Every finding on record at Glendora Canyon Transitional Care Unit

Based on interview and record review, the facility staff failed to document the amount of meal intake on the resident's medical record for one of four sampled residents (Resident 1). This deficient practice had the potential to result in lack of communication between staff and delay and interrupt the provision of care needed to maintain the resident's highest practicable, physical, mental, and psychosocial well-being.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/31/2024 with diagnoses including sepsis (a life-threatening blood infection) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 1's History and Physical (H&P) dated 1/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 1/5/2025, the MDS indicated Resident 1 had intact cognition (ability to understand). The MDS indicated Resident 1 required setup assistance from staff with eating. The MDS indicated Resident 1 required supervision from staff with oral hygiene. The MDS indicated Resident 1 required moderate assistance (helper did less than half the effort) from staff with toileting hygiene, showering/bathing, and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper did more than half the effort) from staff with bed-to-chair transferring. During a concurrent record review and interview with Certified Nurse Assistant 1 (CNA 1) on 3/27/2026 at 11:37 AM, Resident 1's Documentation Survey Report (DSR) for January and February 2025 were reviewed. The DSR indicated the CNAs (in general) documented Resident 1's amount of meal intake for 90 out of 93 meals from 1/1/2025 to 1/31/2025. The DSR indicated the CNAs documented Resident 1's amount of meal intake for 40 out of 45 meals from 2/1/2025 to 2/15/2025. CNA 1 stated the CNAs (in general) should have documented in the resident's medical record after each resident's meal. CNA 1 stated the CNAs needed to document on the resident's medical record if the resident refused to eat. CNA 1 stated it was important to complete the documentation on the resident's medical record before the end of the shift because it was the standard of practice. CNA 1 stated if there was no documentation on the DSR, staff would not know how much the residents ate. CNA 1 stated incomplete medical record documentation would affect the continuity of residents' care. During an interview with the Director of Nursing (DON) on 3/27/2026 at 2:17 PM, the DON stated without documentation, nursing staff would not know if the resident ate or refused the meal. During a review of the CNA's job description dated 10/2020, the job description indicated the CNA should record the resident's food/fluid intake. During a review of the facility's Policy and Procedure (P&P) titled Charting and Documentation, dated 7/2017, the P&P indicated all services provided to the resident should be documented completely in the resident's medical records. The P&P further indicated that documentation should include the date and time the procedure/treatment was provided and the signature and title of the individual documenting.

Based on interview and record review the facility failed to provide medically related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to one of nine sampled residents (Resident 1) when the Social Services Director (SSD) did not assist Resident 1 to apply for health insurance before Resident 1's Medicare (federal health insurance for anyone age [AGE] and older) coverage ended on 11/10/2025. This deficient practice resulted in Resident 1 having no health insurance after 11/10/2025 and resulted in Resident 1 having to shoulder the cost of skilled nursing services Resident 1 received after 11/10/2025.Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 10/28/2025 with diagnoses which included displaced bimalleolar fracture of left lower leg (breaks on either side of the rounded bony projections of the left ankle joint), and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 10/29/2025, the H&P indicated Resident 1 had the ability to make decisions. During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 10/31/2025, the MDS indicated Resident 1 was dependent on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Notice of Medicare Non-Coverage (NOMNC), dated 11/7/2025, the NOMNC indicated Resident 1's Medicare Coverage of Resident 1's current skilled nursing services will end on 11/10/2025. The NOMNC indicated Resident 1 signed the NOMNC on 11/7/2025. During an interview on 2/5/2026 at 12 pm with the SSD, the SSD stated during Resident 1's Interdisciplinary Team (IDT) meeting (when a team of healthcare workers from various disciplines meet to review, update, and coordinate the Plan of Care for residents/patients) on 10/30/2025, Family Member (FM) 1 stated FM 1 was interested in applying for Medi-Cal (California's joint federal-state free or low-cost health coverage) for Resident 1. The SSD stated the SSD referred FM 1 to the Business Office Manager (BOM) so the BOM could assist FM 1 and Resident 1 to apply for Medi-Cal. The SSD stated the SSD should have followed up regarding Resident 1's application for Medi-Cal and should have assisted Resident 1 to apply for health insurance. During an interview on 2/5/2026 at 2:30 pm with the Assistant Director of Nursing (ADON)/ Case Manager (CM), the ADON/CM stated during Resident 1's IDT meeting held on 10/30/2025, the IDT discussed with FM 1 regarding Resident 1's last day of Medicare Coverage and FM 1 stated FM 1 was interested in applying for Medi-Cal for Resident 1. The ADON/CM stated the SSD informed FM 1 during the IDT meeting on 10/30/2025 that the SSD would refer FM 1 to the Business Office Manager (BOM) and the BOM would assist FM 1 and Resident 1 to apply for Medi-Cal. During a concurrent interview and record review on 2/5/2025 at 4 pm, with the Director of Nursing (DON), the DON reviewed the SSD's job description and stated the SSD's job description indicated it was the SSD's responsibility to provide information to resident/families as to Medicare/Medi-Cal and other financial assistance programs available to the resident, and refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. The DON stated the SSD did not follow the job description. During a review of the facility's policy and procedure (P&P) titled, Social Services, dated September 2021, the P&P indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The P&P indicated, The social worker/social services staff are responsible for.assisting with informing and educating residents, families and representatives about health care options and ramifications. and assisting residents with financial and legal matters.

Based on observation, interview, and record review, the facility failed to ensure the kitchen dry storage area was free of fruit flies on 1/13/2026 and 1/14/2026 for one of one kitchen dry storage area. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed the residents at risk for developing foodborne illnesses.Findings: During initial observation of the facility kitchen and interview with Dietary Aide 1 (DA1) on 1/13/2026 at 10:49 AM, in the kitchen dry storage area, multiple fruit flies were observed flying around the open banana and white onion storage containers. DA 1 stated it was not acceptable to have fruit flies in the kitchen for infection control. DA 1 stated fruit flies could lay eggs on food. DA 1 stated everyone in the kitchen was responsible for keeping the area clean. During a concurrent observation and interview with the Director of Nutritional Services (DNS) on 1/14/2026 at 11:35 AM, in the kitchen dry storage area, multiple fruit flies were observed flying around the closed banana and white onion storage containers. The DNS stated it was not acceptable to have fruit flies in the kitchen because they were insects and pests and could contaminate the food. During a concurrent record review and interview with the Infection Prevention Nurse (IPN) on 1/15/2026 at 3:31 PM, the facility's Policy and Procedure (P&P) titled Pest Control for Fruit Flies, dated 5/2020 was reviewed. The facility P&P indicated The facility maintains an on-going pest control program to ensure that the building is kept free of insects. The IPN stated the facility should be free of pests and insects. The IPN stated the fruit flies could land on food and transmit germs to the food. The IPN stated it would place the residents at risk of infections with signs and symptoms of diarrhea and abdominal pain.

Based on interview and record review, the facility licensed nurses failed to document the intravenous (IV, directly into a vein) antibiotic (a medicine that killed bacteria) medication administrations on the Medication Administrative Record (MAR) for two of two sampled residents (Residents 42 and 48). These deficient practices had the potential to result in lack of communication between staff and delay and interruption of care needed to maintain the residents' highest practicable, physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 42's admission Record (AR), the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection [when germs entered the body and caused illness]) and bacteremia (the presence of bacteria in the blood). During a review of Resident 42's History and Physical (H&P) dated 12/25/2025, the H&P indicated Resident 42 could not make decisions. During a review of Resident 42's untitled Care Plan (CP) for bacteremia revised on 12/25/2025, the CP indicated for licensed nursing staff to administer antibiotic medication as ordered. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool) dated 12/29/2025, the MDS indicated Resident 42 had moderate cognitive (ability to understand) impairment. The MDS indicated Resident 42 was independent with eating. The MDS indicated Resident 42 required setup assistance from staff with oral hygiene. The MDS indicated Resident 42 required moderate assistance (helper did less than half the effort) from staff with toileting hygiene, showering/ bathing, and bed-to-chair transfer. During a review of Resident 42's Order Summary Report (OSR) with active orders as of 12/30/2025, the OSR indicated a physician's order (PO) for licensed staff to administer IV ampicillin (antibiotic medication) every six hours for bacteremia, starting on 12/24/2025. During a concurrent record review and interview with Registered Nurse 1 (RN1) on 1/15/2025 at 10:52 AM, Resident 42's MAR for 12/2025 was reviewed. The MAR indicated Resident 42 received 21 out of 23 doses of the IV ampicillin from 12/25/2025 to 12/30/2025. RN 1 stated the MAR did not indicate the IV ampicillin administrations were documented at 6 AM on 12/28/2025 and 12/30/2025. RN 1 stated the RN should document the IV medication administration on the MAR. RN 1 stated it was important to document to prove the action was done. During a concurrent record review and interview with RN 1 on 1/15/2025 at 10:52 AM, Resident 42's Nursing Progress Notes (NPN) dated 12/27/2025 to 12/30/2025 were reviewed. RN 1 stated there were no IV ampicillin administrations documented in the NPN at 6AM for Resident 42 on 12/28/2025 and 12/30/2025. b. During a review of Resident 48's AR, the AR indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including osteomyelitis (an infection in a bone). During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 had intact cognition. The MDS indicated Resident 48 required setup assistance from staff for eating. The MDS indicated Resident 48 required moderate assistance from staff for oral hygiene and personal hygiene. The MDS indicated Resident 48 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, and bed-to-chair transferring. During a review of Resident 48's H&P dated 1/7/2026, the H&P indicated Resident 48 had the capacity to understand and make decisions. During a review of Resident 48's untitled CP for potential for complications due to IV antibiotics for osteomyelitis, revised on 1/13/2026, the CP indicated for licensed nursing staff to administer medication as ordered and document the progress of the therapy. During a review of Resident 48's OSR with active orders as of 1/15/2026, the OSR indicated a physician's order for licensed staff to administer IV piperacillin sod-tazobactam (antibiotic medication) every six hours for osteomyelitis, starting on 1/7/2026. During a concurrent record review and interview with RN 1 on 1/15/2025 at 10:52 AM, Resident 48's MAR for 1/2026 was reviewed. The MAR indicated Resident 48 received 31 out of 32 doses of the IV piperacillin sod-tazobactam from 1/7/2026 to 1/15/2026. RN 1 stated the MAR did not indicate the IV piperacillin sod-tazobactam administration was documented at 5 AM on 1/13/2026. RN 1 stated the nurse might have forgotten to sign the MAR. During a concurrent record review and interview with RN 1 on 1/15/2025 at 10:52 AM, Resident 48's NPN dated 1/13/2026 was reviewed. RN 1 stated there was no IV piperacillin sod-tazobactam administration documented in the NPN on 1/13/2026 at 5 AM. During an interview with the Assistant Director of Nursing (ADON) on 1/16/2026 at 10:01 AM, the ADON stated the licensed nurse should have documented on the MAR after the medication administration to prove it was done. The ADON stated the risk was that the nurse could give an extra dose or the resident could miss a dose. The ADON stated this could affect the effectiveness of the medication. During an interview with the Director of Nursing (DON) on 1/16/2026 at 11:10 AM, the DON stated the licensed nurse should ensure the MAR was completed before leaving the facility. During a review of the facility's policy and procedure (P&P) titled Administering Medication, revised 1/2024, the P&P indicated the individual administering the medication should initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. The P&P further indicated that the individual administering the medication should records in the resident's medical record the following:a. The date and time the medication was administered.b. The dosage.c. The route of administration.d. The injection site (if applicable).e. Any complaints or symptoms for which the drug was administered.f. Any results achieved and when those results were observed.g. The signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility failed to ensure residents were called by their legal (official name recognized by government on documents), proper and preferred names for three of three sampled residents (Residents 14, 96, and 132). These failures had the potential for Residents 14, 96, and 132 to lose their dignity and individuality.Findings: a. During a review of Resident 132's admission Record (AR), the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a type of ischemic stroke caused by a blockage in blood vessels supplying the brain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN- high blood pressure). During a review of Resident 132's Order Summary Report (OSR) dated 1/6/2026, the OSR indicated Resident 132 had an order for 1:1 feeder with all meals every shift. During a review of Resident 132's Minimum Data Set (MDS- a resident assessment tool) dated 1/10/2026, the MDS indicated Resident 132 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 132 required substantial/maximal assistance (helper did more than half the effort) with eating and dependent (helper did all the effort) with oral hygiene, toileting, shower, upper and lower body dressing. During a concurrent observation and interview on 1/13/2026 at 12:35 pm with Certified Nurse Assistant 2 (CNA 2) in the hallway, CNA 2 was passing lunch meal tray to Resident 132. CNA 2 stated Resident 132 was a feeder. During an interview on 1/14/2025 at 11:47 pm with the Infection Prevention Nurse (IPN), the IPN stated all residents should be treated with dignity and respect and referred to by their own legal, proper and preferred names or nicknames. During an interview on 1/15/2026 at 4:08 pm with the Assistant Director of Nursing (ADON), the ADON stated residents should not be labeled as feeder because it would affect the resident's dignity. b. During a review of Resident 96's AR, the AR indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- infection that affects part of the urinary tract), malignant neoplasm (group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body) of prostate, and acute kidney failure (a sudden decline in kidney function). During a review of Resident 96's MDS dated [DATE], the MDS indicated Resident 96 had severely impaired cognition. The MDS indicated Resident 96 was dependent (helper does all of the effort) with oral hygiene, toileting, shower, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 96's OSR dated 12/11/2025, the OSR indicated Resident 96 had an order for 1:1 feeder with all meals every shift. During an interview on 1/14/2026 at 11:18 am with Registered Nurse 1 (RN 1), RN 1 stated, I know the resident, he (Resident 96), is a feeder, someone helped him with meals. RN 1 stated, Resident 96 should not have been addressed as a feeder for resident's dignity. c. During a review of Resident 14's AR, the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 14's untitled Care Plan (CP) revised on 9/28/2025, the CP indicated Resident 14 was on hospice (compassionate care for people who are near the end of life) services with routine level of care related to Alzheimer's disease diagnosis, with a goal to maintain Resident 14's dignity and autonomy at the highest level. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 was rarely or never understood, rarely or never made decisions regarding tasks of daily life and was dependent during eating (helper does all of the effort). During a review of Resident 14's OSR dated 11/19/2025, the OSR indicated Resident 14 had an active order for a regular diet, pureed texture (smooth, pudding like consistency), mildly thick consistency, and needed assistance with meals. During an interview on 1/16/2026 at 9:13 am with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 14 was a feeder. LVN 3 stated Resident 14 had severe Alzheimer's disease and couldn't feed self. LVN 3 stated, a feeder was someone who needed assistance with feeding and all residents who needed help feeding were feeders. During an interview on 1/16/2026 at 10:41 am with the Director of Nursing (DON), the DON stated residents should be called by their last name or how they preferred to be addressed. The DON stated, in order to provide respect and dignity to the resident they should not be called/labeled as feeder. During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, revised 2/2020, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. The P&P indicated, staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. The P&P indicated, staff were expected to treat cognitively impaired residents with dignity and sensitivity.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was set accurately for two of three sampled residents (Residents 48 and 117). These failures had the potential to worsen and impede healing of both residents' wounds and cause further skin injuries.Findings: a. During a review of Resident 117's admission Record (AR), the AR indicated Resident 117 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) after a stroke affecting the left side and hypertension (HTN-high blood pressure). During a review of Resident 117's Order Summary Report (OSR), the OSR indicated active orders for: 1.LALM, every shift, ordered on 5/28/2024. 2.Set LALM according to resident's weight or per resident's comfort, every shift, ordered on 7/26/2023. During a review of Resident 117's History & Physical (H&P) dated 10/9/2025, the H&P indicated the resident did not have the capacity to understand and make decisions with a fluctuating mental status. During a review of Resident 117's Braden Scale (BS - assessment tool used to assess a resident's risk of developing a pressure ulcer/sore) for Predicting Pressure Sore Risk dated 11/6/2025, the BS indicated Resident 117 was At Risk for developing a pressure ulcer. During a review of Resident 117's Minimum Data Set (MDS, a resident assessment tool) dated 11/9/2025, the MDS indicated Resident 117 had moderately impaired cognition (ability to understand), had an open lesion, and a pressure reducing device for the resident's bed as a skin and ulcer/injury treatment. During a review of Resident 117's Current Weights and Vitals, dated 1/1/2026, Resident 117's weight was 148 pounds (lbs.- unit of measurement to measure body mass) During a review of Resident 117's Treatment Administration Record (TAR) dated 1/1/2026 through 1/31/2026, the TAR indicated Resident 117 was receiving continuous treatment for a mid-back cancer lesion (tissue damage) and a left anterior (near the front) lower leg arterial ulcer (painful, slow healing open sore) for 30 days. During a concurrent observation and interview on 1/13/2026 at 9:11 am with Resident 117 in Resident 117's room, Resident 117's was lying in bed with LALM weight setting at 400 pounds with a white sticker labeled 200-300. Resident 117 stated Resident 117 was not comfortable on Resident 117's bed. During a concurrent observation and interview on 1/13/2026 at 9:14 am with Minimum Data Set Nurse (MDSN) in Resident 117's room, Resident 117's LALM weight setting was set to 400 lbs. The MDSN stated Resident 117's LALM should not be set to 400 lbs., but should be on 200-300 lbs. The MDSN stated Resident 117 needed assistance to turn in bed and the LALM was used for pressure relieving as Resident 117 had fragile skin and had a history of pressure ulcers and a left leg arterial ulcer. During an interview on 1/16/2026 at 10:52 am with the Assistant Director of Nursing (ADON), the ADON stated Resident 117 had confusion and forgetfulness and was receiving treatments for a mid-back wound. The ADON stated the LALM should have been set between 100-200 lbs. for Resident 117 or based on the resident's comfort. The ADON stated 400 lbs. was an inappropriate setting. The ADON stated, if 400 lbs. was the resident's preferred setting, nursing staff would call the physician for an order while documenting the discussion with the physician in a progress note. The ADON stated if the LALM was set too firm, there was a possibility it could slow wound healing. During a review of Proactive medical products: Operator's Manual Item for Protekt Aire 4000DX/5000Dx, (undated), the LALM manual indicated the system was designed for prevention, treatment and management of pressure ulcers. The manual indicated to press the up or down buttons to select the correct patient weight. The manual indicated users could adjust air mattress to a desired firmness according to patient's weight or the suggestion for a health care professional. During a review of the facility's policy and procedure (P&P) titled, Specialty Mattress-Pressure Relieving Devices, revised 1/2024, the P&P indicated, the purpose of this procedure was to provide guidelines for the appropriate pressure-relieving devices or LALM for residents at high risk of skin breakdown or further skin breakdown. The P&P also indicated any individual at risk for developing pressure ulcers shall be placed on a redistribution support surface as ordered by the attending physician. The P&P further indicated, to follow the LAL manufacturer's user instructions and adjust the comfort settings or weight setting when indicated. b. During a review of Resident 48's AR, the AR indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcer stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and obesity (excessive fat accumulation in the body). During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 had intact cognition. The MDS indicated Resident 48 required setup assistance from staff for eating. The MDS indicated Resident 48 required moderate assistance (helper did less than half the effort) from staff for oral hygiene and personal hygiene. The MDS indicated Resident 48 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, and bed-to-chair transferring. The MDS further indicated Resident 48 had one or more unhealed pressure ulcer and a pressure reducing device for bed. During a review of Resident 48's History and Physical (H&P) dated 1/7/2026, the H&P indicated Resident 48 had the capacity to understand and make decisions. During a review of Resident 48's Pressure Ulcer Assessment ([NAME]) dated 1/12/2026, the [NAME] indicated Resident 48 had left buttock pressure ulcer stage 4 and required low air loss mattress (LALM) for preventative measures. During a review of Resident 48's untitled Care Plan (CP) revised on 1/13/2026, the CP indicated Resident 48 had left buttock pressure ulcer stage 4 and the CP goal indicated Resident 48 would not develop any further skin breakdown (skin was damaged or started to wear away). During a review of Resident 48's OSR with active orders as of 1/15/2026, the OSR indicated a physician's order for licensed staff to set the LALM according to Resident 48's weight or Resident 48's comfort every shift starting on 1/4/2026. During a review of Resident 48's Monthly Weight Report (MWR) dated 1/15/2026, the MWR indicated Resident 48 weighed 266 lbs. During an observation on 1/14/2026 at 9:59 am in Resident 48's room, Resident 48 was lying on a LALM. The LALM weight setting was set at 350 lbs. During a concurrent observation and interview with Resident 48 on 1/15/2026 at 9:30 am, in Resident 48's room, Resident 48 was lying on a LALM. The LALM was set for a resident who weighed 350 lbs. Resident 48 stated Resident 48 was not comfortable lying on the LALM because there were uneven air pockets on Resident 48's back. During a concurrent observation and interview with Treatment Nurse 1 (TN 1) on 1/15/2026 at 1:50 pm, in Resident 48's room, Resident 48 was lying on a LALM. TN 1 stated Resident 48's LALM was set for a resident who weighed 350 lbs. TN 1 stated the purpose of the LALM was for wound healing and comfort. TN 1 stated the LALM was set up per resident's weight or comfort according to the physician order. During a concurrent record review and interview with TN 1 on 1/15/2026 at 1:50 pm, the undated Operation Manual (OM) for the LALM was reviewed. TN 1 stated the OM indicated to set the LALM according to the resident's weight. TN 1 stated it was not beneficial to Resident 48's left buttock pressure ulcer stage 4 if the LALM was set too high because the LALM was firm. TN 1 stated the licensed nurse should have explained the risks and benefits of the higher LALM setting to the residents. TN 1 stated the licensed nurse should have set up the LALM according to Resident 48's weight at 266 lbs. During a concurrent record review and interview with the Director of Nursing (DON) on 1/16/2026 at 11:10 AM, the facility's P&P titled Specialty Mattress - Pressure Relieving Devices, revised on 1/2024, the P&P indicated staff were to follow the LALM manufacturer's user instructions for setup. The DON stated the license nurse should verify the LALM order with the physician. The DON stated the licensed nurse should have set up the LALM per Resident 48's weight.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents with indwelling catheter (a catheter inserted into the bladder to drain urine) and suprapubic catheter (a soft tube inserted directly into the bladder through a small incision in the lower belly [just above the pubic bone] to drain urine into a bag) for two of four sampled residents (Residents 132 and 33) by failing to: a. Ensure Resident 132's foley catheter (FC - a common type of indwelling catheter, a soft, plastic or rubber tube that is inserted into the bladder to drain urine) was secured to the resident's thigh. b. Ensure Resident 33's suprapubic catheter site was monitored for signs and symptoms of skin breakdown as indicated in residents plan of care and facility's policy and procedure (P&P) titled Suprapubic Catheter Care, Urinary. These failures had the potential to result in catheter-related complications for Residents 33 and 132.Findings: a. During a review of Resident 132's admission Record (AR), the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a type of ischemic stroke caused by a blockage in blood vessels supplying the brain), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN - high blood pressure). During a review of Resident 132's Order Summary Report (OSR) dated 1/5/2026, the OSR indicated Resident 132 had an order for indwelling foley catheter connect to straight drainage for neurogenic bladder (inability to control urination). During a review of Resident 132's untitled Care Plan (CP) dated 1/5/2026, the CP indicated Resident 132 had a foley catheter. The CP goal indicated Resident 132 remained free from catheter- related trauma. During a review of Resident 132's Minimum Data Set (MDS - a resident assessment tool) dated 1/10/2026, the MDS indicated Resident 132 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 132 required substantial/maximal assistance (helper did more than half the effort) with eating and dependent (helper did all the effort) with oral hygiene, toileting, shower, upper and lower body dressing. The MDS indicated Resident 132 had an indwelling catheter (a catheter inserted into the bladder to drain urine). During a concurrent observation and interview on 1/13/2026 at 9:26 am with the Infection Prevention Nurse (IPN) inside Resident 132's room, Resident 132 was lying in bed with a foley catheter. The IPN stated the foley catheter was not secured to Resident 132's thigh. The IPN stated foley catheter tubing should be secured on the resident's thigh to prevent accidental pulling during bed mobility and cause trauma and injury to the resident. During an interview on 1/15/2026 at 4:08 pm with the Assistant Director of Nursing (ADON), the ADON stated foley catheter should be kept secured on the resident's thigh to prevent dislodgement, irritation and injury at the insertion site. During a review of the facility's Policy and Procedure (P&P) titled, Catheter Care, Urinary, revised September 2024, the P&P indicated, Ensure that the catheter remains secured with a leg strap/stabilization device to reduce friction and movement at the insertion site. Catheter tubing should be strapped to the resident's inner thigh. b. During a review of Resident 33's AR, the AR indicated Resident 33 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) and heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs). During a review of Resident 33's OSR dated 1/14/2025, the OSR indicated for licensed staff to irrigate the suprapubic catheter size 18 with distilled water every day shift, for suprapubic catheter treatment related to neuromuscular dysfunction of the bladder. During a review of Resident 33's OSR dated 1/14/2025, the OSR indicated for licensed staff to cleanse suprapubic catheter site with NS, pat dry and apply T-Drain dressing secure with paper tape one time a day. During a review of Resident 33's CP titled Alteration in Bowel and Bladder as manifested by presence of suprapubic catheter due to Neurogenic Bladder and Bowel incontinence, revised 9/12/2025, the CP indicated for nursing staff to monitor Resident 33 for signs and symptoms of skin breakdown. During a review of Resident 33's MDS dated [DATE], the MDS indicated Resident 33 had intact cognition. The MDS indicated Resident 33 required partial/moderate assistance (helper did less than half the effort) with shower, lower body dressing and putting on/taking off footwear. During a concurrent observation inside Resident 33's room and interview on 1/13/2026 at 9:50 am with the Assistant Director of Nursing (ADON), Resident 33 was in bed with suprapubic catheter in placed. The suprapubic catheter site had scattered redness around the area. The ADON stated, there were scattered redness on Resident 33's abdomen. During an interview in 1/14/2026 at 9:38 am with the facility's Treatment Nurse (TN), the TN stated there was an excoriation (loss of skin surface) around the suprapubic catheter site on the abdominal area of Resident 33. The TN stated signs and symptoms of infection and skin breakdown should have been monitored by the TN. The TN stated residents with suprapubic catheter were at high risk for skin irritation. During an interview on 1/16/2025 at 10:56 am with the facility's Director of Nursing (DON), the DON stated residents with suprapubic catheters were at high risk for skin breakdown. The DON stated the suprapubic catheter site, and skin should have been monitored every shift for any changes such as redness, drainage and temperature to prevent infection and skin breakdown. During a review of the facility's P&P titled, Suprapubic Catheter Care, Urinary, revised 10/2020, the P&P indicated, The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. The following information should be recorded in the resident's medical record: Results of skin assessment around the stoma site. Notify the physician of any abnormalities in the skin assessment or the character of urine.

