Every finding on record at Glenwood Care Center

Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan (a plan that includes clear goals to meet a resident's needs) to address a right eye hematoma (a closed wound that develops when an injury causes blood to collect and pool under the skin) for 1 of 2 sampled residents (Resident 1). This failure had the potential for Resident 1 to have wound complications go unnoticed by staff, leading to a potential delay in treatment. During a review of Resident 1's admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), need for assistance with personal care, conjunctivitis (inflammation of the conjunctiva, the white part of the eye and the inner eyelids). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/4/25, Section C indicated a brief interview of mental status score of 11 (BIMS - a measurement of cognitive abilities that ranges from 0 to 15 with scores of 8 - 12 indicates moderate impairment). During a concurrent observation and interview on 11/24/25 at 11:05 a.m., with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed with a crescent shaped purplish discoloration approximately 2 inches long on the right cheek extending from the right eye down to the mouth. Resident 1 stated I don't know where it came from, I just woke up with it, maybe I punched myself, Resident 1 laughed and further stated, I'm really not sure, maybe I fell asleep on the side of the bed. During a record review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) communication form (SBAR) dated 10/10/25, the SBAR indicated Walked into [Resident 1's] room and noticed he had a hematoma under his right eye. I asked if he hit his head and he was unaware of how it happened. During an interview with the Director of Nursing (DON) on 11/24/25 at 12:13 p.m., DON stated he was made aware of the hematoma on 10/11/25 and further stated, I remember it because when it was first discovered, the nurse documented it as a hematoma . I went to look at it myself. it was more of a blister in shape of a C around his right eye, skin was intact and there was no discoloration. During a concurrent interview and record review on 11/24/25 at 12:26 p.m., Resident 1's care plans were reviewed. There were no care plans to address the right eye hematoma. DON stated, we reviewed all the care plans, and it isn't there. it is missing. DON acknowledged that a care plan should have been created to address Resident 1's hematoma when it was first noted and it was not. During a review of the facility's policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning, dated 4/2025, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT- a group of healthcare professionals from various disciplines who collaborate to provide comprehensive, patient-centered care) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs.

Based on observation, interview, and record review, the facility failed to: 1. Ensure N95 masks provided for use to staff and visitors were not expired; and 2. Ensure staff followed proper infection control procedures when Licensed Nurse (LN) 2 did not remove personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against infectious agents) before exiting Resident 101's room. This failure had the potential to significantly reduce the effectiveness of PPE and compromise infection prevention practices. Findings: During an observation on [DATE], starting at 7:46 a.m., the following were observed: Isolation carts containing N-95 (type of mask) PPE located at the front entrances of the following Covid-19 designated rooms 124, 126, 201, 202, 203, 204, 206, 208, 212, 214, 219, and the lobby receptionist area. All had expired N95 face masks. There were 21 positive Covid-19 residents in the facility. All facility staff assigned to the designated rooms were observed wearing N-95 masks. Visitors were encouraged to wear a face mask by the receptionist. There were two different brands of N-95 masks observed. The brand 3M N-95 masks had an expiration date of [DATE], and brand BYD N-95 mask, had an expiration date of [DATE]. During an interview with the Administrator (ADM), on [DATE], at 9 a.m., the ADM stated, he has a memo from CDC (Centers for Disease Control and Prevention - a U.S Federal agency. The leading national public health institute in the United States) regarding extended use from shelf life of N-95 masks. ADM also added that Public Health said the same thing. During a review of the documents received from the ADM, the documents indicated the following. The memo from CDC, dated [DATE], titled Strategies for Conserving the Supply of N-95 Filtering Facepiece Respirators, indicated in part, Crisis Capacity Strategies .use of respirators beyond the designated shelf life for healthcare delivery .Consider using NIOSH (National Institute for Occupational Safety - a Federal Agency responsible conducting research and making recommendations for prevention of work-related injury, illness, disability, and death) approved N-95 respirators beyond the designated shelf life for care of patients with diseases for which a respirator is recommended during their care (e.g. Covid-19, Tuberculosis, Measles, Varicella). During record review of the document/email from Public Health, dated [DATE] the document indicated in part, The strategies for conserving the supply of N-95 filtering facepiece respirators/healthcare workers/CDC designate this intervention for crisis situations. The facility should communicate to licensing that they have reached this point. During an interview with the ADM, on [DATE], at 2 p.m., in the reception area, explained that the CDC memo and the Public Health email specified the approved extended use of N-95 masks past their shelf life only during the declared emergency. ADM agreed that current use was not supported. 50707 2. During a review of Resident 101's Clinical Record (CR), the CR indicated Resident 101 had a diagnosis of COVID-19 (a contagious viral infection that affects breathing) and was on transmission-based precautions (precautions involve using PPE to prevent the spread of infections). During a concurrent observation and interview on [DATE] at 8:55 a.m., with LN 2, LN 2 was observed wearing an isolation gown, mask and face shield while preparing medication outside of Resident 101's room. LN 2 stated Resident 101 was on transmission-based precautions for COVID-19. LN 2 confirmed the PPE was not removed before exiting Resident 101's room and it should have been removed. During an interview with the Infection Preventionist (IPN) on [DATE] at 9:02 a.m., IPN acknowledged LN 2 did not remove PPE before exiting Resident 101's room and should have. During a review of the facility's policy and procedure titled, IPCP Standard and Transmission-Based Precautions, dated ,d+[DATE], the P&P indicated Procedure b. Personal protective equipment (PPE): ii. [NAME] (put on) PPE upon room entry, then doff (remove) and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens.

