 4 when Resident 4 had a seizure activity that lasted for about a minute according to the resident's mother. RN 2 was asked if there was a physician's order for the monitoring of the seizure activity and the side effects of the anti-seizure medications listed above. RN 2 verified there was no physician's order obtained for the monitoring of the seizure activity and the side effects of the anticonvulsant medications for Resident 4. On 2/03/25 at 1418 hours, an interview and concurrent medical record review for Resident 4 was conducted with the CNO. The CNO was informed and verified the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' medications were stored and labeled properly. * The facility failed to ensure the medications were stored inside a locked medication cart and were not left unattended by the licensed nurse. * Resident 12's simethicone (antiflatulence) medication was not labeled with the opened date. These failures had the potential for medication diversion and resident exposure to the expired medications with questionable potency and efficacy. Findings: 1. Review of the facility's P&P titled Medication Storage revised 9/2024 showed the drugs are stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding. All the medications and other drugs, including treatment items, are stored in a locked cabinet or room inaccessible to patients and visitors. Drugs are accessible only to the licensed personnel. The drugs of each resident are kept and stored in secure containers. On 1/30/25 at 0931 hours, during a medication administration observation with LVN 4, LVN 4 was observed preparing for the medication administration for Resident 3. LVN 4 was observed taking the medication out of Medication Cart B. On 1/30/25 at 0941 hours, LVN 4 was observed pushing her computer towards Resident 3's room in preparation for the medication administration. Medication Cart B was observed with the following medications left on top of the cart: one green bottle of refresh eye lubricant, four packets of polyethylene glycol (laxative), and three individual dose of the calcium carbonate (supplement) 500 mg tablets. On 1/30/25 at 0957 hours, LVN 4 was observed returning to Medication Cart B, after the medication administration for Resident 3. The above items were observed on Medication Cart B. LVN 4 verified the above findings and stated the medications should be put away in the medication cart when the medication cart was left unattended. LVN 4 stated the potential risk of leaving the medications unattended on top of the medication cart included the risk of someone taking the medication or the potential for the medication to be administered to another resident. 2. Review of the facility's P&P titled Medication Administration, General Guidelines, revised 3/2024 showed once punctured, multi-dose vials have 28 days expiration. They must be labeled with the expiration date. If not labeled, return to the Pharmacy. On 2/3/25 at 0904 hours, during a medication administration observation with LVN 3, a bottle of simethicone was observed opened without an opened date on the label. LVN 3 verified Resident 12's bottle of simethicone had no open date written on the bottle. LVN 3 stated the nurse who first opened the medication, should have labeled the medication with an opened and expiration date. On 2/3/25 at 1409 hours, an interview was conducted with the CNO and Director of Quality and Risk. The CNO stated the medications in the medication carts should be inside the cart and locked when unattended, to prevent the risk of medication theft, cross-medication administration to another resident and unauthorized access of the medication to anyone walking by. The CNO also stated for the multi-dose medications, the licensed nurses were expected to label the medication with the opened date when it was first opened. The CNO and Director of Quality and Risk were informed and acknowledged the above findings.