Based on observation, interview, and record review, the facility failed to ensure:a. The call lights were accessible for residents in four of four private shower areas.b. The call light was accessible for one of one visually impaired resident (Resident 92).These deficient practices had the potential to result in a delay in meeting the residents' needs for assistance and could lead to falls and accidents. Findings: a. During a concurrent observation and interview with the Director of Nursing (DON) on 1/15/2026 at 10:21 AM, in Room A's private shower area, the emergency call light cord was located outside the shower area. The DON stated the call light cord was not reachable for the residents during shower. The DON stated this placed the residents at risk of injury and delayed help/assistance. The DON stated all staff were responsible for ensuring the call light cords are within resident's reach and easily accessible at all times to maintain safety, including the shower room. During a concurrent observation and interview with the Maintenance Supervisor (MS) on 1/15/2026 at 2:12 PM, in Room A's private shower area, the emergency call light cord was located outside the shower area. The MS stated the shower emergency call light cord was not accessible for residents in Room A. The MS stated the emergency call light cord should be within three feet (units of length used to measure distance) of the shower head so that residents could reach and use in case of emergency. The MS stated the emergency call light cord should be hanging two to six inches from the floor. The MS stated if the call light was not within reach, this placed the residents at risk for fall and injury. The MS stated there were a total of four residents' rooms with private shower area, and none of the emergency call light cords were reachable for residents in the shower. During a review of the facility's Policy and Procedure (P&P) titled, Call System, Resident, dated 9/2022, the P&P indicated the emergency pull cord in shower areas must be within three feet of the shower head. The P&P further indicated that a pull cord must hang to within two to six inches of the floor to ensure a resident could reach it if they had fallen. b. During a review of Resident 92's admission Record (AR), the AR indicated Resident 92 was admitted to the facility on [DATE] with diagnoses including glaucoma (an eye condition that damages the optic nerve), legal blindness (severe vision loss) and history of falling (moving from a higher to a lower level, rapidly and without control). During a review of Resident 92's Minimum Data Set (MDS- a resident assessment tool) dated 1/5/2026, the MDS indicated Resident 92 had severely impaired vision and severely impaired cognition (ability to understand and process information). The MDS indicated Resident 92 required partial/moderate assistance (helper did less than half the effort) with eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 92 required substantial/maximal assistance (helper did more than half the effort) with toileting, shower and upper body dressing. During a review of Resident 92's untitled Care Plan (CP) dated 1/5/2026, the CP indicated Resident 92 had severely impaired vision. The CP interventions included providing the resident with assistance with activities of daily living (ADLs) and a goal for Resident 92 to remain physically safe. During a concurrent observation and interview on 1/13/2026 at 9:17 am with Certified Nurse Assistant 3 (CNA 3) inside Resident 92's room, Resident 92 was trying to get out of bed. Resident 92's call light was wrapped around the bed siderails. Resident 92 stated Resident 92 did not know where Resident 92's call light was and could not see the call light. CNA 3 stated Resident 92 was blind. CNA 3 stated it was important for Resident 92 to know where Resident 92's call light was, to be able to call for help and assistance. During a concurrent interview and record review on 1/14/2026 at 1:27 pm with the Infection Prevention Nurse (IPN), Resident 92's MDS dated [DATE] was reviewed. The IPN stated Resident 92 had severely impaired vision. The IPN stated Resident 92 should have Resident 92's call light in Resident 92's possession and be accessible to Resident 92 all the time to be able to call for assistance and prevent the resident from falling and accidents. During an interview on 1/15/2026 at 4:12 pm with the Assistant Director of Nursing (ADON), the ADON stated legally blind, or visually impaired residents should have an appropriate call light intended for the resident's special needs like the sensor or pad call light to alert staff and assist the resident's needs promptly. During a review of the facility's Policy and Procedure (P&P) titled, Call System, Resident, revised September 2022, the P&P indicated, If the resident has a disability that prevents him/her from making sure of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with professional standards of practice for five of the five sampled residents (Residents 33, 68, 76, 131 and 117) by failing to: a. Ensure Resident 33's nasal cannula tubing (flexible plastic tubing used to deliver oxygen through the nostrils and the tubing is fitted over the patient's ears) was stored appropriately when not in use, there was a physician's order for the use of oxygen at two liters per minute through nasal cannula and there was a cautionary sign posted on Resident 33's door indicating oxygen was in use. b. Ensure Resident 68's inhalation tubing set was dated, stored appropriately when not in use and Resident 68 had a care plan developed for the use of breathing treatment. c. Place an Oxygen in Use sign on the outside of the room entrance door of Resident 76. d. Ensure the respiratory tubing and mask used for breathing treatment for Resident 131 was labeled and changed. e. Place an Oxygen in Use sign on the outside of the room entrance door and in the room while Resident 117 had ongoing oxygen therapy. These failures placed the residents at risk of complications related to the use of oxygen.Findings: a. During a review of Resident 33's admission Record (AR), the AR indicated Resident 33 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including neuromuscular dysfunction of the bladder (lack of bladder control) and heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs). During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool) dated 11/15/2025, the MDS indicated Resident 33 had intact cognition (ability to understand and process information). The MDS indicated Resident 33 required partial/moderate assistance (helper did less than half the effort) with shower, lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 1/13/2026 at 9:48 am, together with the Assistant Director of Nursing (ADON), Resident 33 was lying in bed, asleep with ongoing oxygen at 2 liters per minute (LPM) via nasal cannula. The ADON stated Resident 33's nasal cannula tubing dated 12/29/2025 was hanging on the left side rail of the bed and a plastic bag dated 12/29/2025 was hanging on the oxygen concentrator. The ADON stated Resident 33 was able to remove Resident 33's oxygen and hang the cannula on the bed rails. During a concurrent observation and interview on 1/13/2026 at 9:51 am, together with the ADON, the ADON stated oxygen nasal cannula tubing and bag needed to be changed every Sunday of the week for infection control and once the nasal cannula tubing was not in use, it should be placed inside the plastic bag to prevent contamination of the nasal cannula tubing. The ADON stated there was no cautionary sign (Oxygen in Use) posted outside Resident 33's room indicating oxygen was currently in use and/or smoking was prohibited. The ADON stated there should be an oxygen sign to remind staff, residents and visitors not to smoke inside the room to prevent fire and combustion (process of burning things). During a concurrent observation and interview on 1/14/2025 at 10:56 am, Resident 33 was awake lying in bed. Resident 33 stated I used it (referring to oxygen) sometimes, but I don't need it. During a concurrent interview and record review on 1/15/2026 at 1:32 pm with the ADON of Resident 33's medical records (PointClickCare - PCC, a cloud-based software), the ADON stated there was no physician's (doctors) order for Resident 33's oxygen administration of 2 LPM via nasal cannula. The ADON stated there should be a doctor's order for oxygen administration use for Resident 33 to ensure Resident 33 received safe and accurate oxygen therapy. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, dated 12/2024, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Nasal cannula, mask and humidifier bottle (when indicated) shall be labeled with date and replaced every 7 days or as needed. Oxygen tubing (cannula/mask) shall be stored in a designated plastic bag when not in use. Place an 'Oxygen in Use' sign on the outside of the room entrance door. b. During a review of Resident 68's AR, the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses including fracture (a complete or partial break in a bone) of the right hip, right above the knee amputation (AKA - surgical removal of the portion of the leg above the knee), and history of falling (moving from a higher to a lower level, rapidly and without control). During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68 had intact cognition. The MDS indicated Resident 68 required setup or clean-up assistance (helper sets up or cleans up; resident completes the activity) with eating, required partial/moderate assistance (helper did less than half the effort) with oral hygiene and dependent (helper did all the effort) with toileting, shower, upper and lower body dressing. During a review of Resident 68's Order Summary Report (OSR), dated 1/7/2026, the OSR indicated Resident 68 had an order for DuoNeb Solution (a medication used to treat respiratory conditions) via inhalation every six (6) hours for shortness of breath (SOB) for seven (7) days and every two (2) hours as needed for SOB or wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs). During a concurrent observation and interview on 1/13/2026 at 10:30 am with Certified Nurse Assistant 1 (CNA 1) inside Resident 68's room, CNA 1 stated Resident 68 had an inhalation tubing set on top of the bedside table. CNA 1 stated the inhalation tubing set did not have a label when it was changed, and the tubing set was not being used. During a concurrent interview and record review on 1/13/2026 at 10:40 am with the Infection Prevention Nurse (IPN), Resident 68's OSR, dated 1/7/2026 and care plans were reviewed. The IPN stated Resident 68 had an order for inhalation breathing treatments. The IPN stated there was no care plan developed for Resident 68 on the use of inhalation breathing treatments. The IPN stated a care plan should be developed to ensure staff provided care and interventions specific for the resident. The IPN stated inhalation tubing sets were changed every week and labeled with the date it was changed and placed in a clear plastic bag intended for respiratory supplies when not in use for infection control. During an interview on 1/15/2026 at 4:02 pm with the Assistant Director of Nursing (ADON), the ADON stated oxygen and inhalation tubing sets should be labeled with the date it was changed. The ADON stated oxygen and inhalation tubing sets should be kept inside the clear plastic bag when not in use to keep it clean and prevent cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). The ADON stated care plan should be developed based on the residents' diagnosis, assessment, orders, treatment and medication to communicate among staff the interventions specific to the resident. c. During a review of Resident 76's AR, the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including fracture of the right arm, dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 76's MDS dated [DATE], the MDS indicated Resident 76 had severely impaired cognition. The MDS indicated Resident 76 required partial/moderate assistance with eating and substantial/maximal assistance (helper did more than half the effort) with oral hygiene, toileting, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 76's OSR dated 1/7/2026, the OSR indicated Resident 76 had an order for oxygen at 2 liters (L)/minute (min) via nasal cannula as needed for shortness of breath. During a concurrent observation and interview on 1/13/2026 at 9:06 am with Licensed Vocational Nurse 1 (LVN 1) inside Resident 76's room, Resident 76 was in bed, lying on Resident 76's back with ongoing oxygen set at 2L/min. LVN 1 stated there was no precautionary sign posted outside Resident 76's room indicating oxygen was in use and smoking was prohibited. During an interview and record review on 1/13/2026 at 10:40 am with the IPN, Resident 76's OSR, dated 1/7/2026, was reviewed. The IPN stated Resident 76 had an order for oxygen at 2L/min through nasal cannula. The IPN stated residents on oxygen therapy should have a No smoking, Oxygen in Use sign posted outside the residents' room to remind residents and visitors not to smoke inside the room because oxygen was a fire hazard. During an interview on 1/15/2026 at 4:03 pm with the Assistant Director of Nursing (ADON), the ADON stated all residents on oxygen therapy should have a no smoking sign posted outside the residents' door to alert everybody not to smoke to avoid fire and for the safety of everybody in the facility. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised December 2024, the P&P indicated, Review the resident's care plan to assess any special needs of the resident. Oxygen tubing (cannula, mask) shall be stored in a designated plastic bag when not in use. Place an Oxygen in Use sign on the outside of the room entrance door. Place an Oxygen in Use sign in a designated place on or over the resident's bed. Instruct the resident, his/her family, visitors and roommate I if any) of the oxygen safety precautions. d. During a review of Resident 117's AR, the AR indicated Resident 117 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) after a stroke affecting the left side and hypertension (HTN-high blood pressure). During a review of Resident 117's Care Plan (CP) dated 11/30/2023, the CP indicated Resident 117 used a handheld nebulizer (HHN- device that converts liquid medication into a fine mist for inhalation directly into the lungs) related to the diagnosis of shortness of breath, congestion, and wheezing. The CP intervention/task included changing the HHN and putting it in a new bag weekly, initialing and dating the HHN and bag. During a review of Resident 117's OSR dated 11/6/2024, the OSR indicated Resident 117 had an active order for Ipratropium-Albuterol Solution (medication used to open airways and relax airway muscles to improve breathing) 0.5-2.5 (3) milligrams(mg)/milliliters (ml) to inhale orally every four hours as needed for shortness of breath, congestion, and wheezing via nebulizer. During a review of Resident 117's H&P dated 10/9/2025, the H&P indicated Resident 117 did not have the capacity to understand and make decisions with a fluctuating mental status. During a review of Resident 117's MDS dated [DATE], the MDS indicated Resident 117 had moderately impaired cognition. During a concurrent observation and interview on 1/13/2026 at 9:22 am with the Minimum Data Set Nurse (MDSN) in Resident 117's room, Resident 117's tubing and mask were connected to the nebulizer and were unlabeled on the nightstand in a bag that was dated 11/24/2025 with the resident's name and room number. The MDSN stated, the tubing and mask should be dated, the tubing and the bag should be changed every week and as needed to prevent the resident from developing any infection. The MDSN stated Resident 117 had a cough and was currently getting nebulizer treatments. During an interview on 1/16/2026 at 10:47 am with the Assistant Director of Nursing (ADON), the ADON stated the tubing and mask used for breathing treatment needed to be changed once a week and as needed if contaminated or dirty, it will be changed sooner. The ADON stated the CP interventions should be followed and if it was not done, it would place the resident at risk of getting an infection. During a review of the facility's policy and procedure (P&P) titled, Cleaning, Changing and Disinfection of Resident-Care Items and Equipment, last revised October 2018, the P&P indicated, resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected or changed according to current Centers for Disease Control and Prevention (CDC-national public health agency of the United States) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA-government agency of the United States that ensures safe and healthy working conditions) Bloodborne Pathogens Stadard. The P&P indicated, oxygen tubing, nebulizer tubing and mask are replaced once a week or as needed. e. During a review of Resident 131's AR, the AR indicated Resident 131 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pneumonia (an infection [when germs entered the body and caused illness] in the lungs) and respiratory failure with hypoxia (lungs could not get enough oxygen into the blood). During a review of Resident 131's Physician Order (PO), dated 1/8/2026, the PO indicated oxygen at three liters (L, a unit for measuring the volume of a liquid) per minute (LPM) via nasal cannular continuously every shift for pneumonia. During a review of Resident 131's Physician Progress Note (PPN) dated 1/9/2026, the PPN indicated Resident 131 required supplemental oxygen for respiratory failure with hypoxia. During a review of Resident 131's MDS dated [DATE], the MDS indicated Resident 131 had intact cognition. The MDS indicated Resident 131 was independent with eating. The MDS indicated Resident 131 required moderate assistance (helper did less than half the effort) from staff with oral hygiene, toileting hygiene, showering/bathing, and bed-to-chair transferring. The MDS further indicated Resident 131 was on continuous oxygen. During a review of Resident 131's Medication Administration Record (MAR) for 1/2026, the MAR indicated Resident 131 received oxygen at three LPM via NC continuously every shift from 1/8/2026 evening shift to 1/13/2026 morning shift. During an observation on 1/13/2026 at 10:59 AM in Resident 131's room, Resident 131 was receiving oxygen at three LMP via NC. A non-in-used oxygen tank was observed in Resident 131's room. There was no Oxygen in Use sign observed in the room. There was no Oxygen in Use sign on the room entrance door. During an observation 1/13/2026 at 12:51 PM outside Resident 131's room, there was no Oxygen in Use sign on the room entrance door. Resident 131 was observed sitting on a wheelchair with oxygen concentrator (a machine that took in air and gave extra oxygen to the resident) at bedside. A non-in-used oxygen tank was observed in Resident 131's room. There was no Oxygen in Use sign observed in the room. During a concurrent interview and pictures review with Treatment Nurse 1 (TN 1) on 1/15/2026 at 2:03 PM, the pictures dated 1/13/2026 at 10:59 AM and 12:52 PM were reviewed. The pictures indicated there was no Oxygen in Use sign outside Resident 131's room where the oxygen concentrator and oxygen tank were stored. The TN stated it was important to have the Oxygen in Use sign outside the room because of explosion risks. TN 1 stated the licensed nurse should put up the Oxygen in Use sign for everyone's safety. During an interview with the Director of Nursing (DON) on 1/16/2026 at 11:11 AM, the DON stated there should have a Oxygen in Use sign outside the door where the oxygen concentrator and oxygen tank were stored, even though the oxygen was not in used. The DON stated the Oxygen in Use sign alerted everyone not to light cigarette or smoke in the room for safety. The DON stated the Oxygen in Use sign should have been posted outside the room as soon as the oxygen was in the room. During a review of facility's P&P titled, Oxygen Administration, revised on 12/2024, the P&P indicated staff were to provide safe oxygen administration. The P&P indicated staff were to place an Oxygen in Use sign on the outside of the room entrance door and in a designated place on or over the resident's bed.

Based on observation, interview, and record review, the facility failed to attempt the use of appropriate alternatives to bedrails (a bar that runs along the side of a bed) or siderails (adjustable metal or rigid plastic bars attached to bed) and did not meet the residents' needs before its installation for two of two sampled residents (Residents 76 and 94). These failures placed Residents 76 and 94 at risk for entrapment (an event in which residents were caught, trapped, or entangled in the tight spaces around the bed) and injury from the use of bedrails or side rails.Findings: a. During a review of Resident 76's admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including fracture (a complete or partial break in a bone) of right arm, dementia (a progressive state of decline in mental abilities) , and history of falling (moving from a higher to a lower level, rapidly and without control). During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool) dated 12/23/2025, the MDS indicated Resident 76 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 76 required partial/moderate assistance (helper did less than half the effort) with eating and substantial/maximal assistance (helper did more than half the effort) with oral hygiene, toileting, shower, upper and lower body dressing, and personal hygiene. During a review of Resident 76's Order Summary Report (OSR), dated 12/25/2025, the OSR indicated Resident 76 had an order for bilateral (both sides) 1/4 partial side rails up to use as mobility aid to improve functional ability when in bed every shift. During a concurrent observation and interview on 1/13/2026 at 9:06 am with Licensed Vocational Nurse 1 (LVN 1) inside Resident 76's room, Resident 76 was in bed, lying on Resident 76's back, with 1/4 siderails up on both sides of the bed. LVN 1 stated Resident 76 had a fracture from a fall and was wearing a sling on the right shoulder. LVN 1 stated Resident 76 could not hold on to the side rails using Resident 76's right arm. During a concurrent interview and record review on 1/14/2026 at 11:07 am with the Infection Prevention Nurse (IPN), Resident 76's medical record (chart) and initial siderail use assessment dated [DATE] were reviewed. The IPN stated there was no record and documentation indicating appropriate alternatives were attempted and did not meet Resident 76's needs prior to the application of bilateral 1/4 siderails. The IPN stated the use of less invasive appropriate alternatives should have been attempted first and did not meet the need of the resident prior to the installation of side rails to prevent injury to Resident 76. b. During a review of Resident 94's AR, the AR indicated Resident 94 was admitted to the facility on [DATE] with diagnoses including epilepsy (a chronic brain disorder causing recurring seizures due to abnormal electrical activity in nerve cells), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and history of falling. During a review of Resident 94's OSR, dated 11/24/2025, the OSR indicated Resident 94 had an order for bilateral 1/4 partial side rails up to aid in functional ability when in bed every shift. During a review of Resident 94's MDS dated [DATE], the MDS indicated Resident 94 had severely impaired cognition. The MDS indicated Resident 94 required partial/moderate assistance with eating, oral hygiene and upper body dressing and dependent (helper did all the effort) with toileting, shower, and personal hygiene. During a concurrent observation and interview on 1/13/2026 at 9:14 am with Certified Nurse Assistant 3 (CNA 3) inside Resident 94's room, Resident 94 was in bed, lying on Resident 94's back, with 1/4 siderails up on both sides of the bed. CNA 3 stated Resident 94 was confused. During a concurrent interview and record review on 1/14/2026 at 11:17 am with the Infection Prevention Nurse (IPN), Resident 94's chart and initial siderail use assessment dated [DATE] were reviewed. The IPN stated there was no record and documentation indicating appropriate alternatives were attempted and did not meet Resident 94's needs prior to the application of bilateral 1/4 siderails. The IPN stated the use of less invasive appropriate alternatives should have been attempted first and did not meet the needs of the resident prior to the installation of side rails to prevent injury to Resident 94. During an interview on 1/15/2026 at 4:04 pm with the Assistant Director of Nursing (ADON), the ADON stated, least restrictive appropriate alternatives should have been attempted and did not meet the residents' needs prior to the installation and use of side rails to prevent risk of entrapment and injury to Residents 76 and 94. During a review of the facility's Policy and Procedure (P&P) titled, Bed Rails, Bed Safety, revised February 2020, the P&P indicated, Siderails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation for one of one facility kitchen. This deficient practice has the potential to result in pathogen (germ) exposure to residents and places them at risk for developing foodborne illness.Findings: During an observation in the kitchen in the presence of the Director of Nutritional Service (DNS) on 1/14/2026 at 11:30 AM, the following were observed:1. DA 2 did not wear gloves when DA 2 was preparing residents' beverages.2. DA 2 did not wash hands or wear gloves before pouring the prune juice into the residents' beverage cups after walking to the dry storage area for a new carton of prune juice. 3. DA 2 did not wash hands or wear gloves after touching the refrigerator door and before covering the residents' beverage cups with plastic food wrap. During an interview with DA 2 on 1/14/2026 at 11:35 AM, DA 2 stated DA 2 should wear gloves while handling residents' food for infection control. DA 2 stated it was important to wear gloves to keep food and kitchen clean and prevent food borne illnesses. DA 2 stated beverages such as milk and prune juice were ready-to-drink. DA 2 stated DA 2 should change glove if DA 2 touched a different surface. During an interview with the DNS on 1/14/2026 at 11:36 AM, the DNS stated dietary staff should wear gloves when handling ready-to-eat items. During a concurrent record review and interview with the Infection Prevention Nurse (IPN) on 1/15/2026 at 3:31 PM, the facility's Policy and Procedure (P&P) titled Glove Use Policy dated 2023 was reviewed. The IPN stated the facility P&P indicated staff should wear disposable gloves when preparing and serving any ready-to-eat food. The IPN stated kitchen staff should wear gloves when preparing food and drinks in accordance with the facility P&P. The IPN stated DA 2's hands were considered not clean after touching the prune juice carton and the refrigerator. The IPN stated kitchen staff should wear gloves to prevent food borne illnesses.