Based on record review and interview, the facility failed to ensure interventions in the comprehensive care plan for two of 10 sampled residents (Residents 70 and 5) were implemented when: 1. Monitoring of Resident 70's intake and output (process of tracking the amount of fluid) was not completed. 2. Monitoring for bleeding complications was not implemented and documented in the clinical record of Resident 5 who is taking the anticoagulant medication Apixaban (a medication used to prevent and treat blood clots). These failures had the potential to result in the inappropriate delivery of care and services for these residents and their needs not being met. Findings: 1. During a review of Resident 70's Order Summary dated [DATE], indicated, a physician order was placed [DATE], Intake [the amount of fluid a person drinks or receives via gastrostomy tube(GT)] and output [the amount of fluid that exits the body] monitoring d/t gastrostomy tube [a tube surgically inserted into the stomach for a person to receive food, liquids and medications] use every shift [AM - morning shift, PM - afternoon shift, NOC - night shift] . and Intake and output monitoring d/t gastrostomy tube use every evening shift PM shift to tally all intake and output within 24 hours. During a review of Resident 70's Medication Administration Record (MAR) dated [DATE] - [DATE], indicated Intake and output monitoring d/t gastrostomy tube use every shift on [DATE] NOC shift and on [DATE] PM shift there was no documentation of intake and output. During a review of Resident 70's MAR dated [DATE] - [DATE], indicated, Intake and output monitoring d/t gastrostomy tube use every shift PM to tally all intake and output in 24 hours, there was no documentation of 24-hour input and output on dates [DATE], [DATE] and [DATE]. During a concurrent interview and record review on [DATE] at 3:20 p.m. with Director of Nursing (DON), the Order Summary dated [DATE] was reviewed. The Order summary indicated that two orders for intake and output monitoring were ordered [DATE]. DON acknowledged that the orders should be carried out and documented on the MAR. During a concurrent interview and record review on [DATE] at 3:20 p.m. with Director of Nursing (DON), the [DATE]/,d+[DATE] - [DATE] dated was reviewed. The MAR indicated that Intake and output monitoring d/t gastrostomy tube use every shift on [DATE] NOC shift and on [DATE] PM shift was missing documentation of intake and output and the Intake and output monitoring d/t gastrostomy tube use every shift PM to tally all intake and output in 24 hours, was missing documentation of 24-hour input and output totals on dates [DATE], [DATE] and [DATE]. The DON confirmed that the interventions were not completed for the dates listed and acknowledged that these should have been completed. During a review of the facility 's policy and procedure titled, MAR and TAR Documentation, dated ,d+[DATE], indicated in part, POLICY: It is the policy of this facility that medication and treatment records shall reflect the administration as prescribed by the physician. 43745 2. During a review of Resident 5's Admission Record (AR), dated [DATE], the AR indicated in part Resident 5 was a [AGE] year-old female who was admitted to the facility on [DATE], with admission diagnoses including supraventricular tachycardia (a heart rhythm disorder that causes a very fast or erratic heartbeat), diverticulitis (inflammation of irregular bulging pouches in the wall of the large intestines) and restless leg syndrome (a condition that causes a very strong urge to move the legs). During a concurrent interview and record review with the facility's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing home residents) Coordinator (MDSC), on [DATE] at 3:38 p.m., Resident 5's clinical record was reviewed. MDSC verified in Resident 5's Order Summary Report (OSR), Care Plan Report (CPR), and Medication Administration Record (MAR), that the resident is currently taking the medication, Apixaban oral tablet 5 mg (milligram), give one tablet by mouth two times a day for NSTEMI (Non-ST-elevation myocardial infarction [a type of heart attack where there is a partial of complete blockage of a coronary artery, leading to a reduced blood flow and oxygen to the heart muscle]) prophylaxis. The CPR also indicated the intervention, Monitor/document/report to MD PRN (as needed) s/sx (signs and symptoms) of anticoagulant complications: blood-tinged or frank blood in urine, black tarry stools . bruising, bleeding There was no monitoring documentation found in the resident's medical record. MDSC acknowledged that staff should have entered the monitoring intervention in the resident's order summary so it can be signed off. During an interview with the facility's Administrator (ADM) on [DATE] at 4:44 p.m., ADM was informed that a care plan intervention to monitor for bleeding complications for Resident 5 who is currently taking the medication Apixaban was not implemented. ADM acknowledged the finding. During a review of the facility's policy and procedures (P&P) titled, Management of Anticoagulant Therapy, dated ,d+[DATE], the P&P indicated in part, POLICY: It is the policy of this facility that management of anticoagulant therapy involves use of laboratory results, physician orders, the MAR and monitoring of adverse side effects. The P&P also indicated, PROCEDURES: 1) Residents on anticoagulant/antiplatelet therapy will be monitored for possible side effects which include: a) Passing blood in the urine, b) Passing blood when the resident is having a bowel movement, c) Severe bruising, d) Prolonged nosebleeds

Based on interviews, record review and facility policy and procedure, the facility failed to ensure one of five sampled residents (Residents 55), care plan (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) was revised after a fall. This failure had the potential for Resident 55's evolving needs for fall prevention to go unmet and potentially leading to preventable fall. Findings: During an interview on 05/28/25 at 3:30 p.m. with Resident 55, Resident 55 stated, that he had a fall this morning when he stood up from the wheelchair to put his jacket on and the wheelchair slid back. Resident 55 stated that he did not sustain injury but that this was his 3rd fall in the facility. During a review of Resident 55's Care Plan (CP) dated 05/29/25, the CP indicated that a CP was created and initiated for Has had an actual fall on 5/29/25 by the Director of Staff Development (DSD). During a concurrent interview and record review on 05/29/25 at 4:50 p.m. with Director of Nursing (DON), Resident 55's CP was reviewed. The DON stated that when a resident sustains a fall in the facility the CP should be updated on day of the event and acknowledged that Resident 55's CP was not updated to include the actual fall that occurred 5/28/25 stating that the CP should have been updated. During a concurrent interview and record review on 05/30/25 at 10:19 a.m. with Director of Staff Development (DSD), Resident 55's Progress Notes (PN) dated 04/30/25 - 05/31/25 and CP dated 05/29/25 were reviewed. The PN indicated, Resident 55 was a [AGE] year-old male, with history including but not limited to, Type 2 Diabetes (a chronic condition leading to elevated blood sugar), Paroxysmal Atrial Fibrillation (an irregular heart rhythm), anemia (the body does not have enough healthy red blood cells) and difficulty in walking. DSD stated on 5/28/25 at approximately 10:30 a.m. Resident 55 had an unwitnessed fall. DSD stated that he was the nurse that completed the post fall assessment of Resident 55 on 05/28/25. DSD stated that the post fall assessment and CP were not entered into the electronic health record (EHR) until 05/29/25 at 11:23 p.m., 36 hours after the fall. DSD acknowledges that the Post Fall Assessment and CP should have been completed in EHR when the incident happens. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention, dated 05/2025, indicated in part, PROCEDURES: . 3. If a resident sustains a fall, a post fall assessment, including recommendations and care plan changes will be completed . 8. Care plans will be revised and/or updated to reflect changes in interventions.

Based on observation, interview, and record review, the facility failed to ensure care and services were delivered according to policies and procedures (P&P) for three of 15 sampled residents (Residents 9, 55 and 8) when: 1. The Change of Condition (COC) after the fall was not documented in a timely manner as required by facility policy for Resident 55. 2. The blood pressure (BP) parameter set by the physician when to hold the medication Hydralazine HCl (medication used to lower blood pressure) was not followed for Resident 9. 3. The call light was not placed within reach for Resident 8. These failures had the potential to result in unsafe nursing practices and compromise the health and safety of the affected residents. Findings: 1. During a concurrent interview and record review on 05/30/25 at 10:19 a.m. with Director of Staff Development (DSD), Resident 55's Progress Notes (PN) dated 04/30/25 - 05/31/25 was reviewed. The PN indicated, Resident 55 was a [AGE] year-old male, with history including but not limited to, Type 2 Diabetes (a chronic condition leading to elevated blood sugar) Paroxysmal Atrial Fibrillation (an irregular heart rhythm), anemia (the body does not have enough healthy red blood cells) and difficulty in walking. DSD stated on 5/28/25 at approximately 10:30 a.m. Resident 55 had an unwitnessed fall. DSD stated that the Change of Condition (COC - any incident or change from a residents norm) were not entered into the electronic health record (EHR) until 05/29/25 at 11:23 p.m., 36 hours after the fall. DSD acknowledges that the COC should be done when the incident happens [05/28/25]. During a concurrent interview and record review on 05/30/25 at 10:19 p.m. with DSD, the facility's policy and procedure (P&P) titled Change of Condition Reporting, dated 05/2025 was reviewed. The P&P indicated in part, . 4. All nursing actions will be documented in the licensed progress notes as soon as possible after the resident needs have been met. The DSD acknowledges that Resident 55 needs were met immediately after the fall and that the COC should have been documented at that time per facility policy. 43745 2. During a review of Resident 9's Admission Record (AR), dated 5/30/25, the AR indicated in part Resident 9 was a [AGE] year old male who was initially admitted to the facility on [DATE] with admission diagnoses including essential hypertension (high blood pressure), Type II Diabetes Mellitus (a chronic disease where the body either doesn't produce enough insulin or can't properly use the insulin it produces leading to high blood sugar levels) and Chronic Kidney Disease (a condition where the kidneys are damaged and cannot function properly over a prolonged period). During a review of Resident 9's Order Summary Report (OSR), dated 5/30/25, the OSR indicated the medication order, Hydralazine HCl tablet 25 mg (milligram) give one table by mouth four times a day for hypertension, hold if SBP (systolic blood pressure) less than 110, (Order Date: 2/28/25). During a review of Resident 9's Medication Administration Record (MAR), dated 5/1/25 - 5/31/25, the MAR, under the medication Hydralazine HCl tablet 25 mg ., indicated that the BP parameter set by the physician when to hold the medication was not followed when: On 5/18/25 for the 2100 (9 p.m.) dose, Resident 9 received the medication with a BP reading of 108/79; on 5/22/25 for the 1300 (1 p.m.) dose, Resident 9 received the medication with a BP reading of 108/68; and on 5/23/25 for the 1300 (1 p.m.) dose, Resident 9 received the medication with a BP reading of 105/68. During a concurrent interview and record review on 5/30/25 at 10:54 a.m., with the Director of Nursing (DON), Resident 9's MAR, dated 5/1/25 - 5/31/25 was reviewed. The section of the MAR under the medication order, Hydralazine HCl tablet 25 mg . was reviewed and DON acknowledged that staff did not follow the blood pressure parameter prescribed by the physician on the specific administration dates and times noted above. DON stated, Nurses should follow professional standards when administering the medication. During a review of the facility's P&P titled, MAR (Medication Administration Record) and TAR (Treatment Administration Record), dated 10/2010, the P&P indicated in part, POLICY: It is the policy of this facility that medication and treatment records shall reflect the administration as prescribed by the physician. During a review of the facility's P&P titled, Medication Administration, dated 5/2025, the P&P indicated in part, Essential Points . 13) Hold medication based on parameter as ordered by physician 50707 3. During a review of Resident 8's Admission Record (AR), dated 5/29/25, the AR indicated Resident 8 was admitted on [DATE] with diagnoses that include legal blindness (severe vision loss), generalized muscle weakness, and need for assistance with personal care. During a concurrent observation and interview on 5/27/25 at 4:02 p.m., with Licensed Nurse (LN) 1 in Resident 8's room, Resident 8 was observed sitting in a wheelchair by the window. The call light was observed pinned to the top of the bed, out of Resident 8's reach. LN 1 stated Resident 8 is blind, confirmed the call light is not within reach, and it should be. During a review of the facility's policy and procedure (P&P) titled Call Light/Bell, dated 11/2024, the P&P indicated 5. Place the call device within resident's reach before leaving the room.