Based on interview, medical record review, and facility document review, the facility failed to ensure one of two sampled residents (Resident 1), who were fed by enteral means, received the appropriate treatment and services to prevent complications of the enteral feeding. * CNA 1 administered G-tube feeding to Resident 1 but erroneously connected the G-tube feeding to the saline (instillation) port of the resident's closed suction system (the closed suction system was connected to the resident's tracheostomy tube and provided direct access to the trachea and lungs). The G-tube feeding infused for approximately 30 minutes directly into the resident's lungs until CNA 1 had observed that white fluid was leaking around Resident 1's tracheostomy stoma. Administering G-tube feedings is a nursing function that must be performed by a licensed and trained health care professional. As a result, Resident 1 was admitted to the PICU for aspiration pneumonia. Findings: On 1/18/23 at 1600 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was being treated for aspiration pneumonia in the PICU because a CNA had mistakenly connected the resident's G-tube feeding to his tracheostomy tube on 1/6/23. Family Member 1 stated the CNA had no business touching her son's G-tube feeding. Family Member 1 stated Resident 1 was receiving antibiotics at the acute care hospital, but his condition was like a roller coaster, and he was still fighting the infection from the aspiration pneumonia. Closed medical record review for Resident 1 was initiated on 1/19/23. Resident 1 was admitted to the facility on [DATE]. Review of the Physician H&P General dated 7/21/22, showed Resident 1 had a tracheostomy tube and was gastrostomy dependent. Review of Resident 1's Patient Orders showed an order dated 9/22/22, to administer 270 ml/hour of Jevity 1.2 Cal (type of enteral feeding) tube feeding via the G-tube (for one hour) every four hours. Review of the MDS dated [DATE], showed Resident 1 was totally dependent on the staff for eating (including intake of nourishment through tube feeding). Review of the Nursing Narrative Note entry by RN 1 dated 1/6/23 at 2125 hours, showed at around 2000 hours, the CNAs were asked to check Resident 1's weight. According to the CNAs, they did not disconnect the G-tube feeding when they weighed the resident. However, at 2045 hours, RN 1 was informed by LVN 1 that there was leaking coming out from Resident 1's tracheostomy site and tubing. The note further showed LVN 1 observed the G-tube feeding was mistakenly connected to the resident's closed suction system and Resident 1's oxygen saturation level was 75% (normal oxygen saturation level is between 95% and 100%). LVN 1 stopped the G-tube feeding infusion, rendered care to the resident, and called the RT. The RT reported suctioning a large amount of feeding from the tracheostomy site. The note further showed the G-tube feeding was running over 30 minutes (based on the resident's order for tube feeding, approximately 135 ml [a little more than half of a cup] of G-tube feeding would have infused directly into the resident's lung over the span of 30 minutes). Review of the Nursing Narrative Note entry by LVN 1 dated 1/7/23 at 0052 hours, showed at around 2000 hours, LVN 1 started Resident 1's G-tube feeding. At around 2010 hours, CNA 1 and another CNA weighed Resident 1. At 2045 hours, CNA 1 informed LVN 1 that Resident 1 was leaking from his tracheostomy stoma. Upon entering the room, LVN 1 observed Resident 1 was desatting at 75% oxygen saturation level and pale, and the G-tube feeding was connected to the resident's closed suction system. The note showed LVN 1 immediately turned off the tube feeding and suctioned the resident. The note further showed when CNA 1 was asked about the incident, CNA 1 responded the G-tube feeding got disconnected and she reconnected it back, but unfortunately, CNA 1 connected it to the wrong port. Resident 1 was transferred to the acute care hospital at 2020 hours. Review of Resident 1's SBAR (undated) showed the following: - Situation: Resident 1 had G-tube feeding connected to the saline injection port of his closed suction system. - Background: CNA 1 saw the saline infusion port of the resident's closed suction system and connected the G-tube feeding to it. About 20 minutes later, CNA 1 noticed there was white fluid leaking from Resident 1's tracheostomy stoma and notified LVN 1. - Assessment: CNA 1 should not have manipulated the G-tube feeding. - Recommendation: All CNA staff educated on their scope of practice and instructed not to manipulate support equipment and alarms. On 1/19/23 at 0935 hours, an interview, concurrent closed medical record, and facility document review was conducted with the Nurse Manager. The Nurse Manager verified the above findings. The Nurse Manager stated it was discovered that the G-tube feeding was mistakenly connected to and infusing through the saline port of the resident's closed suction system on 1/6/23. The Nurse Manager stated CNA 1 said she was trying to be helpful by connecting the G-tube feeding but later realized she had connected it to the wrong port when she observed fluid coming from the resident's tracheostomy site. An observation of the G-tube and saline port of the closed suction system showed both ports looked similar, with the Nurse Manager adding that she was an