Based on observation, interview, and record review, the facility failed to develop and implement specific and resident-centered care plans (CP) for four of four sampled residents (Residents 3, 48, 49, and 95). These deficient practices had the potential for Residents 3, 48, 49 to not receive appropriate care, treatment, and/or services related to their needs and the potential to result in burns or injuries to Resident 95 during smoking breaks. Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and psychosis (a severe mental condition in which thought, and emotions were affected that contact was lost with reality). During a review of Resident 3's History and Physical (H&P) dated 12/7/2025, the H&P indicated Resident 3 lacked decision-making capacity. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 12/10/2025, the MDS indicated Resident 3 had severely impaired cognition (ability to understand). The MDS indicated Resident 3 required moderate assistance (helper did less than half the effort) from staff with eating and oral hygiene. The MDS indicated Resident 3 required maximal assistance (helper did more than half the effort) from staff with toileting hygiene, showering/bathing, and bed-to-chair transferring. During a review of Resident 3's Order Summary Report (OSR) with active orders as of 1/15/2026, the OSR indicated a physician's order for licensed staff to administer memantine HCL (medication to treat dementia) twice a day starting on 12/6/2025. The OSR further indicated a physician's order for licensed staff to administer rivastigmine (medication to treat dementia) twice a day starting on 12/6/2025. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 1/15/2026 at 10:48 AM, LVN 2 stated residents' CP (in general) should be specific and updated to ensure quality of care. LVN 2 stated the resident's CP should include the medication name to be specific. During a concurrent record review and interview with Registered Nurse 1(RN 1) on 1/15/2026 at 11:13 AM, all of Resident 3's CP were reviewed. RN 1 stated there were no specific CP to address memantine HCL nor rivastigmine use. RN 1 stated Resident 3's CP should be specific and resident-centered and the licensed nurse should initiate the CP upon admission. RN 1 stated memantine HCL and rivastigmine should have been included in Resident 3's CP because they were part of Resident 3's care. RN 1 stated it would affect nursing care without a specific CP. b. During a review of Resident 49's AR, the AR indicated Resident 49 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia and psychosis. During a review of Resident 49's MDS dated [DATE], the MDS indicated Resident 49 had moderately impaired cognition. The MDS indicated Resident 49 required setup assistance from staff for eating, oral hygiene, and walking. The MDS indicated Resident 49 required supervision from staff with toileting hygiene, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 49 required moderate assistance from staff for showering/bathing. During a review of Resident 49's OSR, with active orders as of 1/15/2026, the OSR indicated a physician's order for licensed staff to administer donepezil (medication to treat dementia) twice a day starting on 3/6/2025. The OSR further indicated a physician's order for licensed staff to administer memantine HCL twice a day starting on 7/4/2025. During a concurrent record review and interview with RN 1 on 1/15/2026 at 11:43 AM, all of Resident 49's CP were reviewed. RN 1 stated there were no specific CP to address donepezil nor memantine HCL use. RN 1 stated donepezil nor memantine HCL should have been included in the CP because they were part of Resident 49's care. During an interview with the Director of Nursing (DON) on 1/16/2026 at 1:36 PM, the DON stated it was beneficial to staff and residents to specify the medication names in the CP. The DON stated the specific CP would guide staff on how to care for the residents with dementia and psychosis. The DON stated the CP should individualize care to monitor the specific side effects of the medication. c. During a review of Resident 48's AR, the AR indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcer stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and needs assistance with personal care. During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 had intact cognition. The MDS indicated Resident 48 required setup assistance from staff for eating. The MDS indicated Resident 48 required partial assistance from staff for oral hygiene and personal hygiene. The MDS indicated Resident 48 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, and bed-to-chair transferring. The MDS indicated Resident 48 had pressure reducing device for bed. During a review of Resident 48's H&P dated 1/7/2026, the H&P indicated Resident 48 had the capacity to understand and make decisions. During a review of Resident 48's OSR with active orders as of 1/15/2026, the OSR indicated a physician's order for licensed staff to set the low air loss mattress (LALM, mattress that provided airflow to reduce pressure) according to Resident 48's weight or per Resident 48's comfort every shift starting on 1/4/2026. During a concurrent observation and interview with LVN 2 on 1/15/2026 at 10:30 AM in Resident 48's room, Resident 48 was observed lying in bed. LVN 2 stated Resident 48 was lying on a LALM. LVN 2 stated the LALM prevented pressure ulcers and should have a CP. During a concurrent record review and interview with LVN 2 on 1/15/2026 at 10:30 AM, all of Resident 48's CP were reviewed. LVN 2 stated there was no specific CP for the use of the LALM. LVN 2 stated the licensed nurse should have developed a specific CP Resident 48's use of the LALM upon receiving the order. LVN 2 stated LALM use was an important intervention for wound management. LVN 2 stated staff would not be able to follow the plan of care without the specific CP which could potentially cause complications with Resident 48's wound. During a review of the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised on 3/2024, the P&P indicated a comprehensive, person-centered care plan that meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The P&P indicated that the comprehensive, person-centered CP should describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P further indicated that the comprehensive, person-centered CP should reflect currently recognized standards of practice for problem areas and conditions. d. During a review of Resident 95's admission Record (AR), the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses including blindness in both eyes, psychosis (a severe mental condition in which thought, and emotions are affected that contact is lost with reality), schizophrenia (a mental illness that is characterized by disturbances in thought), parkinsonism (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait), and a need for assistance with personal care. During a review of Resident 95's History & Physical (H&P) dated 12/8/2025, the H&P indicated Resident 95 had the capacity to understand and make decisions. During a review of Resident 95's Minimum Data Set (MDS, a resident assessment tool) dated 12/11/2025, the MDS indicated Resident 95 had moderately impaired cognition (ability to understand). The MDS indicated Resident 95 needed substantial/maximal assistance (helper does more than half the effort) while eating (ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) and used tobacco. During a review of Resident 95's Smoking Assessment (SA) dated 12/15/2025, the SA recommendations indicated Resident 95 needed supervision while smoking and measures were required (such as smoking apron, cigarette extension). During a review of Resident 95's Care Plan (CP) dated 12/15/2025, the CP indicated Resident 95 was a smoker who needed supervision. The CP indicated interventions to explain the risk and benefits of smoking protector/apron and explain consequences of non-compliance, such as cigarette related burns and other injuries. The CP indicated the resident required SUPERVISION while smoking and had a goal for Resident 95 to not smoke without supervision. During an observation on 1/15/2026 at 2:08 pm, Resident 95 was not wearing a smoking apron and was seated in a wheelchair with his back to the doors, smoking a cigarette outside of the facility. The Activities Assistant (AA) was sitting inside the double doors of the facility looking downward at a phone. During an interview on 1/15/2026 at 2:50 pm with the AA, the AA stated Resident 95 was partially blind and requested someone take Resident 95 on smoke break. The AA stated, the AA was instructed to supervise residents by lighting their cigarettes and observing them from inside through a window since the AA disliked the smoke. The AA stated, the AA periodically kept an eye on the residents and stayed inside the doors during supervision. The AA stated direct supervision required being next to or very close to the resident, which the AA did not do for Resident 95. The AA stated, the AA would not be able to prevent Resident 95 from being burned by cigarette ashes. The AA stated, Resident 95 required a smoking apron and concurred it was important to discuss the risks and benefits of wearing the apron with the resident. The AA stated, Resident 95 would not refuse to wear the smoking apron if it was offered, but smoking aprons were unavailable so the AA did not offer it to Resident 95. During an interview on 1/16/2026 at 11:00 am with the Assistant Director of Nursing (ADON), the ADON stated Resident 95 was a smoker and due to his blindness in both eyes Resident 95 needed supervision and would benefit from a smoking apron to prevent any burns. The ADON stated following the CP was important to guide staff what to do and determine the best interventions for the resident. During an interview on 1/16/2026 at 11:20 am with the Director of Nursing (DON), the DON stated Resident 95 was a smoker who needed supervision and the smoking apron was a necessary shield from cigarette ashes. The DON stated whoever takes Resident 95 to smoke should offer Resident 95 a smoking apron. The DON stated following the CP was vital for patient safety, to prevent fires and accidents from occurring. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last revised 3/2024, the P&P indicated, a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs were developed and implemented for each resident. The P&P indicated, each resident's comprehensive person-centered care plan was consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and/or items included in the plan of care. During a review of the facility's P&P titled, Smoking Policy-Residents, revised 12/2024, the P&P indicated, it was the policy of the facility to establish and maintain safe resident smoking practices. The P&P indicated, any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for two of five sampled residents (Residents 33 and 132) by failing to:a. Wear required personal protective equipment (PPE, equipment that protects people from injury or illness ) while providing care to Resident 33 who was placed on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with an multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing a MDRO, such as, residents with wounds or indwelling medical devices).b. Ensure an EBP signage was posted outside the room of Resident 132 with foley catheter (FC, a common type of indwelling catheter, a soft, plastic or rubber tube that is inserted into the bladder to drain urine). These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 33 and 132 and staff that could result in a widespread infection in the facility. Findings: a. During a review of Resident 33's AR, the AR indicated Resident 33 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) and heart failure (condition when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs). During a review of Resident 33's Order Summary Report (OSR) dated 5/30/2025, the OSR indicated to place Resident 33 on EBP due to presence of foley catheter (thin, sterile tube inserted into the bladder to drain urine). During a review of Resident 33's Care Plan (CP) titled Enhanced Barrier Precautions initiated on 10/14/2025, the CP indicated Resident 33 had an indwelling catheter (foley catheter). The CP indicated for nursing staff to initiate EBP and staff will perform hand hygiene, wear PPE (gown and gloves) before and after high contact care activities. During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool) dated 11/15/2025, the MDS indicated Resident 33 had intact cognition (ability to understand and process information). The MDS indicated Resident 33 required partial/moderate assistance (helper did less than half the effort) with shower, lower body dressing and putting on/taking off footwear. During an observation on 1/13/2026 at 9:48 am, Resident 33 was asleep lying in bed in Resident 33's room. During an observation on 1/13/2026 at 9:50 am, Resident 33 was lying in bed. Assistant Director of Nursing (ADON) did not wear gown and clothes while touching Resident 33's bed and bedding while assessing Resident 33's suprapubic catheter (a soft tube inserted directly into the bladder through a small incision in the lower belly [just above the pubic bone] to drain urine into a bag) site. During an interview on 1/13/2026 at 9:59 am, the ADON stated I forgot to wear a gown. The ADON stated protective gown should have been worn to prevent the spread of infection to the residents. During an interview on 1/14/2026 at 11:36 am with the Infection Preventionist Nurse (IPN, a healthcare professional who specializes in preventing the spread of infections in healthcare settings), the IPN stated staff needed to wear gown, gloves and mask prior to touching Resident 33 who was on EBP to avoid the spread of infection from staff to other residents. The IPN stated staff needed to wear required PPE because residents (in general) were high risk for infection especially with indwelling devices. During an interview on 1/16/2026 at 10:56 am with the Director of Nursing (DON), the DON stated staff should wear proper PPE such as gown and gloves before touching a resident with indwelling device such as a catheter to protect the residents and to prevent the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions, revised 5/20/2025, the P&P indicated, EBP – primarily is the use of gowns and gloves for specific high contact care activities based on the residents characteristics that are associated with a high risk if MDRO colonization and transmission. Presence of indwelling medical devices (e.g., urinary catheter, feeding tube . Gowns and gloves will be used while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of health care personnel hands, clothes and the environment: device care, for example urinary catheter, feeding tube and other indwelling devices. b. During a review of Resident 132's admission Record (AR), the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (a type of ischemic stroke caused by a blockage in blood vessels supplying the brain), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN - high blood pressure). During a review of Resident 132's Order Summary Report (OSR) dated 1/5/2026, the OSR indicated Resident 132 had an order for indwelling foley catheter connect to straight drainage for neurogenic bladder (inability to control urination). During a review of Resident 132's Minimum Data Set (MDS - a resident assessment tool) dated 1/10/2026, the MDS indicated Resident 132 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 132 required substantial/maximal assistance (helper did more than half the effort) with eating and dependent (helper did all the effort) with oral hygiene, toileting, shower, upper and lower body dressing. The MDS indicated Resident 132 had an indwelling catheter (a catheter inserted into the bladder to drain urine). During a concurrent observation and interview on 1/13/2026 at 9:26 am with the IPN inside Resident 132's room, Resident 132 was lying in bed with a foley catheter. The IPN stated there was no EBP signage posted outside Resident 132's room. The IPN stated all residents with indwelling medical devices like FC were at high risk for infection and should be placed on EBP. During an interview on 1/15/2026 at 4:08 pm with the Assistant Director of Nursing (ADON), the ADON stated all residents with indwelling medical devices should have a signage posted outside the resident's room to alert the staff to wear recommended PPE to prevent infection and cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions, revised 5/20/2025, the P&P indicated, EBP – primarily is the use of gowns and gloves for specific high contact care activities based on the residents characteristics that are associated with a high risk if MDRO colonization and transmission. Presence of indwelling medical devices (e.g., urinary catheter, feeding tube . Gowns and gloves will be used while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of health care personnel hands, clothes and the environment: device care, for example urinary catheter, feeding tube and other indwelling devices.

Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) on Informed Consent for Physical Restraint, for the use of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one of one sampled resident (Resident 76). This failure violated Resident 76's rights and placed Resident 76 at risk for psychological distress from hearing the alarm sound. Findings: During a review of Resident 76's admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including fracture (a complete or partial break in a bone) of right arm, dementia (a progressive state of decline in mental abilities) , and history of falling (moving from a higher to a lower level, rapidly and without control). During a review of Resident 76's Order Summary Report (OSR) dated 12/18/2025, the OSR indicated Resident 76 had an order for bed alarm. During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool) dated 12/23/2025, the MDS indicated Resident 76 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 76 required partial/moderate assistance (helper did less than half the effort) with eating and substantial/maximal assistance (helper did more than half the effort) with oral hygiene, toileting, shower, upper and lower body dressing, and personal hygiene. During a concurrent observation and interview on 1/13/2026 at 9:06 am with Licensed Vocational Nurse 1 (LVN 1) inside Resident 76's room, Resident 76 was in bed, lying on Resident 76's back with pad alarm on the bed. LVN 1 stated Resident 76 had a history of falling. During a concurrent interview and record review on 1/14/2026 at 1:47 pm with Infection Prevention Nurse (IPN), Resident 76's medical record (chart) and electronic health record (EHR) were reviewed. The IPN stated there was no record and documentation indicating Resident 76 or Resident 76's family member or responsible party signed a consent prior to the application of bed pad alarm. The IPN stated a consent should be obtained to ensure the resident or the resident's responsible party was informed and the purpose of the use of bed pad alarm was explained for the safety of the resident. During the interview on 1/15/2026 at 4:06 pm with the Assistant Director of Nursing (ADON), the ADON stated bed pad alarm was a mobility alarm that could restrict the residents' mobility while in bed, the alarm sound could cause anxiety and should be consented before its application. During a review of the facility's policy and procedures (P&P) titled, Use of Physical Restraints, revised August 2024, the P&P indicated, Mobility alarms may be considered as physical restraints if typical ability is restricted such as: alarm sound may prevent the resident from changing positions, stand/walk, staff giving reminders not to move/ambulate without assistance. During a review of the facility's P&P titled, Informed Consent for Physical Restraint, revised September 2025, the P&P indicated, Physical restraint/device will be applied after informed consent is obtained by the physician/licensed practitioner and verified by a licensed nurse.

Based on interview and record review, the facility failed to ensure the Advance Directive (AD, a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) for one of eight sampled residents (Resident 10) was readily accessible in accordance with the facility's Policy and Procedure (P&P) titled Advance Healthcare Directives/POLST. This failure had the potential for facility staff to provide medical treatment and services against Resident 10's will. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine), dysphagia (difficulty in swallowing) and encounter for attention to gastrostomy (GT creation of an artificial external opening into the stomach for nutritional support). During a review of Resident 10's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/23/2025, the MDS indicated Resident 10 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 10 was dependent (helper does all of the effort) from staff for oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During an interview and concurrent record review on 1/14/2026 at 9:55 am, with the Infection Prevention Nurse (IPN) of Resident 10's medical records (chart and PointClickCare [PCC, a cloud-based software]), the IPN stated there was no AD in Resident 10's chart and PCC. The IPN stated the IPN could not find the existing AD of Resident 10 in the chart nor PCC. The IPN stated, Resident 10's AD needed to be accessible in the chart or PCC for staff to identify the resident's medical wants and wishes in case of an emergency or change of condition. During an interview and record review on 1/14/2026 at 10:01 am with the Social Service Director (SSD), SSD stated, there was no AD completed upon admission for Resident 10. The SSD stated, Resident 10's AD should be accessible in residents' chart or PCC to determine the resident's wishes in case of an emergency. During an interview on 1/16/2026 at 10:44 am, with the facility's Director of Nursing (DON), the DON stated, the resident's AD needed to be readily accessible by staff in Resident 10's chart or PCC in case of emergency. The DON stated, AD was a legal document and indicated the resident's medical wishes and wants. During a review of the facility's P&P titled, Advance Healthcare Directives/POLST revised 12/2019, the P&P indicated At the time of admission, admission Staff or designee will inquire about the existence of a Advance Healthcare Directive. A copy of the Advance Healthcare Directive is maintained as part of the resident's medical record.

Based on observation, interview, and record review the facility failed to revise a plan of care for one of one sampled resident (Resident 96), as indicated in the facility's policy Care Plans, Comprehensive Person-Centered. This deficient practice had the potential for Resident 96 to not receive appropriate care, treatment and/or services.Findings: During a review of Resident 96's admission Record (AR), the AR indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- infection that affects part of the urinary tract), malignant neoplasm (group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body) of the prostate, and acute kidney failure (a sudden decline in kidney function). During a review of Resident 96's untitled Care Plan (CP) initiated on 12/6/2025, the CP indicated Resident 96 required contact isolation precautions related to Extended Spectrum Beta-Lactamase (ESBL- bacteria that is not easily killed by antibiotics) UTI. The CP indicated for nursing staff to explain to the resident the reasons for the isolation precaution and techniques, and implement appropriate isolation techniques by staff, resident and visitors. During a review of Resident 96's Minimum Data Set (MDS, a resident assessment tool) dated 12/10/2025, the MDS indicated Resident 96 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 96 was dependent (helper does all of the effort) with oral hygiene, toileting, shower, upper and lower body dressing and putting on/taking off footwear. During an observation on 1/13/2026 at 9:26 am, Resident 96 was awake, lying in bed in Resident 96's room. During an interview and concurrent record review on 1/13/2026 at 2:01pm, with the Infection Prevention Nurse (IPN- a healthcare professional who specializes in preventing the spread of infections in healthcare settings), of Resident 96's medical records (PointClickCare - PCC, a cloud-based software), the IPN stated Resident 96 was no longer on contact isolation for ESBL of the urine. The IPN stated contact isolation for Resident 96 was discontinued 10 days after Resident 96 started the antibiotics and Resident 96 did not show any signs and symptoms of infection. The IPN stated Resident 96's care plan for contact isolation needed to be revised to be specific to the resident's care and treatment. During an interview on 1/16/2025 at 10:52 am, with the facility's Director of Nursing (DON), the DON stated the resident's care plan needed to be revised or updated to determine appropriate care and treatment currently needed by the resident. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2024, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: request revisions to the plan of care.

