Every finding on record at Golden Merced Care Center

Based on observation, interview, and record review, the facility failed to provide podiatry (a branch of medicine that cares for the foot, ankle, and lower leg) care for one of three (Resident 12) residents for over one year. This failure resulted in Resident 12 having toenails that were yellowed, long, extending beyond the toes, with the nails on each big toe extending over one inch beyond the toe, having the potential to cause discomfort, risk for skin breakdown, and infection.During a review of Resident 12's admission Record (AR), dated 8/21/26, the PN indicated Resident 12 was [AGE] years old and had been a resident of the facility for almost three years. The PN indicated Resident 12 had diagnoses that included dementia (progressive disease of the brain affecting mood, memory, and judgement) and end-of-life care.During a review of Resident 12's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 5/29/26, the MDS indicated Resident 12's cognitive skills were Severely impaired (not having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment). The MDS indicated Resident 12 was completely dependent on staff for all aspects of her Activities of Daily Living, including hygiene, eating, repositioning in bed, transfers to and from bed, bathing, and dressing.During a review of Resident 12's Order Summary Report (OSR), the OSR indicated she had a physician's order dated 9/1/23 for May have. podiatry consults as needed. The OSR indicated Resident 12 had a physician's order dated 1/30/26 for resident to have a consult with podiatry. Social services has been notified.During a concurrent record review and interview, with the Social Services Director (SSD), on 8/20/26, at 2 p.m., Resident 12's clinical record was reviewed. The SSD stated, It's been over a year since her toenails have been trimmed. Our documentation only goes back one year. So I don't know when the last time her toenails has been trimmed.During an observation on 8/20/26, at 2:08 p.m., with Certified Nursing Assistant (CNA) 3, Resident 12's toenails on both feet were observed. Resident 12's toenails were yellowed and extended beyond the toe, with the nails on both big toes extending over one inch beyond the toe. The nail on the big toe of the left foot was curving inward.A Policy and Procedure regarding podiatry care was requested from the facility, none was provided.

Based on interview and record review, the facility failed to ensure one of eight residents (Resident 8) was safe from potential injury when his sitter (staff person who was assigned to supervise the resident continuously to ensure he did not leave the facility unattended) left the building on a break without determining who was going to supervise Resident 8 in his absence. This failure resulted in Resident 8 leaving the building unsupervised, having the potential for exposure to high temperatures, confusion, fear, and injury from nearby traffic.During a review of the facility document titled 5 Day Summary - Unusual Occurrence (5-Day), dated [DATE], the 5-Day indicated On [DATE], at approximately [6:30 p.m.], the [Registered Nurse, or RN] Supervisor was notified that [Resident 8] had exited the facility unsupervised. Staff observed [Resident 8] outside the facility and immediately assisted him back into the facility via a wheelchair. [Resident 8] was receiving 1:1 supervision for 8 hours daily.During a review of Resident 8's admission Record (AR), dated [DATE], the AR indicated he was a [AGE] year old male with diagnoses that included muscle weakness, history of falls resulting in a broken thigh bone, problems related to life management, cognitive communication deficit, and alcohol and other drug dependence. During a review of Resident 8's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated [DATE], the MDS indicated at Question C0500 a score of 9 out of a possible 15, which indicated Resident 8's cognition was moderately impaired (not having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment). The MDS indicated Resident 8 could mobilize independently in his wheelchair at least 150 feet.During a review of Resident 8's Elopement [leaving the facility without staff knowledge and supervision] Risk Evaluation (ERE), dated [DATE], the ERE indicated he tried to leave the facility through the front [doors], is cognitively impaired with poor decision-making skills (i.e. poor decision cues, intermittent confusion, inattention, disorganized thinking), with wandering plac[ing] the resident at significant risk of getting to an unsafe situation, and verbally expresses desire to leave, go home, or repeatedly pack, and refuses to acknowledge education. The ERE indicated Resident 8 Is an elopement risk.During a review of Resident 8's Care Plan Report (CPR), dated [DATE], the CPR indicated, Resident 8 is an elopement risk [related to] exit seeking. The CPR dated [DATE] indicated as an intervention for his behaviors 1:1 supervision (a staff person sits with and supervises resident continuously) for AM and PM shifts.During a review of Resident 8's Progress Notes (PN), dated [DATE], at 6:30 p.m., the PN indicated, Resident got out of facility unsupervised. Staff brought him back immediately. He is supervised with a sitter 1:1. The PN was written by Licensed Vocational Nurse (LVN) 2.During a review of Resident 8's PN dated [DATE], at 6:40 p.m., the PN indicated, another resident's family member notified writer at [6:30 p.m.] that this Resident got out of facility unsupervised. Writer went outside to look for resident and brought him back immediately. When resident was asked where he was going he stated he was going to his home [approximately 40 miles away]. The PN was written by Registered Nurse (RN) 1. During an interview with Sitter 1, on [DATE], at 10:05 a.m., Sitter 1 stated he was assigned to sit and supervise Resident 8 on [DATE], the day of his elopement from the facility. Sitter 1 stated, I was his sitter that day. About 6:30 p.m., it was my lunchtime. I went to the nursing station and told [LVN 2] and [RN 1] that I was going on break. I said, 'Hey ladies, I'm going on lunch'. I told them twice. They said, 'OK, enjoy your lunch.' The communication was there. I left the premises during this time. After 30 minutes, I came back into the facility and was informed [Resident 8] had left the building out the front door. [Resident 8] was already back inside by the time I returned.During an interview with LVN 2, on [DATE], at 2:40 p.m., LVN 2 stated, I do recall [Sitter 1] telling me he was going on his lunch break. I should have asked him who is covering for him during his break, but I did not. [RN 1] was told by a visiting family member that they saw [Resident 8] outside, down the street. Usually a [Certified Nursing Assistant, or CNA] covers the sitter when they go on break.During an interview with RN 1, on [DATE], at 3:43 p.m., RN 1 stated that on [DATE], a visiting family member notified her that they saw Resident 8 outside the facility. RN 1 stated, He's always on a 1:1 during that time. He is in a wheelchair. [I went] outside to get [Resident 8]. He had left the parking lot, was on the sidewalk [NAME] toward the first traffic light. I don't recall [Sitter 1] telling me he was going on break. My expectation is that when a sitter goes on break, they find their replacement. It is their responsibility. If not, if they can't find coverage, they tell their charge nurse. The charge nurse during this time was [LVN 2].During a review of the facility document titled, Disciplinary Action Form (DAF), dated [DATE], the DAF was addressed to Sitter 1. The DAF indicated, Make sure you have a replacement before you leave the resident who is on 1:1 care.During a review of the website for the National Weather Service, the website indicated the high temperature for the area of the facility on [DATE] was 101 degrees Fahrenheit.During a review of the facility Policy and Procedure (P&P), titled, Elopement, dated 8/26, the P&P indicated, The facility evaluates residents for elopement risk and implements appropriate interventions as indicated via the evaluation process.

Based on interview and record review, the facility failed to ensure 1 of three sampled residents were safe from physical abuse when Resident 1 slapped the face of Resident 2 twice. This failure resulted in Resident 2 experiencing blood in the mouth, pain, redness to the face, and mental anguish evidenced by weeping.During a review of Resident 1's admission Record (AR), dated 5/20/26, the AR indicated Resident 1 was an [AGE] year-old female admitted to the facility with diagnoses that included Alzheimer's Disease and dementia (progressive diseases of the brain affecting memory, mood, and judgement). During a review of Resident 1's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 4/30/26, the MDS indicated at Question GG 0170-K, that Resident 1 was able to walk about the facility independently. During a review of Resident 2's AR, dated 5/20/26, the AR indicated he was a [AGE] year-old male admitted to the facility with diagnoses that included bleeding in the brain, muscle weakness, and repeated falls. During a review of Resident 2's MDS, dated 3/16/26, the MDS indicated at Question GG 0170-I, that Resident 2 was unable to walk. Question GG0170-Q indicated Resident 2 uses a wheelchair to mobilize through the facility. During a review of Resident 1's Progress Notes (PN), dated 5/12/26, at 9:06 p.m., the PN indicated Resident 1 was observed by a CNA [Certified Nursing Assistant] at [6 p.m.] hitting another resident with palm of hand on other resident's face. Resident was observed agitated and told CNA shut up bitch when being questioned for her behavior. During a review of Resident 2's PN, dated 5/12/26, at 6:15 p.m., the PN indicated, This resident was the victim of another resident. At [5:45 p.m.] this resident was in the doorway of the piano room, and the other resident [Resident 1] did not want him there. She walked up and slapped him hard on the left side of his face. He has a red mark on his cheek. During a review of Resident 2's PN dated 5/12/26, at 10:15 p.m., the PN indicated that a CNA stated she witnessed Resident 1 had raised her hand and slapped resident [2] two times to [left] cheek. Redness was noted to [left] cheek assessed mouth area and noted gums to be bleeding [due to] impact from smack. noted tears filling in eyes . The PN was written by Licensed Vocational Nurse [LVN] 1. During an interview on 5/19/26 at 3:30 p.m., with LVN 1, LVN 1 stated she recalled the incident on 5/12/26 between Resident 1 and Resident 2. LVN 1 stated she examined Resident 2 after the incident and looked in his mouth, by the gumline, and there was blood. During a review of the facility document titled, 5 day Summary, dated 5/15/26, addressed to The Department, the 5 Day Summary indicated that on 5/12/26, Resident 1 was seen by CNA slapping Resident 2 on the left side of his face as he was sitting in his wheelchair near the doorway near the piano room of the facility. During resident interview, [Resident 1] stated that she did not want [Resident 2] to be there while she was in the piano room with another resident. During an interview on 5/22/26, at 9 a.m., with CNA 2, CNA 2 stated she was a witness to the incident on 5/12/26 between Resident 1 and Resident 2. CNA 2 stated she observed Resident 1 approach Resident 2 and grabbed his wheelchair and slapped him two times on the face. She was furious because [Resident 2] was in the doorway and [Resident 1] wanted privacy with another resident. [Resident 1] slapped [Resident 2] in the face twice, with an open hand, slapped him so hard it left a mark on his face. After [Resident 2] was slapped, he had tears. He stated to me, 'I am embarrassed.' I comforted him, rubbed his back, he cried a couple of times, then stopped. It was a hard slap. He was holding his face. I told him if he needed to cry, go ahead and let it out. He was saying this in Spanish, I speak Spanish. During a review of the facility's Policy & Procedure titled, Abuse Neglect and Misappropriation of Property Prohibition Policy (P&P), dated 3/25, the P&P indicated, Policy Statement: Each resident has the right to be free from abuse. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical Abuse: Includes, but not limited to, hitting, slapping, punching, choking, pinching, biting, kicking throwing objects, grabbing, and shoving.