Based on observation, interview and record review, the facility failed to ensure the controlled drug record for Lorazepam (a prescription medication to treat anxiety that has a potential for abuse, misuse, and can lead to dependence) was accurate for Resident 547. This failure resulted in an inaccurate count and had the potential for drug diversion (the illegal distribution or abuse of controlled prescription drugs) of controlled medications. Findings: During a review of the facility's policy and procedure (P&P) titled Narcotic Count dated 11/2024, the P&P indicated 2. After the supply is counted and justified, each nurse must record the date and his/her signature verifying that the count is correct. During a concurrent interview and record review on 5/27/25 at 3:00 p.m., with Licensed Nurse (LN) 3, the Controlled Drug Record - Liquids (CDRL) was reviewed for Resident 547's medication Lorazepam. The CDRL indicated that there was a balance of 22.0 milliliter (mL) of liquid Lorazepam. During a concurrent observation and interview on 5/27/25 at 3:00 p.m., with Licensed Nurse (LN) 3 in the Medication Room at Station 1, a bottle of liquid Lorazepam 2 milligrams (mg) per mL for Resident 547 was observed in the refrigerator. The bottle of Lorazepam showed 21mL of liquid remaining in the bottle. LN 3 confirmed the count sheet is incorrect and stated no, it isn't at 22mL and it should be.

Based on observation, interview, and record review, the facility failed to ensure: 1. Expired medications were discarded and not available for use for one sampled resident (Resident 5) and two unsampled residents (Resident 1 and Resident 79). 2. The medication refrigerator temperature was monitored twice a day per facility policy when storing vaccines. These failures had the potential for residents to receive expired and ineffective medications. Findings: 1. During a concurrent observation and interview on 5/29/25 at 3:05 p.m., with the Assistant Director of Nursing (ADON) in the nurses' station two, the following medication were observed to be expired in the medication cart 2: Two bubble packs of Trazodone (a medication used to treat depression) for Resident 79. One packet of DuoNeb (a medication that helps breathing) for Resident 5. Two boxes of Hydrocortisone Suppository (a medication used to treat inflammation) for Resident 1. One box of Bisacodyl Suppository (a medication that loosen stools and increase bowel movements) for all residents to use. ADON stated all the above-mentioned medications are expired and should have been discarded. During a review of the facility's policy and procedure (P&P) titled Storage of Medications dated May 2022, the P&P indicated Expiration Dating (beyond-use dating): G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. 2. During a review of the facility's policy and procedure (P&P) titled Storage of Medications dated May 2022, the P&P indicates, Temperature . F. The Facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC guidelines. During a concurrent observation and interview on 5/29/25 at 2:31 p.m., with the Assistant Director of Nursing (ADON), in the medication storage room [ROOM NUMBER], a bottle of Prevnar 20 (a vaccine that helps protect against pneumonia- an infection of the lungs) for Resident 35 was observed stored in the refrigerator. ADON confirmed vaccines are stored in the medication refrigerator. During a concurrent interview and record review on 5/29/25 3:46 p.m., with ADON, the Refrigerator Temperature Log (RTL) dated May 2025 for Medication room [ROOM NUMBER] was reviewed. The RTL indicated the refrigerator temperature is checked once a day. The ADON confirmed the temperatures of the refrigerator are monitored once a day during the night shift. ADON acknowledged the refrigerator temperatures should have been checked twice a day and they were not.

Based on observation, interview, and record review, the facility failed to ensure temperature and humidity levels in the dry food storage room were properly monitored and documented. This failure had the potential to result in inaccuracies of information which can affect interventions to increase the shelf-life (the length of time that a commodity may be stored without becoming unfit for use , consumption or sale) of the stored food items. Findings: During a concurrent observation and interview, on 5/24/25 at 9:20 a.m., with the facility's Dietary Supervisor (DS) in the kitchen's dry food storage room, an installed analog indoor thermometer with hygrometer (a device that measures indoor temperature and humidity levels) was observed. The temperature and humidity levels read 70 F (degrees Fahrenheit) and 68% (percent) respectively. When asked to review the temperature and humidity log for the current month, DS stated, We only create a log when the temperature inside the room feels warmer than normal . when the temperature reads over 80 F. During an interview with the facility Administrator (ADM) and DS on 5/28/25 at 11:43 a.m., ADM and DS acknowledged that the dry food storage room and humidity level readings should be properly monitored, and the readings documented and/or logged by staff so that accurate information is available in case a corrective action is required. During a review of the facility's policy and procedures (P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated in part, PROCEDURES FOR DRY STORAGE . 1) The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. Thermometer should be placed in all storage areas and checked frequently. Recommended temperature is 50 F - 85 F, if dry food storage goes above 85 F, take corrective action