Based on observation, interview, and record review, the facility failed to ensure policies and procedures (P&P) on Smoking were implemented for one of one sampled resident (Resident 95) when Resident 95 did not receive direct supervision and was not offered a smoking apron during smoking break. This failure had the potential to place Resident 95 at risk for burns and accidents during smoking break. Findings: During a review of Resident 95's admission Record (AR), the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses including blindness in both eyes, psychosis (a severe mental condition in which thought, and emotions are affected that contact is lost with reality), schizophrenia (a mental illness that is characterized by disturbances in thought), parkinsonism (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait), and a need for assistance with personal care. During a review of Resident 95's History & Physical (H&P) dated 12/8/2025, the H&P indicated Resident 95 had the capacity to understand and make decisions. During a review of Resident 95's Minimum Data Set (MDS, a resident assessment tool) dated 12/11/2025, the MDS indicated Resident 95 had moderately impaired cognition (ability to understand). The MDS indicated Resident 95 needed substantial/maximal assistance (helper does more than half the effort) while eating (ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) and used tobacco. During a review of Resident 95's Smoking Assessment (SA) dated 12/15/2025, the SA recommendations indicated Resident 95 needed supervision while smoking and measures were required (such as smoking apron, cigarette extension). During an observation on 1/15/2026 at 2:08 pm, Resident 95 was not wearing a smoking apron and was seated in a wheelchair with his back to the doors, smoking a cigarette outside of the facility. The Activities Assistant (AA) was sitting inside the double doors of the facility looking downward at a phone. During an interview on 1/15/2026 at 2:50 pm with the AA, the AA stated Resident 95 was partially blind and requested someone take Resident 95 on smoke break. The AA stated, the AA was instructed to supervise residents by lighting their cigarettes and observing them from inside through a window since the AA disliked the smoke. The AA stated, the AA periodically kept an eye on the residents and stayed inside the doors during supervision. The AA stated direct supervision required being next to or very close to the resident, which the AA did not do for Resident 95. The AA stated, the AA would not be able to prevent Resident 95 from being burned by cigarette ashes. The AA stated, Resident 95 required a smoking apron and concurred it was important to discuss the risks and benefits of wearing the apron with the resident. The AA stated, Resident 95 would not refuse to wear the smoking apron if it was offered, but smoking aprons were unavailable so the AA did not offer it to Resident 95. During an interview on 1/16/2026 at 11:20 am with the Director of Nursing (DON), the DON stated Resident 95 was a smoker who needed supervision and the smoking apron was a necessary shield from cigarette ashes. The DON stated, for safety reasons, Resident 95 needed someone to assist Resident 95. The DON stated Resident 95 was at risk for accidents, burns, causing accidents or hurting others. The DON stated direct supervision was when the staff was directly next to the resident and the supervising staff should be outside with the resident during smoking time. During a review of the facility's P&P titled, Smoking Policy-Residents, revised 12/2024, the P&P indicated, it was the policy of the facility to establish and maintain safe resident smoking practices. The P&P indicated, any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition/medication directly into the stomach) site as ordered by the physician and as indicated in the plan of care for one of one sampled resident (Resident 10). This failure had the potential for complications related to tube feedings for Resident 10.Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine), dysphagia (difficulty in swallowing) and encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support). During a review of Resident 10's History and Physical (H&P) dated 6/21/2025, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Order Summary Report (OSR) dated 6/20/2025, the OSR indicated Resident 10 had a treatment order for licensed staff to clean the GT site with normal saline (NS, a saltwater solution), pat dry and apply dry dressing daily and inspect the site for signs and symptoms of infection, drainage, swelling or irritation. During a review of Resident 10's untitled Care Plan (CP) initiated on 7/25/2025, the CP indicated Resident 10 required enteral feeding via GT. The CP indicated for licensed nursing staff to provide enteral feeding as ordered. During a review of Resident 10's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/23/2025, the MDS indicated Resident 10 was dependent (helper does all of the effort) from staff for oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent observation inside Resident 10's room and interview on 1/13/2026 at 10:21 am with facility's Assistant Director of Nursing (ADON), Resident 10 was awake, lying in bed. The ADON stated there was no GT dressing on Resident 10's GT site. The ADON stated there should be dry dressing in placed as ordered by the doctor. During an interview on 1/14/2026 at 9:35 am with the Treatment Nurse (TN), the TN stated Resident 10's GT site should have dry dressing to protect the resident's skin from irritation. During an interview on 1/16/2026 at 1:46 pm with the facility's Director of Nursing (DON), the DON stated the purpose of the dry dressing was to prevent infection and to maintain cleanliness of the GT site. The DON stated the GT dressing should be changed and applied daily by the licensed nurse as ordered by the doctor. During a review of the facility's policy and procedures (P&P) tiled, Enteral Feedings - Safety Precautions, revised 5/2020, the P&P indicated, Preventing Skin Breakdown: Keep the skin around exit site clean, dry and lubricated (as necessary).

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 2) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program to be free from abuse. As a result, on 8/23/2025 Resident 1 pushed Resident 2 and Resident 2 fell to the floor. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for an assessment and evaluation due to an unwitnessed fall. Resident 2 sustained an acute (sudden) comminuted (the bone breaks into multiple small fragments) fracture (partial or complete break of the bone) of the right 5th metacarpal (the bone in the hand that connects the little finger to the wrist).Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with a diagnoses that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia [a mental illness that is characterized by disturbances in thought] and a mood disorder, such as depression [serious illness that negatively affects how one feels, thinks and acts] or bipolar disorder [serious mental illness that causes unusual shifts in mood]), and legal blindness (severe visual impairment that meets specific criteria established by law). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 2's cognition (ability to understand and process information) was severely impaired. The MDS indicated Resident 2 needed partial to moderate assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance [the caregiver places one or two hands on the resident's body to help with balance but provides no other assistance to perform the functional mobility task] as resident completes the activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and with walking. During a review of Resident 2's Situation, Background, Assessment and Recommendation (SBAR, structured communication framework that helps teams share information about the condition of a resident) Communication Form, dated 8/23/2025, timed at 12:18 pm, the form indicated (on 8/23/2025), at 11:30 am, Resident 2 was having a verbal conversation with Resident 1 when suddenly Resident 2 fell on the floor unwitnessed. The form indicated Resident 2 told staff, He [Resident 1] pushed me, and [I] ended [on] the floor; my back is painful. The form indicated Resident 2's pain was rated 1 out of 10 (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt). The form indicated Medical Doctor (MD) 1 was notified 8/23/2025 at 12 pm, and the facility received a new order for laboratory [blood] work. During a review of Resident 2's Progress Notes (PN), dated 8/23/2025, timed at 2 pm, the PN indicated Resident 2 was transferred to GACH 1's Emergency Department (ED) for an assessment due to an unwitnessed fall. During a review of Resident 2's PN, dated 8/23/2025, timed at 11:40 pm, the PN indicated Resident 2 returned to the facility from GACH 1 with a right-hand 5th metacarpal fracture. During a review of Resident 2's GACH 1's right wrist X-ray (imaging study that takes pictures of bones and soft tissues) results, dated 8/23/2025, timed at 2:28 pm, the X-ray indicated an acute comminuted fracture of the right 5th metacarpal beginning in the distal diaphysis (the main or midsection (shaft) of a long bone) and extending to the distal epiphysis with suspected intra-articular extension [(the rounded end of the bone). The breaking of the long bone leading to the little finger in multiple pieces with a high likelihood of damage to the joint surface]. During a review of Resident 1's AR, the AR indicated Resident 1 was admitted to the facility 6/8/2025 with diagnoses that included type 2 diabetes (a disease that results in elevated levels of glucose in the blood) and essential hypertension (high pressure of blood pushing against the wall of the arteries). During a review of Resident 1's History and Physical (H&P) Examination, dated 6/9/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's SBAR Communication Form, dated 8/23/2025, the form indicated Resident 1 had a disagreement with [Resident 2] and Resident 1 pushed Resident 2. During an interview on 8/28/2025 at 11 am with Resident 1, Resident 1 stated on 8/23/2025 (could not remember the time) Resident 1 had an altercation (a conflict that can range from verbal arguments to physical fights, occurring between two or more individuals receiving care) with Resident 2. Resident 1 stated Resident 2 was sitting across the hall and Resident 1 was walking into Resident 1's room when Resident 2 said something to Resident 1 and Resident 1 told Resident 2 to, shut up and mind his [Resident 2's] own business. Resident 1 stated Resident 2 was walking toward Resident 1 and, I pushed and dropped Resident 2 to the ground, and he [Resident 2] started yelling he [Resident 1] hit me. During an interview on 9/2/2025 at 1 pm with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on 8/23/2025 at 11:30 am LVN 4 yelled out, Resident 2 is on the floor. LVN 3 stated, LVN 3 ran toward LVN 4 and when LVN 3 arrived Resident 2 was on the floor on Resident 2's left side, and Resident 1 was standing over Resident 2. LVN 3 stated Resident 1 told Resident 2, That is what you get they should have kicked you out a long time ago. LVN 3 stated Resident 2 did not respond to Resident 1, turned to LVN 3 and stated, My back and arm are hurting [pain unrated], call an ambulance because I do not feel I can get up from the floor. LVN 3 stated Resident 2 complained of 7 out of 10 pain on Resident 2's back and [right] arm. During an interview on 9/2/2025 at 2:33 pm with LVN 4, LVN 4 stated LVN 4 heard a staff (unidentified) say Mister fell. LVN 4 stated LVN 4 rushed down the hallway and observed Resident 1 standing by Resident 1's room yelling and laughing at Resident 2 and stated, That is what you get you should not be here, yea I pushed him so what, I pushed him. Resident 2 was lying on the floor and stated, Help me, I can't get up. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P indicated, residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The P&P indicated, this includes but is not limited to freedom from corporal punishment (the use of physical force to cause pain or discomfort as a way to discipline or correct a behavior), involuntary seclusion (keeping someone separated from others against their will), verbal, mental, sexual, or physical abuse. The P&P indicated, the resident abuse, neglect and exploitation prevention program consisted of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: b. other residents.

Based on interview and record review, the facility failed to report and a physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) incident to the California Department of Public Health (CDPH, State Agency) for one of three sampled residents (Resident 2) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program.This deficient practice resulted in the delay of notification to the State Agency and had the potential to result in residents residing at the facility to be subjected to further abuse.Cross Reference F600Findings:During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with a diagnoses that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia [a mental illness that is characterized by disturbances in thought] and a mood disorder, such as depression [serious illness that negatively affects how one feels, thinks and acts] or bipolar disorder [serious mental illness that causes unusual shifts in mood]), and legal blindness (severe visual impairment that meets specific criteria established by law).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 2's cognition (ability to understand and process information) was severely impaired and needed partial to moderate assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance [the caregiver places one or two hands on the resident's body to help with balance but provides no other assistance to perform the functional mobility task] as resident completes the activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and with walking.During a review of Resident 2's Situation, Background, Assessment and Recommendation (SBAR, structured communication framework that helps teams share information about the condition of a resident) Communication Form, dated 8/23/2025, timed at 12:18 pm, the form indicated (on 8/23/2025), at 11:30 am, Resident 2 was having a verbal conversation with Resident 1 when suddenly Resident 2 fell on the floor unwitnessed. The form indicated Resident 2 told staff, He [Resident 1] pushed me, and [I] ended [on] the floor.During an interview on 9/2/2025 at 2:33 pm with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 1 was standing by his room yelling and laughing at Resident 2 that is what you get you should not be here, yea I pushed him so what, I pushed him. Resident 2 was lying on the floor and stated, help me, I can't get up. LVN 4 stated I notified the Administrator (ADM) and the Director of Nursing (DON) of the incident and stated LVN 3 told LVN 4 not to fill out the abuse reporting form because the ADM and DON told LVN 3, the ADM and the DON would fill out the form [and report to the State Agency]. LVN 4 stated, LVN 4 was a mandated reported and abuse should be reported within 2 hours to the State Agency, the Ombudsman (an official, public advocate, helps to resolve issues between parties through various types of informal mediation), and the police department.During a concurrent interview and record review on 9/3/2025 at 3:30 pm with DON, the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021 was reviewed. The P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consist of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: b. other residents, 9. Investigate and report any allegations within time frames required by federal requirements. The DON stated we [the facility] failed to report the incident that occurred on 8/23/2025 within two hours to the State Agency.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who required hemodialysis (HD, process of removing excess water, substances, and waste products from the blood in people whose kidneys could no longer perform these functions) received HD care and services in accordance with the resident's care plan and the facility's own policies and procedures by failing to: 1. Notify Resident 1's Primary Care Physician 1 (PCP 1), Resident 1's nephrologist (MD 2, kidney specialist), or the facility's Medical Director (MedDir) promptly (with little or no delay) regarding Resident 1's change in condition that started on 8/14/2021 and obtain the necessary orders to meet Resident 1's HD needs. 2. Ensure ongoing communication and collaboration with [CONDITION(S)] Center 1 (DC 1) to coordinate Resident 1's HD care and services in relation to Resident 1's missed HD and malfunction of HD [CONDITION(S)] catheter (soft tube placed in a large vein to facilitate HD). 3. Ensure effective communication between the licensed nurses (in general) to facilitate ongoing assessment of Resident 1's condition and monitoring for complications according to the resident's care plan. As a result, Resident 1 experienced increased confusion (inability to clearly think or reason), lethargy (state of sleepiness, deep unresponsiveness, and inactivity) and shortness of breath related to pulmonary congestion (accumulation of fluid in the lungs), due to not having HD for six days. This required hospitalization and placed Resident 1 at a high risk for further respiratory distress (severe shortness of breath due to lack of oxygen), [CONDITION(S)] (sudden, unexpected loss of heart function, breathing, and consciousness), and possible death. Resident 1 was transported with Advanced Life Support (ALS, provided when a patient is in more critical condition and a paramedic is required before and/or during transport to the emergency facility) to General Acute Care Hospital 1 (GACH 1) on 8/17/2021. Cross Reference with F580 and F656 Findings: 1. A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan on HD, initiated on 6/20/2021, indicated the following interventions: a. Coordinate the resident's care in collaboration with the [CONDITION(S)] center. b. Monitor for signs and symptoms of fluid or electrolyte imbalance (maldistribution of fluid or minerals in the blood or tissues throughout the body). c. Monitor for labs and report to the physician as needed. d. Monitor/document for peripheral [CONDITION(S)] (swelling of lower legs and hands) and ascites (abdominal swelling) and notify physician, if identified. e. Monitor/document/report to physician as needed any signs and symptoms of renal insufficiency (poor kidney functions), changes in the level of consciousness (person's awareness and understanding of what is happening to his/her surroundings), changes in skin turgor (skin's elasticity), oral mucosa (mucous membrane lining the inside of the mouth), and changes in heart and lung sounds. f. Observe for abdominal distention (increase in abdominal pressure with an increase in overall abdominal diameter) and monitor for abdominal girth (measurement of the distance around the abdomen at a specific point). A review of Resident 1's Order Summary Report from period 6/19/2021 to 8/1/2021 indicated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 6/23/2021, indicated Resident 1 did not have any impairment in cognition (mental action or process of acquiring knowledge and understanding). A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of DC 1's Nursing - Progress Notes Report for Resident 1, dated 8/11/2021, indicated skilled nursing facility (SNF) called DC 1 to notify them that Resident 1 accidentally pulled out his HD catheter. The report indicated [CONDITION(S)] Center Nurse 1 (DCN 1) assisted the SNF in making [MEDICATION(S)] Radiology (IR, performing minimally invasive procedures with the use of radiological image guidance) arrangements for the HD catheter replacement. A review of Resident 1's Health Status Note, dated 8/12/2021, indicated Resident 1 came back to the SNF from the GACH 3 with a new HD catheter in place to the left internal jugular vein (IJV, vein of the neck that drains blood from brain, face, and neck) and went to his HD appointment at DC 1 on the same day. A review of Resident 1's [CONDITION(S)] Communication Record, dated 8/14/2021, indicated DCN 2 was unable to dialyze (treat by means of [CONDITION(S)]) Resident 1. The record indicated Resident 1 needed another replacement of HD central venous catheter (CVC, tube used as a HD catheter placed in a large vein in the neck, chest, groin, or arm). A review of the attached order, dated 8/14/2021, indicated MD 2's order Nursing Home to arrange HD CVC replacement. A review of Resident 1's Health Status Note, dated 8/14/2021 timed at 5 pm, indicated Licensed Vocational Nurse (LVN 1) received communication from DC 1 regarding inability to dialyze Resident 1 due to the malfunction of HD catheter, which was placed on 8/12/2021. The note indicated Resident 1's last HD was done on 8/12/21. The note indicated primary care provider (PCP 1) was aware of the missed [CONDITION(S)]. The note indicated Case Manager (CM 1) was aware of the need to schedule a HD catheter replacement for Resident 1. A review of Resident 1's Change in Condition Evaluation, dated 8/14/2021 timed at 6:46 pm, indicated Resident 1's HD catheter was not functioning well. The evaluation indicated Registered Nurse (RN 1) documented, Catheter has gotten worse, which sometimes happen even after it is newly placed. The evaluation indicated RN 1 notified PCP 1 on 8/14/2021 at 7 p.m. The resident's clinical records did not indicate any recommendations from PCP 1. A review of Resident 1's Change in Condition Evaluation, dated 8/16/2021 timed at 2:46 pm, indicated LVN 2 observed Resident 1 with increased confusion and lethargy was unable to complete full sentences, and was disoriented to time and place. The evaluation indicated LVN 2 notified PCP 1 on 8/16/2021 at 2 p.m. and obtained PCP 1's recommendation to send resident to ED (Emergency Department). However, a review of the Care Communications (facility's internal electronic communication system used by healthcare workers to communicate any changes in a resident's condition), dated 8/16/2021 timed at 3:06 p.m., indicated LVN 2 paged PCP 1 but was awaiting PCP 1 to return the call with orders. A review of Resident 1's Change in Condition Evaluation, dated 8/17/2021 timed at 4:13 am, indicated LVN 3 observed Resident 1 with increased confusion with other symptoms or signs of [CONDITION(S)] (sudden inability to pay attention, disorganized thinking). The evaluation indicated LVN 3 observed Resident 1 unable to answer a question and finish a sentence. The evaluation indicated LVN 3 observed Resident 1 with chills and general weakness. The evaluation indicated LVN 3 notified PCP 1 on 8/17/2021 at 3:30 am and obtained PCP 1's recommendation to send Resident 1 to the hospital (not specified) via 911 (emergency services). A review of Resident 1's Nursing Home to Hospital Transfer Form, dated 8/17/2021, indicated Resident 1 left the facility to GACH 1 due to altered mental status. A review of Resident 1's ED Report from GACH 1, dated 8/17/2021, indicated Resident 1 presented to the ED due to altered mental status, confusion, shortness of breath. The Report indicated Resident 1 did not have [CONDITION(S)] for five days due to malfunction of the [CONDITION(S)] catheter that was in place in the left IJV. A review of Resident 1's Consultation Report from GACH 1, dated 8/17/2021, indicated Resident 1's shortness of breath likely from fluid overload due to missing hemodialysis, as Chest X-ray (creates pictures of the inside of the body), revealed pulmonary congestion. The Report indicated recommendations for hemodialysis with fluid removal. A review of Resident 1's Discharge Summary from GACH 1, dated 8/23/2021, indicated that Resident 1 was transferred to GACH 5 to have HD catheter replacement and resumed HD on 8/19/2021, because the HD catheter replacement at GACH 1 was unsuccessful. During a telephone interview on 9/20/2021 at 12:30 p.m., Certified Nursing Assistant (CNA 1) stated on 8/16/2021 (7 am - 3 pm shift), LVN 2 and RN 2 were aware of Resident 1's increased confusion and decided to transfer Resident 1 to the hospital (in general). CNA 1 stated she did not know the reason why Resident 1 was not transferred to the hospital during her shift. During a telephone interview on 9/20/2021 at 1:15 pm, RN 1 stated she was unable to recall about the exact details of the incident when Resident 1 came back to the facility on [DATE] (3 pm -11 pm shift) from DC 1 due to a malfunction of the HD catheter. RN 1 stated she was not able to speak with PCP 1 directly to obtain any orders. RN 1 stated she left a message for PCP 1 and endorsed the incident to the next nurse. RN 1 stated if a resident (in general) missed a [CONDITION(S)] session during the weekend, he/she must wait until Monday when the surgeon's office opens. RN 1 stated depending on the resident (in general), he/she could last a few days or weeks without [CONDITION(S)]. During a telephone interview on 9/20/2021 at 4:34 pm, RN 2 was unable to recall calling PCP 1 for Resident 1 on 8/16/2021 (7 am - 3 pm shift) regarding a change in condition (COC). RN 2 was unable to recall making arrangements for Resident 1's HD catheter replacement on 8/16/2021 (7 am - 3 pm shift), stating CM 1 was responsible for making arrangements to have the HD catheter replaced. RN 2 stated that if there was delay in establishing a HD catheter, the resident (in general) must be transferred to the hospital via 911 with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 9/20/2021 at 4:51 pm, LVN 2 stated she recalled attempting to contact PCP 1 regarding Resident 1's increased confusion on 8/16/2021 (7 am - 3 pm shift) but not getting a response from PCP 1 during her shift. LVN 2 was unable to recall if RN 2 or CM 1 were made aware of Resident 1's change in condition, but she stated the RN Supervisor (in general) was responsible for making arrangements for resident transfers to the hospital. LVN 2 stated she did not recall notifying the MedDir or MD 2. LVN 2 was unable to recall the reason why Resident 1 was not transferred during her shift even though her documentation indicated she notified PCP 1 on 8/16/2021 at 2 pm with PCP 1's order to Send resident to ED. During a telephone interview on 9/21/2021 at 4:18 pm, PCP 1 stated he did not receive any notification from the SNF on 8/14/2021 and 8/15/2021 regarding Resident 1's missed [CONDITION(S)] due to the HD catheter malfunction. PCP 1 stated the SNF staff sent him a notification on 8/16/2021 about Resident 1 not feeling well, and PCP 1 stated he must have called them back, but could not recall the exact details of the conversation. PCP 1 stated if the SNF staff informed him that Resident 1 did not have HD for at least three days on 8/16/2021, he would have given the order to transfer the resident to the ED immediately. PCP 1 stated he spoke to the SNF staff on 8/17/2021 regarding Resident 1's transfer to another ED because the other ED was full. PCP 1 stated the SNF staff should have notified MD 2 to obtain orders for laboratory tests to determine Resident 1's plan of care. During a telephone interview on 9/23/2021 at 7:53 am, LVN 3 stated when he started his shift on 8/16/2021 (11 pm -7 am shift), Resident 1 did not look good anymore. LVN 3 stated Resident 1 had increased confusion and was unable to finish a sentence. LVN 3 stated LVN 2 documented Resident 1 had not received HD since 8/14/2021 but LVN 2 had not received a response from PCP 1. LVN 3 stated after calling PCP 1's number about two to three times, PCP 1 called back on 8/17/2021 at 3:30 am, and gave LVN 3 an order to send Resident 1 to the hospital via 911. LVN 3 stated if he did not obtain the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 3 stated it was not a common facility practice to contact the MedDir to obtain an emergency order to transfer a resident to the hospital. During a telephone interview on 9/23/2021 at 8:26 am, RN 4 stated she did not recall getting a report from the previous nurse about the need to follow up with PCP 1 regarding Resident 1's COC, missed HD session, malfunction of HD catheter site, or pending transfer to the hospital when she started her shift on 8/16/2021 (11 pm - 7 am shift). RN 4 stated if she received this information during the change-of-shift report, she would have questioned why Resident 1 still has not been transferred to the hospital. RN 4 stated LVN 3 notified her about Resident 1's increased confusion and having no [CONDITION(S)] for four days. RN 4 stated if LVN 3 was not able to contact PCP 1 that shift, she would have called the MedDir to obtain advice on what to do besides continuous monitoring of Resident 1. During a telephone interview on 9/23/2021 at 12:30 pm, MD 2 stated he did not receive a call from the facility on 8/14/2021 and 8/15/2021. MD 2 stated if the SNF staff notified him that Resident 1 did not have [CONDITION(S)] for at least three days, he would have given the order to send Resident 1 to the ED immediately to ensure emergency capabilities, requested for STAT potassium level (laboratory blood test to be drawn immediately), and ordered a medication to lower the potassium level due to a concern for dangerously high levels of potassium that could lead to [CONDITION(S)]. During a telephone interview on 9/27/2021 at 3:08 pm, LVN 1 was unable to recall if she called PCP 1 on 8/14/2021 (3 pm - 11pm shift) to inform about the missed [CONDITION(S)] related to the HD catheter malfunction when Resident 1 came back to the SNF from DC 1. LVN 1 stated she did not recall contacting MD 2 because MD 2's name and contact information were not on Resident 1's chart. During a telephone interview and a concurrent review of Resident 1's medical records on 9/28/2021 at 12:15 pm, the Director of Nursing (DON) stated if unsuccessful to reach PCP 1, LVN 2 should have called the MedDir to get some advice and determine the plan of care. The DON stated LVN 2 endorsed to the next shift the need to follow up with PCP 1, but there was no documented evidence that the 3 pm -11 pm shift nurses assigned to Resident 1 on 8/16/2021 followed up with PCP 1 or notified the MedDir of the incident. During a telephone interview on 9/28/2021 at 1:49 pm, with regard to the discrepancy on LVN 2's notes on 8/16/2021 (7 am - 3 pm shift), the DON stated LVN 2 informed her that PCP 1 did not respond during her entire shift on 8/16/2021 (7 am - 3 pm shift) but LVN 2 admitted going back to her charting on Resident 1's Change in Condition Evaluation, dated 8/16/2021 timed at 2:46 pm, to add the physician's recommendation Send resident to ED, after Resident 1 had already been transferred to the ED. 2. During a telephone interview on 9/20/2021 at 1 pm, CM 1 stated she did not know Resident 1 until she was asked to make an appointment for Resident 1's HD catheter replacement on 8/16/2021. CM 1 stated she did not speak with PCP 1. CM 1 stated she contacted DC 1 on 8/16/2021 to inform them about the scheduled HD catheter replacement on 8/17/2021 at GACH 3. During a telephone interview on 9/21/2021 at 4:36 pm, DCN 1 stated DC 1 was closed on 8/15/2021. DCN 1 stated SNF staff notified DC 1's social worker (DCSW) on 8/16/2021 regarding Resident 1's appointment for HD catheter replacement scheduled on 8/17/2021. DCN 1 stated Resident 1 had not received HD for four days at that time. DCN 1 stated if a resident's (in general) HD catheter malfunction occurred on a weekend, it would be better to send the resident to the ED to get the HD catheter replaced and resume HD treatments sooner. DCN 1 stated outpatient IR departments were open only Monday to Friday with long waiting periods due to insurance verification and Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) test requirements. DCN 1 stated while waiting for the HD catheter to be replaced for a resident (in general), the nurse must obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 9/23/2021 at 12:30 pm, MD 2 stated after he received a HD catheter replacement request for Resident 1 on 8/16/2021, he coordinated with three other medical doctors (unidentified) to arrange Resident 1's admission to GACH 4. MD 2 stated Resident 1 was a no-show, at GACH 4, but he did not receive any notification or call from the SNF regarding what happened. MD 2 stated he incidentally found out from Resident 1's Family Member 1 (R1FM1) that Resident 1 was transferred to GACH 1 instead. MD 2 stated he was not aware that Resident 1 had not had HD since 8/14/2021. During a telephone interview on 9/27/2021 at 3:08 pm, LVN 1 stated when Resident 1 came back from DC 1 after a missed HD session on 8/14/2021, she did not speak with DC 1 nurse directly. LVN 1 stated it was not a common facility practice to call the nephrologist (in general) directly. During a telephone interview and a concurrent review of Resident 1's medical records on 9/28/2021 at 12:15 pm, the DON stated it was not a common SNF practice to contact the nephrologist (in general) directly, although the SNF staff could have reached out to the [CONDITION(S)] center (in general) to obtain the nephrologist's advice or orders. 3. During a telephone interview on 9/20/2021 at 1:54 pm, LVN 4 stated he was assigned to Resident 1 on 8/16/2021 (3 pm - 11 pm shift), but he could not recall any report from the previous shift regarding following up with PCP 1 regarding Resident 1's COC, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 9/20/2021 at 2:15 pm, RN 3 stated he was the RN Supervisor on 8/16/2021 (3 pm - 11 pm shift), but he could not recall any report from the previous shift regarding Resident 1's COC or the need to follow up with PCP 1 regarding a hospital transfer or need for a HD catheter replacement. During a telephone interview on 9/20/2021 at 4:34 pm, RN 2 stated she was unable to recall being notified of Resident 1's COC or the need to arrange Resident 1's HD catheter replacement on 8/16/2021 (7 am - 3 pm shift). RN 2 stated CM 1 was responsible with making arrangements to have the HD catheter replaced. RN 2 stated that if there was delay in establishing a [CONDITION(S)] catheter, the resident (in general) must be transferred to the hospital via 911 with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a telephone interview on 9/23/2021 at 8:26 a.m., RN 4 stated she did not recall getting a report from the previous nurse about Resident 1's COC, missed HD session, malfunction of HD catheter site, or pending transfer to the hospital when she started her shift on 8/16/2021 (11 pm - 7 am shift). RN 4 stated if she received this information during change-of-shift report, she would have questioned why Resident 1 still has not been transferred to the hospital. During a telephone interview on 9/23/2021 at 10:48 am, RN 5 stated she worked on 8/15/2021 (7 am - 3 pm and 3 pm - 11 pm shifts), but she was unable to recall receiving a report on Resident 1's COC on 8/14/2021, missed [CONDITION(S)] session, or malfunction of the HD catheter, needing replacement. During a telephone interview on 9/27/2021 at 3:08 p.m., LVN 1 stated when Resident 1 came back from DC 1 after a missed HD treatment on 8/14/2021 (3 pm - 11 pm shift), LVN 1 sent a communication note to CM 1 to arrange for Resident 1's HD catheter replacement. LVN 1 stated CM 1 worked on weekdays, so she was not able to speak to CM 1 directly or obtain a response from CM 1 during her shift. LVN 1 was unable to recall if she called PCP 1 to inform him of the missed HD related to the HD catheter malfunction. In addition, LVN 1 stated she did not update Resident 1's HD care plan. LVN 1 stated it was important to update Resident 1's care plan for any COC to determine resident-specific interventions to address the COC. LVN 1 stated the nurse must also note any COC to ensure 72-hour monitoring by the licensed nurses every shift. During a telephone interview and a concurrent review of Resident 1's medical records on 9/28/2021 at 12:15 pm, the DON stated there was no documented evidence indicating a continuous 72-hour monitoring was done for Resident 1 on 8/14/2021 11 pm - 7 am shift, 8/15/2021 7 am - 3 pm shift, 8/15/2021 3 pm - 11 pm shift, 8/15/2021 11-7 shift, and 8/16/2021 3-11 shift following the change in condition on 8/14/2021. The DON stated the care plan was not updated on 8/11/2021 and 8/14/2021 when Resident 1 had changes in condition related to the [CONDITION(S)] catheter functionality. The DON stated it was important to update the care plan to ensure consistent implementation of the interventions across all shifts. A review of the facility's policy and procedures, titled Hemodialysis Access Care, dated 9/2010, indicated the medical nurse must document in the resident's medical record every shift as follow: a. Location of catheter b. Condition of dressing and interventions, if needed c. If [CONDITION(S)] was done during shift d. Any part of report from [CONDITION(S)] nurse post-[CONDITION(S)] being given e. Observations post-[CONDITION(S)] A review of the facility's policy and procedures, titled Change in a Resident's Condition or Status, dated 5/2017, indicated the facility must promptly notify the resident, the attending physician, and representative of changes in the resident's medical/mental condition. The policy indicated the nurse must notify the attending physician or physician on-call where there has been a significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, or a need to transfer the resident to a hospital or treatment center. A review of the facility's policy and procedures, titled Medical Director, undated, indicated physician services must be under the supervision of the Medical Director. The policy indicated the Medical Director functions included acting as a consultant to the director of nursing services in matters relating to resident care services, helping assure that residents receive adequate services appropriate to meet their needs, and helping assure that the resident care plan accurately reflects the medical regimen. A review of the facility's policy and procedures, titled Care Plans, Comprehensive Person-Centered, undated, indicated the assessments of resident must be ongoing and care plans must be revised as information about the residents and residents' conditions change. It indicated the comprehensive, person-centered care plan must aid in preventing or reducing decline in the resident's functional status and/or functional levels.