Based on interview and record review, the facility failed to implement adequate supervision, care planned interventions and Interdisciplinary Team's (IDT- a mandated group of healthcare professional including physicians, nurses, social workers, and therapists who collaborate to create and manage a comprehensive, individualized care plan for resident) recommended safety measures for 1 of 3 sampled residents (Resident [Res] 1) who was at high risk for falls. Resident 1 had four falls between 4/19/26 and 4/25/26, including an initial fall resulting in a right hip fracture (partial or complete break in a bone, often caused by high-force impact or stress) on 4/19/26, and two additional falls within four hours of readmission to the facility on 4/23/26 and another fall on 4/25/26. These failures resulted in pain and suffering, requiring Res 1 to be transferred back to emergency room (ER) via ambulance for evaluation on 4/23/25 and 4/25/26 and placed Res 1 at increased risk for more injuries and worsening of right hip fracture.During a review of Res 1's History and Physical (H&P) dated, 4/19/26 from [Hospital A], the H&P indicated, Res 1 was a [AGE] year old male with a past medical history of dementia [a loss of brain function that happens with certain diseases and affects memory, thinking, language, judgment, and behavior, making it hard for a person to do daily activities on their own], cerebrovascular accident [CVA- medical emergency that happens when blood flow to part of the brain is suddenly blocked or a blood vessel in the brain break], gout [type of painful arthritis (joint disease) that happens when sharp, needle-like crystals build up in joints], sacral pressure ulcer [a wound on the skin and tissue over the sacrum, the triangular bone at the very bottom of the spine, just above the tailbone], bilateral upper and lower contractures [permanent or long-lasting tightening of muscles, tendons, or skin on both sides of the body, affecting both the arms and the legs, which makes it difficult to straighten joints fully], functional quadriplegia [complete inability to move due to severe, end-stage physical or mental disability without structural damage to the spinal cord or brain], left femur [ the thighbone in the left leg, extending from the hip to the knee] fracture [broken bone] and epilepsy [a brain condition that causes a person to have recurring, unprovoked seizures]. Res 1 presented to ER after falling out of bed at his skilled nursing facility. Positive loss of consciousness and positive head strike post fall. Pelvic roentgenogram [a fast, painless imaging test that uses a small amount of radiation to create images of the bones in the hip and pelvic region] identified a right femoral fracture, avulsion fracture of the right greater trochanter [a rare injury where a piece of bone is pulled off by the hip muscles] and Res 1 was admitted to the hospital for Closed right hip fracture [a severe injury where the upper femur breaks but does not pierce the skin, usually causing extreme pain, inability to walk, and swelling].During a concurrent interview and record review on 5/1/26 at 12:20 p.m. with the Nurse consultant (NC) and Facility Administrator (ADM), Res 1's Electronic Medical Record (EMR) undated was reviewed. The review of Nursing Progress Note, by Licensed Vocational Nurse (LVN)1 dated 4/19/26 at 1:00 p.m. indicated that, Writer was passing patient room when writer heard a yelling help coming from room, writer found patient on the floor with gown and a brief, bed was place on the lowest position call light was attached to bed sheet, patient was laying down on left side near bed, immediate call for assist from staff to help place patient back safe to bed, head to toe assessment was completed notice redness on right shoulder small abrasion, resident refused to move extremities stated he was in pain, and hit his head, when he fell towards the floor, Patient was asked what happened he stated he turned and fell toward the floor, and he hit his head on the floor, complain of back pain, MD was notified new order sent out to ER orders were carried out . NC stated that Res 1 was assessed per policy and had a high fall risk upon admission to the facility. NC stated that it was Res 1's first fall at the facility and care plan was updated based on IDT team's recommendations. NC stated that Res 1 was assessed for injuries and was sent to the [Hospital A] for further evaluation and Nursing Note, dated 4/19/26 at 5:09 p.m. indicated that facility was notified that Res 1 was admitted for right hip fracture (partial or complete break in a bone, often caused by high-force impact or stress). The review of document titled IDT fall review dated 4/20/26 indicated, . Once resident returns from acute IDT has recommendations . Offer fall mats bilaterally to decrease potential injury .During a concurrent interview and record review on 5/1/26 at 12:25 p.m. with the NC, Res 1's EMR undated was reviewed. NC stated that Nursing note dated 4/26/26 at 7:30 p.m. indicated that resident arrived back to the facility from [Hospital A] on 4/23/26 at 4:28 p.m. and was already restless upon admission to facility and experienced two more falls within four hours of readmission. The review of Nursing Note, by LVN 2 dated 4/23/26 at 8:50 p.m. indicated, At [6:35 p.m.] resident was found on the floor on his [left ] side next to his bed. RN supervisor evaluated resident, resident assisted back to bed and placed on neuro checks. Resident's son [son's name] made aware via phone. At [8:20 p.m.], resident was again noted to be on the floor next to his bed on his left side again . Resident also placed on one to one for safety. NC stated she was unable to find any updated documented interventions after the initial fall on 4/23/26 at 6:35 p.m. in Res 1's EMR that could have potentially prevented the second the fall on 4/23/26. NC stated she was unable to find any documentation of whether fall prevention mats were placed for Res 1 as recommended during the IDT and care planned after the initial fall on 4/19/26. NC stated she was also not able to find any documentation indicating whether the 1:1 [one health care worker continuously observing one patient in person to prevent falls] companion sitter for safety was initiated after the first fall on 4/23/26. NC stated sitter should have been initiated after the first fall upon readmission to the facility and it would have potentially prevented the second fall on 4/23/26. NC stated that Res 1 was restless upon readmission to facility on 4/23/26, Res 1's fall risk score was high and Res 1 was returning to the facility from [Hospital A] after a right hip fracture that resulted from the fall at the facility on 4/19/26. NC stated she was unable to comment what interventions were in place and whether care planned interventions discussed after the fall on 4/19/26 were implemented upon readmission on [DATE]. During a concurrent interview and record review on 5/1/26 at 12:29 p.m. with the NC, Res 1's Care Plan for falls was reviewed. The review of Care plan for falls indicated it was initiated on 3/16/26 upon admission of Res 1 to facility and was updated on 4/19/26, 4/23/26 and 4/25/26. NC stated that offer floor mats bilaterally to decrease potential injury were care planned on 4/20/26 and 1:1 supervision was care planned on 4/24/26 and she would have expected staff to implement these interventions.During a review of Res 1's ED Physician Note, dated 4/24/26 from [Hospital A], the ED physician note indicated, admit date [DATE] 10:31 [a.m.] . Mode of Arrival: Ambulance . Chief Complaint ED: Fall . Subjective Nursing Assessment: [Brought in by ambulance (BIBA)] from [facility name] [diagnose] with recent hip [fracture] [discharged ] last night and had 2 falls post return back to the facility.patient was not a surgical candidate . Discussed all results, diagnosis, treatment plan, prescriptions, and discharge back to [Skilled Nursing Facility (SNF)]. The patient verbalized understanding and agrees to be discharged at this time. They understand to return to the ED for worsening of symptoms or concern for their safety . Disposition Discharge .During a concurrent interview and record review on 5/1/26 at 12:30 p.m. with the NC, Res 1's electronic medical record (EMR) undated was reviewed. NC stated that Nursing Notes dated 4/24/26 indicated that Res 1 was sent out to Emergency Department (ED) for an evaluation on 4/24/26 around 9:10 a.m. after two falls on 4/23/26. NC stated Res 1 returned to the facility on 4/24/26 at 3:10 p.m. The review of document titled IDT fall Review, dated 4/24/26 at 9:45 a.m. indicated . Describe new interventions to prevent future falls . 72 [hour] alert charting. Resident to have [Bilateral] floor mats to decrease risks of injury . 1:1 companion sitter in place. Wide mattress . NC stated that facility plan was to initiate 1:1 sitter to prevent any more falls. During a concurrent interview and record review on 5/1/26 at 12:28 p.m. with the NC, Res 1's Nursing Note, by LVN 1 dated 4/25/26 at 12:40 indicated, Staff reported to writer that patient was found on the floor, when writer arrive(d) patient was found laying on right side of body on a fetal position with his knees drawn towards his chest, on the safety floor mat, writer observe(d) bed in the lowest position and call light attach(ed) to the bed sheet, head was facing toward bed frame, and wearing a gown and clean dry brief and safety mat in place, immediate([NAME]) assist(ed) patient back to bed with staff help, RN was called to room and report was given, head to toe assessment completed no visible injuries noted , resident able to move all extremities without pain, mild red scratch noted on left hip measurement length 2.5 cm no drainage noted no bleeding or no warmth to touch, neurological assessment completed with no deficits noted, no other skin issues noted neruo check initiated and will continue per protocol . new order place(d) 1:1 with patient for safety, orders were carried out patient continues with [neuro] checks and with a 1: 1, orders were carried out for stat (urgent/immediate) right hip x-rays . NC stated Res 1 experienced another fall [4th fall at the facility since 4/19/26] on 4/25/26 and was sent out again to the ER for evaluation on 4/25/26 at 9:45 p.m. and returned to the facility on 4/26/26 at 4:00 a.m. NC stated she was not able to comment why Res 1 was not re-started on 1:1 for safety as care plan indicated and IDT recommendation on 4/24/26 after the two falls on 4/23/26. NC stated the nursing documentation does not reflect that patient had 1:1 companion sitter for safety when returned to the facility on 4/24/26 after evaluation in ER. NC stated documentation reflects Res 1 was with 1:1 for safety prior to leaving for evaluation in ER and it appears 1:1 was not restarted after Res 1 returned to the facility on 4/24/26. NC stated that documentation reflected 1:1 sitter was started by nurse after the fall on 4/25/26. NC stated Res 1 had a high fall risk, had a fall at the facility resulting in hip fracture on 4/19/26, had two more falls on 4/23/26 within four hours of returning to the facility, Res 1 was sent out for evaluation and returned to the facility and experienced another fall, total four falls since 4/19/26. NC stated that fall on 4/25/26 would have been prevented if the care plan and IDT recommendations were followed. NC stated she was unable to find any documentation that indicated Res 1 was with 1:1 companion sitter for safety at the time of fall on 4/25/26. During a review of Res 1's ED Physician Note, dated 4/25/26 from [Hospital A], the ED physician note indicated, . admit date : [DATE] [10:08 p.m.] . Mode of Arrival: Ambulance . Subjective Nursing Assessment: BIBA [brought in by ambulance] from [facility name] for [Right] HIP [Fracture], [Res 1] fell from bed this morning, XRAY [common, fast, and painless medical imaging technique to produce internal body images] CONFIRMED FROM FACILITY RT FEMORAL NECK FRACTURE [a serious hip injury, often caused by falls] . history of a right hip fracture diagnosed during a prior hospitalization on 4/19. The patient is bedridden . He was admitted to the care center in April has had multiple falls, including incidents on April 19 and April 24. The patient denies pain at present . Patient has a known history of a right hip fracture was seen on prior hospitalization for which orthopedics have determined that this is a nonoperative management. Patient not having any pain or tenderness on evaluation. I did repeat the x-ray which did show femoral neck fracture consistently with history. I did also compare images from priors and it appears there are no change in the fracture upon my independent review. No other injuries found on examination . Patient stable for discharge . During an interview on 5/1/26 at 2:15 p.m. with the ADM the ADM stated that he was familiar with Res 1 and was made aware of all falls. ADM stated that he expected facility staff to follow policies and procedures. ADM stated that sitter for safety should have been in place for Res 1 after the initial fall on 4/23 and it would have potentially prevented the subsequent falls on 4/23/26 and 4/25/26. ADM stated that he had approved the sitter and would have to review the documentation and staffing sheet to confirm whether sitter was present or not when Res 1 experienced second fall on 4/23/26 and the fall on 4/25/26. ADM stated he expected the facility staff to follow up with IDT recommendations and care planned interventions.During a concurrent interview and record review on 5/1/26 at 1:38 p.m. with LVN 1, Res 1's Nursing Notes, dated 4/19/26 to 4/26/26 were reviewed. LVN 1 stated that she was the assigned nurse on 4/19/26 and 4/25/26 when Res 1 had fallen. LVN 1 validated that she had to call and get order for 1:1 safety sitter on 4/25/26 after the fall. LVN 1 stated she was not able to comment on why Res 1 did not have assigned sitter on 4/25/26 prior to the fall. LVN 1 stated that she was not the assigned nurse when Res 1 had two falls on 4/23/26, however, she did send out Res 1 for evaluation on 4/24/25 in the morning following the two falls due to Res 1 grimacing in pain. During a concurrent interview and record review on 5/1/26 at 2:00 p.m. with LVN 2, Res 1's Nursing Notes, dated 4/19/26 to 4/26/26 were reviewed. LVN 2 stated that he was the assigned nurse on 4/23/26 when Res 2 had a fall on 4/23/26 at 6:35 p.m. and 8:20 p.m. LVN 2 stated that he does not recall Res 1 having a safety sitter after the first fall. LVN 2 stated that supervisor assessed the Resident and safety sitter was started after the second fall. LVN 2 stated that Res 1 was assessed and physician was notified. LVN 2 stated Res 1 should have had 1:1 sitter after the first fall. LVN 2 stated he does not recall why the sitter was not initiated. LVN 2 reviewed the IDT notes for 4/24/26 and care plan for Res 1. LVN 2 stated that documentation does not reflect that Res 1 continued with 1:1 safety sitter after it was initiated on 4/23/26 and LVN 1 had to call and get order for the sitter on 4/25/26 after the fall. LVN 2 stated that having the sitter with Res 1 potentially would have prevented the fall on 4/25/26. During a concurrent phone interview and record review on 5/5/26 at 3:44 p.m. with the Assistant Director of Nursing (ADON) Res 1's EMR was reviewed for all Progress notes between 4/19/26 to 4/26/26. The DON stated she was familiar with Res 1. The ADON stated she had reviewed the care plan updates and IDT notes for all falls for Res 1. The ADON stated that she was contacted after the first fall on 4/23/26 and had asked the facility to start 1:1 sitter to ensure Res 1's safety. The ADON stated she was not able to find any documentation indicating that 1:1 sitter was initiated or the rationale for not starting 1:1 sitter for Res 1's safety. The ADON stated the documentation indicated that sitter was initiated after the second fall on 4/23/26 and patient was sent out to ER for evaluation in the morning of 4/24/26. The ADON stated that Res 1 returned in the afternoon on 4/24/26 and it was unclear from documentation that 1:1 sitter was restarted. The ADON stated she expected the facility staff to continue with 1:1 sitter upon Res 1's return on 4/24/26. The ADON stated Res 1 had another fall on 4/25/26 and documentation reflects patient was not placed with 1:1 sitter as care planned and recommended by IDT team. The ADON stated that 1:1 sitter was important to ensure resident safety and potentially would have prevented second fall on 4/23/26 and the fall on 4/25/26 requiring evaluation in ED. The ADON stated she would also like to check staffing sheets as the EMR does not reflect Res 1 had 1:1 sitter present on 4/23/25 until after the second fall and was not present at the time of fall on 4/25/26. The ADON stated the LVN 1's documentation clearly states that she had to call and get an order for 1:1 sitter after the fall on 4/25/26. The ADON stated she expected staff to follow care plan interventions and IDT recommendations. During a phone interview on 5/5/26 at 4:20 p.m. with the ADM, the ADM stated that he was unable to find any documentation to confirm that 1:1 safety sitter was started for Res 1 prior to second fall on 4/23/26. The ADM also stated he was unable to find documentation that indicated whether one to one sitter was present at the time of fall on 4/25/26 in accordance with documented care plan intervention and IDT recommendations. The ADM stated he expected staff to follow facility policies and procedures along with care planned interventions and IDT recommendations. The ADM stated documentation needs improvement and without documentation he was unable to confirm whether sitter was present in the room for Res 1.During a review of the facility's policy and procedure (P&P) titled, . Fall Management and Neurological Check . The center implements a fall management plan based on medical history review and resident evaluation . The LN updates care plans reflecting individualized intervention in an attempt to reduce or prevent falls . The residents care plan is reviewed quarterly and after a fall to determine effectiveness of current intervention and considers the residents goals, choices and preferences . A new intervention is not required with each fall, as not all falls require an intervention nor a change in intervention. A systematic review of current interventions is completed post fall and root cause is identified . Should a new intervention be implemented, previous interventions are reviewed for discontinuation to determine if they were ineffective .

Based on interview and record review, the facility failed to ensure a safe environment for one of four residents (Resident 3) when a Certified Nursing Assistant (CNA 2) failed to get the help and assistance of a second caregiver for a bed bath and linen change, as required by Resident 3's clinical documentation, and instead performed this activity without help. This failure resulted in Resident 3 falling from her bed to the floor, causing pain, anxiety, and a skin tear to her right wrist.During a review of the document titled SOC 341 dated, 3/30/26, the SOC 341 indicated that on 3/30/26, a charge nurse was called into [Resident 3's] room by CNA [2] at approximately 10 am related to a fall related to a bed bath. [Charge Nurse] assessed resident. Resident reported right arm skin tear on [top of] wrist. [Resident 3] was sent to the [Emergency Department] for further evaluation at 10:15 [a.m. CNA 2] immediately suspended pending investigation.During a review of the document titled 5 Day Summary, dated 4/3/26, the 5 Day Summary Report indicated following the incident on 3/30/26, Resident 3 was alert and able to state yes when asked if she had pain. Upon staff interview, CNA [2] stated that I turned resident [3] on her side to put new bed sheet on when she rolled all the way over onto the floor. [Resident 3] depends on staff for ADL [Activities of Daily Living] care. The interdisciplinary team [IDT, a group of healthcare professionals from different disciplines, such as dietary, activities, and nursing, who work together to improving resident health outcomes] reviewed the incident and determined that [Resident 3] fall is to be caused by CNA [2] not following Kardex appropriately.During an interview on 4/9/26, at 1:30 p.m., with the Director of Nursing (DON), the DON stated, A Kardex is like a CNA care plan, it's in PCC [Point Click Care, the facility's electronic documentation system] and explains how to care for the patient in the safest manner. The Kardex says [Resident 3] was supposed to have another person present for the bath & linen change. When I interviewed [CNA 2], she said she knew how to use the Kardex. I asked her if she was aware [Resident 3] was a 2-person assist . [CNA 2] answered that she didn't ask for help.During a review of Resident 3's admission Record (AR) dated 4/10/26, the AR indicated, Resident 3 was [AGE] years old and had medical diagnoses that included the inability to move her right arm and leg due to a previous stroke (a medical emergency occurring when blood flow to part of the brain is interrupted or a blood vessel bursts, depriving brain tissue of oxygen and causing cells to die; common symptoms include sudden numbness/weakness (often one-sided), confusion, trouble speaking, vision problems, and dizziness).During a review of Resident 3's Progress Notes (PN), dated 3/30/26, at 10:44 a.m., the PN indicated, Writer was called to resident's room around 10 am related to fall sustained during bed bath. Writer found resident unclothed, laying on her back. There was blood on the floor under her right arm. resident said her shoulder hurt, right arm had L shaped skin tear on [top of] wrist measuring 3-4 cm [centimeters] During a review of Resident 3's PN, dated 3/30/26, at 2:36 p.m., the PN indicated, IDT met regarding resident had a fall on 3/30/26, approx. [10 a.m.] resident was found on the floor in her room, [Registered Nurse] reports she observed resident unclothed, on her back, blood under and besides her R[ight] arm. resident complained of shoulder pain and skin tear noted to [top of ] wrist measuring 3-4 inches [sic] on each side . observed CNA [2] standing on L[eft] side of resident's bed, bed observed to be approx. 3 feet above ground level. resident was alert, and able to state yes when asked if she had pain. Per CNA [2] she was performing a bed bath and resident rolled too far on the bed and landed on the floor, resident has a diagnosis of [stroke causing inability to use right side of her body].During a review of Resident 3's PN, dated 3/30/26, at 9:58 p.m., the PN indicated, Resident appeared anxious when head of bed was elevated during brief changes / taking medication. Writer and CNA assured resident that she is in a safe place and had bed in lowest position upon exiting room.During a review of Resident 3's PN, dated 3/31/26, at 11:17 p.m., the PN indicated, Observed to have some anxiety when bed is adjusted. Ensured resident that she is in a safe place and staff will make sure her bed is in lowest position before leaving the room.During a review of Resident 3's Kardex Report, dated 3/30/26, the Kardex Report indicated, Bed Mobility: Assistance by 2 staff to turn and reposition in bed. Ensure / provide a safe environment.During a review of Resident 3's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 4/2/26, the MDS indicated at Question GG0100 - A, that Resident 3 was assessed to be Dependent - a helper completed all the activities of Self-Care. the resident's need for assistance with bathing.During a review of Resident 3's MDS, dated 4/2/26, the MDS indicated at Question GG0115 that she had Impairment on one side of her Upper extremity (shoulder, elbow, wrist, hand), and Impairment on both sides of her Lower extremity (hip, knee, ankle, foot).During a review of Resident 3's MDS, dated 4/2/26, the MDS indicated at Question GG0170 A - Roll left and right: The ability [of the resident] to roll from lying on back to left and right side, and return to lying on back on the bed an answer of 1, indicating Resident 3 was assessed to be Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.During a review of a document ( statement) written by CNA 2, undated, the statement indicated, I [CNA 2] was given [Resident 3] a bed bath I turned resident on her side to put new sheets on when I was putting the sheet on she rolled all the way over on to the Floor. That's when I went to get the nurse. It happened So Fast. During an interview on 4/15/26, at 11:18 a.m., with CNA 2, CNA 2 stated she recalled the incident with Resident 3 on 3/30/26. CNA 2 stated she recalled her written statement and stated it was accurate. CNA 2 stated, I was working with [Resident 3] alone. I don't check the Kardex all the time. I don't check it as much as I should.