Based on interviews, record reviews, and facility policy review the facility failed to ensure the Minimum Data Set (MDS) was accurate for 2 (Resident #15 and Resident #18)) of 19 sampled residents. Findings included: A facility policy titled, Resident Assessment Instruments/MDS [Minimum Data Set], updated in November 2023, revealed 7. Each person completing a section of the MDS attests to its accuracy by affixing his/her electronic signature to that section of the MDS. 1. An Admission Record revealed the facility admitted Resident #15 on 03/18/2024, with diagnoses to include urinary calculus (kidney stone), obstructive and reflux uropathy (urine accumulation in the kidney), and benign prostatic hyperplasia (overgrowth of prostate tissue) with lower urinary tract symptoms. An admission MDS, with an Assessment Reference Date (ARD) of 03/25/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #15 did not have an indwelling catheter. Resident #15's Physician Orders, with active orders as of 05/23/2024, revealed an order dated 03/19/2024, for an indwelling catheter for h a diagnosis benign prostatic hyperplasia with obstructive uropathy. During an interview on 05/23/2024 at 10:49 AM, the MDS Coordinator stated the MDS was not accurate as the MDS indicated Resident #15 did not have an indwelling catheter. 2. An Admission Record revealed the facility admitted Resident #18 on 10/22/2021, with a diagnosis to include need for assistance with personal care. An annual MDS, with an Assessment Reference Date (ARD) of 10/25/2023 revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #18 did not use tobacco. During an interview on 05/23/2024 at 10:49 AM, the MDS Coordinator stated the MDS was not accurate as it indicated Resident #18 did not use tobacco. During an interview on 05/23/2024 at 11:18, the Administrator and the Director of Nursing both stated the MDS should be accurate.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and 2), had their health status accurately assessed using the Minimum Data Set ((MDS) a comprehensive assessment that helps nursing home staff identify health problems and track the improvement or decline of those problems). This facility failure had the potential to result in staff providing inappropriate care and the residents not achieving or maintaining their highest practical level of well-being. Findings: During a review of Resident 1's Admission Record (AR), dated 2/29/24, the AR indicated, Resident 1 was a [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. During a review of Resident 1's Physician Progress Note (PPN), dated 10/31/2023, the PPN indicated, Resident 1 had surgery on 10/25/23 for debridement of right posterior (back side) thoracolumbar (region of the spine) paramedian (close to the midline) wound with reconstruction with paraspinal muscle (muscles that support the back) flap and thoracolumbar spinal hardware exchange. Resident 1 also had impaired range of motion ((ROM) how much a body part can be moved) and weakness of bilateral lower extremities (legs), paraparesis (partial paralysis of the legs) with some muscle atrophy (muscle wasting) and a history of chronic right foot drop (difficulty lifting the front part of the foot). Resident 1 was receiving intravenous ((IV) directly into a vein) meropenem (antibiotic). During a review of Resident 1's MDS, dated [DATE], the MDS indicated: a. Section A2300 the assessment observation end date was 11/6/23, b. Section GG0115 no impairment in functional (the required amount to maintain maximal independence) ROM of lower extremities that interfered with daily functions or placed the resident at risk of injury, c. Section J2000 no major surgery in the 100 days prior to admission, d. Section J2100 no major surgical procedure during the prior hospital stay that requires active care (skilled nurses provide medical assistance with medication, wound care, and other medical needs) during the skilled nursing facility (SNF) stay, e. Section J2300-5000 no surgical procedure identified, f. Section M1040 has an infection of the foot and other open lesions on the foot; has surgical wounds, g. Section M1200 gets surgical wound care treatments, application of nonsurgical dressings, and application of dressings to feet. During a review of Resident 1's Progress Note (PN): - Dated 2/2/24 at 4:04 p.m., Patient requires one person assist with transfer, personal hygiene, adl's and bed mobility. Patient uses wheelchair for locomotion. - Dated 2/3/24 at 9:12 p.m., Requires one person extensive assist with transfer, personal hygiene, adl's and bed mobility. - Dated 2/4/24 at 10:07 a.m., the PN indicated, Pt requires one person ext assist w/ transfer, personal hygiene, ADL's and bed mobility pt uses wheelchair for locomotion. - Dated 2/5/24 at 2:12 p.m., the PN indicated, Resident needs 1person extensive assist w/ bed mobility transfer toileting and ADL's . Uses wheelchair for locomotion. During a review of Resident 1's MDS, dated [DATE], the MDS indicated: a. Section A2300 the assessment observation end date was 2/6/24, b. Section GG0115 no impairment in functional ROM of lower extremities that interfered with daily functions or placed the resident at risk of injury, c. Section GG0120 walker and wheelchair were not normally used, d. Section GG0170 required helper to provide verbal cues and/or touching/steadying and/or contact guard assistance to complete walking 10 feet, walking 50 feet with two turns and walking 150 feet. Required helper to provide set up or clean up prior to or following moving fromsitting to standing, transferring from chair/bed to chair, transferring to a toilet, and transferring to tub/shower. Does not use a wheelchair or scooter, e. Section I8000 has left and right foot drop During a concurrent interview and record review on 3/27/24 at 4:20 p.m., with the Assistant Director of Nursing (ADON) and the Director of Rehabilitation (DOR), Resident 1's: - PPN dated 10/31/23, - MDS, dated [DATE], - PN's dated 2/2/24 at 4:04 p.m., 2/3/24 at 9:12 p.m., 2/4/24 at 10:07 a.m., and 2/5/24 at 2:12 p.m., and - MDS, dated [DATE] were reviewed. ADON stated Resident 1 had major surgery just prior to admission and if section J2000 and J2100 were answered correctly, then J2300-5000 would have identified the surgery. ADON also stated Resident 1 did use a wheelchair and had right foot drop, not left foot drop. ADON further stated the NN and PN don't match the MDS. DOR stated their assessment of Resident 1 was limited to their time during therapy. During a review of Resident 2's AR, dated 2/29/24, the AR indicated, Resident 2 was a [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. During a review of Resident 2's PPN, dated 1/30/24 at 12:35 p.m., the PPN indicated, Resident 2 was admitted ,d+[DATE] after falling off his scooter and fracturing his right hip. Resident 2 had a history of an amputation (surgically cutting off) of his right leg through tibia (larger shin bone) and fibula (smaller shin bone) and had a history of amputation of his left great toe. Resident 2 continued to be wheelchair bound with weakness of both lower extremities. During a review of Resident 2's MDS, dated [DATE], the MDS indicated, a. Section A2300 the observation end date was 12/20/23 b. Section GG0115 no impairment in functional ROM of lower extremities that interfered with daily functions or placed the resident at risk of injury, c. Section GG0120 wheelchair was not normally used, and d. Section GG170 uses a wheelchair. During a concurrent interview and record review on 3/27/24 at 4:20 p.m., with the ADON and the DOR, Resident 2's PPN dated 1/30/24 and MDS dated [DATE] were reviewed. ADON and DOR stated, the MDS sections don't match, have conflicting information, and don't match the information on the PPN. DOR further stated their assessment of Resident 2 was limited to their time during therapy. During a review of the Centers for Medicare & Medicaid (CMS) Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (User's Manual), dated October 2023, the User's Manual indicated, GG0115 . Steps for Assessment 1. Review the medical record for references to functional range-of-motion limitation during the 7-day observation period. 2. Talk with staff members who work with the resident as well as family/significant others about any impairment in functional ROM . GG0120 . Steps for Assessment 1. Review the medical record for references to locomotion during the 7-day observation period. 2. Talk with staff members who work with the resident as well as family/significant others about devices the resident used for mobility during the observation period . GG0170 . Steps for Assessment 1. Assess the resident's mobility performance based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident's medical record during the assessment period . If the resident's functional status varies, record the resident's usual ability to perform each activity. Do not record the resident's best performance and do not record the resident's worst performance, but rather record the resident's usual performance . I8000 . There may be specific documentation in the medical record by a physician . J2100 . Major Surgery Refers to a procedure that meets the following criteria: 1. The resident was an inpatient in an acute care hospital for at least 1 day in the 100 days prior to admission to the skilled nursing facility (SNF), and 2. The surgery carried some degree of risk to the resident's life or the potential for severe disability . J2000 . Steps for Assessment . 2. Review the resident's medical record to determine whether the resident had major surgery during the inpatient hospital stay that immediately preceded the resident's Part A admission . J2300-5000 . Code surgeries that are documented to have occurred in the last 30 days, and during the inpatient stay that immediately preceded the resident's Part A admission, that have a direct relationship to the resident's primary SNF diagnosis.