Based on interview and record review, the facility staff failed to follow its own policy and procedure for Change in a Resident's Condition or Status, by failing to promptly (with little or no delay) notify Primary Care Provider 1 (PCP 1), the nephrologist (MD 2, kidney specialist), or the facility's Medical Director (MedDir) and obtain the necessary orders for one of four sampled residents (Resident 1) who had a change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) that started on 8/14/2021. As a result, Resident 1 who required hemodialysis (HD, process of removing excess water, substances, and waste products from the blood in people with non-functioning kidneys) missed the scheduled HD treatments on 8/14/2021 and 8/17/2021. Resident 1 experienced increased confusion (inability to clearly think or reason), lethargy (sleepiness, deep unresponsiveness, and inactivity) and shortness of breath related to pulmonary congestion (accumulation of fluid in the lungs), due to not having HD for six days. This required hospitalization and placed Resident 1 at a high risk for further respiratory distress (severe shortness of breath due to lack of oxygen), [CONDITION(S)] (sudden, unexpected loss of heart function, breathing, and consciousness), and possible death. Resident 1 was transported with Advanced Life Support (ALS, provided when a patient is in more critical condition and a paramedic is required before and/or during transport to the emergency facility) to General Acute Care Hospital 1 (GACH 1) on 8/17/2021. Cross Reference with F698 and F656 Findings: 1. A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan on HD, initiated on 6/20/2021, indicated the following interventions: a. Coordinate the resident's care in collaboration with the [CONDITION(S)] center. b. Monitor for signs and symptoms of fluid or electrolyte imbalance (abnormal distribution of fluid or minerals in the blood or tissues throughout the body). c. Monitor for labs and report to the physician as needed. d. Monitor/document for peripheral [CONDITION(S)] (swelling of lower legs and hands) and ascites (abdominal swelling) and notify physician, if identified. e. Monitor/document/report to physician as needed any signs and symptoms of renal insufficiency (poor kidney functions), changes in the level of consciousness (person's awareness and understanding of what is happening to his/her surroundings), changes in skin turgor (skin's elasticity), oral mucosa (mucous membrane lining the inside of the mouth), and changes in heart and lung sounds. f. Observe for abdominal distention (increase in abdominal pressure with an increase in overall abdominal diameter) and monitor for abdominal girth (measurement of the distance around the abdomen at a specific point). A review of Resident 1's Order Summary Report from period 6/19/2021 to 8/1/2021 indicated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 6/23/2021, indicated Resident 1 did not have any impairment in cognition (mental action or process of acquiring knowledge and understanding). A review of Resident 1's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of DC 1's Nursing - Progress Notes Report for Resident 1, dated 8/11/2021, indicated skilled nursing facility (SNF) called DC 1 to notify them that Resident 1 accidentally, pulled out his HD catheter (soft plastic tube inserted into a vein). The report indicated [CONDITION(S)] Center Nurse 1 (DCN 1) assisted the SNF in making [MEDICATION(S)] Radiology (IR, performing minimally invasive procedures with the use of radiological image guidance) arrangements for the HD catheter replacement. A review of Resident 1's Health Status Note, dated 8/12/2021, indicated Resident 1 came back to the SNF from the GACH 3 with a new HD catheter in place to the left internal jugular vein (IJV, vein in the neck that drains blood from brain, face, and neck) and went to his HD appointment at DC 1 on the same day. A review of Resident 1's [CONDITION(S)] Communication Record, dated 8/14/2021, indicated DCN 2 was unable to dialyze (treat by means of [CONDITION(S)]) Resident 1. The record indicated Resident 1 needed another replacement of HD central venous catheter (CVC, tube used as a HD catheter placed in a large vein in the neck, chest, groin, or arm). A review of the attached order, dated 8/14/2021, indicated MD 2's order Nursing Home to arrange HD CVC replacement. A review of Resident 1's Health Status Note, dated 8/14/2021 timed at 5 pm, indicated Licensed Vocational Nurse 1 (LVN 1) received communication from DC 1 regarding inability to dialyze Resident 1 due to the malfunction of HD catheter, which was placed on 8/12/2021. The note indicated Resident 1's last HD was done on 8/12/21. The note indicated Primary Care Provider 1 (PCP 1) was aware of the missed [CONDITION(S)]. The note indicated Case Manager 1 (CM 1) was aware of the need to schedule a HD catheter replacement for Resident 1. A review of Resident 1's Change in Condition Evaluation, dated 8/14/2021 timed at 6:46 pm, indicated Resident 1's HD catheter was not functioning well. The evaluation indicated Registered Nurse 1 (RN 1) documented, Catheter has gotten worse, which sometimes happen even after it is newly placed. The evaluation indicated RN 1 notified PCP 1 on 8/14/2021 at 7 p.m. The resident's clinical records did not indicate any recommendations from PCP 1. A review of Resident 1's Change in Condition Evaluation, dated 8/16/2021 timed at 2:46 pm, indicated LVN 2 observed Resident 1 with increased confusion and lethargy was unable to complete full sentences, and was disoriented to time and place. The evaluation indicated LVN 2 notified PCP 1 on 8/16/2021 at 2 p.m. and obtained PCP 1's recommendation to send resident to ED (Emergency Department). A review of the Care Communications (facility's internal electronic communication system used by healthcare workers to communicate any changes in a resident's condition), dated 8/16/2021 timed at 3:06 p.m., indicated LVN 2 paged PCP 1 but was awaiting PCP 1 to return the call with orders. A review of Resident 1's Change in Condition Evaluation, dated 8/17/2021 timed at 4:13 am, indicated LVN 3 observed Resident 1 with increased confusion with other symptoms or signs of [CONDITION(S)] (sudden inability to pay attention, disorganized thinking). The evaluation indicated LVN 3 observed Resident 1 unable to answer a question and finish a sentence than usual. The evaluation indicated LVN 3 observed Resident 1 with chills and general weakness. The evaluation indicated LVN 3 notified PCP 1 on 8/17/2021 at 3:30 am and obtained PCP 1's recommendation to send Resident 1 to the hospital (not specified) via 911 (emergency services). A review of Resident 1's Nursing Home to Hospital Transfer Form, dated 8/17/2021, indicated Resident 1 left the facility to GACH 1 due to altered mental status. A review of Resident 1's ED Report from GACH 1, dated 8/17/2021, indicated Resident 1 presented to the ED due to altered mental status, confusion, shortness of breath. The Report indicated Resident 1 did not have [CONDITION(S)] for five days due to malfunction of the [CONDITION(S)] catheter that was in place in the left IJV. A review of Resident 1's Consultation Report from GACH 1, dated 8/17/2021, indicated Resident 1's shortness of breath likely from fluid overload due to missing hemodialysis, as Chest X-ray (creates pictures of the inside of the body), revealed pulmonary congestion. The Report indicated recommendations for hemodialysis with fluid removal. A review of Resident 1's Discharge Summary from GACH 1, dated 8/23/2021, indicated that Resident 1 was transferred to GACH 5 to have HD catheter replacement and resumed HD on 8/19/2021, because the HD catheter replacement at GACH 1 was unsuccessful. During a telephone interview on 9/20/2021 at 12:30 p.m., Certified Nursing Assistant 1 (CNA 1) stated on 8/16/2021 (7-3 shift), LVN 2 and RN 2 were aware of Resident 1's increased confusion and decided to transfer Resident 1 to the hospital (in general). CNA 1 stated she did not know the reason why Resident 1 was not transferred to the hospital during the 7-3 shift on 8/16/2021. During a telephone interview on 9/20/2021 at 1:15 pm, RN 1 stated she was unable to recall about the exact details of the incident when Resident 1 came back to the facility on [DATE] (3-11 shift) from DC 1 due to a malfunction of the HD catheter. RN 1 stated she was not able to speak with PCP 1 directly to obtain any orders. RN 1 stated she left a message for PCP 1 and endorsed the incident to the next nurse. RN 1 stated if a resident (in general) missed a [CONDITION(S)] session during the weekend, he/she must wait until Monday when the surgeon's office opens. RN 1 stated depending on the resident (in general), he/she could last a few days or weeks without receiving [CONDITION(S)] treatment. During a telephone interview on 9/20/2021 at 4:34 pm, RN 2 stated she was unable to recall calling PCP 1 for Resident 1 on 8/16/2021 (7-3 shift) regarding a change in condition (COC). RN 2 stated she was unable to recall making arrangements for Resident 1's HD catheter replacement on 8/16/2021 (7-3 shift), and stated CM 1 was responsible for making arrangements to have the HD catheter replaced. RN 2 stated that if there was delay in establishing a HD catheter, the resident (in general) must be transferred to the hospital via 911 with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 9/20/2021 at 4:51 pm, LVN 2 stated she recalled attempting to contact PCP 1 regarding Resident 1's increased confusion on 8/16/2021 (7-3 shift) but not getting a response from PCP 1 during her shift. LVN 2 was unable to recall if RN 2 or CM 1 were made aware of Resident 1's change in condition, but she stated the RN Supervisor (in general) was responsible for making arrangements for resident transfers to the hospital. LVN 2 stated she did not recall notifying the Medical Director (MedDir) or Resident 1's nephrologist (MD 2, physician who specializes in kidney disorders). LVN 2 was unable to recall the reason why Resident 1 was not transferred during her shift even though her documentation indicated she notified PCP 1 on 8/16/2021 at 2 pm with PCP 1's order to Send resident to ED. During a telephone interview on 9/21/2021 at 4:18 pm, PCP 1 stated he did not receive any notification from the SNF on 8/14/2021 and 8/15/2021 regarding Resident 1's missed [CONDITION(S)] due to the HD catheter malfunction. PCP 1 stated the SNF staff sent him a notification on 8/16/2021 about Resident 1 not feeling well, and PCP 1 stated he must have called them back, but could not recall the exact details of the conversation. PCP 1 stated if the SNF staff informed him that Resident 1 did not have HD for at least three days on 8/16/2021, he would have given the order to transfer the resident to the ED immediately. PCP 1 stated he spoke to the SNF staff on 8/17/2021 regarding Resident 1's transfer to another ED because the other ED was full. PCP 1 stated the SNF staff should have notified MD 2 to obtain orders for laboratory tests to determine Resident 1's plan of care. During a telephone interview on 9/23/2021 at 7:53 am, LVN 3 stated when he started his shift on 8/16/2021 (11-7 shift), Resident 1 did not look good anymore. LVN 3 stated Resident 1 had increased confusion and was unable to finish a sentence. LVN 3 stated LVN 2 documented Resident 1 had not received HD since 8/14/2021 but LVN 2 had not received a response from PCP 1. LVN 3 stated after calling PCP 1's number about two to three times, PCP 1 called back on 8/17/2021 at 3:30 am, and gave LVN 3 an order to send Resident 1 to the hospital via 911. LVN 3 stated if he did not obtain the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 3 stated it was not a common facility practice to contact the MedDir to obtain an emergency order to transfer a resident to the hospital. During a telephone interview on 9/23/2021 at 8:26 am, RN 4 stated she did not recall getting a report from the previous nurse about the need to follow up with PCP 1 regarding Resident 1's COC, missed HD session, malfunction of HD catheter site, or pending transfer to the hospital when she started her shift on 8/16/2021 (11-7 shift). RN 4 stated if she received this information during the change-of-shift report, she would have questioned why Resident 1 still has not been transferred to the hospital. RN 4 stated LVN 3 notified her about Resident 1's increased confusion and having no [CONDITION(S)] for four days. RN 4 stated if LVN 3 was not able to contact PCP 1 that shift, she would have called the MedDir to obtain advice on what to do besides continuous monitoring of Resident 1. During a telephone interview on 9/23/2021 at 12:30 pm, MD 2 stated he was Resident 1's nephrologist in DC 1. MD 2 stated he did not receive a call from the facility on 8/14/2021 and 8/15/2021. MD 2 stated if the SNF staff notified him that Resident 1 did not have [CONDITION(S)] for at least three days, he would have given the order to send Resident 1 to the ED immediately to ensure emergency capabilities, requested for STAT potassium level (laboratory test to be drawn immediately to determine potassium concentration in the blood), and ordered a medication to lower the potassium level due to a concern for dangerously high levels of potassium that could lead to [CONDITION(S)]. During a telephone interview on 9/27/2021 at 3:08 pm, LVN 1 was unable to recall if she called PCP 1 on 8/14/2021 (3-11 shift) to inform about the missed [CONDITION(S)] related to the HD catheter malfunction when Resident 1 came back to the SNF from DC 1. LVN 1 stated she did not recall contacting MD 2 because MD 2's name and contact information were not on Resident 1's chart. During a telephone interview and a concurrent review of Resident 1's medical records on 9/28/2021 at 12:15 pm, the Director of Nursing (DON) stated if unsuccessful to reach PCP 1, LVN 2 should have called the MedDir to get some advice and determine the plan of care. The DON stated LVN 2 endorsed to the next shift the need to follow up with PCP 1, but there was no documented evidence that the 3-11 shift nurses assigned to Resident 1 on 8/16/2021 followed up with PCP 1 or notified the MedDir of the incident. During a telephone interview on 9/28/2021 at 1:49 pm, with regard to the discrepancy on LVN 2's notes on 8/16/2021 (7-3 shift), the DON stated LVN 2 informed her that PCP 1 did not respond during her entire shift on 8/16/2021 (7-3 shift) but LVN 2 admitted going back to her charting on Resident 1's Change in Condition Evaluation, dated 8/16/2021 timed at 2:46 pm, to add the physician's recommendation Send resident to ED, after Resident 1 had already been transferred to the ED. A review of the facility's policy and procedures, titled Change in a Resident's Condition or Status, dated 5/2017, indicated the facility must promptly notify the resident, the attending physician, and representative of changes in the resident's medical/mental condition. The policy indicated the nurse must notify the attending physician or physician on-call where there has been a significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, or a need to transfer the resident to a hospital or treatment center. A review of the facility's policy and procedures, titled Medical Director, undated, indicated physician services must be under the supervision of the Medical Director. The policy indicated the Medical Director functions included acting as a consultant to the director of nursing services in matters relating to resident care services, helping assure that residents receive adequate services appropriate to meet their needs, and helping assure that the resident care plan accurately reflects the medical regimen.