Based on interview and record review, the facility failed to accurately identify and document all wounds present on readmission when the facility did not document the sacral wound identified in the hospital discharge summary and this wound was not reported to the wound care provider.This failure resulted in the resident's sacral wound not being identified, assessed, communicated, or treated following re-admission from the hospital.During a review of Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 10/28/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (T2DM-high blood sugar), anemia (lack of health red blood cells to transport oxygen, leading to fatigue and weakness), Chronic Atrial Fibrillation (the heart's irregular and rapid rhythm is continuous), Chronic Kidney disease, stage 3 (CKD- kidney disease where damage reduced function), Heart failure (the heart is not pumping blood efficiently), Pressure ulcer of unspecified site, unspecified stage (localized damage to the skin and/or underlying tissue usually over a bony prominence) and Pancytopenia (medical condition deficiency of all three types of blood cells: red blood cells, white blood cells, and platelets, can increase risk of infection, and bleeding problems.)During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 8/5/25, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) score 10 out of 15, which indicated Resident 1 was moderately impaired. During a review of Resident 1's MDS, dated 8/5/25, the MDS indicated Resident 1 had Section M- Skin conditions (a resident assessment tool used to identify resident's risk for skin breakdown focusing on pressure ulcers/wound, documenting wounds and lesion, detailing the treatments being used) assessment completed indicated Resident 1 was at risk of developing pressure ulcers/injures. During a review of resident 1's hospital History and Physical (H&P), dated 10/6/25, the H&P indicated, Resident 1 had two pressure wounds on the sacrum and right heel,During a review of Resident 1's hospital Physician Note- Discharge Summary Note (Discharge Summary- a comprehensive report that summarizes a resident's hospitalization, including their diagnoses, and care they received), dated 10/13/25, the Discharge Summary indicated Resident 1 was diagnosed with infected pressure sore right heel and sacrum.During an interview on 10/27/25 at 1:18 p.m. with the Director of Nurses (DON), the DON stated Resident 1 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. DON stated Resident 1 returned with intravenous (IV) antibiotics (medication used to treat bacterial infection given directly into the blood stream). The DON further indicated Resident 1 was admitted again to the hospital on [DATE] for sepsis.During a concurrent interview and record review on 11/19/25 at 9:15 am with Licensed Vocational Nurse (LVN) 1, Resident 1's long term weekly skin evaluation (skin eval), dated 10/18/25, was reviewed. The skin eval indicated that the admission nurse only identified the right heel as having a pressure ulcer. LVN 1, who also serves as the wound nurse for the facility, stated that it is the responsibility of the admission nurse (the nurse who is receiving the resident returning to the facility) to obtain the report, take vitals, conduct a full body skin assessment, document findings, update care plans, and place orders for proper care. LVN 1 further indicated that the nurses should review the hospital discharge summary, and if there were any discrepancies during the assessment of Resident 1, the nurse should have used all available resources for clarification. LVN 1 noted on 10/13/25 Resident 1 was readmitted from the hospital without wound treatment orders. LVN 1 clarified that if the discharge summary had been reviewed, it would have indicated that Resident 1 had two wounds: one on the right heel and one on the sacrum.During a concurrent interview and record review on 11/19/25 at 10:00 a.m., with LVN 1 Resident 1's Treatment Administration Record (TAR), dated Oct. 2025 was reviewed. The TAR indicated treatment orders to the right heel did not start until 10/16/25. LVN 1 confirmed Resident 1 returned to the facility on [DATE] and became aware of Resident 1 not having treatment orders after returning to work. LVN 1 stated when Resident 1 returned on 10/13/25 the nurse admitting Resident 1 back to the facility should have ensured treatment orders to the identified wounds of Resident 1. During an interview on 11/19/25 at 10:27 am, LVN 2 stated that it had been the responsibility of the receiving nurse to accurately assess the resident from head to toe and verify all treatment and medication orders. LVN 2 further stated if a resident had been admitted with wounds and no treatment orders, the nurse was expected to follow up with the medical provider or the wound nurse to initiate treatment promptly.During an interview on 11/19/25 at 10:55 am with the DON, the DON stated it is the expectation of the admitting nurse to complete a full admission assessment on Resident 1. DON confirmed when Resident 1 returned to the facility on [DATE] Resident 1 returned with paperwork from the hospital that included the discharge summary and medication orders. The DON further stated the hospital indicated two wounds, one on the right heel and two the sacrum. The DON added if the admission nurse did not see a wound the hospital stated was there, the admission nurse should have clarified the discrepancy. The DON agreed by not addressing the sacral wound it went unassed by the wound care nurse and this should have been evaluated, Resident 1 had been re-admitted with an infected wound.During an interview on 11/19/25 at 1:56 p.m., with the wound care Nurse Practitioner (NP), it was stated weekly rounds were conducted with LVN 1, reviewing the list of residents with wounds or skin conditions to evaluate and make recommendations. The NP stated on 10/14/25, weekly rounds were completed and did wound care with other residents, but not with LVN 1, as LVN 1 was not working that day. The NP mentioned there was no information about Resident 1's return on 10/13/25 or knowledge of a sacral wound. The NP confirmed Resident 1 was not seen on 10/14/25. The NP confirmed residents returning from the hospital come with discharge summaries and that the admitting nurse should have reviewed and identified all wounds. If a resident returned with identified wounds but no treatment orders, the admitting nurse should have contacted the facility physician or the wound nurse to get orders. The NP stated it was impossible to determine when the sacral wound developed because there was no prior information about it. The NP described the process of a wound assessment, which included looking for signs of infection: redness, heat, swelling, abnormal drainage, and odor. The NP explained that if the notes showed no signs of infection, it meant none were observed. It was also noted that the heel wound looked better than before, with old eschar (a layer of dead skin) removed. The NP could not recall specific details about swelling on that day but confirmed that the documentation accurately reflected the findings.During a review of the facility's policy and procedure (P&P) titled, Nursing admission Evaluation, dated 7/2014, the P&P indicated, The nurse completes the nursing admission evaluation at admission.During a review of the facility's P&P titled, Skin Integrity, dated 7/2025, the P&P indicated .the facility has a systemic approach and monitoring process for evaluating and documenting skin integrity.a resident is admitted with.pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wound.with admission, the LN completes the following: a. Documents skin impairment that includes measurements of size, color, presence of odor. c. obtains a treatment order and documents on the TAR after order is implemented.During a review of the facility's document titled, Licensed Practical (Vocational) Nurse (LPN)/(LVN), dated 8/2024, the document indicated .Duties and Responsibilities.Preform administrative duties by completing medical forms, reports, evaluations, studies, charting, etc.Assist in the admission process.Ensure newly admitted residents have physician orders for immediate care.Monitor the skin health of the resident; provide preventative skin care; administer wound treatments as ordered.

Based on observation, interview and record review, the facility failed to ensure a safe environment and adequate supervision to prevent elopement ( a person left a place without anyone knowing or without permission) for 1 of 3 sampled residents (Resident 1), when the Wander Guard alarm system failed to activate when Resident 1 exited through a secured door and staff were not immediately alerted to the resident's departure.This failure resulted in Resident 1 leaving the facility unsupervised, placing Resident 1 at risk for serious injury, harm or death due to potential environmental hazards, including vehicular traffic.During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), and abnormalities of gait (walking) and mobility ( how easily a person could move their body when sitting, standing or using a wheelchair).During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), dated 5/20/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had moderate cognitive impairment.During an interview on 7/16/25 at 12:11 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she heard Resident 1's Wander Guard did not sound when she left the facility, but was not on shift the day the incident happened. CNA 1 explained when a resident wearing a Wander Guard approaches an exit door, the system is supposed to trigger an alarm. CNA 1 stated it was important for the system to be working, because that was how they knew everyone was in the facility.During an observation on 7/16/25 at 12:18 p.m. in Resident 1's room, Resident 1 was observed sitting up in her bed. She was well groomed and dressed for the day. Resident 1 was oriented (person knew basic information such as who they are, the day, and what was happening around them) to self but displayed confusion regarding the day and the current situation. Resident 1's demeanor was calm. A Wander Guard device was observed on her left wrist.During an interview on 7/16/25 at 12:38 p.m. with CNA 2, CNA 2 stated there had been a recent elopement and they heard there was a possible malfunction of a Wander Guard. CNA 2 explained it was important for the alarm to sound, as it alerts staff when a high-risk resident is attempting to leave the facility. CNA 2 stated residents who wear a Wander Guard typically have dementia and stated the alarm has a distinct sound that differs from the call light.During an interview on 7/16/25 at 12:45 p.m. with Registered Nurse (RN) 1, RN 1 stated the alarm system notifies staff immediately when a resident wearing a Wander Guard attempt to leave the facility. RN 1 stated the system is a very important safety precaution, as elopements can result in falls, serious injuries and even death.During an interview on 7/16/25 at 1:19 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Wander Guards helped ensure resident safety, so it's important that the system functions properly. The LVN shared Resident 1 can be difficult to redirect.During a concurrent interview and review of Wander Guard Daily Functioning Log dated for month July 2025 with the Activities Director (AD), The AD stated Wander Guards system is checked daily, typically in the morning. The AD explained that the facility uses an approved system device that displays the Wander Guard number if it is active. If the number does not appear, the device is not active. The device only tests the Wander Guard that is placed on the resident wrist or ankle. The July 2025 log indicated on July 10, the day of the incident, Resident 1's Wander Guard was documented as active and had passed the daily check.During an interview on 7/16/25 at 2:24 p.m. with the Administrator (ADMIN), the ADMIN stated on the day of the incident, Resident 1 requested her medication around 10:35p.m. The nurse informed Resident 1 it was too early to administer her medication but assured her it would be given at the earliest appropriate time. Resident 1 then returned to her room. At 11:00p.m. the nurse went to administer the medication; Resident 1 was not there. Approximately thirty minutes later Resident 1 was found down the street in front of a Farmers Insurance building. Resident 1 was returned to the facility by staff. Upon reentry, Resident 1's Wander Guard alarm sounded. However, staff reported the alarm did not activate when Resident 1 initially exited the facility and they were not alerted to her departure. The ADMIN stated this may have been a potential system malfunction and emphasized that it is important to keep residents safe.During a review of Resident 1's Care Plan Report (CP), revised 1/3/25, the CP indicated, Resident 1 was identified as an elopement risk/wanderer and a fall risk. The goal was for Resident 1 to remain safely within the facility. Interventions included assessing Resident 1 for falls, identifying patterns of wandering and what they may indicate and checking the functionality of the Wander Guard.During a review of the facilities policy and procedure (P&P) titled, Elopement/Wandering, revised 2/2025, the P&P indicated, the maintenance department or designee tests the monitoring system (at alarmed exits) on a daily basis using the manufactured supplied device (as applicable) and documents the test.

Based on interview and record review, the facility failed to ensure the facility was free from accidents or hazards when one of three sampled residents (Resident 1) eloped (exited the facility without supervision or staff knowledge) from the facility when staff did not respond to a security alarm timely. This failure had the potential for Resident 1 to become lost, disoriented, physically injured from a fall or traffic collision, when he was found approximately 350 feet away from the facility. Findings: During a review of the facility document titled Subject: Unusual Occurrence, dated 7/9/25, the document indicated, On 7/8/25 at approximately 5:10 PM, [Resident 1] was seen ambulating in the south hallway. Approximately 10 minutes later he was reported to be in the [fast food restaurant] parking lot across the street from the back of the facility. Staff immediately responded and were able to guide [Resident 1] back to the facility. Nursing staff assessed [Resident 1] for any injuries and no injuries noted to him. [Security Alarm] system at the back door was in place and functioning. Nurse reported to hear alarm and responded at time of the event. During a review of Resident 1's admission Record (AR), dated 7/17/25, the AR indicated Resident 1 had been in the facility over one year. During a review of Resident 1's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 4/21/25, the MDS indicated at Question C0500 a score of 3 out of a possible 15, which indicated Resident 1's cognition (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment) had severe impairment. During a review of Resident 1's Care Plan Report (CPR), dated 7/9/25, the CPR indicated Resident 1 had an episode of elopement on 7/8/25 [related to] impaired cognition. The CPR dated 4/5/24 indicted Resident 1 is an elopement risk/wanderer. Intervention/Tasks: [electronic security bracelet that activates an alarm whenever the bracelet comes near a sensor, usually installed next to exit doors] to left wrist to prevent resident from wandering outside unattended area. During a review of Resident 1's Elopement Risk Assessment (ERA), dated 4/2/25, the ERA indicated, Yes the resident is at risk for elopement. During an interview on 7/11/25, at 10:30 a.m., with the Administrator, the Administrator stated Resident 1 can walk and does not need the use of a wheelchair. The Administrator stated the staff person who first responded to the Security System alarm from Resident 1 on 7/8/25, was Licensed Vocational Nurse (LVN) 3. The Administrator stated, She is reporting that she didn't see [Resident 1] when she checked the alarm and opened the door to look for him. Ten minutes later, a former employee recognized him at [the nearby fast-food restaurant] and called an employee here and informed us of [Resident 1's] location. During an interview on 7/11/25, at 11:10 a.m., with the Administrator, the Administrator stated it is her expectation that, when a door alarm goes off, it gets checked by staff in one minute or less, as soon as they hear it. We have 15 residents with [security alarm bracelets]. During an interview on 7/23/25, at 8:55 p.m., with LVN 3, LVN 3 stated she recalled responding to a door alarm on 7/8/25. LVN 3 stated, I responded to one of the alarms at the back door on the south station [of the facility]. The alarm was going off, I was there within five minutes. I went outside and didn't see anyone, the alarm was going off. Then I went to the front door and looked there. I don't know why I went to the front door to look, the front door alarm was not going off. During a review of Google Maps, the distance from the South Station exit of the facility, to the fast-food restaurant, was measured to be approximately 350 feet (a standard football field is 300 feet). During a review of the facility's policy and procedure (P&P) titled, Elopement/Wandering, dated 2/25, the P&P indicated, Definitions: Elopement: The resident/patient exits the [facility] without staff knowledge.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) had elopement (when a resident leaves the facility, or a designated safe area within the facility, without proper authorization or supervision, which potentially endangers themselves) risk factors assessed when he was admitted to the facility. This failure resulted in Resident 1 eloping from the facility. Findings: During a review of Resident 1 ' s admission Record (AR), dated 6/11/25, the AR indicated he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (also known as a type of ' stroke ' which occurs when blood flow to a part of the brain is interrupted, leading to lack of blood supply and subsequent brain tissue death; symptoms can include sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, vision problems, dizziness, and loss of coordination), problems relate to life management difficulty, need for assistance with personal care, and alcohol abuse. During a review of Resident 1 ' s Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 5/1/25, the MDS indicated at Question C0500 a score of 4 out of a possible 15, which indicated Resident 1 ' s cognition (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident ' s environment) was severely impaired. During a review of Resident 1 ' s Progress Notes (PN), dated 5/29/25, at 5:13 p.m., the PN indicated, Writer was on his way home when writer noticed an individual in a wheelchair heading towards [nearby street]. Writer pulled over and noticed that individual was actually [Resident 1]. Writer got out of vehicle and approached [Resident 1]. Writer asked resident where [sic] he was attempting to go and he stated ' I have family that lives around here. ' [Resident 1] currently in bed resting. The PN was written by Licensed Vocational Nurse (LVN) 1. During an interview on 6/11/25, at 11:50 a.m., with LVN 1, LVN 1 stated, I was leaving work in my car and I noticed [Resident 1] in his wheelchair [on a nearby sidewalk about 1,000 feet from the front door of facility, per Google Maps]. [Resident 1] stated, ' I have family near here. ' I got out of my car and wheeled him back to facility with no further incident. We applied a Wander guard [an electronic security bracelet, that sets off alarm when it activates a sensor, often placed by exit doors to alert staff that a resident may be attempting to leave the building without supervision] to him upon his return. There ' s been no further episodes of elopement. If I had to guess, he left the building via the front doors. During a review of Resident 1 ' s Order Summary Report (OSR), dated 6/11/25, the OSR indicated Resident 1 had a physician ' s order dated 5/29/25 for a Wander Guard to right ankle to prevent resident from wandering outside attended area. During an interview on 6/11/25, at 12:45 p.m., with LVN 2, LVN 2 stated she performs new admission paperwork for residents when they are admitted to the facility. LVN 2 stated, elopement risk assessments are usually done by the 2nd shift after the resident arrives in the facility. LVN 2 stated they are to be done certainly by 24 hours after admission. During a review of Resident 1 ' s admission – readmission Nursing Evaluation ([NAME]), the [NAME] indicated it was completed on 6/5/25. During a concurrent record review and interview on 6/11/25, at 12:50 p.m., with the Administrator, Resident 1 ' s clinical record was reviewed. The Administrator stated all residents admitted to the facility are to have a Nursing admission Evaluation done at admission. The Administrator stated Resident 1 ' s Nursing admission Evaluation was not done until 6/5/25 (41 days after Resident 1 ' s admission to the facility). The Administrator stated, This assessment captures his elopement risk, which was not done. I don ' t know why it was not done. This should have been done at admission. During a review of the facility ' s policy and procedure (P&P) titled, Nursing admission Evaluation, dated 7/14, the P&P indicated, The nurse completes the Nursing admission Evaluation at admission. Members of the IDT [Interdisciplinary Team, made up of representatives of different departments such as Nursing, Dietary, Activities, Social Services] review the Nursing admission Evaluation upon completion to facilitate a complete evaluation and plan of care for the resident. During a review of the facility ' s P&P titled, Elopement/Wandering, dated 2/25, the P&P indicated, The Center evaluates residents for wandering and/or exit seeking behavior and implements appropriate interventions as indicated via the evaluation process. At admission, the licensed nurse (LN) completes the Nursing admission Evaluation, to determine the resident ' s risk for wandering/elopement. The LN gathers as much information as possible at the time of admission from the family, significant other, or responsible party regarding previous elopement attempts or desire to leave the premises.