experienced nurse and both ports looked very similar and could easily be mistaken for the other. The Nurse Manager verified it was not with the CNA's scope of practice to administer or manipulate the G-tube feeding or closed suction system. On 2/9/23 at 1410 hours, a telephone interview was conducted with LVN 1. LVN 1 verified the findings of his Nursing Narrative Note entry. LVN 1 stated at around 2000 hours on 1/6/23, he started Resident 1's tube feeding after checking for the correct placement. LVN 1 stated CNA 1 and another CNA had weighed the resident shortly after this. LVN 1 stated at around 2045 hours, CNA 1 informed him there was fluid leaking from around Resident 1's tracheostomy stoma. LVN 1 reported seeing the G-tube feeding connected to and infusing through the saline port of the closed suction system when he entered the room. LVN 1 stated there was feeding coming out from the resident's tracheostomy site and tubing. LVN 1 stated he asked CNA 1 what had happened, and CNA 1 stated the G-tube feeding got disconnected and she connected it to the port. LVN 1 stated he asked CNA 1 why she did not call for help instead, but CNA 1 did not respond. LVN 1 verified it was not within the CNA's scope of practice to connect or disconnect the G-tube feeding. Review of CNA 1's written statement (undated) showed CNA 1 discovered Resident 1's G-tube feeding was disconnected. CNA 1 noted the resident had something covering his neck with something protruding that looked like that is where to connect the food. CNA 1 proceeded to connect the G-tube feeding to the port because she did not want the resident's shirt to get wet. LVN 1 was notified after CNA 1 noticed the resident was leaking from the tracheostomy site. LVN 1 discovered the resident's G-tube feeding was connected to the wrong end. Review of the acute care hospital's ED Note-Physician dated 1/6/23 at 2249 hours, showed Resident 1's G-tube feeding was connected to his tracheostomy tube for approximately 30 minutes today around 2045 hours; unsure how many ml of the tube feeding was infused. Following the incident, Resident 1 presented with respiratory issues. Under the section for Differential Diagnosis, the physician documented iatrogenic (medical disorder, illness, or injury caused in the process of medical treatment) aspiration pneumonia, pulmonary hemorrhage. Upon suctioning, there was blood tinged/brown fluid from the tracheostomy, likely related to tube feeding mixed with blood. The chest x-ray showed significant bilateral infiltrates with concern for aspiration pneumonia. Resident 1 was admitted to the PICU and treated with antibiotics. Review of the acute care hospital's PICU Progress Note dated 1/20/23 (Day 13 of Resident 1's hospital stay), showed Resident 1's diagnoses included acute on chronic respiratory failure with hypoxemia and aspiration pneumonia (pneumonitis due to inhalation of food and vomit). Under the section forAssessment/Plan, the physician documented Resident 1 was admitted after being accidentally fed through his tracheostomy, was more lethargic than usual for the last few days, and the resident's ventilator settings were increased due to hypercapnia (a buildup of carbon dioxide in the bloodstream).

Based on observation, interview, and clinical record review, the facility failed to ensure Resident 1 was as free from accident hazards as possible. Resident 1 was nonverbal, had contractures to her arms and hands, and was unable to move her extremities. On 1/18/15, while attempting to dry Resident 1's hair, LVN 1 left a hairdryer on and placed in close proximity to Resident 1's left hand. A few hours later, a staff member noticed Resident 1 had sustained blisters from a second degree burn to her left hand and left shoulder. Findings: Review of an article titled Hair Dryer Burns in Children published in 1990, by the Official Journal of the American Academy of Pediatrics showed testing of home hairdryers was done to determine their heat output. At the highest heat settings, the hairdryers rapidly generated temperatures in excess of 110°C (230 degrees F). After the hairdryers were turned off, the protective grills maintained sufficient temperatures to cause full-thickness burns for up to 2 minutes. These cases and the results of testing demonstrate that hairdryers must be added to the list of known causes of accidental and non-accidental burns in children. www.medicinenet.com showed a first degree burn is superficial and causes local inflammation of the skin. Sunburns often are categorized as first degree burns. The inflammation is characterized by pain, redness, and a mild amount of swelling. The skin may be very tender to touch. A second degree burn is deeper than a first degree burn and in addition to the pain, redness and inflammation, there is also blistering of the skin. Clinical record review for Resident 1 was initiated on 3/16/15. Resident 1, a pediatric, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the computerized note (untitled) dated 1/18/15, showed Resident 1 was identified to have blisters to her left hand. The "primary nurse and CNA are unaware of how it may have happened." Review of the Nursing Progress/Summary Notes dated 1/18/15 at 1500 hours, identified Resident 1 had blisters to her left hand. At 2000 hours, staff documented there were multiple open, weeping fluid blisters to her left hand. On 