Based on record review and interview the facility failed to monitor and verify one of five sampled certified nursing assistants (CNA) certification credentials prior to expiration dates. This failure risks residents being cared for by individuals who lack valid authorization to practice as a CNA. Findings: During a review of facility policy and procedure titled, Verification of Licenses, dated ,d+[DATE], indicated in part . It is the policy of the company to verify all employees in positions which require licensure or certification, have a current license or other authorization to practice in the state(s) in which they work. Under facility policy titled Procedure indicated in part . 6. The Department manager or designee should monitor expiration dates of all licenses and credentials and notify employees in advance of such dates. The Department manager or designee should contact the appropriate agency to verify the license or certification. When renewed the copy of the valid license/certification and or a verification form will be added to the personnel file by the Department manager or a designee . During a concurrent interview and record review on [DATE], starting at 10:30 a.m., with assistant director of nursing (ADON) and director of staff development (DSD), while reviewing Sample CNA1 personnel file, file revealed that CNA1 has been employed by facility as a CNA since [DATE]. Further records revealed that CNA 1 State certification expired on [DATE]. The ADON acknowledged the expiration date, occurred over 10 months ago, and stated, Not sure when the lapse occurred, we asked the employee and she believed everything was OK. When management went into the State data base the system indicated some problem with training but we have been unable to clarity. During a review of monthly attendance record, indicated employee CNA1 was removed from the schedule effective [DATE], and last day worked had been [DATE].

Based on interview and record review, the facility failed to ensure one of two sampled Residents (Resident 2) was provided a written bed-hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization ) notice when transferred to the hospital. This failure had the potential to result in Resident 2 and their representative not being aware of the facility's bed-hold and reserve bed payment (payments made by the State to the facility to hold a bed during a resident ' s temporary absence from a nursing facility) policy. Findings: During a review of the facility's policy and procedure (P&P) titled, Bed Hold, dated 10/2020, the P&P indicated, It is the policy of this facility that the facility shall inform the resident, or the resident's representative, in writing of the right to exercise the bed hold provision of seven (7) days . This information shall be provided upon . Transfer to general acute hospital. During a review of Resident 2' s Nursing Home to Hospital Discharge Form (NHTHDF), dated 4/30/23, at 4:55 p.m., the NHTHDF indicated, Resident 2 was transferred to the hospital. During an interview on 5/2/23, at 5 p.m., with the Director of Admissions (DOA), DOA stated he spoke with Resident 2' s Representative (RR) by phone today and they, Refused bed-hold. During a review of Resident 2' s Progress Note (PN), dated 5/2/23, at 5:41 p.m., authored by DOA, the PN indicated, Spoke with [family name] (son) and informed him that the patient is on a Medi-Cal bed hold and is on day 3 of 7. Per son, he no longer wants to continue on holing the bed for [Resident 2 name] as of today. During an interview on 5/31/23, at 12:45 p.m., with the Director of Nursing (DON), DON stated Res 2 and their RR were not notified in writing of the facility bed-hold policy. DON further stated, They are notified by phone. DON added the facility does not have a process in place for notifying the resident or their representative in writing after they have been transferred to the hospital.

Based on interview and record review, the facility failed to treat one of two sampled residents (Resident 1) in a dignified manner when a Certified Nurse Assistant (CNA 1) responded to Resident 1's request for care with a statement that was rude, inconsiderate and disrespectful. This facility failure resulted in emotional distress for Resident 1 when Resident 1 reported she experienced feeling sad and had the potential to result in other residents not being treated with dignity and respect. Findings: During a review of facility policy and procedure (P&P) titled Residents Rights dated 11/2020, the P&P indicated, The resident has the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. During an interview on 4/20/2023, at 12:30 p.m., with Resident 1's daughter, daughter stated, When I arrived at the facility on April, 19 (4/19/23), my mom's roommate (Resident 2) told me that the nurse was rude the previous night (4/19/23). She (Resident 2) explained to me that my mom was screaming for help and the nurse (CNA 1) told her to stop screaming. When my mom continued to scream, the nurse (CNA 1) told her if she (Resident 1) didn't listen to her, then she (CNA 1) was not going to listen to her (Resident 1). My mom told me what happened, and that it made her upset. My mom (Resident 1) was upset the whole day. I reported the incident to the Administrator on 4/19/23 at 18:30. During an interview on 4/20/2023, at 12:30 p.m., with Resident 1, Resident 1 stated, I was screaming because I needed help. The nurse came in and told me to stop screaming. The nurse told me if I didn't listen to her and stop then she wouldn't listen to me. She was rude to me and made me feel sad. During a review of Resident 1's medical record on 4/20/23, the medial record indicated, Resident 1 requires two-person assist for transfers, toileting and ADL's (Activities of daily living). Resident is Spanish speaking, alert, oriented and able to make needs known. During an interview on 4/20/23, at 13:42 p.m., with the Director of Staff Development (DSD), DSD stated, The nurse should never speak to a resident like she (CNA 1) spoke to her (Resident 1). It is not acceptable no matter what. During an interview on 4/20/23, at 14:00 p.m., with the Director of Nurses (DON), DON stated, We are currently investigating the incident and the nurse has been suspended pending the investigation. This is a customer service issue that must be addressed. IDT met and determined this was poor customer service and the nurse will be re-educated on tone of voice to be used when speaking to our customers. During an interview on 4/20/23, at 13:15 p.m. with the Administrator (ADM), ADM stated, The daughter reported that she (Resident 1) was screaming because she needed help and CNA (CNA 1) stated if you don't listen to me, then I won't listen to you. We immediately initiated an investigation and suspended the employee pending investigation. It is not acceptable to speak to our residents like that, the nurse will receive corrective action and possibly termination.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was discharged home with the correct medications prescribed by the resident's physician. This facility failure led to Resident 1 being discharged with another resident ' s medications, which the resident took at home and had the potential to lead to serious medication side effects. Findings: During the review of the facility ' s policy and procedure titled, Release of Medications, dated 02/2019, the policy indicated, The Transfer/Discharge form and Discharge Summary will be reviewed with the resident and/or resident representative. The Transfer/Discharge form with the most recent medication list will be discussed by a Licensed Nurse upon discharge. During an interview with the facility administrator (ADM 1) on 08/19/22, at 12:30 p.m., ADM 1 indicated, the facility received a call from Resident 1 ' s family member explaining the resident's medication bottle was labeled with a different name than Resident 1's name. Resident 1 had also been given the medication since discharge on 08/07/22. The following medications were provided to Resident 1 at discharge: [MEDICATION(S)] (medication to treat seizures and [CONDITION(S)]), [MEDICATION(S)] (medication to treat high blood pressure), [MEDICATION(S)] (medication which improves the flow of blood through the blood vessels). During a review of the physician medication active orders for Resident 1, dated 07/01/22 , the physician medication orders did not include the medications Resident 1 was sent home with by the facility. During an interview with the director of nursing (DON) on 08/19/22, at 12:30 p.m., DON explained the discharging nurse failed to follow the facility policy and procedure, which required discussing each discharge medication with the resident or resident's responsible party by reviewing the physician ' s list of discharge medications with the actual medications being provided to the resident at discharge. The discharging licensed nurse should have discussed each medication with the resident/resident's representative based upon the medication being provided and the physician ' s MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review and interview, the facility failed to report to the California Department of Public Health (Department) one of 2 sampled residents (Resident 1) left the facility in the care of a family member, was unable to be located from 1:32 p.m. on 5/31/22 until 8 a.m. on 6/1/22, and then refused to return to the facility. This failure to report an incident resulted in a violation of California Code of Regulations, Title 22, Chapter 3, section , which requires facilities to report unusual occurrences to CDPH within 24 hours. This deficient practice delayed the Department's investigation and placed other residents who may have a potential for elopement risk in a unsafe situation. Findings: The facility policy and procedure titled, Unusual Occurrence Reporting dated 10/2010, indicated in part . Unusual occurrences shall be reported by the facility within twenty-four (24) hours by telephone (and confirmed in writing) or telegraph to the local health officer and the Department . During a review of Resident 1 ' s Minimum Data Set (MDS) (an assessment tool for residents), dated May 2022, the MDS indicated, Resident 1 had a Brief Interview for Mental Status (BIMS 0-15 score system to measure mental capacity, 0 to 7 severe impairment, 8-12 moderate impairment and 13-15 intact) of 12. During a review of Resident 1's physician order, dated 5/14/2022 the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] & procedures. During a review of the clinical record for Resident 1, the progress notes dated 5/31/22, at 11:10 p.m., and 6/1/22 at 12:52 a.m., indicated in part . Patient was last seen 5/31/22 at 1:32 P.M. leaving facility without signing out. Further record review indicated on 6/1/22, MD and police were notified. Further review of notes did not indicate that the Department was notified. During an interview with the Administrator (Adm1) on 7/18/22, starting at 12:15 p.m., the Adm1 acknowledged the event was an unusual occurrence and the facility did not notify the Department. The Adm1 stated, I should have notified CDPH.