Based on observation, interview, and record review, the facility failed to ensure three of twenty-three sampled residents (Resident 351, Resident 2, and Resident 501) were free from significant medication errors (causes the resident discomfort or jeopardizes his or her health and safety) by failing to: 1. Ensure the licensed nurses administered twelve doses of [MEDICATION(S)] (medication used to treat [CONDITION(S)] (a sudden, uncontrolled electrical disturbance in the brain) 150 milligrams (mg, unit of measurement) from 4/17/2021 to 4/23/2021, three doses of [MEDICATION(S)] (medication to treat partial [CONDITION(S)]) 100 mg on 4/17/2021, 4/21/2021, and 4/22/2021, one dose of [MEDICATION(S)] (medication used to treat seizures) 100 mg tablet on 4/17/2021, and six doses of [MEDICATION(S)] 200 mg from 4/17/2021 to 4/22/2021. 2. Ensure to follow Resident 2's pharmacy medication label instructions not to crush one tablet of [MEDICATION(S)] (medication used to treat low potassium, a mineral the body needs to work properly, and to treat certain heart conditions), extended release (ER, the medication is release slowly overtime) tablet 20 milliequivalent (mEq, unit of measurement), not to open one capsule of tamsulosin (generic for [MEDICATION(S)], medication used to treat prostate, a male organ condition) 0.4 mg, and not to open one capsule of [MEDICATION(S)] 24 hours ER (a medication to treat high blood pressure and certain heart conditions). 3. Ensure Resident 501 received medications timely. As a result, Resident 351 experienced [CONDITION(S)] episodes (five) on 4/21/2021 at 10:40 am, requiring transfer to General Acute Care Hospital 1 (GACH 1) for evaluation of seizures, placed Resident 2 at risk to experience chemical imbalances and harm, and the potential of not meeting the medication needs of the residents which may affect residents' health condition. The Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment or death to a resident) situation on 4/23/2021 at 6:58 pm, in the presence of the Administrator (ADM) and Director of Nursing (DON). The ADM and DON were informed of the facility's failure to have systems in place to ensure Resident 351 received scheduled medications as prescribed. These deficient practices resulted in serious actual harm to Resident 351 and potential for serious harm for Resident 2 and threatened the health and safety of all 150 residents in the facility with prescribed scheduled and PRN medications and supplements. On 4/24/2021 at 3:05 pm the survey team verified the implementation of the acceptable Plan of Action (POA, a detailed plan) by observation and record review. The POA was not accepted on 4/24/2021. On 4/25/2021 at 4:39 pm the survey team confirmed the removal of the IJ after verification and acceptance of the POA and after following up with observation, interviews, and record review in the presence of the ADM and DON. The ADM and DON provided an acceptable plan of action on 4/25/2021: A. On 4/23/2021, Resident 351 was monitored for [CONDITION(S)] activity from 7 am to 11 pm by the charge nurses (unidentified) and the resident did not have a [CONDITION(S)] activity noted and was documented in the medication administration record of the resident. B. On 4/23/2021 at 10:29 pm, the pharmacy delivered [MEDICATION(S)]. [MEDICATION(S)] was administered to Resident 351 by a Charge nurse (unidentified) on 4/23/2021 at 10:30 pm. Resident 351 received all medications as ordered. C. On 4/23/2021, the DON investigated Resident 351's Medication Administration Record (MAR) entry dated 4/18/2021. LVN (Licensed Vocational Nurse) 8 stated that she signed the medication [MEDICATION(S)] at 4/18/2021 as given. This was signed in error because the medication was not available. On 4/19/2021, LVN 8 documented that [MEDICATION(S)] was not in the cart and previous documentation was an error. D. On 4/23/2021, the DON provided one to one education with LVN 8 involved regarding accuracy of MAR documentation follow up with Pharmacy if medication was not available in the medication cart and to immediately notify the DON and/or Assistant DON (ADON). E. On 4/24/2021, the Pharmacy Consultant completed MRR (Medication Regimen Review) to current residents receiving anti-[CONDITION(S)] medications for [CONDITION(S)] and other medications to determine if any medication error was noted. No medication error identified by the Pharmacy Consultant. F. On 4/23/2021 and 4/24/2021, the DON, ADON, Infection Preventionist (IP, nurse who helps prevent and identify the spread of infections), and the Director of Staff Development (DSD) conducted a two-way medication audit (process where a charge nurse checks the MAR of residents that are due for weekly summary on their respective shifts and compares the MAR with the actual medications on hand), of current residents with order for antiseizure medications. To validate that medications were available in the medication cart; to validate that there were at least five to seven days' supply of anti-[CONDITION(S)] medications available in the medication cart, to meet the residents' needs and to validate that the anti-[CONDITION(S)] medications were given on 4/23/2021 accurately reflected what medications were administered to a respective resident. There were currently sixteen residents with order for anti-[CONDITION(S)] medications. The DON, ADON, and the IP nurse, reviewed the number of anti-[CONDITION(S)] medications available on hand. G. On 4/23/2021, the DON provided a one to one in-service to the Charge Nurses assigned to Resident 351 on 4/17/2021, 4/18/2021, 4/19/2021, 4/20/2021, 4/22/2021 and 4/23/2021 on the importance of accurately documenting medications given in the MAR and the importance of following up with the Pharmacy if medication was not available and communicating this issue with the physician and with the DON immediately. H. Two-way medication audit to current residents receiving antiseizure drugs started on 4/23/21 by the DON and ADON. The Pharmacy Nurse consultants (licensed nurses employed by the pharmacy) conducted a two-way medication audits on 4/24/2021 and 4/25/2021. I. On 4/24/2021, the Pharmacy Consultant provided training and evaluation of competencies to all active RNs (Registered Nurse) and LVNs with regards to the identification, prevention, intervention, care, treatment and correction of factors that can cause seizures and hospitalization and will be done on a quarterly basis and as needed. J. On 4/24/2021, Pharmacy Consultant conducted an assessment of the all active RNs and LVNs regarding their knowledge and competency with regards to the identification, prevention, intervention, care, treatment and correction of factors that can cause seizures and hospitalization and this will be done on a quarterly basis and as needed. K. The DON, Pharmacy Nurse Consultant and/or designee randomly conducted a two-way medication audit to residents with orders for anti-[CONDITION(S)] drug to validate for compliance. L. A Clinical team consisting of the DON and/or designee and MDS (Minimum Data Set) nurse conducted new admit chart review of medication orders, review of MAR for accuracy and validated that the admission medications were ordered and available in the medication cart daily. M. The DON, Nursing Supervisor, and the Medical Record staff reviewed the MAR daily during the Clinical team Meeting to validate that MAR documentation was complete. N. The Pharmacy Nurse Consultant conducted a two-way medication audit of residents with order for anti-[CONDITION(S)] to validate for compliance. The facility developed a Medication Management Advisory Committee (MMAC) consist of the following members: ADM, DON, Consultant, Pharmacist, Medical Director and DSD. The purpose of the MMAC was to assist with the identification of dispensing, ordering and delivery and receiving process of medication, medication-related errors, evaluate causes, and take appropriate actions to promote safe prescribing, ordering, receiving, dispensing, and administration of medications. The duties and responsibilities of MMAC included to: assessing pharmaceutical management systems, including administration policies to identify high-risk areas for medication related errors, risk reduction to improve resident safety by reducing the risk of medication related errors. The MMAC 1st meeting was held on 4/24/21 at 10:45 am. The Committee conducted a root cause analysis. Cross Reference F755 Findings: 1. A review of Resident 351's Admission Record indicated the facility admitted the resident on 4/17/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 351's Order Summary Report dated 4/17/2021 indicated for the resident to receive [MEDICATION(S)] 150 mg twice a day for [CONDITION(S)], Lamotrigine100 mg one time a day for [CONDITION(S)], [MEDICATION(S)] tablet 200 mg twice a day for [CONDITION(S)], and [MEDICATION(S)] 100 mg twice a day for [CONDITION(S)]. A review of Resident 351's Progress Notes dated 4/17/2021and timed at 8:18 pm, indicated the facility was waiting for the pharmacy to deliver [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. A review of Resident 351's untitled care plan dated 4/17/2021, indicated the resident had a [CONDITION(S)] disorder and the nursing interventions were to administer [CONDITION(S)] medications as ordered and to monitor side effects and effectiveness. A review of Resident 351's Initial History and Physical dated 4/18/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 351's Progress Notes dated 4/18/2021 and timed at 5:25 pm, indicated the facility was waiting for the pharmacy to deliver [MEDICATION(S)] 200 mg and [MEDICATION(S)] 150 mg. A review of Resident 351's Progress Notes dated 4/19/2021 and timed at 9:21 am indicated the facility was waiting for the pharmacy to deliver [MEDICATION(S)] 200 mg and [MEDICATION(S)] Medication not in cart previous documentation an error. A review of Resident 351's Progress Notes dated 4/20/2021 and timed at 4:23 pm. Indicated the facility was waiting for the pharmacy to deliver [MEDICATION(S)]. A review of Resident 351's Change in Condition Evaluation dated 4/21/2021 and timed at 11 am, indicated during a patio visit with FAM 1 (Family member), Resident 351 was noted with a [CONDITION(S)] episode and was transferred to a GACH1 via 911 (emergency services). During observation on 4/21/2021 at 10:40 am, at the facility's patio visitation area during a rapid response code (relating to a person or group of people whose job is to react quickly to a dangerous or important situation), Resident 351 was sitting on a chair and a facility staff (unidentified) was holding resident's head and provided oxygen. During an interview on 4/21/2021 at 10:46 am, Resident 351's Family Member (FAM 1), stated she was with Resident 351 at the patio for her visitation when Resident 351's upper body started shaking for about five minutes. During an observation on 4/21/2021 at 10:48 am, at the facility's patio visitation area, the paramedics (a person trained to give emergency medical care to people who are injured or ill) arrived at the scene and transferred Resident 351 to a GACH1. A review of Resident 351's GACH 1's Emergency Department (ED) General notes dated 4/21/21, and timed at 12:18 pm, indicated Resident 351was nonresponsive (not reacting in any way) and had about five witnessed seizures on 4/21/2021 that lasted approximately one minute. The ED notes indicated the resident was discharged back to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 351's Progress Notes dated 4/21/2021 and timed at 5:35 pm, indicated the morning medications (on 4/21/2021) were not given to the Resident 351 prior the patio visit. During an interview and a review of Resident 351's Medication Administration Record (MAR) on 4/21/2021 at 12:10 pm, the ADON stated Resident 351's MAR dated on 4/21/2021 and timed at 9 am, indicated the resident did not receive [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. During an interview on 4/21/2021 at 12:17 pm, Licensed Vocational Nurse 4 (LVN 4) stated she did not give Resident 351's [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] that were due on 4/21/2021 at 9 am. LVN 4 stated [MEDICATION(S)] was not available at the facility. During interview on 4/21/2021 at 3:45 pm, LVN 6 stated the pharmacy did not deliver [MEDICATION(S)]. LVN 6 stated [MEDICATION(S)] was not available in the facility and Resident 351 did not receive [MEDICATION(S)] on 4/20/2021. During an interview and a review of Resident 351's MAR on 4/22/2021 at 1:35 pm Registered Nurse 2 (RN 2) stated Resident 351's MAR indicated the resident did not receive the following: [MEDICATION(S)] 150 mg from 4/17/2021 to 4/22/2021, [MEDICATION(S)] 100 mg on 4/17/2021 at 5 pm, 4/21/2021, and on 4/22/2021 at 9 am, [MEDICATION(S)] 100 mg on 4/17/2021 at 5 pm, [MEDICATION(S)] 200 mg on 4/17/2021 at 5 pm, and on 4/18/2021 to 4/22/2021 at 9 am. During an interview and a review of Resident 351's Progress Notes on 4/22/2021 at 1:45 pm RN 2 stated Resident 351's Progress Notes dated from 4/17/2021 to 4/22/2021, did not indicate any documentation regarding the delivery for [MEDICATION(S)]. RN 2 stated there was no documentation regarding the delivery of [MEDICATION(S)]. During an interview and observation on 4/22/2021 at 2:26 pm, LVN 8 checked the Emergency Kit Drug Storage (E-Kit, to provide medications during emergency situations) in the medication room and stated that [MEDICATION(S)] was not in the E-kit medication list. During an interview and an observation of the medication cart located in the second floor and assigned to the LVN 10, on 4/23/2021 at 1:29 pm, LVN 10 stated Resident 351's [MEDICATION(S)] was not available in her medication cart. During an interview 4/23/2021 at 1:46 pm, LVN 10 stated the [MEDICATION(S)] was not covered by insurance. During an interview on 4/23/2021 at 2:13 pm, RN 2 stated [MEDICATION(S)] was not sent to the facility because it was expensive. During an interview on 4/23/2021 at 5 pm, RN 2 stated she could not find the records for the medication ordered and received for Resident 351. During a telephone interview on 4/30/2021 at 3:37 pm, the DON stated Resident 351's Progress Notes dated 4/18/2021, and timed at 9:24 am and 4/19/2021 at 9:23 am, did not indicate any comments of why [MEDICATION(S)] was not given. During a telephone interview on 5/3/2021 at 1:29 pm, DON stated Resident 351 should have received her medications upon her admission on 4/17/21. The DON stated if the medication was not delivered the licensed nurses (in general) should have followed up with the pharmacy and should have called Resident 351's physician to inform of the missed [CONDITION(S)] medications. A review of the facility's Med-Pass Policy and Procedure with a review date of 1/27/2021 indicated all medications were administered as prescribed, and the facility maintained accurate records of medication order and receipt. The policy indicated new medications ordered, timely delivery was required so that medication administration was not delayed and if two consecutive doses of vital medication were withheld or refused, the physician was notified. A review of the facility's policy and procedure, titled Policy and Procedures for Med-Pass, with a review date of 1/27/2021, indicated Medication Error/Discrepancy, as an omission of a vital medication due to prescribing, dispensing, or administering error. The policy indicated the Significant, considered medication errors and adverse drug reactions that requiring hospitalization . A review of the facility's policy and procedure, titled Policy and Procedures for Med-Pass, with a review date of 1/27/2021, indicated that in the event of a significant/non-significant medication error or adverse drug reaction, immediate action was taken, as necessary, to protect the resident's safety and welfare. The attending physician was notified promptly (unspecified time) of any significant/non-significant error or adverse medication reaction. A review of the facility's policy and procedure, titled Policy and Procedures for Med-Pass, with a review date of 1/27/2021, indicated medications were administered within sixty (60) minutes of scheduled time. The policy also indicated all medications were administered as prescribed and the facility maintains accurate records of medication order and receipt. A review of the facility's policy and procedure, titled Policy and Procedures for Med-Pass, with a review date of 1/27/2021, indicated for New, medications inform the pharmacy of the need for prompt delivery and request delivery within four hours. The policy indicated the timely delivery of new order was required so that medication administration was not delayed. 2. A Review of Resident 2's Admission Record indicated the facility admitted the resident on 3/6/2018 and readmitted him on 11/3/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's medication order for tamsulosin 0.4 mg, dated 11/17/2020, indicated capsules should be swallowed whole; do not crush, chew or open. A review of Resident 2's medication Order for [MEDICATION(S)] extended release tablet 20 mEq dated 11/17/2020, indicated give with food and full glass of fluid. Do not crush or chew. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/16/2021 indicated the resident did not have signs and symptoms of possible swallowing disorder, however, the resident was placed on mechanically altered diet which required the change in texture of food or liquids. During a medication administration observation on 4/21/2021 at 9:15 am Licensed Vocational Nurse 1 (LVN 1) prepared fourteen medications for Resident 2 outside of the resident's room. During the preparation, LVN 1 opened 1 capsule of tamsulosin, 1 capsule of [MEDICATION(S)] 24 hours ER and crushed a tablet of [MEDICATION(S)] M20. During an interview on 4/21/2021 at 9:33 am, LVN 1 stated she was not aware those medications should be swallowed as is. LVN 1 stated she would contact the pharmacy for clarification because the resident could not swallow tablet or capsule. A review of the facility's Med-Pass Policy and Procedure with a review date of 1/27/2021 indicated all medications were administered as prescribed. 3. On 4/22/2021 at 12 noon during an observation, LVN 4 was preparing Resident 501's medication outside of the resident room During a concurrent interview, LVN 4 stated she was assigned 26 residents for the day and responsible for their medication administration. LVN 4's assigned residents included those resided in the yellow zone (a quarantine cohort for residents with suspected or under investigation for potential COVID-19 infection) which required donning [putting on] and doffing [taking off] additional personal protective equipment [such as gowns]). On 4/22/2021 at 1:47 PM during an interview, DON acknowledged Resident 501 received the 9 am medications at noon which was late. A review of the facility's policy and procedure, Administering Oral Medications (revised October 2020), the facility did not denote specifications on the medication administration timing.

Based on observation, interview, and record review, the facility failed to ensure three of twenty-three sampled residents (Resident 351, Resident 2, and Resident 501) received pharmaceutical services to meet the needs of each resident in a consistent manner in accordance with physician orders and facility's Med-Pass policy and procedures by failing to: 1. Ensure to administer Resident 351's twelve doses of [MEDICATION(S)] (medication used to treat [CONDITION(S)], a sudden, uncontrolled electrical disturbance in the brain) 150 milligrams (mg, unit of measurement) from 4/17/2021 to 4/23/2020 (six days and a half), three doses of [MEDICATION(S)] (medication to treat partial [CONDITION(S)]) 100 mg on 4/17, 4/21, on 4/22/2021, one dose of [MEDICATION(S)] (medication used to treat seizures) 100 mg tablet on 4/17/2021, and six doses of [MEDICATION(S)] 200 mg from 4/17/2021 to 4/22/2021 as ordered by the physician to manage the resident's [CONDITION(S)]. 2. Follow Resident 2's pharmacy medication label instructions not to crush one tablet of [MEDICATION(S)] (medication used to treat low potassium, a mineral the body needs to work properly, and to treat certain heart conditions), extended release (ER, the medication is release slowly overtime) tablet 20 milliequivalent (mEq, unit of measurement), not to open one capsule of tamsulosin (generic for [MEDICATION(S)], medication used to treat prostate, a male organ condition) 0.4 mg, and not to open one capsule of [MEDICATION(S)] 24 hours ER (a medication to treat high blood pressure and certain heart conditions). 3.Ensure timely medication administration for Resident 501 observed; as a result, Resident 501 received the 9 am medications at around noon time. As a result, Resident 351 experienced [CONDITION(S)] episodes (five) on 4/21/2021 at 10:40 am, requiring transfer to General Acute Care Hospital 1 (GACH 1) for evaluation of seizures and placed Resident 2 at risk to experience chemical imbalances and harm.These deficient practices had the potentials of not meeting the medication needs of the residents which may affect residents' health condition. The Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment or death to a resident) situation on 4/23/2021 at 6:58 pm, in the presence of the Administrator (ADM) and Director of Nursing (DON). The ADM and DON were informed of the facility's failure to have systems in place to ensure Resident 351 received scheduled and as needed (PRN) medications and supplements as prescribed. These deficient practices resulted in serious actual harm to Resident 351 and potential for serious harm for Resident 2 and threatened the health and safety of all 150 residents in the facility with prescribed scheduled and PRN medications and supplements. On 4/24/2021 at 3:05 pm the survey team verified the implementation of the acceptable Plan of Action (POA, a detailed plan) by observation and record review. On 4/25/2021 at 4:39 pm the survey team confirmed the removal of the IJ after verification of the POA and after following up with observation, interviews, and record review in the presence of the ADM and DON. The ADM and DON provided an acceptable plan of action: A. On 4/23/2021, Resident 351 was monitored for [CONDITION(S)] activity from 7 am to 11 pm by the charge nurses (unidentified) and the resident did not have a [CONDITION(S)] activity noted and was documented in the medication administration record of the resident. B. On 4/23/2021 at 10:29 pm, the pharmacy delivered [MEDICATION(S)]. [MEDICATION(S)] was administered to Resident 351 by a Charge nurse (unidentified) on 4/23/2021 at 10:30 pm. Resident 351 received all medications as ordered. C. On 4/23/2021, the DON investigated Resident 351's Medication Administration Record (MAR) entry dated 4/18/2021. Licensed Vocational Nurse 8 (LVN 8) involved stated that she signed the medication [MEDICATION(S)] at 4/18/2021 as given. This was signed in error because the medication was not available. On 4/19/2021, LVN 8 documented that [MEDICATION(S)] was not in the cart and previous documentation was an error. D. On 4/23/2021, the DON provided one to one education with LVN 8 involved regarding accuracy of MAR documentation follow up with Pharmacy if medication was not available in the medication cart and to immediately notify the DON and/or Assistant DON (ADON). E. On 4/24/2021, the Pharmacy Consultant completed MRR (Medication Regimen Review) to current residents receiving anti-[CONDITION(S)] medications for [CONDITION(S)] and other medications to determine if any medication error is noted. No medication error identified by the Pharmacy Consultant. F. On 4/23/2021 and 4/24/2021, the DON, ADON, Infection Preventionist (IP, nurse who helps prevent and identify the spread of infections), and the Director of Staff Development (DSD) conducted a two-way medication audit (process where a charge nurse checks the MAR of residents that are due for weekly summary on their respective shifts and compares the MAR with the actual medications on hand), of current residents with order for antiseizure medications. To validate that medications were available in the medication cart; to validate that there were at least five to seven days' supply of anti-[CONDITION(S)] medications available in the medication cart, to meet the residents' needs and to validate that the anti-[CONDITION(S)] medications were given on 4/23/2021 accurately reflected what medications were administered to a respective resident. There were currently sixteen residents with order for anti-[CONDITION(S)] medications. The DON, ADON, and the IP nurse, reviewed the number of anti-[CONDITION(S)] medications available on hand. G. On 4/23/2021, the DON provided a one to one in-service to the Charge Nurses assigned to Resident 351 on 4/17/2021, 4/18/2021, 4/19/2021, 4/20/2021, 4/22/2021 and 4/23/2021 on the importance of accurately documenting medications given in the MAR and the importance of following up with the Pharmacy if medication was not available and communicating this issue with the physician and with the DON immediately. H. Two-way medication audit to current residents receiving antiseizure drugs started on 4/23/21 by the DON and ADON. The Pharmacy Nurse consultants (licensed nurses employed by the pharmacy) conducted a two-way medication audits on 4/24/2021 and 4/25/2021. I. On 4/24/2021, the Pharmacy Consultant provided training and evaluation of competencies to all active Registered Nurses (RNs) and LVNs with regards to the identification, prevention, intervention, care, treatment and correction of factors that can cause seizures and hospitalization and will be done on a quarterly basis and as needed. J. On 4/24/2021, Pharmacy Consultant conducted an assessment of the all active RNs and LVNs regarding their knowledge and competency with regards to the identification, prevention, intervention, care, treatment and correction of factors that can cause seizures and hospitalization and this will be done on a quarterly basis and as needed. K. The DON, Pharmacy Nurse Consultant and/or designee randomly conducted a two-way medication audit to residents with orders for anti-[CONDITION(S)] drug to validate for compliance. L. A Clinical team consisting of the DON and/or designee and MDS nurse conducted new admit chart review of medication orders, review of MAR for accuracy and validated that the admission medications were ordered and available in the medication cart daily. M. The DON, Nursing Supervisor, and the Medical Record staff reviewed the MAR daily during the Clinical team Meeting to validate that MAR documentation was complete. N. The Pharmacy Nurse Consultant conducted a two-way medication audit of residents with order for anti-[CONDITION(S)] to validate for compliance. The facility developed a Medication Management Advisory Committee (MMAC) consist of the following members: ADM, DON, Consultant, Pharmacist, Medical Director and DSD. The purpose of the MMAC was to assist with the identification of dispensing, ordering and delivery and receiving process of medication, medication-related errors, evaluate causes, and take appropriate actions to promote safe prescribing, ordering, receiving, dispensing, and administration of medications. The duties and responsibilities of MMAC included to: assessing pharmaceutical management systems, including administration policies to identify high-risk areas for medication related errors, risk reduction to improve resident safety by reducing the risk of medication related errors. The MMAC 1st meeting was held on 4/24/21 at 10:45 am. The Committee conducted a root cause analysis. Cross Reference F760 Findings: 1. A review of Resident 351's Admission Record indicated the facility admitted the resident on 4/17/2021 with diagnoses including [CONDITION(S)] (brain disorder that cause [CONDITION(S)]) and [CONDITION(S)] (condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth). A review of Resident 351's Physician's Order dated 4/17/2021 indicated for the resident to receive [MEDICATION(S)] 150 mg twice a day for [CONDITION(S)], Lamotrigine100 mg one time a day for [CONDITION(S)], [MEDICATION(S)] tablet 200 mg twice a day for [CONDITION(S)], and [MEDICATION(S)] 100 mg twice a day for [CONDITION(S)]. A review of Resident 351's Progress Notes dated 4/17/2021and timed at 8:18 pm, indicated the facility was waiting for the pharmacy to deliver [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. A review of Resident 351's Care Plan dated 4/17/2021, indicated the resident had [CONDITION(S)] disorder and the nursing interventions included administering [CONDITION(S)] medications as ordered and monitoring side effects and effectiveness of the medications. A review of Resident 351's Initial History and Physical dated 4/18/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 351's Progress Notes dated 4/18/2021 and timed at 5:25 pm, indicated the facility was waiting for the pharmacy to deliver [MEDICATION(S)] 200 mg and [MEDICATION(S)] 150 mg. A review of Resident 351's Progress Notes dated 4/19/2021 and timed at 9:21 am indicated the facility was waiting for the pharmacy to deliver [MEDICATION(S)] 200 mg and [MEDICATION(S)] Medication not in cart previous documentation an error. A review of Resident 351's Progress Notes dated 4/20/2021 and timed at 4:23 pm. Indicated the facility was waiting for the pharmacy to deliver [MEDICATION(S)]. A review of Resident 351's Change in Condition Evaluation dated 4/21/2021 and timed at 11 am, indicated during a patio visit with FAM 1, Resident 351 was noted with a [CONDITION(S)] episode and was transferred to GACH 1 via 911 (emergency services). A review of Resident 351's GACH 1's Emergency Department (ED) General notes dated 4/21/21, and timed at 12:18 pm, indicated Resident 351was nonresponsive (not reacting in any way) and had about five witnessed seizures on 4/21/2021 that lasted approximately one minute. The ED notes indicated the resident was discharged back to the facility on [DATE] with diagnoses of [CONDITION(S)] disorder and breakthrough [CONDITION(S)] (suddenly experiences a [CONDITION(S)]). A review of Resident 351's Progress Notes dated 4/21/2021 and timed at 5:35 pm, indicated the morning medications (on 4/21/2021) were not given to the resident prior the patio visit. During observation on 4/21/2021 at 10:40 am, at the facility's patio visitation area during a rapid response code (relating to a person or group of people whose job is to react quickly to a dangerous or important situation), Resident 351 was sitting on a chair and a facility staff (unidentified) was holding resident's head and provided oxygen. During an interview on 4/21/2021 at 10:46 am, Resident 351's FM 1, stated she was with Resident 351 at the patio for her visitation when Resident 351's upper body started shaking for about five minutes. During an observation on 4/21/2021 at 10:48 am, at the facility's patio visitation area, the paramedics (a person trained to give emergency medical care to people who are injured or ill) arrived at the scene and transferred Resident 351 to a GACH. During an interview and a review of Resident 351's MAR on 4/21/2021 at 12:10 pm, the MAR did not have a check mark on 4/21/2021 at 9 am for the [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. The ADON confirmed Resident 351's MAR dated on 4/21/2021 and timed at 9 am, indicated the resident did not receive [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. During an interview on 4/21/2021 at 12:17 pm, Licensed Vocational Nurse 4 (LVN 4) stated she did not give Resident 351's [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] that were due on 4/21/2021 at 9 am. LVN 4 stated [MEDICATION(S)] was not available at the facility. During interview on 4/21/2021 at 3:45 pm, LVN 6 stated the pharmacy did not deliver [MEDICATION(S)]. LVN 6 stated [MEDICATION(S)] was not available in the facility and Resident 351 did not receive [MEDICATION(S)] on 4/20/2021. During an interview and a review of Resident 351's MAR on 4/22/2021 at 1:35 pm RN 2 confirmed Resident 351's MAR indicated the resident did not receive the following: [MEDICATION(S)] 150 mg from 4/17/2021 to 4/22/2021, [MEDICATION(S)] 100 mg on 4/17/2021 at 5 pm, 4/21/2021, and on 4/22/2021 at 9 am, [MEDICATION(S)] 100 mg on 4/17/2021 at 5 pm, [MEDICATION(S)] 200 mg on 4/17/2021 at 5 pm, and on 4/18/2021 to 4/22/2021 at 9 am. During an interview and a review of Resident 351's Progress Notes on 4/22/2021 at 1:45 pm RN 2 confirmed Resident 351's Progress Notes dated from 4/17/2021 to 4/22/2021, did not indicate any documentation regarding the delivery for [MEDICATION(S)]. RN 2 stated there was no documentation regarding the delivery of [MEDICATION(S)]. During an interview 4/23/2021 at 1:29 pm, LVN 10 stated Resident 351's [MEDICATION(S)] was not available in the facility. During an interview on 4/23/2021 at 5 pm, RN 2 stated she could not find the records for the medication ordered and received for Resident 351. During a telephone interview on 4/30/2021 at 3:37 pm, the DON stated Resident 351's Progress Notes dated 4/18/2021, and timed at 9:24 am and 4/19/2021 at 9:23 am, did not indicate any comments of why [MEDICATION(S)] was not given. During a telephone interview on 5/3/2021 at 1:29 pm, DON stated Resident 351 should have received her medications upon her admission on 4/17/21. The DON stated if the medication was not delivered the licensed nurses (in general) should have followed up with the pharmacy and should have called Resident 351's physician to inform of the missed [CONDITION(S)] medications. DON added, Resident 351's physician was not informed right away and the order of [MEDICATION(S)] was not followed up with the pharmacy. A review of the facility's Med-Pass Policy and Procedure with a review date of 1/27/2021 indicated all medications were administered as prescribed, and the facility maintained accurate records of medication order and receipt. The policy indicated new medications ordered, timely delivery was required so that medication administration was not delayed and if two consecutive doses of vital medication were withheld or refused, the physician was notified. 2. A Review of Resident 2's Admission Record indicated the facility admitted the resident on 3/6/2018 and readmitted him on 11/3/2020 with diagnoses included dysphagia (difficulties in swallowing), hypertension (high blood pressure). A review of Resident 2's medication order for tamsulosin 0.4 mg, dated 11/17/2020, indicated capsules should be swallowed whole; do not crush, chew or open. A review of Resident 2's medication Order for [MEDICATION(S)] extended release tablet 20 mEq dated 11/17/2020, indicated give with food and full glass of fluid. Do not crush or chew. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/16/2021 indicated the resident did not have signs and symptoms of possible swallowing disorder, however, the resident was placed on mechanically altered diet which required the change in texture of food or liquids. During a medication administration observation on 4/21/2021 at 9:15 am Licensed Vocational Nurse 1 (LVN 1) prepared fourteen medications for Resident 2 outside of the resident's room. During the preparation, LVN 1 opened 1 capsule of tamsulosin, 1 capsule of [MEDICATION(S)] 24 hours ER and crushed a tablet of [MEDICATION(S)] M20. During an interview on 4/21/2021 at 9:33 am, LVN 1 stated she was not aware those medications should be swallowed as is. LVN 1 stated she would contact the pharmacy for clarification because the resident could not swallow tablet or capsule. A review of the facility's Med-Pass Policy and Procedure with a review date of 1/27/2021 indicated all medications were administered as prescribed. 3.On 4/22/2021 at 12 noon during an observation, LVN 4 was preparing Resident 501's medication outside of the resident's room During a concurrent interview, LVN 4 stated she was assigned to 26 residents for the day and responsible for their medication administration. LVN 4 stated assigned residents included those residing in the yellow zone (a quarantine cohort for residents with suspected or under investigation for potential COVID-19 infection) which required donning [putting on] and doffing [taking off] additional personal protective equipment [such as gowns]). During an interview on 4/22/21 at 1:47 pm , DON acknowledged Resident 501 received the 9 am medications at noon and stated the medications were administered late. A review of the facility's policy and procedure titled Administering Oral Medications, with a revised date of October 2020, indicated the facility did not denote specifications on the medication administration timing.