Based on observation, interview, and record review, the facility failed to ensure the safety and security of the residents when 15 of 15 sliding glass doors (located in resident rooms that exited to the exterior of the building) were noted to be unsecured, with no system to alert staff if a person entered or exited the facility via these 15 doors. This failure resulted in one resident (Resident 1) eloping (the act of leaving facility premises, or enters an unsafe area, without facility knowledge and/or supervision) via one of the 15 unsecured sliding glass doors twice in one day, and after the second elopement was found by staff 0.6 miles from the facility in a confused state. This placed Resident 1 at significant risk for injury, including trauma from a traffic collision; and, resulted in the potential for other ambulatory residents to elope via the 15 unsecured doors in the facility, and the potential for unknown visitors to enter the facility via the 15 unsecured doors. Findings: During a review of Resident 1 Admission Record (AR) , dated [DATE], the AR indicated Resident 1 had diagnoses that included dementia (a progressive state of decline in mental abilities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and disorientation (the condition of having lost one's sense of direction). During a review of Resident 1's Progress Notes (PN) , dated [DATE], at 4:04 p.m., the PN indicated, Resident [1] was spotted entering the building through the front door. Receptionist asked how she got out and she said through the back door. Writer walked around the side of the building where resident room has a sliding door. The door opens to a walkway that is open on both ends. A woman approached writer as I was examining the gate that leads to the front parking lot and was told that she saw a lady coming through the gate 10 minutes prior. During a review of Resident 1 PN dated [DATE], at 6:02 p.m., the PN indicated, Writer was notified by [Registered Nurse 1] that resident [1] was last seen at about 5:50 p.m. [Staff including Registered Nurse 1] were seen leaving the facility to look for resident and writer went through the back door in search of resident as well. Resident was found by [Registered Nurse 1] at . grocery store at 6:15 p.m. and redirected back to the facility at about 6:20 p.m. Resident [1] had the sliding back door of her room open and went out from there. Resident [1] was asked why she left the facility, resident stated, I am tired of being here, I want to go home, I was taking a walk to my house, my house is on the 16thstreet, I don't want to be here anymore, please allow me to go home. Writer educated resident [1] on the risks of leaving facility without a proper way of discharge, counselled on being hurt/injured/getting lost without the knowledge of the facility staff and family members. During a review of Resident 1 PN dated [DATE], at 6:32 p.m., the PN indicated, Resident [1] found by [Registered Nurse 1] and returned to facility around 6:30 p.m. Resident [1] ambulates independently with no problems. When resident asked why she left resident [1] stated, I wanted to go home so I left. Resident reports she left through her glass door in her room. Residents' doors don't have alarms. Gate outside doors don't have locks. During a review of Resident 1's Care Plan Report (CPR) dated [DATE], the CPR indicated Resident 1 is an elopement risk/wanderer related to History of attempts to leave facility unattended. During a concurrent observation and interview on [DATE] at 11:55 a.m., with Maintenance Supervisor, (MS ), a tour of the 15 rooms on the North facing hall (rooms 27, 29, 31, 33, 35,37, 39, 40, 41, 43, 44, 45, 47,49, and 51), each room was noted to have a sliding glass door leading to a sidewalk on the exterior of the facility. Both ends of the sidewalk led to a wooden gate which could be opened by pulling on a string. Each gate opened to a parking lot and city streets beyond. The MS confirmed that the 15 sliding glass doors provide 15 exits from the facility that residents have access to. The MS stated that there are no alarms or system to alert staff when any one of the 15 doors are opened and there are no alarms or system to alert staff when the two wooden gates are opened. The MS also stated that there are no alarms or system to alert staff when any one of the 15 doors are opened to gain entry into the building. The MS stated, I feel handcuffed, because I feel like I can't do anything to keep my residents safe. During an interview on [DATE] at 2:06 p.m., with the Administrator, the Administrator nodded her head in agreement that there were 15 sliding glass doors that ambulatory residents could leave the building without staff knowledge and that unknown visitors could enter the building without staff knowledge through the same 15 sliding glass doors. Administrator stated, I probably have less than five ambulatory residents right now. During an interview on [DATE] at 3:15 p.m. with Registered Nurse [RN] 1, RN 1 stated that on [DATE], that she went looking for Resident 1 in her car and found her in front of a store 0.6 miles from the facility. RN 1 stated she watched Resident 1 cross multiple lanes of traffic with busy streets. The address of the store was verified with RN 1 using Google Maps, and RN 1 agreed Google Maps indicated the walking distance between the facility and the store was 0.6 miles. RN 1 stated she spoke with Resident 1 and convinced her to return with her to the facility. During a review of the facility's policy and procedure (P&P) titled, Elopement/Wandering , dated ,d+[DATE], the P&P indicated, The [facility] evaluates residents for wandering and/or exit seeking behavior and implements appropriate interventions as indicated via the evaluation process. Definitions: Elopement: The resident/patient exits the [facility] without staff knowledge or the resident/patient enters an unsafe area without staff knowledge or presence. During a review of the Facility Assessment (FA), dated [DATE], the FA indicated the Resident Profile as having an average daily census as 102 residents. The FA indicated the facility averages 7 to 8 admissions and discharges per week. The FA indicated the facility admits and provides services to residents with Impaired cognition, Memory Loss, and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and other dementias .

Based on observation, interview, and record review the facility failed to meet professional standards of quality for three of six sampled residents (Residents 4, 221, and 321) when 1. Resident 221's physician order for routine oxygen administration was not followed This failure had the potential to cause Resident 221 to experience negative health effects from lack of oxygen. 2. Resident 321 had an incorrect medication order for a Lidocaine Patch (medication that is used to relieve pain). This failure had the potential to result in incorrect placement of the Lidocaine Patch and the potential for the resident to experience ineffective pain control. 3. Resident 4's order for use of Pressure Reduction mattress for pressure redistribution was not being followed. This failure had the potential for Resident 4 to experience delayed healing of a wound, and to not receive necessary wound care. Findings: 1. During a review of Resident 221's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/21/25, the AR indicated, Resident 221 was admitted to the facility on [DATE] with a primary diagnosis of pleural effusion (buildup of excess fluid between the layers of tissue lining the lungs and chest cavity). During a concurrent observation and interview on 3/17/25 at 11:09 a.m. in Resident 221's room with Resident 221, Resident 221's nasal cannula (a thin, flexible tube with two prongs, used to deliver supplemental oxygen through the nostrils) was stored in a bag and her oxygen concentrator (a medical device that takes in air from the surrounding environment and delivers a concentrated, purified stream of oxygen to the resident) was turned off. Resident 221 stated she needed oxygen and did not know why it was turned off. During a concurrent interview and record review on 3/19/25 at 9:43 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 221's Order Summary Report, dated 3/17/25 was reviewed. The Order Summary Report indicated Resident 221 was to receive one to four liters (L- a unit of measurement) of oxygen via her nasal cannula. LVN 6 stated Resident 221 had a pleural effusion which meant she had trouble breathing and needed more oxygen than a regular person. LVN 6 stated Resident 221's order was for continuous oxygen delivery and not a PRN (as needed) order. LVN 6 stated if nurses were choosing when to administer Resident 221's oxygen then they needed to call the doctor to get a new order. During an interview with the Director of Nursing (DON), the DON stated if Resident 221 did not need continuous oxygen then the nurses needed to call the doctor to obtain an order for the PRN use of oxygen. The DON stated Resident 221 may have received the inappropriate amount of oxygen if her order was not correct During a review of the facility's policy and procedure (P&P) titled, Medication Order dated 4/08, the P&P indicated, .(b) All drug orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The name, quantity or specific duration of therapy, dosage and time or frequency of administration of the drug, and route of administration if other than oral shall be specified. P.R.N. order shall include the indication for use of a drug .1) Medication orders specify the following .c. Dosage and frequency of administration. 51134 2. During an observation on 3/19/25 at 8:31 a.m. with Licensed Vocational Nurse (LVN) 2 at the South one medication cart in front of Resident 321's room, LVN 2 was observed referring to medication administration record (MAR - a report that details the medications to be administered to a resident) for a Lidocaine Patch order. LVN 2 proceeded to walk into Resident 321's room with the Lidocaine patch and explained to the resident the Lidocaine Patch was a pain medication and was to be placed behind the right shoulder. Resident 321 stated she needed the patch on her right shoulder and a Lidocaine patch on her stomach below the colostomy bag because that is where she felt pain. LVN 2 stepped out of the room and referred to the MAR for the order. LVN 2 re-entered Resident 321's room and explained the medication order was for the right shoulder and proceeded to place the Lidocaine patch. During a record review of Admission Record (AR) dated 3/20/25, the AR indicated Resident 321 was admitted into the facility on [DATE]. During a record review of Resident 321's Order Summary Report (OSR) dated 3/20/25, the OSR indicated, .Lidocaine External Patch 4% (Lidocaine) Apply to affected area topically [medication that is applied directly to the surface of the body] one time a day for pain . Order Date: 3/18/2025 . During a concurrent interview and record review on 3/20/25 at 9:10 a.m. with LVN 3, Resident 321's Lidocaine Patch order was reviewed. The Lidocaine Patch order indicated, .Lidocaine External Patch 4% (Lidocaine) Apply to affected area topically one time a day for pain . LVN 3 stated the medication order does not specify where the Lidocaine Patch should be placed. LVN 3 stated, I would not know where to put [the Lidocaine Patch] looking at this order. LVN 3 stated it is important for the order to state where to place the patch, so it is placed in the correct location, and it is effective for the resident. During an interview on 3/21/25 at 11:02 a.m. with the Pharmacy Consultant (PC), the PC stated the Lidocaine Patch order for Resident 321 is incomplete and does not state where the patch needs to be applied. The PC stated it is important to have a complete order to know where the medication should be placed and to relieve the resident of pain. During a concurrent interview and record review on 3/21/25 at 3:12 p.m. with the Director of Nursing (DON) the Lidocaine patch order for Resident 321 was reviewed. The DON stated the order should have clarified where to place the patch. The DON stated it is important for the medication order to have the affected site listed so the area of pain for the resident is addressed. The DON stated if the affected site is not listed and the Lidocaine patch is placed in the wrong location, the resident will have ineffective pain control. During a review of the facility's policy and procedure (P&P) titled, Medication Order dated 4/2008, the P&P indicated, .1) Medication orders specify the following .e. Route of administration (If facility policies allow, orders are assumed to be P.O. unless otherwise specified) . The P&P indicated, .Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe . The P&P indicated, . Procedures . c. The prescriber is contacted to verify or clarify an order ([example] when the resident has allergies to the medication, there are contraindications to the medication, the directions are confusing) . 51284 3. During a concurrent observation and interview on 3/17/25 at 11:20 a.m. with Resident 4, in Resident 4's room, Resident 4 was observed lying in bed facing the entry way of his door. Resident 4 was alert and oriented. Resident 4 stated he has been lying in bed for months. During a review of Resident 4's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/19/25, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of Paraplegia ( Condition causes partial or complete loss of function of the lower half of the body), Type 2 Diabetes Mellitus (condition where the body does not use insulin properly or does not produce enough insulin), and Pressure ulcer of the sacral region unstageable [ a full thickness [injury extends beyond the two outer layers of skin and into fat and muscle], to the bottom of the back. During a review of Resident 4's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/5/25, the MDS Section C indicated, Resident 4's Brief Interview for Mental Status (BIMS- an assessment to be used by facility to screen and Identify memory, orientation, and judgement status of the resident) assessment score was 15 out of 15, (0-15 scale- 0-6 severe cognitive deficit, 7-12 moderate cognitive deficit 13 -15 no cognitive deficit) indicating Resident 4 was cognitively intact. During a review of Resident 4's Braden scale- (a standardized clinical tool that assesses 6 risk areas for pressure ulcers), dated 1/15/25, indicated a total score of 12 which is high risk for developing pressures ulcers. With scoring ranging from 1-3 or 4 and total scoring ranging from 6 to 23. A lower Braden Scale indicates a lower level of functioning and, therefore, higher level of risk for pressure ulcer development. During review of Resident 4's Order Summary Report (OSR), dated 3/19/25, the OSR indicated, .Pressure Reduction mattress for Pressure redistribution every shift . During a concurrent observation and interview on 3/19/25 at 9:34 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 was observed helping Resident 4 change positions in bed. CNA 2 stated Resident 4 had a regular mattress and not a Pressure Reduction mattress for pressure redistribution. During a concurrent interview and record review on 3/19/25 at 10:01 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 4's OSR, dated 3/19/25, was reviewed. LVN 4 stated the physician orders were to be followed. LVN 4 stated Resident 4 had refused the use of the mattress. LVN 4 stated Resident 4's refusal of Pressure Reduction Mattress was not documented. LVN 4 stated the use of the Pressure reduction mattress is important for Resident 4's wound healing. During an interview on 3/20/25 at 11:38 a.m. with the Director of Nursing (DON), the DON stated Resident 4 had no documentation of refusal of Pressure Reduction Mattress. The DON stated nurses should have informed the physician of Resident 4's refusal. The DON stated not following physician orders could result in Resident 4's wounds worsening. During a review of the facility's P&P titled, Pressure Injury Prevention, dated 4/2018, the P&P indicated, . document an individual's significant risk factors of developing pressure ulcers . evaluate and document the progress . despite existing interventions . During a review of facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated 2/2024, the P&P indicated, .Detailed information relating to the request, refusal, or discontinuation of treatment are documented in the resident's medical record . The healthcare practitioner must be notified of refusal or treatment .