Based on interview and record review, the facility failed to meet professional standards for one of two sampled residents (Resident 1) when physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This facility failure has the potential to negatively impact Resident 1 physical well-being. Findings: According to Nursing Fundamentals by [NAME], [NAME] and Wilkins, second edition, 2010 p. 322, Documentation is the professional responsibility of all health care practitioners. It provides written evidence of the practitioner's accountability to the client, the institution, the profession, and society. During a review of ResMed's (a California based medical device company, that provides cloud connectable devices and masks for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Air leakage from the machine also indicated beyond threshold levels for both months, thus rendering the machine ineffective. During a review of Resident 1's Order Summary Report, (OSR), dated 12/4/21, the OSR included a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/18/22, at 11:30 a.m., with the Director of Nursing (DON), DON confirmed there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated that there was the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/12/22, at 1:15 p.m., with Licensed Nurse 1 (LN 1), LN 1 states that Resident 1 is often confused at night, and removes the [CONDITION(S)] mask to scream, and this happens most of the night. LN 1 further states that there is no documentation to see if the [CONDITION(S)] was on the entire night. During an interview on 4/12/22, at 1:35 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, that Resident 1 sleeps with the [CONDITION(S)] for a while, wakes up, and takes off the mask and starts screaming. CNA 1 also confirms that this happens a lot at night. During an interview on 4/12/22, at 4:15 p.m., with LN 2, LN 2 confirmed Resident 1 is on and off the [CONDITION(S)] because he continuously takes it off. LN 2 further states there are no measures to monitor and document if the machine is on or not. The facility was unable to provide any other medical records for Resident 1, to document staff were monitoring and tracking if the [CONDITION(S)] machine was on and remained with the resident from the evening to the night shift per physician order.

Based on interview and record review the facility failed to follow its policy and procedure to notify the primary care physician when one of two sampled residents (Resident 1) refused medications. This facility failure has the risk of negatively impacting Resident 1 ' s health. Findings: During a review of facility's policy and procedure (P&P) titled, Medication Administration, revised 10/2010, the P&P indicated in part . 15. Refusal of medications: [MEDICAL RECORD OR PHYSICIAN ORDER] a) Attempt to offer x3 b) Should resident continue to refuse x 3 attempts, document in the EMAR c) Notify attending Physician upon refusal of essential medications. During a review of Resident 1 ' s electronic medical record (EMR), record document titled, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (antipsychotic medication to treat patients with thought disorders) tablet 2 milligrams (mg), 1 tablet by mouth daily. 2. [MEDICATION(S)] (medication to treat tremors) 1 mg at bedtime. 3. [MEDICATION(S)] (antipsychotic drug to treat persons with thought disorders) 50 mg by mouth twice daily. 4. [MEDICATION(S)] (medication to treat anxiety and/or restlessness) 1 mg by mouth daily as needed. 5. [MEDICATION(S)] (medication to treat blood pressure) 25 mg, ½ tablet daily. Further medical record review revealed, Resident 1 refused medications on 8/20/21, there was no documentation in Resident 1 ' s EMR that would indicate nursing staff offered medications three times. There was no documentation that Resident ' 1 physician was notified that Resident 1 refused medications on 8/20/21. During a concurrent interview and record review on 2/1/22, starting at 4:15 p.m., with director of nursing (DON), the DON acknowledged that medications Resident 1 had refused on 8/20/21, were considered essential medications. DON further identified, that Resident 1 ' s medical record did not include documentation that Resident 1 ' s physician was notified of Resident 1 ' s refusal to take medications. DON stated, On the twentieth [8/20/21] we [facility staff] do not have documentation, it ' s not here, indicating medical record.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set ((MDS) a collection of data used to guide care planning and monitoring for residents in long term care) for one of 2 sampled residents (Resident 1), in the areas of: 1. Section G, Functional Status, at G0400A, limitation in range of motion (movement) of the upper extremity (arm). 2. Section M, Skin Conditions, at M1200C, turning/repositioning program, and M1200D, nutrition or hydration intervention to manage skin problems. For Resident 1, these facility failures had the potential to result in care planning interventions (actions to be taken) inconsistent with their needs. Findings: According to Fundamentals of Nursing (Potter et al.; Elsevier: 2017, p. 66), The long-term care setting includes skilled nursing facilities .Individual state regulations, TJC [The Joint Commission], and The CMS [Centers for Medicare and Medicaid Services] govern documentation requirements in these facilities. The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is federally mandated for use in long-term care facilities by CMS. Compliance with state and federal requirements and reimbursement for care provided in a long-term care facility depend on accurate completion of the required documentation to justify the care provided . During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 8/2017, the P&P indicated, The comprehensive care plan will be developed by the IDT within seven (7) days of completion of the Resident minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment . 1. During a review of Resident 1's MDS, dated [DATE], the MDS indicated, section G0400, Resident 1 had no impairment of the upper extremity (shoulder, elbow, wrist, hand) on either side. During a review of Resident 1's Initial Admission Record (IAR), dated 7/29/21, at 6:57 p.m., the IAR indicated, Resident 1 had a contracture (deformity) of the left arm. During a review of Resident 1's (untitled) physician encounter note (Note), dated 7/30/21, at 9 a.m., the Note indicated, Resident 1's range of motion of right-sided extremities (arms and legs) were impaired (weak or damaged) and flaccid (limp) [CONDITION(S)] (not able to move) affecting the right dominant side. During a review of Resident 1's Occupational Therapy (OT) evaluation, dated 7/30/21, the OT indicated, right and left arms impaired at the shoulder, wrist, and hand. Functional limitations (not able to use normally) present due to contracture in the areas of self feeding, hygiene/grooming, dressing, toileting and transferring. During an interview on 10/29/21, at 4:10 p.m., with a Director of Nursing (DON), DON stated, Contracture should be reflected at G0400. 2. During a review of Resident 1's MDS, dated [DATE], the MDS indicated, in section M1200C, no turning or repositioning program and, in section M1200D, no nutrition or hydration intervention to manage skin problems were initiated. During a review of Resident 1's Nutrition Evaluation and RDN (Registered Dietician) Review (NE), dated 8/1/21, at 9:32 a.m., the NE indicated, Resident 1 had nutritional supplements ordered and was at a high risk of malnutrition (lack of proper nutrition). During a review of Order Summary (Order), dated 8/1/21, at 11:41 a.m., the Order indicated: a. HPN [nutritional supplement], two times a day for low [MEDICATION(S)] [a protein produced in the liver], wound healing for 30 days give SF [sugar free] 4 oz [ounces]. b. Prostat [nutritional supplement] two times a day for low [MEDICATION(S)], wound healing for 30 days give SF 30 cc [cubic centimeters] with 30-60cc of water or per pt's [Resident 1's] preference. During an interview on 10/18/21, at 5:49 p.m., with the DON, the DON stated, the MDS section M1200C and M1200D are not marked for turning/repositioning program and nutrition or hydration intervention to manage skin problems. The DON further acknowledged the MDS sections should have been marked.