Based on observation, interview, and record review, the facility failed to provide range of motion exercises (activity aimed at improving movement of a specific joint, a point where two bones make contact) to four of four sampled residents (Residents 46, 35, 72, and 100) as indicated in the facility's Restorative Nursing Services policy. This deficient practice resulted for Resident 46 to experience pain and decline in mobility that caused severe worsening of contracture (deformity and stiffness of joints) of the resident's left upper extremity (LUE, left shoulder, elbow, and hand) and had the potential to cause a decline in range of motion (ROM, the full movement potential of a joint) and promote the development of contractures to Residents 35, 72, and 100. Findings: a. A review of Resident 46's Admission Record indicated Resident 46 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 46's Joint Mobility Screening, dated 1/25/21, indicated Resident 46's passive range of motion (PROM, amount of motion at a given joint when the joint is moved by an external force or by a therapist) for the left shoulder and left elbow had minimal (less than<25%) loss of motion. Resident 46's left hand had moderate (26-50%) to severe (more than> 50%) loss of motion. A review of Resident 46's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 1/25/21, indicated Resident 46 was seen for an Evaluation Only. OT evaluation indicated Resident 46's LUE had impaired ROM at the shoulder, elbow, forearm, wrist, and hand. OT evaluation indicated Resident 46 verbalized 0/10 pain at rest and 7/10 intermittent (not continuous or steady) sharp pain in left hand. A review of Resident 46's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 1/25/21, indicated Resident 46 was seen for an Evaluation Only due to behaviors including being uncooperative, resistive, and refusal to participate in the evaluation. PT Evaluation indicated Resident 46's LUE was impaired with decreased ROM in the left elbow and shoulder. PT Evaluation also indicated Resident 46 had flexion contractures (chronic loss of joint motion) in the left hand. PT Evaluation indicated Resident 46 verbalized 0/10 pain (no pain) at rest and 8/10 (severe pain) intermittent aching pain in left hand with passive stretching. A review of Resident 46's Interdisciplinary Team (IDT, involving two or more disciplines or fields of study) Conference, dated 1/29/21, did not indicate Resident 46 had limited range of motion to the LUE. IDT Conference indicated Resident 46 had no complaints of pain and discomfort. A representative from Rehabilitation services signed as present during the IDT Conference. A review of Resident 46's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 1/29/21 indicated Resident 46 usually understood others and was able to express ideas and wants. The MDS Indicated Resident 46's cognition (thinking and memory skills) was severely impaired for daily decision making. The MDS indicated Resident 46 had no functional limitations in range of motion in both arms. A review of Resident 46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 46's Joint Mobility Screening, dated 4/5/21, indicated Resident 46's PROM had severe (>50%) loss of motion at the left shoulder, elbow, and hand. A review of Resident 46's OT Evaluation and Plan of Treatment, dated 4/5/21, indicated Resident 46 had a contracture with impaired LUE ROM to the shoulder, elbow, forearm, wrist, and hand. The OT Evaluation indicated Resident 46's muscle tone had a fixed (motionless) position. During an observation and interview on 4/21/21, at 10:27 am, Resident 46 was awake in her room lying in bed. Resident 46 presented with LUE shoulder internal rotation (rotated toward the body), elbow flexion (bent), wrist flexion (wrist bent downward toward the palm), and finger flexion (fingers bent into the palm). Resident 46 stated nobody assisted her with the LUE exercises. Resident 46 stated she had pain to her left arm. A review of Resident 46's Restorative Nursing tracking log, dated 4/2021, indicated Resident 46 was not seen for PROM to the LUE with RNA on 4/12/21, 4/16/21, and 4/21/21. During an observation on 4/22/21, at 11:40 am, in Resident 46's room, RNA 1 attempted to perform LUE PROM with Resident 46. Resident 46 yelled upon RNA 1's attempt to perform PROM to the LUE and requested pain medication. A review of Resident 46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/22/21, at 2:23 pm, RNA 1 stated Resident 46 was not seen for PROM to LUE on 4/12/21, 4/16/21, and 4/21/21 since there was no RNA staff available. RNA 1 described the RNA session performed with Resident 46 on the morning of 4/22/21. RNA 1 stated that Resident 46 was very tired upon entry to the room. RNA 1 performed PROM to the left hand without any complaints from Resident 46. RNA 1 stated that Resident 46 started to scream when RNA 1 attempted to move the left elbow into extension. RNA 1 stopped, and Resident 46 asked for pain medication. RNA 1 returned at 10:40 a.m. after pain medication administration, but Resident 46 continued to refuse due to pain. During an interview on 4/22/21, at 1:07 pm, Occupational Therapist 1 (OT 1) stated Resident 46 was seen for Evaluation Only on 1/25/21 due to aggressive behavior. OT 1 stated he attempted to perform ROM to Resident 46's LUE during the evaluation, but the resident was resistive. OT 1 stated there were no range of motion interventions in place after the OT Evaluation to prevent Resident 46 from losing ROM. During an interview on 4/23/21 at 11:09 a.m., RNA 1 stated Resident 46 needs pain medication prior to RNA sessions to participate. RNA 1 also attempted to rotate Resident 46's left wrist during the session but stopped when the resident started screaming in pain. During an interview on 4/23/21, at 9:12 am, DOR stated Resident 46 experienced a significant change in LUE PROM since Resident 46 went from a minimal loss of motion on 1/25/21 to severe loss of motion on 4/5/21. DOR stated Resident 46 could have benefited from a trial RNA program to provide PROM to LUE after refusal to participate in PT and OT evaluations on 1/25/21. DOR stated Resident 46's ROM should have been monitored at least monthly to determine if Resident 46 would benefit from PROM with RNA services since there was an already identified ROM limitation to the LUE. b. A review of the Admission Record indicated Resident 35 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS, dated [DATE], indicated Resident 35's cognition (thinking and memory skills) was severely impaired for daily decision making. MDS indicated Resident 35 had functional limitations in both arms and both legs. A review of Resident 35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In a review of the Restorative Nursing tracking log, dated 4/2021, Resident 35's log was blank for 4/21/21. During an interview on 4/22/21, at 11:28 am, RNA 1 stated all residents on RNA program were not seen on 4/21/21 since RNA staff was pulled to perform Certified Nursing Assistant (CNA) duties due to staffing shortage. During an interview on 4/22/21, at 11:40 am, RNA 1 confirmed Resident 35 was not seen for PROM to both arms on 4/21/21 based on the Restorative Nursing tracking log due to CNA staffing shortage. During an interview on 4/22/21, at 12:22 pm, the Director of Staff Development stated it was important for residents to receive RNA services to prevent decline in function. c. A review of the Admission Record indicated Resident 72 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 72's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS, dated [DATE], indicated Resident 72 never understood others and was never able to express ideas and wants. Resident 72's cognition (thinking and memory skills) was severely impaired for daily decision making. Resident 72 was totally dependent for transfers, dressing, and bathing. A review of Resident 72's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. RNA program for PROM to the RLE and LLE, five times per week as tolerated, during the day shift. 2. RNA to perform RUE and LUE PROM as tolerated, five times per week, during the day shift. In a review of the Restorative Nursing tracking log, dated 4/2021, Resident 72's log was blank for 4/20/21 and 4/21/21. During an observation on 4/21/21 at 9:39 am, in Resident 72's room, Resident 72 was observed with a rounded spine while lying on his back. Resident 72 actively moved the right arm and right leg. Resident 72's left arm was positioned with shoulder internal rotation, elbow, wrist, and hand flexion. Resident 72's left leg was positioned with hip flexion (knee raised up), knee flexion with the left foot almost touching the back upper leg, and ankle plantar flexion (toes pointed downward). CNA 2 attempted to raise Resident 72's left shoulder for a skin check to the left arm pit. Resident 72 immediately opened eyes and mouth in pain when CNA 2 raised the left arm. During an interview on 4/22/21, at 11:28 am, RNA 1 stated all residents on RNA program, including Resident 72, were not seen on 4/21/21 since RNA staff was pulled to perform CNA duties due to staffing shortage. RNA 1 stated that there was no evidence that Resident 72 was seen for PROM to BUE and BLE on 4/20/21 based on the Restorative Nursing tracking log for 4/2021. During an interview on 4/22/2,1 at 12:22 pm, Director of Staff Development (DSD) stated it was important for residents to receive RNA services to prevent decline in function. d. A review of the Admission Record indicated Resident 100 was readmitted to the facility on [DATE]. Resident 100's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS, dated [DATE], indicated Resident 100 never understood others and was never able to express ideas and wants. Resident 100's cognition was severely impaired for daily decision making. Resident 100 was totally dependent for transfers, dressing, and bathing. MDS indicated Resident 100 had functional limitations in range of motion in both arms and legs. A review of Resident 100's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. RNA for PROM to LLE (left lower extremity - left leg), five times a week as tolerated, and PROM to RLE (right lower extremity - right leg), five times a week as tolerated. 2. RNA for PROM to RUE (right upper extremity - right arm) and LUE (left upper extremity - left arm), five times a week as tolerated. During an interview on 4/22/21, at 11:40 am, RNA 1 stated Resident 100 did not receive RNA services. During an interview on 4/22/21, at 2:58 pm, Director of Nursing (DON) stated the facility did not have any RNA tracking logs for Resident 100. DON stated that there was no evidence that Resident 100 was provided RNA services in response to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated 7/2017, P&P indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence. P&P indicated Residents may be started on a restorative nursing program upon admission, during stay or when discharged from rehabilitative care.