Based on observation, interview and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. The facility had a clear plastic bag of what appeared to be frozen chicken with no labels or closure device, stored in one of two freezers. 2. The chest freezer did not have a thermometer to monitor the internal freezer temperature. 3. The cook did not take the temperature of the tray of meat loaf or the tray of au gratin potatoes during the lunch tray line service. These failures had the potential to place residents in the facility at risk for food born illness. Findings: 1. During a concurrent observation and interview on [DATE] at 9:52 a.m. with the District Manager of the kitchen (DMK), in one of two freezers, a clear plastic bag of what appeared to be frozen, and frost bitten (the surface of frozen food dries out and becomes leathery or discolored due to moisture loss), chicken had no labels or closure device on the bag. The DMK stated the meat should be in a labeled, airtight container for food freshness and safety. The DMK stated without placing the meat in an airtight container, ice could form on the meat causing the meat to lose flavor and moisture. The DMK stated the food needs to have a label to prevent the residents from being served expired foods which could lead to food born illness. 2. During a concurrent observation and interview on [DATE] at 10:10 a.m. with the Dietary Aid (DA), there was not a thermometer in the chest freezer. The DA stated, there should be a thermometer in the freezer and the thermometer should be checked every day and recorded and put on a log. During a concurrent observation and interview on [DATE] at 10:11 a.m. with the DMK in the facility's kitchen, the DMK stated the freezer should have had an internal thermometer to monitor the temperature inside the freezer to ensure food is being kept at a temperature to prevent bacterial growth and food born illness. 3. During a concurrent observation and interview on [DATE] at 11:30 a.m. with the DMK during the lunch tray line observation, the Lead [NAME] (LC), did not take the temperature of the au gratin potatoes or the meat loaf before serving. The DMK stated the LC should have taken the temperature of the au gratin potatoes and meat loaf prior to serving. During a concurrent interview and record review on [DATE] at 2:41 p.m. with the DMK, the facility's policy and procedure (P&P) titled, Food and Storage dated ,d+[DATE] was reviewed. The P&P indicated, . All food .shall be stored I in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Date and rotate items; first in first out .discard food past the use-by or expiration date . must be stored in containers that have tight fitting lids . The DMK stated all food should be handled following the food and safety codes to help prevent residents from food borne illness. During a review of California Code of Regulations (CCR), Title 22 Security, Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, Chapter 8.5 - Intermediate Care Facilities/Developmentally Disabled-Habilitative, Article 3 - Services Section 76888 - Food and Nutrition Services-Food Storage dated, [DATE], the CCR indicated, . All readily perishable foods or beverages shall be maintained at temperatures of 7 C (45 F) or below, or at 60 C (140 F) or above, at all times, except during necessary periods of preparation and service. Frozen foods shall be stored at minus 18 C (0 F) or below at all times. There shall be an accurate thermometer in each refrigerator and freezer and in any other storage space used for perishable food . Keep hot food hot-at or above 140 F. Place cooked food in chafing dishes, preheated steam tables, warming trays, and/or slow cookers .

Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for four of 12 sampled residents (Residents 25, 20, 12, 371, and all residents who received medications from South one medication cart) when: 1. Resident 25's visibly soiled, uncovered, and unlabeled graduated cylinder (a plastic container with calibration marks [evenly spaced lines marked along the cylinder that indicate volume measurements] used for measuring volumes of liquids) was on top of a toilet shared by two residents. This failure had the potential to cause cross-contamination and the spread of bacteria and other pathogens (disease causing microorganisms) leading to the risk of infection for residents. 2. Resident 20's nasal canula (a device that delivers extra oxygen through a tube and into the nose) was touching the ground and nebulizer equipment (drug delivery device that turns liquid medicine into a fine mist that is breathed in through a mask or mouthpiece) was stored in the same bag where the nasal canula tubing was supposed to have been stored. These failures had the potential to increase the risk of cross-contamination and infections. 3. Resident 12's humidifier bottle and solution (a container filled with sterile [free of germs] or distilled [water is purified to remove contaminants] water that adds moisture to oxygen before it is delivered to a patient, preventing dryness in the airways) was expired and not replaced. This failure had the potential to lead to bacterial growth in the humidifier solution, increasing the risk of respiratory infections. 4. LVN 5 did not don appropriate personal protective equipment (PPE-specialized clothing, equipment, or devices worn to protect a person from hazards in the workplace or environment) when performing a dressing change for Resident 371's left leg wound. This failure had the potential to cause Resident 371's wound to become infected and lead to other residents becoming infected if LVN 5's clothing became cross contaminated (the physical movement or transfer of harmful bacteria from one person, object or place to another). 5. An envelope containing resident money was stored in the South one medication cart. This failure had the potential to result in transfer of infectious microorganisms (a living thing, such as bacterium, virus or fungus, that is so small it must be viewed with a microscope) onto the medications, equipment and surfaces inside the medication cart. Findings: 1. During a review of Resident 25's Admission Record (AR) dated [DATE], the AR indicated, Resident 25 was initially admitted to the facility on [DATE] with diagnoses of cystitis (inflammation of the bladder), displacement of nephrostomy catheter (nephrostomy catheter a tube that is put into the kidney to drain urine directly from the kidney) tip positioned outside the renal collecting system (a series of tubules and ducts in the kidneys where urine flows and drains), diabetes mellitus (condition that happens when your blood sugar is too high), urinary tract infection (an infection in any part of the urinary system), presence of urogenital implants (artificial material in the urinary organs or genitals), obstructive and reflux uropathy (obstructive and reflux uropathy,), and calculus of kidney (kidney stones). During a review of Resident 25's Order Summary Report (OSR) dated [DATE], the OSR indicated, .change foley q (every) 3 weeks .enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) r/t (related to) nephrostomy tube .foley catheter (a device that drains urine [pee] from your urinary bladder into a collection bag). output every shift for foley . During a review of Resident 25's Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated [DATE], the MDS section C indicated, .cognitive skills for daily decision-making score of 3 .severely impaired . During a concurrent observation and interview on [DATE] at 11:55 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 25's bathroom, a visibly soiled, uncovered, and unlabeled graduated cylinder was on top of the toilet. LVN 1 stated the graduated cylinder was visibly soiled with brown stains with small amount of dried urine on the bottom of the container and was unlabeled. LVN 1 stated the graduated cylinder was used to measure Resident 25's urine output from her foley catheter. During an interview on [DATE] at 9:20 a.m. with the Infection Preventionist (IP), the IP stated a used and visibly soiled graduated cylinder should not have been stored atop the toilet in the bathroom. The IP stated the graduated cylinder should have been thoroughly cleaned after each use, free of stains and any other contents inside or outside, placed in a plastic bag, and stored in a separate location inside the resident's closet. The IP stated the graduated cylinder should have had resident identifiers written on it such as the resident's name. The IP stated there was a potential for cross-contamination if another resident touched the soiled graduated cylinder . The IP stated it was important to have resident identifiers written on the graduated cylinder so it would not be used on other residents, which posed a potential for cross-contamination and risk of infection. During an interview on [DATE] at 5:08 p.m. with the Assistant Director of Nursing (ADON), the ADON stated a container used to empty urine should not have been left on top of the toilet as it was not clean. The ADON stated the container should have been cleaned and labeled, stored in a bag, and placed in area where there was no risk for cross-contamination with other residents. The ADON stated there was a potential for cross-contamination that could have led to other residents getting sick. During an interview on [DATE] at 5:15 p.m. with the Director of Nursing (DON), the DON stated she expected the graduated cylinder to have been labeled with the resident's name, cleaned after each use, stored in separate bag, and stored away from contact with other residents. The DON stated there was a potential for cross-contaminations and the spread of infection if another resident or staff used the soiled and unlabeled graduated cylinder. During a review of Resident 25's Care Plan (CP) dated [DATE], the CP indicated, . monitor and document intake and output from right nephrostomy collection bag . During a review of the facility's policy and procedure (P&P) titled, Infection Control Policies and Practices dated [DATE], the P&P indicated, .This Center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .the Governing Board .have adopted our infection control policies and procedures and practices as outlined herein, to reflect he Center's need and operational requirements for preventing transmission of infections and communicable diseases . During a review of the professional reference (PR) found on https://www.vumc.org/periop-services/sites/default/files/public_files/L-Care-of-the-Patient-with-Catheters-and-Drains.pdf titled, Overview Care Of The Patient With Catheters And Drains dated 2012, the PR indicated, .use a clean graduated cylinder that is only used for that patient . 2. During a review of Resident 20's AR dated [DATE], the AR indicated, Resident 20 was initially admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems), acute on chronic systolic (congestive) hearth failure (refers to the heart being unable to pump enough blood around the body), covid 19 (a contagious disease caused by the coronavirus), and obstructive sleep apnea (a sleep disorder that affects breathing while you sleep). During a review of Resident 20's OSR dated [DATE], the OSR indicated, .change foley q (every) 3 weeks .enhanced barrier precautions r/t (related to) nephrostomy tube .foley catheter output every shift for foley . During a review of Resident 20s MDS dated [DATE], the MDS section C indicated, Resident 20 had a BIMS (Brief Interview for Mental Status (BIMS) is an assessment used in nursing homes and other long-term care facilities to monitor cognition) score of 10. A score of 10 indicated, Resident 20 had moderately impaired cognition (condition in which people have more memory or thinking problems than other people their age). During a review of Resident 20's OSR dated [DATE], the OSR indicated, .O2 (oxygen) at 4 liters (L-a unit of measure) via nasal canula every shift for COPD .oxygen ,d+[DATE] Liters continuous O2 via Nasal Canula or face mask to keep Oxygen above 90% .levalbuterol HCL (medication used to treat COPD) inhalation nebulization solution 1.25 mg/3ml (milligram/milliliter-a unit of measure) . During an observation on [DATE] at 2:50 p.m. in Resident 20's room, Resident 20 was asleep. Resident 20's oxygen concentrator (machines that take air from the surroundings, extract oxygen and filter it into purified oxygen for patients to breathe) was set to 2.5L. Resident 20's nasal canula was on the floor and nebulizer equipment was stored in a plastic bag hanging from the oxygen concentrator. During an interview on [DATE] at 9:34 a.m. with the IP, the IP stated the nasal canula tubing should not have been on the floor. The IP stated this put Resident 20 at risk for infection because the floor was not clean, and bacteria could have travelled up the nasal canula to Resident 20's nose. The IP stated the nasal canula delivered oxygen directly into the resident's mucosal membrane (the moist, inner lining of some organs and body cavities such as the nose) in her nose. The IP stated the nebulizer equipment should not have been stored in the bag used to store the nasal canula. The IP stated nasal canula and the nebulizer equipment should have been stored in their own dedicated bags. The IP stated there was a potential for cross-contamination with the nebulizer equipment being stored in the nasal canula bag because they were two completely different pieces of equipment and should have been stored separately. The IP stated the Central Supply Clerk (CSC) was responsible for ensuring the nasal canula and the nebulizer equipment were stored in different bags. During an interview on [DATE] at 10:09 a.m. with the CSC, the CSC stated she was responsible for replacing the nasal canula and nebulizer equipment every week. The CSC stated the nasal canula and nebulizer equipment should be stored in different bags to prevent cross-contamination. During an interview on [DATE] at 4:47 p.m. with the ADON, the ADON stated the nasal cannula should not have touched the floor, and the nebulizer equipment should not have been stored in the same bag as the nasal cannula. The ADON stated the nasal cannula on the ground posed an infection risk to Resident 12 because the dirty floor could have contained bacteria, which might have come into contact with Resident 12's mucosal membrane and caused an infection. The ADON stated staff were expected to store the nasal canula and nebulizer equipment in separate bags to prevent cross-contamination. During an interview on [DATE] at 4:57 p.m. with the DON, the DON stated she expected the nasal cannula tubing to remain off the floor and for the nebulizer equipment to be stored in its own bag. The DON stated, allowing the nasal cannula tubing to the touch the floor posed a risk of cross-contamination and infection due to the presence of pathogens (disease causing organisms). The DON stated the nasal cannula and nebulizer tubing were two different pieces of equipment used on different parts of the body, further increasing the risk of cross-contamination if improperly stored. During a review of Resident 20's CP dated [DATE], the CP indicated, . [Resident 20] has COPD. [Resident 20] is at risk for sob (shortness of breath) .the resident will have no s/sx (signs or symptoms) of poor oxygen absorption with oxygenation saturation greater than 90% .give aerosol or bronchodilators (medication that make breathing easier) as ordered . During a review of the facility's P&P titled, Infection Control Policies and Practices dated [DATE], the P&P indicated, .This Center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .the Governing Board .have adopted our infection control policies and procedures and practices as outlined herein, to reflect he Center's need and operational requirements for preventing transmission of infections and communicable diseases . During a review of the facility's P&P titled, Respiratory Care; Oxygen Administration dated ,d+[DATE], the P&P indicated, .Oxygen equipment, tanks, humidifier bottles, cannulas, masks, and other related items are checked with administration .equipment that is soiled .is replaced . 3. During a review of Resident 12's AR dated [DATE], the AR indicated, Resident 12 was initially admitted to the facility on [DATE] with a diagnosis of mild intermittent asthma (a type of asthma [a chronic condition that inflames and narrows the airways in the lungs] wherein a person has symptoms on no more than 2 days per week), encounter for screening with other viral diseases (a routine test done to a population to identify unrecognized disease carrier state), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), personal history of transient (temporary) ischemic attack and cerebral infarction ( a temporary lack of blood flow to part of the brain). During a review of Resident 12's OSR dated [DATE], the OSR indicated, .Administer Oxygen ,d+[DATE] liter per min via NC (nasal canula) as needed for shortness of breath (SOB) of O2 sat <(above) 90% every shift for SOB .change oxygen tubing, concentrator bottle and clean filter every week every night shift every Sun (Sunday) . During a review of Resident 12s MDS dated [DATE], the MDS section C indicated, Resident 12 had a BIMS score of 08. A score of 08 indicated, Resident 12 had moderately impaired cognition. During an observation on [DATE] at 3:03 p.m. in Resident 12's room, Resident 12 was sitting in her wheelchair asleep. An oxygen humidifier bottle that was nearly full of humidifier solution was connected to her oxygen concentrator and had a date of ,d+[DATE]. During a concurrent observation and interview on [DATE] at 3:16 p.m. with Certified Nursing Assistant (CNA) 1, Resident 12's humidifier bottle and solution had a date of ,d+[DATE]. CNA 1 stated the humidifier bottle, and solution was dated ,d+[DATE] and was out of date. During an interview on [DATE] at 9:28 a.m. with the IP, the IP was shown a picture, taken by surveyor, of the humidifier bottle and solution taken in Resident 12's room. The IP stated the humidifier bottle and solution were dated ,d+[DATE]. The IP stated the humidifier bottle and solution were out of date and should have been replaced. The IP stated, the humidifier bottle should have been changed weekly because stagnant (lack of movement or flow, becoming stale) humidifier solution could have potentially allowed bacteria and mold to grow that could have caused and worsened respiratory illnesses for Resident 12. The IP stated, the CSC was responsible for changing the humidifier bottle weekly and should have changed the bottle a week after ,d+[DATE]. During an interview on [DATE] at 9:57 a.m. with the CSC, the CSC stated she was responsible for changing the supplies of residents on oxygen. The CSC stated she kept track of the rooms with oxygen concentrators. The CSC stated she was supposed to change the humidifier bottles every week. The CSC stated she failed to change Resident 12's humidifier bottle and solution. The CSC stated it was important to have changed the humidifier bottle and solution because if the solution runs out, the oxygen could potentially have dried out Resident 12's mucosal membrane leading to cracking, bleeding, and discomfort. The CSC stated bacteria could have potentially grown in the expired and stagnant humidifier solution and had the potential to cause infections to Resident 12. During an interview on [DATE] at 4:49 p.m. with the ADON, the ADON stated the humidifier solution with a date of ,d+[DATE] was three weeks out of date and should have been replaced. The ADON stated she expected the humidifier bottle and solution to have been changed every week by the CSC or nurse. The ADON stated it was important to change the humidifier bottle and solution weekly so the solution inside did not become stagnant and allowed bacteria to grow. The ADON stated bacteria in the solution could have potentially caused respiratory infections to Resident 12 and worsened her asthma. During an interview on [DATE] at 5:01 p.m. with the DON, the DON stated she expected the humidifier bottle and solution to be changed weekly. The DON stated an expired and potentially stagnant humidifier solution had the potential to cause bacteria to grow in the solution and cause respiratory infections to Resident 12. During a review of Resident 12's CP dated [DATE], the CP indicated, . [Resident 12] has oxygen therapy r/t mild intermittent Asthma AEB (as evidenced by) SOB .Administer ,d+[DATE] LPM (liters per minute) oxygen .monitor oxygen therapy every shift .Resident is on Oxygen Therapy . During a review of the facility's job description (JD) titled, Central Supply Clerk undated, the JD indicated, .determine if inventory quantities are sufficient .rotate stock using first in first out .stocking nursing stations with the appropriate nursing supplies .orders and maintains inventory of supplies and fills requests according to procedures . During a review of the facility's JD titled, Registered Nurse dated 2022, the JD indicated, .Registered Nurse .follow company policy and procedures to ensure a safe and comfortable environment .deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . During a review of the facility's P&P titled, Infection Control Policies and Practices dated [DATE], the P&P indicated, .This Center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .the Governing Board .have adopted our infection control policies and procedures and practices as outlined herein, to reflect he Center's need and operational requirements for preventing transmission of infections and communicable diseases . During a review of the facility's P&P titled, Respiratory Care; Oxygen Administration dated ,d+[DATE], the P&P indicated, .Oxygen equipment, tanks, humidifier bottles, cannulas, masks, and other related items are checked with administration .equipment that is soiled .is replaced . 48424 4. During a review of Resident 371's AR, dated [DATE], the AR indicated, Resident 371 was admitted to the facility on [DATE] with diagnoses which included acute embolism and thrombosis of left lower extremity (a blood clot forming in a vein in the left leg, potentially blocking blood flow and leading to complications) and acquired absence of the left leg (surgical removal of the leg). During an observation on [DATE] at 4:20 p.m. in Resident 371's room, LVN 5 was changing resident 371's dressing. LVN 5 was not wearing a gown. LVN 5 stated Resident 371 had an amputated leg, and a wound had developed on it. LVN 5 stated Resident 371 was at risk for infection. LVN 5 stated Resident 371 was on enhanced barrier precautions (equipment such as gown and gloves, designed to reduce the transmission of multidrug-resistant organisms), and staff were required to wear a gown and gloves when entering the room to provide care. During an interview on [DATE] at 11:23 a.m. with the IP, the IP stated Resident 371 was on enhanced barrier precautions and nursing staff were required to wear gloves and a gown when providing care to him. The IP stated Resident 371 had a recent left leg amputation and had a wound to the surgical site, LVN 5 should have worn a gown when doing his dressing change because that helped protect the resident from infection and it helped protect the nurse from cross contaminating her own clothes. During an interview on [DATE] at 3:03 p.m. with the DON, the DON stated LVN 5 should not have gone into Resident 371's room without a gown. The DON stated not wearing the proper PPE when caring for residents could spread infections to other residents if any contamination attached to LVN 5's clothes. The DON stated LVN 5 not wearing the appropriate PPE did not follow the facility's infection control policy. During a review of the facility's P&P titled, Infection Control Policies and Practices dated [DATE], the P&P indicated, .This Center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .the Governing Board .have adopted our infection control policies and procedures and practices as outlined herein, to reflect the Center's need and operational requirements for preventing transmission of infections and communicable diseases . During a review of the Professional Reference (PR) found on https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated [DATE], the PR indicated, . [Multi Drug Resistant organisms] (MDROs - germs which have become resistant to medications) may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply . 51134 5. During a concurrent observation and interview on [DATE] at 9:15 a.m. at South one medication cart with Licensed Vocational Nurse (LVN) 2, when inspecting the locked drawer for scheduled medications, a folder with two 10-dollar bills was found. The folder was labeled, Weekend and after hours trust $20.00 only for residents who have trust account. **See list inside folder. LVN 2 stated the money is kept in this cart for residents with a trust who ask for money after hours when the business office is closed or on the weekends. LVN 2 stated there is a list inside the envelope with residents who have a trust, and this gets updated daily by the business office and this list is given to the LVN responsible for the cart. During a concurrent observation and interview on [DATE] at 8:50 a.m. with LVN 3 at South one medication cart, an envelope containing money was observed in the locked drawer. LVN 3 stated she was unaware there was money in the cart. LVN 3 stated, I haven't been told about the money in this cart but if it is here, I am responsible for it. LVN 3 stated resident money should not be in the cart. LVN 3 stated money held in the medication cart could be an infection control issue because money is dirty, and medications are stored there . During an interview on [DATE] at 11:23 a.m. with the Infection Preventionist (IP), the IP stated she was unaware money was stored in the medication cart and stated money should not be stored in the medication cart. The IP stated money is one of the dirtiest things and having it near medications is not acceptable. The IP stated having money stored next to medication could make the medications dirty. During an interview on [DATE] at 11:42 a.m. with the Pharmacy Consultant (PC), the PC stated he was unaware money was being kept in the South one medication cart. The PC stated money should not be stored in the medication cart because of how dirty it is, and it is mixing with clean medications. During an interview on [DATE] at 3:33 p.m. with the Director of Nursing (DON), the DON stated she was unaware money was kept in the South one medication cart. The DON stated the money should not remain in the medication cart and should be moved. The DON stated money kept in the medication cart can be an infection control issue and everything in the medication cart needs to remain clean. During a review of the facility ' s policy and procedure (P&P) titled, Infection Control Policies and Practices dated ,d+[DATE], the P&P indicated, .This Center ' s infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .

Based on interview, and record review the facility failed to develop and implement a baseline care plan (a document which specified goals, interventions, and monitoring strategies for patients) for three of nine sampled residents (Residents 221, 222, and 421) when: 1. Residents 221 and 222 did not have their baseline care plans completed within 48 hours of their admission to the facility This failure had the potential to cause Residents 221 and 222 to not have their respiratory care needs met 2. Resident 421 did not have his baseline care plan for a PICC (peripherally inserted central catheter- a thin, flexible tube that is inserted into a vein in the upper arm used to deliver medications directly into the heart) completed within 48 hours of his admission to the facility. This failure had the potential to cause Resident 421 to not have his care needs met potentially leading to poor patient outcomes (adverse effects) such as developing infections that could lead to a decline in health. Findings: 1. During a review of Resident 221's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/21/25, the AR indicated, Resident 221 was admitted to the facility on [DATE] with a primary diagnosis of pleural effusion (buildup of excess fluid between the layers of tissue lining the lungs and chest cavity). During a review of Resident 222's AR, dated 3/21/25, the AR indicated, Resident 222 was admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection of the lungs that causes the air sacs to become inflamed and fill with fluid), chronic obstructive pulmonary disease (COPD- an ongoing lung condition caused by damage to the lungs) and pleural effusion. During a concurrent interview and record review on 3/20/25 at 11:01 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 221 and 222's care plans, dated 3/20/22, were reviewed. Resident 221 and 222's care plan did not include any interventions for their admitting diagnoses or physician orders. LVN 1 stated both Resident 221 and 222 had orders for the use of oxygen and nurses at the facility were responsible for care planning the oxygen order upon admission. LVN 1 stated Residents 221 and 222 had respiratory conditions and staff needed to care plan goals and interventions which would help them breathe better. LVN 1 stated the care plan drives residents' care, and upon admission nurses needed be aware of the basic needs of each resident. During an interview on 3/21/25 at 1:46 p.m. with the Minimum Data Set Registered Nurse (MDSRN), the MDSRN stated the nurses caring for the residents were responsible for ensuring baseline care plans were created for newly admitted residents. The MDSRN stated Residents 221 and 222 should have had their diagnoses and physician's orders care planned. The MDSRN stated care planning was important because it ensured staff were aware of a resident's medical needs and what each resident required to help them feel better. Accurate care planning was also needed to better communicate with other nurses who might not know what the resident requires. During an interview on 3/21/25 at 3:03 p.m. with the Director of Nursing (DON), the DON stated baseline care planning should have been done for Residents 221 and 222. The DON stated care planning was important because it created interventions which staff could implement to try to get residents healthy enough to discharge home. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline dated 3/22, the P&P indicated, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. physician orders 48430 2. During a review of Resident 421's AR dated 3/20/25, the AR indicated Resident 421 was admitted to the facility on [DATE] with a primary diagnosis of late syphilitic oculopathy (an eye condition that can happen if syphilis isn't treated), type two diabetes mellitus (a condition where the body doesn't use insulin [a type of compound that regulates sugar levels in the blood] well and can't keep blood sugar at normal levels), epilepsy (brain disorder that causes recurring, unprovoked seizures (sudden, uncontrolled bursts of electrical activity in the brain that can cause temporary changes in behavior, consciousness, and body movements), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 421's Minimum Data Set (MDS-a standardized uniform comprehensive assessment of all residents) dated 3/11/25, the MDS indicated, Resident 421 had a BIMS (Brief Interview for Metal Status-a screening tool used to evaluate a person's cognitive [an individual's thinking, reasoning, and remembering process] ability) score of 15 (a BIMS score of 15 indicated Resident 421 had intact cognitive function). During a review of Resident 421's Order Summary Report (OSR) dated 3/20/25, the OSR indicated, .D/C (discontinue) PICC line after IV (intravenous-in the vein) Antibiotic (medicine to treat bacterial infection) therapy is completed . During a concurrent observation and interview on 3/17/25 at 3:30 p.m. with Resident 421 in his room, Resident 421 had a PICC line on his right upper arm. Resident 421 stated, he was here for short term antibiotic therapy for an eye infection. During a concurrent observation and interview on 3/20/25 at 10:27 a.m. with Resident 421 in the facility's lobby, Resident 421 was sitting on a chair waiting for his ride to pick him up. Resident 421's PICC line was removed and was discharged . Resident 421 stated, Registered Nurse (RN) 1 removed his PICC line about 30 to 40 minutes ago. During a concurrent interview and record review on 3/20/25 at 2:14 p.m. with the Director of Nurses (DON), Resident 421's Care Plan (CP-a form where that summarizes a person's health conditions, specific care needs, and current treatments) dated 3/5/25 to 3/20/25 was reviewed. The CP did not indicate PICC line care plans were implemented. The DON stated, there were no CP for Resident 421's PICC line but should have had a baseline care plan implemented when he was admitted . During a concurrent interview and record review on 3/20/25 at 3:11 p.m. with Registered Nurse (RN) 1, Resident 421's CP dated 3/5/25 to 3/20/25 was reviewed. CP did not indicate PICC line care plans were implemented. RN 1 stated, Resident 421 did not have a baseline care plan for his PICC line and should have had one. RN 1 stated, baseline care plans should have been completed within 48 hours of admission. RN 1 stated, a CP was important because it guides resident care and offers a way to measure treatment outcomes. RN 1 stated, if no CP were implemented, the was a potential for Resident 421's health status to decline. During a concurrent interview and record review on 3/20/25 at 3:11 p.m. with RN 1, Resident 421's CP dated 3/5/25 to 3/20/25 was reviewed. The CP did not indicate PICC line care. RN 1 stated, Resident 421 should have had a care plan for his PICC line. RN 1 stated, a baseline care plan should have been completed within 48 hours of admission. RN 1 stated, CPs were important as they guided care and tracked progress of the treatment. RN 1 stated, without a CP, Resident 421's health could have declined. During an interview on 3/21/25 at 5:38 p.m. with the DON, the DON stated, she expected a baseline care plan to be implemented within 48 hours of a resident's admission. The DON stated, it was important because it created interventions which staff could implement to guide care and lead to the resident's optimal health before discharging. During a review of the facility's P&P titled, Care Plans-Baseline dated 3/22, the P&P indicated, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. physician orders