Based on interview and record review, the facility failed to: 1. Develop and implement a care plan (document that specifies a resident's assessed needs and outlines what type of care , how the care will be given, and who will provide the care) for the actual problems of bowel and bladder incontinence (inability to control urination or defecation) for one of 2 sampled residents (Resident 1). 2. Adequately develop a person-centered care plan for the actual problem of pressure injuries (bed sores) including a frequency for the intervention (action to be taken to improve or prevent worsening the problem) of turning and repositioning for one of 2 sampled residents (Resident 1). These facility failures had the potential to result in decreased quality of life (comfort, health, and happiness) and decreased quality of care (health services that safe, efficient, patient-centered, timely, efficient, and equitable). Findings: During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 8/2017, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan [a document describing agreed goals of care by the healthcare team] for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. 1. During a review of Resident 1's Bowel and Bladder Evaluation (B&B Eval), dated 7/29/21, at 6:56 p.m., the B&B Eval indicated, Resident 1 was always incontinent of bowel and bladder and an unlikely candidate for bowel and bladder re-training. Review of resident 1's Braden Scale for Predicting Pressure Score Risk (Braden Scale), dated 7/29/21, at 6:56 p.m., the Braden Scale indicated, Resident 1 was confined to bed and made occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. During a concurrent interview and record review, on 10/18/21, at 7:20 p.m., with the Director of Nursing (DON), Resident 1's Plan and Braden Scale were reviewed. DON stated, Should be, a care plan for actual incontinence of bowel and bladder. 2. During a review of Resident 1's Plan titled, admitted with multiple pressure injuries: SCROTUM, COCCYX, SACRUM, dated 7/30/21, the Plan indicated, Interventions . Needs monitoring/reminding/assistance to turn/reposition. Review of the National Pressure Injury Advisory Panel (NPIAP) website, 1a._pressure-injury-preventi.pdf (ymaws.com), accessed on 10/21/21, indicated, Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. During a review of Resident 1's Initial Admission Record (IAR), dated 7/29/21, at 6:57 p.m., the IAR indicated, Resident 1 had three Stage IV (full thickness skin loss with exposed bone, tendon or muscle) pressure ulcers and four Stage II (partial thickness skin loss) pressure ulcers. During an interview on 9/10/21, at 9 a.m., with the DON, the DON stated turning and repositioning is not required every two hours with the use of, Specialty mattresses. The DON further stated, turning and repositioning is required, Frequently. During a review of the Owner's Manual (OM) titled, Air Advance Mattress & Air Advance Bariatric Mattress, undated, the OM indicated, This product is not designed to and cannot replace good caregiving practices and treatment including, but not limited to . frequent positioning. During a concurrent interview and observation on 9/10/21, at 3:35 p.m., with a certified nursing assistant (CNA1), at a hallway kiosk (computer for charting). CNA1 demonstrated the process for documenting turning and repositioning using the kiosk. CNA1 pointed out the frequency indicates how often they need to document. CNA1 further stated, there is only one resident who requires every two-hour documentation and doesn't understand why that one is different from the other residents. During an interview on 9/10/21, at 4:45 p.m., with a licensed nurse (LN3), LN3 stated, there isn't any resident on bedrest who requires turning and repositioning right now. LN3 further stated, the standard of care is, Frequently, not every two hours anymore. During an interview on 9/18/21, at 5:49 p.m., with the DON, the DON stated Frequently, means, Frequently. the DON further stated, Not on a schedule.