Based on observation, interview, and record review, the facility failed to provide wound care services for three of seven sampled residents (Residents 201, 203 and 34) by failing to: a. Resident 201 1. Implement Resident 201's physician orders and to develop interventions to treat and assess Resident 201's Moisture Associated Skin Damage (MASD, caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). 2. Implement Resident 201's Care Plan related to Pressure Injury (PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin), Stage 3 (full thickness tissue loss of skin, subcutaneous, [under the skin], fat may be visible but bone, tendon or muscle are not exposed), to reposition Resident 201 every two hours. 3. Implement Resident 201's Operational Manual recommendations for the use of the low air loss mattress (LAL, mattress that operates using a blower based pump that was designed to circulate a constant flow of air to prevent or help heal pressure injuries). 4. Implement Resident 201's physician orders to provide wound care for Resident 201's sacrococcyx (sacral, a triangular shaped bone at the bottom of the spine, coccyx, [tailbone]) extending to the buttocks (seat of the body) moisture associated skin damage (MASD) on 2/24/2021, 2/25/2021 and 2/26/2021 and to provide wound care for Resident 201's stage 3 pressure injury to the sacrococcyx site on 3/6/2021, 3/21/2021, 4/9/2021, 4/12/2021, and 4/20/2021 These deficient practices resulted in Resident 201 to acquire a Stage 3 Pressure Injury to the sacrococcyx area. b. For Resident 203, the facility failed to implement Resident 203's physician orders to provide wound care on 4/12/2021 and 4/20/2021 to Resident 203's lumbar (relating to the lower part of the bac) PI Stage 4 (full thickness skin loss with extensive destruction, tissue necrosis (the death of body tissue) or damage to muscle, bone, or supporting structures such as tendon, joint capsules [the surfaces of the joint are separated by a very thin space].) as indicated. c. For Resident 34, the facility failed to implement the physician orders to ensure Resident 34's pressure injury Stage 3 was covered with a wound dressing (bandage, patch, a piece of soft material that covers and protects an injured part of the body), and provide wound care treatment on 4/20/2021 as indicated in the physician's order. These deficient practices placed Residents 203 and 34 at risk of developing or worsening an infection to the pressure injury wound sites. Findings: 1. A review of Resident 201's Admission Record indicated the facility admitted the resident on 2/3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 201's Nursing Admission assessment dated [DATE], indicated the resident did not have skin breakdown and no pressure injuries upon admission to the facility. A review of Resident 201's History and Physical dated 2/4/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 201's untitled care plan dated 2/4/2021, indicated the resident had the potential for PI development and the interventions were to follow facility policies (unspecified) to prevent skin breakdown. A review of Resident 201's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/9/2021, indicated Resident 201 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 201 required extensive assistance with two person physical assist for bed mobility and transfers. The MDS indicated Resident 201 was at risk for developing pressure ulcer (PI). A review of Resident 201's Order Summary dated 2/22/2021, timed at 5:28 pm, indicated to cleanse Resident 201's sacrococcyx MASD with soap and water, pat dry and to apply [MEDICATION(S)] (used to treat or prevent minor skin irritations) ointment and cover with dry dressing one time daily for fourteen days. During an observation on 4/20/2021 at 10:50 am, in Resident 201's room, Resident 201 was lying in bed and had his eyes closed. During an interview and a review of Resident 201's medical record on 4/26/2021 at 3 pm, Licensed Vocational Nurse 5 (LVN 5) stated Resident 201's Order Summary dated 2/22/2021 and timed at 5:28 pm, indicated Resident 201 had a treatment order for MASD for fourteen days. LVN 5 stated Resident 201's medical record did not contain a care plan with interventions and no nursing assessment notes regarding the resident's MASD. LVN 5 stated Resident 201's Treatment Administration Record (TAR) dated 2/22/21 to 2/28/21, indicated Resident 201 did not receive MASD treatment on 2/22/2021, 2/24/2021, and on 2/25/2021. During a telephone interview on 5/3/2021 at 2:45 pm, the Director of Nursing (DON) stated Resident 201's MASD was considered a change in the resident's condition. The DON stated the facility process was to assess Resident 201's skin, document, notify the physician, the resident's representative, obtain orders from the physician, follow up with the orders, and to create a plan of care with interventions. During a telephone interview and a review of Resident 201's medical record (care plans and change of condition forms) on 5/3/2021 at 2:57 pm, DON stated Resident 201's medical record did not indicate a change of condition and a care plan were created for the resident's MASD. DON stated without a care plan, there was no guidance as to what interventions to implement for the resident to prevent skin breakdown. During a telephone interview and concurrent review of Resident 201's medical record on 5/3/2021 at 3:21 pm, DON stated the facility failed to ensure Resident 201's treatments were done as ordered, failed to initiate a change of condition, and to develop a care plan for MASD. A review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol, with a revised date of April 2018, indicated the physician would order pertinent wound treatments and the physician would guide the care plan as appropriate especially when the wounds were not healing. A review of the facility's Care plans, Comprehensive Person- Centered Policy with a revised date of December 2016, indicated to develop and implement a comprehensive person- centered care plan for each resident to meet their physical, psychosocial and functional needs. 2. A review of Resident 201's care plan, dated 3/4/2021, indicated the resident had a sacrococcyx pressure injury (no Stage specified) related to regression of MASD, impaired mobility, and [CONDITION(S)] (a condition in which the blood doesn't have enough healthy red blood cells). The care plan indicated the interventions included to administer treatment as ordered, avoid positioning the resident on his back, assist Resident 201 to turn and reposition at least every two hours, more often as needed or as tolerated, and LAL mattress for wound management. During an observation on 4/20/2021 at 10:50 am, Resident 201 was lying on his back in bed and he had his eyes closed. During multiple observations on 4/22/2021 at 9:29 am, on 4/23/2021 at 8:42 am, on 4/23/2021 at 2:42 pm, on 4/24/2021 at 10:55 am, on 4/24/2021 at 11:58 am, on 4/24/2021 at 1 pm, on 4/24/2021 at 1:36 pm, on 4/24/2021 at 2 pm, on 4/24/2021 at 2:49 pm, on 4/24/21 at 3:38 pm, on 4/25/2021 at 1:49 pm, on 4/25/2021 at 2:03 pm, on 4/25/2021 at 3:56 pm, and on 4/25/2021 at 4:03 pm Resident 201 was observed lying on his back. During an observation and an interview on 4/25/2021 at 4:03 pm, inside Resident 201's room, Certified Nursing Assistant 8 (CNA 8) stated Resident 201 was total dependent on staff for turning and repositioning in bed and stated Resident 201 had a wound on his buttock and the resident was lying on his back. CNA 8 stated she was assigned to care for Resident 201 and she would get really busy and did not have time to turn and to reposition the resident. CNA 8 stated she was not able to provide good quality of care to Resident 201 because she had eighteen residents to care for. CNA 8 stated she documented she turned the resident every two hours regardless if she did not. CNA 8 stated the facility did not have a system in place to remind the staff to reposition residents in bed. During an interview on 4/26/2021 at 3:26 pm, LVN 5 stated she did not know who monitored the CNAs (in general) to ensure CNAs such as CNA 8 repositioned Resident 201 at least every two hours to prevent new pressure injuries and to prevent the wounds from worsening or further skin breakdown. During an interview on 4/26/2021 at 4:31 pm, the DON stated she did not know whether the facility had a program for turning and repositioning residents and stated that the charge nurse and Register Nurse (RN) Supervisor were responsible to remind the CNAs to turn and reposition the residents. A review of the Facility Policy and Procedures titled, Support Surface Guidelines, with a revised date of September 2013, indicated for residents that reclined and depend on the staff for repositioning to change position at least every two hours. 3. A review of Resident 201's Weights and Vitals Summary, indicated Resident 201's weight taken on 4/1/2021 was 184 pounds. A review of Resident 201's Order Summary dated 3/4/2021 and timed at 3:35 pm, indicated to provide the resident with a LAL mattress for wound management. During an observation on 4/21/2021 at 9:36 am, inside Resident 201's room Resident 201 was lying on his back on the LAL mattress and the resident's LAL mattress setting was at 450 pounds. During the concurrent observation the LAL mattress had one sheet folded in half and one flat sheet (three layers) over the LAL mattress. During an observation and interview on 4/23/2021 at 8:55 am, LVN 5 stated Resident 201's LAL mattress was set at 450 pounds. LVN 5 stated the LAL mattresses had to be set up by the resident's weight. LVN 5 stated Resident 201's weight was 184 pounds. LVN 5 stated she was responsible to make sure the LAL mattress was set according to Resident 201's weight but she failed to make sure it was set at the right weight. LVN 5 then lifted Resident 201's blanket and stated there was one flat sheet and one folded draw sheet (three layers) over the LAL mattress, and stated Resident 201 was wearing an adult brief. During an interview on 4/26/2021 at 3:26 pm, LVN 5 stated she did not receive an in service for the LAL mattress for Resident 201 and stated she was not sure if it should be set according to Resident 201's weight. During an interview on 4/26/2021 at 4:31 pm, the DON stated the LAL mattress should only have one flat sheet, no draw sheet, and the resident should not wear an adult brief. If more than one layer is over the LAL mattress, the LAL mattress would not be effective. During an interview on 4/26/2021 at 4:40 pm, the Director of Staff Development (DSD), stated it was important for the nurses to make sure Resident 201 had minimal sheets over the LAL mattress for wound healing management. DSD stated there should be a flat sheet over the LAL mattress to ensure that the resident was closest to the mattress to promote circulation. DSD stated Resident 201 should not have pads or adult briefs. The DSD stated the settings for the LAL mattress were important to prevent skin breakdown. The DSD stated she did not provide training to the nursing staff regarding the LAL mattress. During a telephone interview on 4/30/2021 at 3:50 pm, Resident 201's Physician Assistant 1/Wound Specialist (PA1) stated Resident 201's LAL mattress should be set according to the resident's weight. A review of Resident 201's undated LAL mattress Operational Manual indicated to cover the mattress with a cotton sheet. 4. A review of Resident 201's Braden Scale (tool to predict for pressure injury risk), dated 2/10/2021, indicated a score of 10 (a score of 10-12 reflects high risk for pressure ulcer). A review of Resident 201's Braden Scale (tool to predict for pressure ulcer risk), dated 3/04/21, indicated a score of 11 (a score of 10-12 reflects high risk for pressure ulcer). A review of Resident 201's Order Summary dated 3/4/2021 and timed at 3:35 pm, indicated to provide the resident with a LAL mattress for wound management. A review of Resident 201's Skin Ulcer Report dated 3/4/2021, indicated regression of MASD to sacrococcyx area stage 3 pressure injury (acquired) measured 7.0 centimeters (cm, a metric unit of length) length x 8.0 cm length, and width x 0 cm depth. During an interview and a review of Resident 201's medical records on 4/23/2021 at 9:56 am, LVN 5 (wound care nurse) stated the resident 201's Treatment Administration Record (TAR) indicated the treatment to Resident 201's Stage 3 Sacrococcyx pressure injury were not done as ordered by the physician on 2/25/2021, 2/28/2021, 3/6/2021, 3/21/2021, 4/9/2021, 4/12/2021, and 4/20/2021. LVN 5 stated she was off on 3/6/2021 and that she was assigned to work as a medication nurse on 3/21/2021. LVN 5 stated the wound treatments for Resident 201 were not administered those two days. LVN 5 stated that the days that were left blank, indicated the treatments were not administered and that failing to administer the wound treatments as ordered, could result in potential wound infection, wound deterioration and delayed healing. During Resident 201's wound treatment observation on 4/23/21 at 2:45 pm, LVN 5 described Resident 201's wound as a Stage 3, 100% granulation (part of the healing process), light serosanguineous (discharge that contains both blood and a clear yellow liquid known as blood drainage), epithelization (tissue lining the inner and outer body surfaces) for peri-wound (tissue surrounding a wound) 100%, and stated the measurements were 3 cm in width, 1.5 cm in length, and 1 cm in depth. During an interview on 4/26/2021 at 4:31 pm, the DON Resident 3 was supposed to receive wound treatments as ordered so the pressure injury would not get worse. The DON stated that the treatments for Resident 201 had to be administered as ordered by the physician to prevent the risk of infection and further deterioration of the wound. A review of the facility's Wound Care Policy with a revised date of March 2018 indicated the purpose of the guideline for the care of the wound was to promote healing. b. A review of Resident 203's Admission Record indicated the facility readmitted the resident on 3/20/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 203's MDS dated [DATE], indicated Resident 203was severely impaired with cognitive skills for daily decision making and required extensive assistance with two for bed mobility and transfers. A review of Resident 203's care plan dated 4/9/2021, indicated Resident 203 had a lumbar spine pressure injury related to [CONDITION(S)], fragile skin, and decreased mobility and the goal was for Resident 203's lumbar spine pressure injury to show signs and symptoms of healing and remain free from infection through the target date 6/21/2021. The care plan indicated the interventions included to administer treatment as ordered. A review of Resident 203's Physicians Orders dated 4/11/2021, indicated to cleanse lumbar spine pressure injury with normal saline (NS, sterile solution), pat dry and apply collagen powder (improve skin hydration) with calcium alginate (topical wound dressing) and cover with dry dressing two times a day (BID) for 14 days. A review of Resident 203's Physicians Orders, dated 4/13/2021, indicated to administer [MEDICATION(S)] (antibiotic medication) 800-160 milligrams (mg, a unit of measurement) [MEDICATION(S)] [MEDICATION(S)] (antibiotic medication), one tablet by mouth, two times a day for lumbar wound infection, for ten days. A review of Resident 203's Physicians Orders, dated 4/19/2021, indicated to cleanse lumbar spine pressure injury with NS, pat dry and apply collagen powder with calcium alginate (topical wound dressing) and cover with dry dressing two times a day (BID) for 14 days. During an observation and interview on 4/20/2021 at 3:37 pm, Resident 203 was awake lying in bed and stated that she had a pressure injury on her back. Resident 203 stated she did not receive daily wound treatments. Resident 203 stated her wound was infected and she received medication for infection. During an interview and a review of Resident 203's medical record on 4/22/2021 at 12:30 pm, LVN 5 stated the resident's TAR indicted the resident did not receive wound treatments on 4/12/2021 and 4/20/2021. LVN 5 stated that it was important to administer the wound treatment as ordered to prevent wound infections and for the overall benefit of Resident 203 to prevent deterioration of the wound. During an interview and a review of Resident 203's TAR on 4/22/2021 at 3:17 pm, the DON stated the facility failed to administer Resident 203's wound treatments are ordered on 4/12/2021 and on 4/20/2021. A review of the facility's Pressure Ulcer/ Skin Breakdown- Clinical Protocol with a revised date of April 2018, indicated the physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing approaches, dressing and application of topical agents. c. A review of Resident 34's Admission Record indicated the facility admitted the resident on 1/29/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 34's Order Summary Report dated 4/12/2021, indicated to apply Venelex (combination medicine used to treat skin wounds, bed sores, and other skin conditions resulting from decreased blood flow) ointment to buttocks two times a day for pressure injury. A review of Resident 34's Order Summary Report dated 4/15/2021 indicated to cleanse right buttocks pressure injury, pat dry, apply Venelex with Calcium Alginate (provide an optimal environment for wound healing) cover with dry dressing every day shift. A review of Resident 34's Minimum Data Set, dated dated dated [DATE], indicated the resident did not have the capacity to understand and make decisions due to inability to speak and was total dependent (required full staff performance) on bed mobility (ability to move easily), toilet use and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). The MDS indicated Resident 34 was always incontinent (insufficient voluntary control) of urination and defecation. A review of Resident 34's Care Plan dated 4/13/2021 indicated the resident had a right buttock pressure injury and the intervention was to administer treatment as ordered. During an observation in Resident 34's room and interview with CNA 2 on 4/21/2021 at 11:10 am, Resident 34's room had a urine odor upon entering the room. CNA 2 checked the resident for wetness and Resident 34's bed had urine stained and CNA 2 stated the resident's adult brief was soaked with urine. CNA 2 repositioned resident on his side and checked resident's lower back, and Resident 34 did not have dressing on his Stage 3 pressure injury on his right buttock and was exposed to the wet adult brief and urine. During the concurrent observation and interview, CNA 2 stated she was not sure if Resident 34was changed in the morning and stated the resident should not be left wet. During concurrent observation of Resident 34's wound care treatment and interview with LVN 5 on 4/21/2021 at 12:23 pm, LVN 5 stated there was no dressing covering Resident 34's pressure injury on his right buttock. LVN 5 stated there should be a dressing as per the resident's physician order. During an interview and record review of Resident 34's medical record on 4/22/2021 at 12:17 pm, LVN 5 stated the resident's TAR indicated the resident did not receive wound care treatments on 4/20/2021. LVN 5 stated it was important to follow the wound care as ordered to ensure wound healing, avoid worsening and infection to the wound. LVN 5 stated it was important to make sure the dressing was dated and with the nurse's initial to make sure it was done daily as ordered, or to know when it is due for change. A review of the facility's Activities of Daily Living (ADL), Supporting Policy with a review date of March 2018, indicated residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal hygiene. The policy also indicated, appropriate care services would be provided for residents who were unable to carry ADLs independently with the consent of the resident and in accordance with the plan of care. A review of the facility Care plans, Comprehensive Person- Centered Policy revised 12/2016, indicated to develop and implement a comprehensive person- centered care plan for each resident to meet their physical, psychosocial and functional needs. A review of the facility's Pressure Ulcer/ Skin Breakdown- Clinical Protocol revised 4/2018, indicated the physician would order pertinent wound treatments, including pressure reduction surfaces, wound cleansing approaches, dressing and application of topical agents. A review of the facility's Wound Care Policy revised 3/2018, the policy indicated the purpose of the guideline for the care of the wound is to promote healing. The policy also indicated, verify with the physician's order, and review the resident's care plan for any special needs and documentation of the wound care given including signature and title of the person recording the date.

Based on observation, interview and record review, the facility failed to implement the physician's admission order for medication and follow their policy and procedure to have the resident's medication available within four hours of admission, for two of three sample residents (Residents 1& 2). A) Resident 1 missed two doses of [MEDICATION NAME] (medication used to treat high blood pressure and heart rhythms disorder); one missed on 12/20/14 and one missed at 5 p.m. on 4/21/16; and parameters for the medication were not documented. Resident 1 was admitted to the hospital on [DATE] for [MEDICAL CONDITION]. ([MEDICAL CONDITION] is a fast, irregular heart rhythm involving the upper heart chambers). B) Resident 2 was admitted on [DATE], the resident missed the first dose of insulin on 5/13/16. This deficient practice had the potential to prevent healing and contribute to the elevation of blood sugar level which can lead to further illness. There was no documentation the facility staff had checked her blood sugar level the morning of 5/13/16. Findings: a. A review of the clinical record for Resident 1, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the acute hospital discharge report, dated 12/19/14, at 1:13 p.m., indicated to administer [MEDICATION NAME] 120 milligrams (mg) orally once a day to Resident 1. The Davis Drug Guide 9th edition, Page 311, indicates the medication should be taken at the same time each day because a missed dose could worsen the person s health condition. A review of Resident 1's medical record contained the following: 1. admission orders [REDACTED]. The order further indicated to hold if the systolic blood pressure (SBP) (Systolic: the beat during contraction of the left ventricle of the heart) is less than 110 or heart rate less than 60. 2. A progress note, dated 12/20/14, at 3:57 p.m., indicated the physician was notified the [MEDICATION NAME] 120 mg was not delivered by the pharmacy. Resident 1's morning (9:00 a.m.) routine medication, the first dose at the facility was not administered. 3. The following day there was a progress note, dated 12/21/14, at 2:26 p.m., indicated [MEDICATION NAME] 120 mg at 9:00 a.m., was held due to Resident 1's SBP <110. The physician was notified. 4. The physician, on 12/21/14, then ordered new parameters to hold the medication and ordered to check the blood pressure at 5:00 p.m. on 12/21/14. The physician ordered, if the SBP was greater than 100 to administer one dose of [MEDICATION NAME] 120 mg. There was no documentation Resident 1's blood pressure was checked at 5 p.m. on 12/21/14. On the medication record the order was documented incorrectly. It was transcribed to be done on 12/22/14, instead of 12/21/14. By 12/21/14, Resident 1 went two days without being administered two doses of [MEDICATION NAME] as ordered. 5. On 12/22/14, the physician ordered to clarify the parameters for [MEDICATION NAME] 120 mg orally once a day to hold if SBP <100 and HR less than or equal to 55. (< means less than) 6. The medication record, indicated on 12/22/14, [MEDICATION NAME] 120 mg was administered at 9:00 a.m. to Resident 1. 7. The same day, on 12/22/14, there was another physician order [REDACTED]. The order included to do an electrocardiogram (EKG) test on 12/22/14 and to check the apical pulse* and blood pressure at 10:30 p.m. on 12/22/14. The order also indicated if apical pulse was greater or equal to 120 beats and SBP greater or equal to 100, to administer an additional dose of [MEDICATION NAME] 120 mg. The documented heart rate for Resident 1, on 12/22/14, at 8:14 a.m., was 80 beats per minute and 90, at 9:00 a.m., when [MEDICATION NAME] was administered on 12/22/14. *(Apical pulse: the beat of the heart as felt through the walls of a peripheral artery, such as an artery at the wrist) 8. The EKG, dated 12/22/14, at 4:15 p.m., indicated no interpretation because of artificial pacemaker. 9. The medication record, dated 12/22/14, at 10:30 p.m., indicated a dose of [MEDICATION NAME] was administered because Resident 1's heart rate was 120. 10. On 12/23/14, at 9:00 a.m., Resident 1 was administered her routine [MEDICATION NAME] and her heart rate was 100 beats per minute. 11. A nursing progress note, dated 12/23/14, at 1:14 p.m., indicated the physician came to examine Resident 1, at around 11:00 a.m., Resident 1's apical pulse was 150. The physician ordered to send Resident 1 to the acute care hospital via emergency system (911), at 11:20 a.m. 12. A physician progress notes [REDACTED]. Resident 1 was transferred to the acute care hospital. The acute care hospital record, dated 12/23/14, at 12:06 p.m., indicated Resident 1 was brought in by ambulance for A-fib** from the facility. Resident 1 was complaining of heart palpitations. The resident reported she has a history of A-fib and was off her medication for three days while in the facility. Resident 1's heart rate was 160 at arrival to the acute care facility. Resident 1 was discharged to her home per her request after receiving treatment and her heart rhythm converted to 84. (The date of discharge from the hospital is unclear 12/23/14 or 12/24/14). ** ([MEDICAL CONDITION] is a fast, irregular heart rhythm involving the upper heart chambers. It is the most common abnormal heart rhythm in adults.) According to United States National Library of Medicine by the National Institutes of Health, dated 4/20/15, indicated the normal heart rate is 60 to 100. <https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm> b. A review of Resident 2's medical record, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 5/13/16, at 1:10 p.m., during an interview, the licensed vocational nurse (LVN 1) stated Resident 2 was a new admission from 5/12/16 and did not receive her 6:00 a.m. dose of insulin on 5/13/16. A review of Resident 2's medical record, indicated a physician order, dated 5/12/16, for [MEDICATION NAME] 70/30 25 units once a day for diabetes before breakfast. There was no blood sugar level record at 6:00 a.m. for Resident 2. Resident 2's medication record, dated 5/13/16, at 8:05 a.m., indicated the 25 units of insulin was not administered before breakfast because the medication was no available and staff were waiting the delivery from the pharmacy.

The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.The facility failed to ensure that Resident 1 had sufficient fluid intake to prevent dehydration (excessive loss of body water) by failing to:1) Develop a preventive plan of care to prevent dehydration for Resident 1, who was assessed with [REDACTED]. 3) Notify and consult with Resident 1 ' s physician regarding her poor intake as indicated in the facility ' s policy.On February 15, 2011, an unannounced visit was made to the facility to investigate allegations that a resident was transferred to the acute hospital emergency room due to being severely dehydrated.A review of the admission face sheet revealed that Resident 1 was a [AGE] year old female who was readmitted from the acute hospital to the facility on [DATE], with the [DIAGNOSES REDACTED]. The muscle that controls swallowing is frequently affected.The Minimum Data Set (MDS) a standardized assessment and care planning tool dated 8/21/10, indicated that Resident 1 had modified independence in cognitive skills, along with a short term memory recall and a chewing problem. The assessment further indicated that Resident 1 required supervision and set-up help in eating and had a urinary tract infection. The review of the MDS Resident Assessment Protocol Summary (RAPS) for Resident 1 dated 8/31/10, revealed that the nutritional status and the area of dehydration and fluid maintenance was triggered for care planning and a decision was made to proceed with a care plan in both areas. However, a review of the medical record did not contain a plan of care to address both dehydration and fluid maintenance.The registered dietician ' s assessment of Resident 1 ' s estimated daily fluid needs as indicated on 9/1/10 was 1,500 cc of fluid per day. According to the laboratory report dated October 29, 2010, Resident 1 ' s blood urea nitrogen (BUN) was 18 mg/dl which was within the normal range (10-20 mg/dl). Blood Urea nitrogen measures the amount of urea nitrogen in the blood. BUN levels may vary according to the status of hydration with increased levels seen in dehydration (Mosby ' s Diagnostic and Laboratory Test Reference. Ninth Edition).On 12/8/10, the physician ordered to administer [MEDICATION NAME] 15 milligram (an antidepressant drug) to Resident 1 at bedtime, due to depression as manifested by poor appetite, and monitor the resident ' s poor appetite and to record the percentage of food consumed at each meal. Resident 1 ' s Meal Intake Record for the month of January 2011 (between 1/1/2011 and 1/27/11) were as follows: 1) 60 percent (%) for 14 meals 2) 50 % for 28 meals 3) 40 % for 22 meals 4) 30 % for 12 meals. Resident 1 ' s Meal Intake Record for 1/27/2011 revealed that the resident meal intake for dinner had dropped to 20 %. On 1/28/11, Resident 1 consumed 20% of her breakfast, lunch and dinner meals. On 1/29/11, Resident 1 consumed 20% of her breakfast meal and there was no documented record of food intake for her breakfast meal on 1/30/11. There was no documentation in the licensed nurse ' s progress notes that the attending physician was notified that Resident 1 ' s food consumption percentage had dropped to 20% on 1/2711, 1/28/11 or 1/29/11. There was no documented evidence that alternative measures were implemented to ensure that Resident 1 received the required 1500 ccs of fluid as noted by the registered dietitian to prevent dehydration. Also, there was no documented evidence that the licensed nurse monitored the fluid intake of the resident. Additionally, the medical record did not contain any update to the plan of care to address how the facility would ensure that the resident had sufficient fluids to prevent dehydration while the resident ' s intake had decreased to 20 % on 1/2711, 1/28/11 and 1/29/11. A review of the physician ' s progress notes dated January 30, 2011, at 11 a.m., contained a notation by Employee 1, indicating that Resident 1 had an altered level of consciousness (ALOL) a blood pressure of 90/50, a pulse rate of 77, and a respiratory rate of 16. The registered nurse practitioner was notified and gave orders to perform stat labs and a chest x-ray. It was also noted that at 11:50 p.m., 50 minutes later, the resident ' s daughter called the facility stating that she wanted the patient transferred to the emergency room (ER) and a new telephone order was received to transfer the resident to the ER. However, a review of the physician's order [REDACTED]. At 11:50 a.m., the resident ' s blood pressure had dropped to 86/50. The licensed nurse notes further indicated at 12:35 p.m., that the Medic 1 ambulance employee arrived at the facility (Transportation arranged by the daughter) and stated " We will call 911 because her blood pressure dropped to 74/50. We will take her downstairs and meet 911 there. " At 12:45 p.m. Resident 1 was transferred to the ER for evaluation.A review of the acute hospital emergency room record dated 1/30/11, indicated that when the resident was admitted to the emergency room she was alert, confused, had dry mucous membranes and appeared to be dehydrated. The noted clinical impression included dehydration, muscle wasting, pneumonia and urinary tract infection. Additionally, the laboratory results from the acute hospital dated 1/30/11, indicated that Resident 1 had a moderate amount of bacteria in her urine and the blood urea nitrogen was 28 mg/dl which is above the normal range (7-18 mg/dl). Consequently, Resident 1 was administered one liter of 0.9 percent normal saline intravenously for hydration. Resident 1 was also administered [MEDICATION NAME] (an antibiotic) 750 milligram intravenously for a urinary tract infection. Resident 1 stayed at the acute hospital on [DATE], for seven hours and was transferred to another acute hospital on [DATE], at 8:16 p.m. On 12/7/11, at 4:20 p.m., the medical record of Resident 1 was reviewed with Staff 2 and Staff 3. They both disclosed and confirmed that there was no written plan of care developed to address Resident 1 ' s nutritional problem since the MDS assessment protocol dated 8/31/10, was completed. They also confirmed that there was no documented evidence that the physician was notified of the resident ' s reduced intake for three consecutive days (on 1/27/11, 1/28/11 or 1/29/11) even though, Staff 4 and Staff 5 had signed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 12/21/11, at 3:15 p.m., Staff 4 revealed that she did not ask Staff 6 about Resident 1 ' s meal percentage for breakfast and lunch on 1/28/11. She further stated that she signed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff 4 stated and acknowledged that the resident ' s decreased consumption in food and fluid intake might have resulted in the resident ' s dehydration. Staff 4 also stated that the physician was not made aware of Resident 1 ' s 20 percent meal intake for breakfast, lunch and dinner on 1/28/11, because she did not remember if Staff 6 had reported it to her. During an interview on 12/23/11, at 2:15 p.m., Staff 6 disclosed that she provided care to Resident 1 on 1/28/11, and 1/29/11, and that she was worried that Resident 1 was sick due to eating only 20 percent of her meal on 1/28/11 and 1/29/11. Staff 6 stated that on 1/29/11, she reported to Staff 5 that Resident 1 had been " eating less " for two days. Staff 6 disclosed she did not document in the patient ' s record that Staff 5 was made aware that Resident 1 had been eating less for two days. During an interview on 12/23/11, at 2:30 p.m., Staff 5 stated she was aware that Resident 1 was " eating poorly " and did not remember if Staff 6 had reported that Resident 1 ' s meal intake was 20 percent for breakfast on 1/29/11. She further stated that she did not notify the physician that Resident 1 ' s meal intake was 20 percent on 1/27/11, 1/28/11 and 1/29/11, because she signed the MAR indicated [REDACTED]. A review of the facility ' s policy and procedure regarding patient meal intake disclosed that intake of food and fluid at meals and snacks is to be monitored to determine the adequacy of nutrient intake. The policy stipulates that the licensed staffs are to monitor the percentage of meal taken, notify nutrition services if intake has declined for the past three consecutive days and to notify the physician. However, the above policy and procedure was not followed. The facility failed to ensure that Resident 1 had sufficient fluid intake to prevent dehydration (excessive loss of body water) by failing to:1) Develop a preventive plan of care to prevent dehydration for Resident 1, who was assessed with [REDACTED]. 3) Notify and consult with Resident 1 ' s physician regarding her poor intake as indicated in the facility ' s policy.As a result, Resident 1 became severely dehydrated and was consequently transferred to the acute hospital emergency room where she received Intravenous hydration due to dehydration and antibiotics for a urinary tract infection. The above violations had a direct relationship to the health, safety and security of Resident 1.