1/19/15 at 1030 hours, staff documented Resident 1 also had a small blister to her left shoulder. Review of Resident 1's physician's orders [REDACTED]. On 1/22/15 at 1315 hours, a physician's orders [REDACTED]. Review of Resident 1's Comprehensive Skin Assessments showed the following: * On 1/18/15 at 1600 hours, showed blisters and redness to the dorsal aspect (back) of Resident 1's left hand. The photograph showed multiple raised, fluid filled blisters. Staff documented if the blister was to open to apply Bacitracin (antibiotic) ointment four times a day for 10 days. * On 1/20/15 at 1100 hours, Resident 1's left hand blisters opened and draining serous fluid. The affected area measured 6 cm (length) x 4 cm (width). Staff documented Bacitracin ointment was to be started after the C&S of the left hand blister drainage was obtained. The photograph showed some of the blisters had popped and others remained filled with fluid. * On 1/23/15 at 0900 hours, the left hand blisters and redness were present and continued to be treated with Bacitracin ointment. * On 1/26/15 at 1800 hours, Resident 1's left hand blisters were assessed to be a second degree burn. * On 1/29/15 at 2000 hours, staff documented all of Resident 1's blisters had popped. The treatment was changed to Silvadene cream (medication used to treat burns) daily and to cover with a non-stick dressing for seven days. On 3/10/15 at 1000 hours, staff documented Resident 1's left hand wound had completely healed. Review of Resident 1's Doctors' Progress Note dated 1/24/15, showed an evaluation was completed by an Infectious Disease Consultant. The doctor documented Resident 1 had a recent appearance of blisters over the left dorsal hand and fingers, and to treat the blisters as a "second degree burn" injury. Review of a (untitled) document dated 3/11/15 at 1616 hours, showed on 2/5/15, the left hand (blisters) healing well and appeared to be in much less pain. Review of the Restorative Administration Record for January 2015, showed Resident 1 was to have PROM to her upper extremities and the application of bilateral elbow extensor splints for 12 hours a day five days per week. However, the RNA documented on the reverse side of the sheet from 1/20/15 to 1/30/15, the PROM and left hand splint were not provided due to the resident's left hand wound. On 3/16/15 at 1405 hours, Resident 1 was observed sitting in her wheelchair next to her bed. She was unable to respond to verbal commands. Her arms and hands were contracted and the top of her left hand had multiple skin (pigment) discolorations as a result of the burn. On 3/16/15 at 1455 hours, Resident 1's attending physician was interviewed. The physician stated Resident 1 had limited movement in her extremities and required total assistance from the staff for all ADL care. When asked how Resident 1 sustained the burn to her left hand, the physician stated he could not think of anything "hot enough" to cause a burn, but the item would have to be very close (to the left hand). An interview with RN 1 was conducted on 3/16/15 at 1540 hours. RN 1 stated Resident 1 was showered every day on the day shift. She stated the resident's hair was washed during the showers. On 3/16/15 at 1550 hours, an interview was conducted with CNA 1. CNA 1 stated before the burn to the resident's left hand, the resident's family and staff used a hairdryer to dry the resident's hair. CNA 1 stated the hairdryer was stored in Resident 1's room but had been removed after the 1/18/15 incident. On 3/16/15 at 1605 hours, an interview was conducted with LVN 1. LVN 1 stated she was assigned to work as a caregiver for Resident 1 on 1/18/15. LVN 1 stated on the morning of 1/18/15, she gave Resident 1 a shower and washed her hair. She stated while Resident 1 was still lying on the shower gurney, she took the hairdryer from Resident 1's bedside to dry the resident's hair. LVN 1 stated when she was going to dry the back of her hair, she took the hairdryer from her left hand and placed it down near the top of the gurney, on the left side, so she could raise Resident 1's head. She stated the hairdryer was remained on while she was repositioning the resident's head. LVN 1 stated Resident 1's arms/hands were contracted (when lying down the resident's hands were up by her head) and the heat from of the hairdryer was blowing in the direction toward the resident's left hand. When LVN 1 was asked if she thought the burn could have been caused by the hairdryer being left on and placed at the head of the shower gurney, she stated the hairdryer was "the only thing it could have been." When LVN 1 was asked if the burn to Resident 1's hand could have been prevented, she stated "yea." She stated she could have placed Resident 1 in a wheelchair before she dried her hair; like she had seen other CNAs do. When LVN 1 was asked if she was aware of Resident 1's left shoulder blister that was observed on 1/19/15, she stated "no." During an interview on 3/16/15 at 1635 hours, the DON stated Resident 1 required total care from the staff for all her ADL care. When asked how Resident 1 sustained the burn to her left hand, the DON stated she was unable to determine the cause. The DON stated since the incident to Resident 1's left hand, all hairdryers had been removed from all residents' rooms and were to have a safety check by the Maintenance Director.