Based on interview and record review, the facility failed to ensure one of 2 sampled residents (Resident 1), received care according to accepted standards of clinical practice (appropriate treatment based on credible scientific evidence) when interventions (actions to be taken) for repositioning and turning (changing position to relieve pressure and restore blood flow to the skin) did not adhered to the accepted standard of care. For Resident 1, these facility failures had the potential to result in decreased quality of care (health services that are safe, effective, patient-centered, timely, efficient, and equitable). Findings: According to Fundamentals of Nursing (Potter et al; Elsevier: 2017, p. 2), When giving care, it is essential to provide service according to standards of practice .The Standards of Practice describe a competent level of nursing care. During a review of Resident 1's Initial Admission Record (IAR), dated 7/29/21, at 6:57 p.m., the IAR indicated, Resident 1 had three Stage IV (full thickness skin loss with exposed bone, tendon or muscle) pressure ulcers and four Stage II (partial thickness skin loss) pressure ulcers. During a review of Resident 1's Braden Scale for Predicting Pressure Sore Risk (Braden Scale), dated 7/29/21, at 6:56 p.m., the Braden Scale indicated Resident 1 was confined to bed and makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. During a review of Resident 1's care plan ((Plan) specifies the assessed needs, outlines what type of action or care is required to meet those needs and who will provide the care) titled, admitted with multiple pressure injuries: SCROTUM, COCCYX, SACRUM, dated 7/30/21, the Plan indicated, Interventions .Needs monitoring/reminding/assistance to turn/reposition. During an interview on 9/10/21, at 9 a.m., with a director of nursing (DON), the DON stated turning and repositioning is not required every two hours with the use of, Specialty mattresses. The DON further stated, turning and repositioning is required, Frequently. During a review of the Owner's Manual (OM) titled, Air Advance Mattress & Air Advance Bariatric Mattress, undated, the OM indicated, This product is not designed to and cannot replace good caregiving practices and treatment including, but not limited to . frequent positioning. During an interview on 10/18/21, at 5:49 p.m., with the DON, the DON stated Frequently, means, Frequently. The DON further stated, Not on a schedule. Review of the National Pressure Injury Advisory Panel (NPIAP) website, 1a._pressure-injury-preventi.pdf (ymaws.com), accessed on 10/21/21, indicated, Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preference .Continue to reposition an individual when placed on any support surface. During an interview on 10/18/21, at 7:35 p.m., with the DON, the DON stated no nursing reference is available to use as a guide when choosing the best person-centered evidence-based interventions. The DON further stated, You [nurses] know what to do.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) who was identified as high fall risk and a history of removing a tab alarm (warning system to alert staff when attempts are made to transfer self unassisted), had alternate safety measures implemented and supervision for a fall related injury. As a result, Resident 1 fell sustaining blunt force trauma to the head and died . Findings: Record review revealed, Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] indicated, Resident 1 sometimes understands, has impaired recall ability, impaired vision, and needs extensive assist with bed mobility and transfer. Review of Resident 1's fall risk assessment dated [DATE], identified Resident 1 at high risk for falls and the care plan included interventions to place Resident 1's bed in low position and locked, use of side rails, and use of tab alarm when Resident 1 was in bed or in the wheelchair. Review of physician orders [REDACTED]. During an interview on [DATE] at 1:20 p.m., a licensed nurse (LN 1) recalled the events at 3 a.m. on [DATE] when a certified nursing assistant (CNA 1) called on the radio summoning a nurse. LN 1 recalled seeing Resident 1 lying on the floor mattress perpendicular to the bed with his head between the bars of the frame of the bed. Resident 1 had a large gash down to the brain from middle of eyebrow to past his ear and was not breathing and did not have a pulse. LN 1 indicated the tab alarm was intact sitting on the bed and not connected to Resident 1. LN 1 added, (Resident 1) is known for taking his tab off. During an interview on [DATE] at 1:30 p.m. and 2:30 p.m., LN 2 and CNA 1 explained also having knowledge Resident 1 would remove his tab alarm. CNA 1 stated, Several times he (Resident 1) has taken the tab alarm off in the past. During an observation on [DATE] at 2:45 p.m. revealed, Resident 1's room was located near the exit at the end of the hall from the nurses' station. Resident 1's bed was electric and contained a hand control device. The hand control device raised and lowered the entire bed, the head of the bed, and the knee. The bed contained a control panel located on the footboard with four lock buttons for each of the bed positions. During an interview on [DATE] at 10:20 a.m., LN 3 explained, Resident 1, on [DATE], was found at least twice to have his legs dangling over the side of the bed with the tab alarm intact but disconnected from his gown and sometimes Resident 1 would remove the entire gown from his body leaving the tab alarm clipped to the gown. LN 3 explained this behavior happened on several shifts. LN 3 indicated reporting this information to the oncoming shift to keep an eye on him because he takes his tab alarm off. Despite knowledge of Resident 1 having a history of removing the tab alarm, the fall care plan continued to identify the tab alarm as a viable intervention to alert staff when Resident 1 attempted unassisted transfers from the bed or wheelchair. During an interview on [DATE] at 11:15 a.m., CNA 2 explained having knowledge Resident 1 removes the tab alarm and liked to play with the bed control remote device. On [DATE], Resident 1 was seen playing with the bed control remote device and CNA 2 removed the bed control remote device from Resident 1's hands and placed it toward the end of the bed. During an interview on [DATE] at 12:30 p.m., CNA 3 confirmed also having knowledge Resident 1 had a history of [REDACTED]. During an interview on [DATE] at 1:45 p.m., the director of nurses (DON) explained, the facility process for reporting resident care issues to the next shift and the interdisciplinary team for care plan revisions. The DON explained the 24 hour report document was the method used for this communication. Concerns or changes can be filled out by anyone employed by the facility and these forms are read every morning by all department managers during stand-up meeting. The DON further explained, any nurse can implement nursing measures such as a bed pad sensor alarm (alarms when a resident changes pressure on the bed when exiting the bed) or a floor mat alarm that detects when there is an unsafe bed exit. The DON further indicated we even have a motion sensor alarm. Despite these alternative measures, there was no documented evidence these alternatives had been explored for Resident 1. During an interview on [DATE] at 11 a.m. and concurrent review of the manufacturer investigative report dated [DATE], the bed manufacturer director of quality (DOQ) indicated an alternate means of preventing the patient from rolling/climbing out of bed should be initiated if an individual is capable of injuring himself/herself. Safety measures should be considered for patients identified as high risk for entrapment. These patients would include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status, or a combination of these factors. The DOQ confirmed, Resident 1's bed was purchased by the facility with an override control panel at the foot of the bed. This control panel allows staff to override the hand bed control remote device. Review of the medical examiner autopsy report dated [DATE] revealed the cause of Resident 1's death was Blunt Force Trauma of Head with multiple skull fractures and laceration of the brain.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) who was identified as high fall risk and a history of removing a tab alarm (warning system to alert staff when attempts are made to transfer self unassisted), had alternate safety measures implemented and supervision for a fall related injury. As a result, Resident 1 fell sustaining blunt force trauma to the head and died . Findings: Record review revealed, Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] indicated, Resident 1 sometimes understands, has impaired recall ability, impaired vision, and needs extensive assist with bed mobility and transfer. Review of Resident 1's fall risk assessment dated [DATE], identified Resident 1 at high risk for falls and the care plan included interventions to place Resident 1's bed in low position and locked, use of side rails, and use of tab alarm when Resident 1 was in bed or in the wheelchair. Review of physician orders [REDACTED]. During an interview on [DATE] at 1:20 p.m., a licensed nurse (LN 1) recalled the events at 3 a.m. on [DATE] when a certified nursing assistant (CNA 1) called on the radio summoning a nurse. LN 1 recalled seeing Resident 1 lying on the floor mattress perpendicular to the bed with his head between the bars of the frame of the bed. Resident 1 had a large gash down to the brain from middle of eyebrow to past his ear and was not breathing and did not have a pulse. LN 1 indicated the tab alarm was intact sitting on the bed and not connected to Resident 1. LN 1 added, (Resident 1) is known for taking his tab off. During an interview on [DATE] at 1:30 p.m. and 2:30 p.m., LN 2 and CNA 1 explained also having knowledge Resident 1 would remove his tab alarm. CNA 1 stated, Several times he (Resident 1) has taken the tab alarm off in the past. During an observation on [DATE] at 2:45 p.m. revealed, Resident 1's room was located near the exit at the end of the hall from the nurses' station. Resident 1's bed was electric and contained a hand control device. The hand control device raised and lowered the entire bed, the head of the bed, and the knee. The bed contained a control panel located on the footboard with four lock buttons for each of the bed positions. During an interview on [DATE] at 10:20 a.m., LN 3 explained, Resident 1, on [DATE], was found at least twice to have his legs dangling over the side of the bed with the tab alarm intact but disconnected from his gown and sometimes Resident 1 would remove the entire gown from his body leaving the tab alarm clipped to the gown. LN 3 explained this behavior happened on several shifts. LN 3 indicated reporting this information to the oncoming shift to keep an eye on him because he takes his tab alarm off. Despite knowledge of Resident 1 having a history of removing the tab alarm, the fall care plan continued to identify the tab alarm as a viable intervention to alert staff when Resident 1 attempted unassisted transfers from the bed or wheelchair. During an interview on [DATE] at 11:15 a.m., CNA 2 explained having knowledge Resident 1 removes the tab alarm and liked to play with the bed control remote device. On [DATE], Resident 1 was seen playing with the bed control remote device and CNA 2 removed the bed control remote device from Resident 1's hands and placed it toward the end of the bed. During an interview on [DATE] at 12:30 p.m., CNA 3 confirmed also having knowledge Resident 1 had a history of [REDACTED]. During an interview on [DATE] at 1:45 p.m., the director of nurses (DON) explained, the facility process for reporting resident care issues to the next shift and the interdisciplinary team for care plan revisions. The DON explained the 24 hour report document was the method used for this communication. Concerns or changes can be filled out by anyone employed by the facility and these forms are read every morning by all department managers during stand-up meeting. The DON further explained, any nurse can implement nursing measures such as a bed pad sensor alarm (alarms when a resident changes pressure on the bed when exiting the bed) or a floor mat alarm that detects when there is an unsafe bed exit. The DON further indicated we even have a motion sensor alarm. Despite these alternative measures, there was no documented evidence these alternatives had been explored for Resident 1. During an interview on [DATE] at 11 a.m. and concurrent review of the manufacturer investigative report dated [DATE], the bed manufacturer director of quality (DOQ) indicated an alternate means of preventing the patient from rolling/climbing out of bed should be initiated if an individual is capable of injuring himself/herself. Safety measures should be considered for patients identified as high risk for entrapment. These patients would include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, altered mental status, or a combination of these factors. The DOQ confirmed, Resident 1's bed was purchased by the facility with an override control panel at the foot of the bed. This control panel allows staff to override the hand bed control remote device. Review of the medical examiner autopsy report dated [DATE] revealed the cause of Resident 1's death was Blunt Force Trauma of Head with multiple skull fractures and laceration of the brain.