Based on observation, interview, and record review the facility failed to properly store medication in three of five medication carts and one of two medication storage rooms when: 1. South one medication cart contained: a. An unopened insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen intended for refrigeration storage for Resident 56, and b. No open dates were placed on medications for Resident 78, Resident 99, Resident 322, Resident 222, and Resident 72. 2. South two medication cart contained: a. Six insulin pens with no open dates for Resident 68, Resident 53, Resident 5, and Resident 17. b. Expired medication for Resident 66, c. Four eye drop bottles did not have an open date, and d. Three respiratory medications did not have an open date. 3. North one medication cart contained: a. Discontinued medication for Resident 2, b. Two multi-dose (bottle or vial of liquid medication that contains more than one dose of medication) medications did not have open dates for Resident 15 and Resident 63, and c. One over the counter (OTC) medication was expired. 4. North medication storage room contained: a. Two expired medications, b. One medication bottle with an incorrect expiration date, c. Three opened bottles stored on the shelves for unopened OTC medications, and d. Medication refrigerator contained a discontinued medication for Resident 100. These failures had the potential to result in decreased medication potency that could compromise the therapeutic effectiveness of stored medications and result in adverse reactions from medications stored incorrectly, expired and improperly labeled. Findings: 1. During an observation on 3/19/25 at 9:25 a.m. at South one medication cart with Licensed Vocational Nurse (LVN) 2, observed: a. For Resident 56 an unopened Glargine (a long-acting synthetic insulin used to treat type 1 diabetes [condition where pancreas makes little or no insulin which leads to high blood sugar levels] and type 2 diabetes [long term condition where the body has trouble controlling blood sugar and using it for energy]) pen. Pen was not stored in refrigerator as recommended by manufacturer b. For Resident 78 and Resident 99, observed Insulin Glargine with no open date. For Resident 322 observed two eye drop medications, Brinzolamide ophthalmic (eye drop used to treat increased eye pressure caused by glaucoma [eye disease that damages the optic nerve, which connects the eye to the brain] or ocular hypertension [when pressure inside the eye is high than normal]) suspension (liquid medication prepared when the drug doesn't dissolve but is crushed into fine particles) and brimonidine tartrate (eye drop used to treat glaucoma and lower intraocular pressure), and one inhaler (a handheld medical device used to deliver medication directly into the lungs through inhalation), fluticasone propionate and salmeterol (combination of medication used to treat asthma and COPD), with no open date on the bottle. For Resident 222 observed four inhalers, that included albuterol sulfate (short acting medication that provides relief from an asthma attack by relaxing the smooth muscles in the airways), tiotropium bromide (bronchodilator medication breathed in through the mouth to help open up air passages in the lungs), levalbuterol (medication that can treat or prevent bronchospasm [sudden narrowing of the airways in the lungs resulting in difficulty breathing])and breztri aerosphere (medication used to treat long term chronic obstructive pulmonary disease [COPD- a chronic lung disease causing difficulty in breathing] ), with no open date. For Resident 72 observed a bottle of dabigatran (medication that can treat and prevent blood clots) with no open date. During a review of Resident 56's Order Summary Report (OSR) dated 3/20/25, the OSR indicated, Insulin Glargine Solution 100 UNIT/ML [milliliter- unit of volume] Inject 20 unit subcutaneously [under the skin] one time a day for diabetes [chronic disease where the body either doesn't produce enough insulin or cant effectively use the insulin in produces, leading to high blood sugar levels] . Order Status: Active . Start Date: 02/12/2025 . During a review of Resident 78's OSR dated 3/20/25, the OSR indicated .Insulin Glargine Subcutaneous Solution 100 UNIT/ML . Inject 30 unit subcutaneously two times a day for [diabetes] . Order Status: Active . Start Date: 06/18/2024 . During a review of Resident 99's OSR dated 3/20/25, the OSR indicated, . [Insulin Glargine] Subcutaneous Solution Pen-Injector 100 UNIT/ML .Inject 16 unit subcutaneously at bedtime for TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS .Order Status: Active . Start Date: 02/15/2024 . During a review of Resident 322's OSR dated 3/20/25, the OSR indicated, .Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate) Instill 1 drop in both eyes every 12 hours for glaucoma . Order Status: Active . Start Date: 03/18/2025 . [Brinzolamide] . Instill 1 drop in both eyes every 12 hours for glaucoma . Order Status: active . Start Date: 03/18/2025 . The OSR indicated, .Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT . I puff inhale orally one time a day . Order Status: Active . Start Date: 03/19/2025 . During a review of Resident 222's OSR dated 3/20/25, the OSR indicated, .Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours . Order Status: Active . Start Date: 03/13/2025 . Breztri Aerosphere Inhalation Aerosol 160-9-4.8 MCG/ACT (Budesonide-Glycopyrrolate-Formoterol Fumarate) 2 puff inhale orally two times a day . Order Status: Active . Start Date: 03/13/2025 . The OSR indicated, Tiotropium Bromide Monohydrate Inhalation Capsule 18 MCG (Tiotropium Bromide Monohydrate) . 1 capsule inhale orally one time a day . Order Status: Active . Start Date: 03/14/2025 .[Levalbuterol] 1.25 MG/3ML .3 ml inhale orally via nebulizer [a device for producing a fine spray of liquid] every 6 hours as needed for shortness of breath while awake . Order Status: Active . Start Date: 03/13/2025 . During a review of Resident 7's OSR dated 3/20/25, the OSR indicated, . [Dabigatran] oral capsule 150 MG Give 1 capsule by mouth every 12 hours for prevent blood clots . Order Status: Active . Start Date: 03/13/2025 . During an interview on 3/19/25 at 10:30 a.m. with LVN 2, LVN 2 stated it is important to have an open date on the medication itself because if the medication gets separated from the box, the nurse will be unaware when the medication was opened. 2. During an observation on 3/19/25 at 10:35 a.m. at South two medication cart with LVN 6, observed: a. Six insulin pens with no open date. These medications included Resident 68's Insulin glargine and lispro [short-acting human made insulin helps to control blood sugar levels], Resident 53's insulin glargine, Resident 5's Insulin glargine and insulin lispro, and Resident 17's Insulin glargine; b. For Resident 66, observed an expired Insulin glargine; c. For Resident 17, observed two eye drop medications, brimonidine 0.2% and latanoprost 0.005%, with no open date; and d. For Resident 66, observed two inhalers, Combivent Respimat inhaler and albuterol, with no open date and for Resident 20 a bag of levalbuterol with no open date. During a review of Resident 68's OSR dated 3/20/25, the OSR indicated, .Humalog Injection Solution 100 UNIT/ML . Inject 14 unit subcutaneously three times a day for [diabetes type 2] . Order Status: Active . Start Date: 12/25/2024 .Insulin Glargine Solution 100UNIT/ML Inject 45 unit subcutaneously at bedtime for [diabetes type 2] hold if [blood sugar] 150 [greater than] and notify [Medical Doctor] . Order Status: Active . Start Date: 04/01/2024 . During a review of Resident 53's OSR dated 3/20/25, the OSR indicated, . Insulin Glargine subcutaneous solution 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously at bedtime for type 2 diabetes mellitus without complications . Order Status: Active . Start Date: 3/12/25 During a review of Resident 5's OSR dated 3/20/25, the OSR indicated, .[Humalog] Injection Solution 100 UNIT/ML .Inject as per sliding scale . Order Status: Active . Start Date: 10/13/2023 . [Insulin Glargine] subcutaneous solution 100 UNIT/ML . Inject 20 unit subcutaneously at bedtime . Order Status: Active . Start Date: 8/11/2024 . During a review of Resident 17's OSR dated 3/20/25, the OSR indicated, . [Insulin Glargine] Subcutaneous Solution Pen-Injector [device used to inject medication under the skin] 300 UNIT/ML .Inject 24 unit subcutaneously in the morning for diabetes hold for blood sugar [less than] 100 . Order Status: Active . Start Date: 10/07/2024 . During a review of Resident 66's Order Review undated, the Order Review indicated, .Insulin Glargine Subcutaneous Solution 100 UNIT/ML . Directions: Inject 10 unit subcutaneously one time a day for TYPE 2 DIABETES MELLITTUS WITHOUT COMPLICATIONS for 5 days . Status: Completed . End Date: 3/13/2025 . During a review of Resident 17's OSR dated 3/20/25, the OSR indicated, Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate) Instill 1 drop in both eyes three times a day for Glaucoma . Order Status: Active . Start Date: 08/23/2024 .[Latanoprost] .Instill 1 drop in both eyes at bedtime for Glaucoma . Order Status: Active . Start Date: 06/17/2023 . During a review of Resident 66's OSR dated 3/20/2025, the OSR indicated, . Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG/3ML .1.25 mg inhale orally every 4 hours as needed for shortness of breath or wheezing while awake . Order Status: Active . Start Date: 03/07/2025 . [Ipratropium-Albuterol] Inhalation Aerosol Solution 20-100 MCG/ACT .1 puff inhale orally two times a day . Order Status: Active . Start Date: 03/08/2025 . During a review of Resident 20's OSR dated 3/20/25, the OSR indicated, .Levalbuterol HCL Inhalation Nebulization Solution 1.25 MG/3ML (Levalbuterol HCL) ml inhale orally via nebulizer three times a day . Order Status: Active . Start Date: 03/05/2025 . During a concurrent interview and record review on 3/21/25 at 9:08 a.m. with LVN 1, the insulin order for Resident 66 was reviewed. The insulin order indicated, .Insulin Glargine Subcutaneous Solution 100 UNIT/ML . Directions: Inject 10 unit subcutaneously one time a day for TYPE 2 DIABETES MELLITTUS WITHOUT COMPLICATIONS for 5 days . Status: Completed . End Date: 3/13/2025 . LVN 1 stated this medication has been discontinued and the medication should not be in the medication cart. LVN 1 stated expired or discontinued medications should not remain in the medication cart because a medication error (preparation or administration of medication is not in accordance with prescriber's orders, manufacturers specifications or professional standards) could occur. 3. During an observation on 3/19/25 at 12:04 p.m. with LVN 8 at North one medication cart, observed: a. For Resident 2, observed a discontinued bubble pack (card that packages doses of medications within small, clear or light-resistant, amber-colored plastic bubbles) of Lorazepam; b. For Resident 15 observed a multi-dose Lactulose (medication to treat constipation) bottle with no open date, Resident 63 ' s multi-dose Sucralfate (medication that treats stomach ulcers) bottle with no open date; and c. Observed an expired cetirizine hydrochloride (antihistamine medication used to treat allergy symptoms like itchy eyes, sneezing, stuffy nose or hives). During a review of Resident 2's OSR dated 3/21/25, the OSR indicated, .[Lorazepam] Oral Tablet 0.5 MG .Give 1 tablet by mouth every 6 hours as needed for inability to relax for 14 days . Order Status: Discontinued . Revision Date: 03/12/2025 . During a review of Resident 15's OSR dated 3/20/25, the OSR indicated, .Lactulose oral solution 10 GM/15ML .45 mL by mouth every 6 hours . Order Status: Active .Start Date: 03/04/2025 . During a review of Resident 63's OSR dated 3/20/25, the OSR indicated, .Sucralfate Oral Suspension 1 GM/10ML .Give 10 mL by mouth before meals for [treatment] and prevention . Order Status: Active . Start Date: 03/07/2024 . During an interview on 3/19/25 at 12:21 p.m. with LVN 3, LVN 3 stated it is important to remove expired medication from the medication cart because the strength of the medication will not be as effective. 4. During an observation on 3/19/25 at 3:38 p.m. with the Infection Preventionist (IP) at the North medication storage room, observed: a. Three medication bottles, including Reguloid (medication used to treat constipation) with a written open date of 5/29/24, Fish oil (dietary source of omega-3 fatty acids) with a written open date of 4/24/24, and Nephro vitamins (medication used to treat or prevent vitamin deficiency) with a written open date of 1/8/25, stored on shelves designated for unopened OTC medications; b. Observed two packets of topical analgesics (medication applied directly to the skin to relieve pain) that were expired; c. Observed a bottle of unopened Famotidine with an incorrect expiration of 3/27 written on the bottle when manufacturer date was 01/2026; and d. Observed Resident 100's discontinued Latanoprost Ophthalmic Solution 0.005% in the medication refrigerator. During a review of Resident 100's Order Audit Report dated 3/21/25, the Order Audit Report indicated, .Latanoprost Ophthalmic Solution 0.005% .Instill 1 drop in both eyes at bedtime for glaucoma . Order Status: Discontinued . During an interview on 3/19/25 at 3:59 p.m. with the IP, the IP stated it is important to not have expired medication in the medication storage room because the potency (power) of the medication will not be what it needs to be, and the resident will not be receiving an accurate dose of medication. The IP stated if a medication is labeled incorrectly, like an incorrect expiration date, a nurse could be giving an expired medication. During a concurrent observation and interview on 3/20/25 at 8:29 a.m. with Central Supply (CS) in the North medication storage room, medications that were expired and medications with open dates were reviewed. CS stated the expiration date written on Famotidine was an incorrect date. CS stated only unopened OTC medications are to be placed in the medication room. CS stated when OTC medications are seen with an open date in the medication storage room, they should be placed in the bin labeled, Discontinued medication for destruction. CS stated for the topical analgesics that were expired, they should have been removed from the medication room. During an interview on 3/20/25 at 8:38 a.m. with LVN 9, LVN 9 stated open bottles should not be put back into the medication storage room because these medications can expire without staff being aware. LVN 9 stated open dates for medications should be placed directly onto the bottle and not just the packaging because the packaging can be thrown away and a medication could end up with no open date written on it. LVN 9 stated for OTC medications, such as eye drops, staff should place the resident's name and open date on the bottle. LVN 9 stated placing only the room number for a resident on the bottle should not be done because the resident may be moved, and the medication may be given to another resident. During an interview on 3/21/25 at 11:02 a.m. with the Pharmacy Consultant (PC), the PC stated for labeling medications, at a minimum an open date needs to be placed directly onto the medication, or on an open date sticker on the medication, and not just the packaging the medication comes in. The PC stated it is important to remove expired medications from the medication cart such as insulins and eye drops because expired medications may not be as effective and expired eye drops could be an infection control issue. The PC stated discontinued medications should be removed from the medication cart because these medications may continue to be administered without an order. During an interview on 3/21/25 at 3:33 p.m. with the Director of Nursing (DON), the DON stated it is important to put open dates on the medication itself because some medications have a shelf life (length of time an item remains usable) and expire when the medication is opened. The DON stated for the medication storage room, opened OTC medications should not be placed back onto the shelves because the medication could expire past its shelf life. The DON stated expired medications in the medication carts and the medication storage rooms should be removed because if they are not, they may be administered and lead to a medication error. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the facility: Storage of Medications dated 4/2008, the P&P indicated, .F. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area .M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists .

Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans for four of 12 sampled residents (Resident 71 and Resident 72, Resident 47 and Resident 223) when: 1. Resident 71 had an incomplete care plan for anxiety medication, and no care plan for Sertraline (anti-depressant medication) and Olanzapine (antipsychotic medication that alters brain chemistry to help reduce symptoms of the mind where there has been some loss of contact with reality). 2. Resident 72 did not have individualized care plans for Quetiapine (antipsychotic [class of drugs used to treat psychotic disorders] medication used to treat schizophrenia [a chronic mental health conditional characterized by significant disruptions in thought processes, perceptions, emotions and behavior] and bipolar disorder [chronic mental health condition characterized by extreme shifts in mood, energy and behavior]), Buspirone (medication used to treat anxiety disorders), and Lorazepam (anti-anxiety medication). These failures had the potential to result in Resident 71 and Resident 72 not having their mental and psychosocial (relating to the interrelation of social factors and individual through and behavior) needs met. 3. Resident 223 did not have a care plan for Apaxiban, Insulin (regulates blood sugar levels in the body), diabetic (the body does not produce insulin resulting in high blood sugar levels), care, or hemodialysis (a treatment that cleans the blood to filter out waste and excess fluid). These failures put Resident 223 at risk for harm by not monitoring or identifying risk of uncontrolled bleeding and harmful side effects and by not monitoring effects of insulin on the Resident's blood sugar. 4. Resident 47 did not have a care plan for apixaban (anticoagulant - prevent blood clots from forming). This failure put Resident 47 at risk for harm by not monitoring or identifying risk of uncontrolled bleeding and harmful side effects. Findings: 1. During a record review of Resident 71's AR dated 3/21/25, the AR indicated resident 71 was admitted into the facility on [DATE]. The AR indicated, . Diagnosis Information .bipolar disorder .post-traumatic stress disorder [PTSD - a disorder in which a person has difficultly recovering after experiencing or witnessing a terrifying event] . During a record review of Resident 71's Care Plan (CP) Report dated 2/23/25, the CP Report indicated, . Goal: The resident will show decreased number (SPECIFY) episodes or anxiety through the review date. Date initiated: 02/23/2025. Revision on 03/17/2025. Target Date: 03/24/2025 . Did not observe a care plan in place for the medications Sertraline and Olanzapine. During a concurrent interview and record review on 3/21/25 at 8:59 a.m. with LVN 3, Resident 71's CP Report for anti-anxiety medication was reviewed. The CP Report indicated, .Goal: The resident will show decreased number (SPECIFY) episodes or anxiety through the review date . LVN 3 stated this care plan is incomplete and specify was not edited. LVN 3 stated it is important to have a specific number included to know how many behaviors to observe for and to see if the medication is effective. LVN 3 was unable to locate care plans for the medications Sertraline and Olanzapine. LVN 3 stated there should be care plans for these medications because they are antipsychotics and staff need to monitor the resident for behaviors. 2. During a record review of Resident 72's Admission Record (AR) dated 3/20/25, the AR indicated Resident 72 was admitted into the facility on [DATE]. The AR indicated, .Diagnosis Information . Cerebral Infarction (medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue) . metabolic encephalopathy (condition where brain's function is impaired due to an imbalance in the body's metabolism) . bipolar disorder . During a record review of Resident 72's Care Plan (CP) dated 3/20/25, the CP indicated, Focus: [Resident 72] uses psychotropic medications [substances that affect the brain and nervous system, altering mood, perception and behavior] (Quetiapine) for bipolar disorder m/b [manifested by] verbal and physical aggression towards staff. She is at risk for drug-related complications. Date initiated: 03/20/2025. Revision on: 03/20/2025 . During a record review of Residents 72's CP dated 3/20/25, the CP indicated, Focus: [Resident 72] uses anti-anxiety medication Buspirone r/t [related to] repetitive statements, I want to go home. She is at risk for drug-related complications. Date initiated: 03/20/2025. Revision on: 03/20/2025 . During a record review of Resident 72's CP dated 03/20/25, the CP indicated, Focus: [Resident 72] uses anti-anxiety medications [Lorazepam] r/t anxiety m/b inability to relax. She is at risk for drug-related complications. Date Initiated: 03/20/2025. Revision On: 03/20/2025 . During a concurrent interview and record review on 3/21/25 at 8:54 a.m. with Licensed Vocational Nurse (LVN) 3, the medication orders for Quetiapine, Buspirone, and Lorazepam and care plans for these medications were reviewed. LVN 3 stated the medication order for Seroquel indicated a start date of 2/18/25. LVN 3 stated the medication order for Buspirone indicated a start date of 2/18/25. LVN 3 stated the medication order for Lorazepam indicated a start date of 3/5/25. LVN 3 stated the care plans for Quetiapine, Buspirone, and Lorazepam were created on 3/20/25. LVN 3 stated the care plans for these medications should have been in place when the medications were ordered. LVN 3 stated it is important to have care plans for these medications because the resident needs to be monitored to determine if the medication is effective for the resident. During an interview on 3/21/25 at 3:23 p.m. with the Director of Nursing (DON), the DON stated the CP for Resident 71 is incomplete because it does not specify the number of episodes to observe for. The DON stated it is important to have specific number of episodes to observe for to see if medication is working or not and determine if the current dose of the medication needs to be adjusted. The DON acknowledged Resident 71's care plans for Quetiapine, Buspirone, and Lorazepam were missing and not created when the medication was ordered. The DON acknowledged for Resident 72 the care plans for Sertraline and Olanzapine were missing and should have been created. The DON stated it is important to have comprehensive care plans so interventions can be implemented, and this is especially important for short term residents so they can be healed and back to bassline prior to discharge. During a record review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 12/2016, 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 . The P&P indicated, . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) . 41608 3. During a record review of Resident 223's Admission Record (AR) dated 3/19/25, the AR indicated Resident 223 was admitted into the facility on [DATE]. The AR indicated, . Gangrene (the death of body tissue, typically due to lack of blood flow or a serious bacterial infection, often affecting limbs like toes, fingers, and feet), post amputation (the surgical removal) of left toes, Type II Diabetes (DM- body does not produce enough insulin or use it properly, leading to high blood sugar levels), End Stage Renal Disease (ESRD-kidneys can no longer adequately filter waste and excess fluid from the blood), Peripheral Vascular Disease (PVD-blood vessels outside the heart and brain narrow or become blocked, reducing blood flow and potentially causing pain, numbness and other issues), Hemodialysis (a treatment that cleans the blood to filter out waste and excess fluid) . During a review of Resident 223's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 223's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status on a scale of 0-15 [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 223 had no cognitive deficit. During a review of Resident 223's Order Summary (OS), dated 1/2/25, the OS indicated, . MWF dialysis at Satellite Healthcare Merced . pick up 1300 (1 p.m.), chair time 1500 (3 p.m.) . During a review of Resident 223's Medication Administration Record (MAR), dated 2/1/25, the MAR indicated, Resident 223 was prescribed Apaxiban Oral Tablet 5 MG (milligram-unit of measure), Give 1 tablet by mouth two times a day for DVT (Deep Vein Thrombosis - blood clot), prevention .Insulin Glargine Solostar Subcutaneous Solution Pen Injector 100 Unit/ML (milliliter-unit of measure), (Insulin Glargine) inject 5 units subcutaneously (into the skin), at bedtime for Diabetes . During a concurrent interview and record review on 3/21/25 at 6:38 p.m. with Director of Nurses (DON), Resident 223's Care Plans (CP) dated 2/1/25 were reviewed. The CP indicated, no Care Plan for anticoagulants, insulin, diabetic care, or hemodialysis were created. The DON stated, the care plan provides directions for staff to care for residents, without a care plan the resident may not get the care that is needed. During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, dated 09/13, the P&P indicated, .A comprehensive, person centered care plan that included measureable objectives and timetables to meet the resident'sphysical, psychosocial and functional needs is developed and implemented for each resident . 51284 4. During a review of Resident 47's Admission Record (AR) dated 3/19/25, the AR indicated, Resident 47 was initially admitted to the facility on [DATE] with diagnoses of heart failure ( a condition in which the heart is unable to pump sufficient blood to meet the body's needs), supraventricular tachycardia (abnormally fast heart rhythm) and morbid obesity (overweight-weight is more than 80 to 100 pounds above the ideal body weight). During a review of Resident 47's Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 1/9/25, the MDS section C indicated, .cognitive skills for daily decision-making score of 15 .cognitively intact . During a review of Resident 47's Order Summary Report (OSR) dated 12/3/24, the OSR indicated .apixaban 5 mg tablet twice a day for supraventricular tachycardia . During an interview on 3/19/25 at 5:45 p.m. with the Minimum Data Set Nurse (MDSN), The MDSN stated Resident 47 did not have a care plan for apixaban. The MDSN stated it is important to have a care plan for apixaban, apixaban is an anticoagulant (medication that is used to prevent blood clots). The MDSN stated Resident 47 is at risk for bleeding. During a concurrent interview and record review on 3/21/25 at 4:35 p.m. with LVN 5, Resident 47's Care Plan, dated 3/19/25 and OSR, dated 12/3/24 were reviewed. LVN 7 stated the order for apixaban was started on 12/3/25. LVN 7 stated Resident 47's care plan for apixaban should have been entered sooner. LVN 7 stated care plans are important because it provides a form of communication to care for each resident. During an interview on 3/21/25 at 4:55 p.m. with the DON, The DON stated it is the expectation of the facility to document completely and timely. DON stated care plans are resident centered. During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, dated 09/13, the P&P indicated, .The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment .care plans are revised as information about the residents and residents' condition change .

Based on observation, interview, and record review the facility failed to ensure residents' food preferences for food brought in from the outside were met by warming food up when the facility microwave was removed from the resident food storage area and staff was instructed, they could no longer warm up food for residents. This failure resulted in residents' frustration and denial of food preferences not being warmed to acceptable temperatures for palatability. This failure resulted in residents not having the ability to warm up their frozen foods which lead to frustration and denial of food preferences not being warmed to acceptable temperatures for palatability. Findings: During a concurrent observation and interview on 3/17/25 at 11:33 a.m. with Resident 102 in Resident 102's room, a collection of canned and packaged food was on the top right side of Resident 102's counter. Resident 102 stated he has food brought in for evening snacks, or to eat if he did not want to eat what was on the menu from the kitchen. Resident 102 stated the Certified Nursing Assistant (CNA), would warm up the food for him. During an interview on 3/18/25 at 1:20 p.m. with Resident 102, Resident 102 stated he was no longer able to have his food warmed up and the facility microwave has been removed from the Resident Food Storage Room (RFSR). Resident 102 stated that he was frustrated and had spent a lot of his own money to buy food that he would normally eat at night at home. Resident 102 stated, . it is my right. Resident 102 stated this afternoon was the first time warming up the food from his room has been an issue since his admission on 3/26/24. During a review of Resident 102's Admission Record (AR) dated 3/20/25, the AC indicated Resident 102 was admitted on [DATE] with diagnosis of . Heart Failure (HF), Diabetes Mellitus (DM) Type II (body does not produce enough insulin or use it properly, leading to high blood sugar levels), Kidney Failure . During a review of Resident 102's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 102's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status on a scale of 015 [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 102 had no cognitive deficit. During an interview on 3/18/25 at 2:01 p.m. with Resident 47, Resident 47 stated the facility was violating her rights by not heating up the food her family brings her from home. Resident 47 stated that her family bought her food, and the staff refuse to heat it up. Resident 47 stated that staff used to heat up the food and now they no longer heat it for her, and she cannot eat the food frozen. Resident 47 stated this makes her feel upset During a review of Resident 47's Admission Record (AR) dated 3/19/25, the AR indicated, Resident 47 was initially admitted to the facility on [DATE] with diagnoses of heart failure ( a condition in which the heart is unable to pump sufficient blood to meet the body's needs), supraventricular tachycardia (abnormally fast heart rhythm) and morbid obesity (overweight-weight is more than 80 to 100 pounds above the ideal body weight). During a review of Resident 47's Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 1/9/25, the MDS section C indicated, .cognitive skills for daily decision-making score of 15 .cognitively intact . During an observation on 3/19/25 at 4:17 p.m. in the hall of the facility, Maintenance Assistant (MA), was observed removing the microwave from the resident food storage room and taking it down the hall to the Medical Records office. During a concurrent observation and interview on 3/19/25 at 5:26 p.m. with Certified Nursing Assistant (CNA) 3, in the resident food storage room, 11 frozen meals were noted in the resident freezer. CNA 3 stated, . residents are no longer able to have their food heated up as of approximately two weeks ago, the administration did not provide an explanation they just stated the staff was no longer able to warm up food for residents. The microwave was then removed from the resident food storage room . several residents have complained, but the facility has not come up with an alternative . During an interview on 3/21/25 at 1:54 p.m. with the Activities Director (AD), the AD stated, . the Administrator (ADM) told us to inform residents during the Resident Council Meeting on 3/6/25, staff will no longer be heating up food in the microwave. The residents were not happy but those were the instructions that were given . During an interview on 3/21/25 at 3:33 p.m. with the Registered Dietitian (RD), the RD stated she was not aware that staff was not warming up food for residents. The RD stated staff could have an in-service training regarding heating up food for residents or have a thermometer available to take the temperature of the food after it has been microwaved. The RD stated there were several options that the facility could look into to provide ways to heat up food for residents. During an interview on 3/21/25 at 5:26 p.m. with the Director of Staff Development (DSD), the DSD stated, the microwave was removed for resident safety. The CNA staff were not equipped with thermometers or trained on how to properly heat up food in the microwave. The facility did not come up with an alternate way to heat up food for residents. During an interview on 3/21/25 at 6:10 p.m. with the ADM, the ADM stated , . the reasons for stopping the staff from heating up resident food were, the time it takes for the staff to reheat the food, the staff are not trained to take the temperature of food, and there was not a thermometer or temperature log for staff to take the temperature of the food or log the temperatures . the facility needs to find a way to heat up food for residents .

48430 Based on observation, interview and record review, the facility failed to provide care in a manner that maintained dignity and respect for two of three sampled residents (Resident 25 and 47) when: 1.Resident 25's urinary catheter (flexible tube inserted into bladder to drain urine) bag was uncovered and visible to other residents and visitors. This failure had the potential to compromise Resident 25's dignity and privacy by exposing their foley catheter bag, leading to embarrassment or psychosocial harm. 2. A 20-minute time limit for morning Activities of Daily Living (ADL- tasks done on a daily basis to take care of your body, like bathing, brushing hair, brushing teeth, eating, and using the bathroom) care, for Resident 47, was implemented by using a timer, resulting in the resident feeling rushed and singled out. This failure resulted in the violation of resident 47's right to dignity leaving her feeling singled out by staff. Findings: 1. During a review of Resident 25's Admission Record (AR) dated 3/19/25, the AR indicated, Resident 25 was initially admitted to the facility on [DATE] with diagnoses of cystitis (inflammation of the bladder), displacement of nephrostomy catheter (nephrostomy tube [a tube that is put into the kidney to drain urine directly from the kidney] tip positioned outside the renal collecting system [a series of tubules and ducts in the kidneys where urine flows and drains], diabetes mellitus (condition that happens when your blood sugar is too high), urinary tract infection (an infection in any part of the urinary system), presence of urogenital implants (artificial material in the urinary organs or genitals), obstructive and reflux uropathy (obstructive and reflux uropathy,), and calculus of kidney (kidney stones). During a review of Resident 25's Order Summary Report (OSR) dated 3/21/25, the OSR indicated, .change foley q (every) 3 weeks .enhanced barrier precautions r/t (related to) nephrostomy tube .foley catheter output every shift for foley . During a review of Resident 25's Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 12/12/24, the MDS section C indicated, .cognitive skills for daily decision-making score of 3 .severely impaired . During an observation on 3/17/25 at 11:46 a.m. in Resident 25's room, Resident 25's foley catheter was not covered by a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible). During a concurrent observation and interview on 3/19/25 at 11:55 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 25's room, Resident 25's foley was not covered with a dignity bag. LVN 1 concurred, the foley catheter did not have a dignity bag. LVN 1 stated, the foley catheter drainage bag should have been covered. During an interview on 3/19/25 at 3:35 p.m. with the Director of Nursing (DON), the DON stated, she expected Resident 25's foley catheter bag to be covered with a dignity bag. The DON stated, a dignity bag always needed to cover the foley catheter bag. The DON stated, not having a dignity bag violated dignity, privacy, and HIPPA (Health Insurance Portability and Accountability Act- establishes federal standards protecting sensitive health information from disclosure without patient's consent) regulations. The DON stated, the dignity bag needed to be provided so other residents would not know Resident 25's condition. During a review Resident 25's Care Plan (CP) dated 12/30/24, the CP indicated, .[Resident 25] has a Foley catheter r/t (related to) calculus of kidney (kidney stone), obstructive uropath, (blocking of urine by an object such as a kidney stone) [Resident 25] is at risk for infection . During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 02/21, the P&P indicated, .Residents are treated with dignity and respect at all times .Staff protect confidential clinical information .signs indicating the resident's clinical status or care needs are not openly posted .promote, maintain, and protect resident privacy . 2. During a review of Resident 47's Admission Record (AR) dated 3/19/25, the AR indicated, Resident 47 was initially admitted to the facility on [DATE] with diagnoses of heart failure ( a condition in which the heart is unable to pump sufficient blood to meet the body's needs), supraventricular tachycardia (abnormally fast heart rhythm) and morbid obesity (overweight-weight is more than 80 to 100 pounds above the ideal body weight). During a review of Resident 47's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/9/25, the MDS section C indicated Resident 47 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 47 was cognitively intact. During a concurrent observation and interview on 3/17/25 at 10:52 a.m. with Resident 47, in Resident 47's room, Resident 47 was observed seated in a wheelchair in front of the television, dressed, and applying makeup. During the observation, Resident 47 stated that the facility only allows her 20 minutes to receive morning care. During an interview on 3/18/25 at 2:54 p.m. with Resident 47's Family Member (FM), FM stated his frustration regarding the facility's use of a 20-minute timer to limit his mother's morning care. FM stated he felt his mother was being singled out, as no other resident in the facility was known to be subjected to a timed limit for morning care. During a review of Resident 47's Progress note, dated 3/3/25, the Progress note indicated, . Administrator ordered a timer on 2/26/25 to be used by staff to decrease extensive time spent with resident . resident was informed that the use of the timer was being implemented on 3/1/25 and that the timer would be set for 20 minutes for morning care. Resident expressed dissatisfaction . During a concurrent observation and interview on 3/19/25 at 9:34 a.m. with Certified Nursing Assistant (CNA) 2 in Resident 47's room, CNA 2 was providing morning care to Resident 47. CNA 2 stated Resident 47 will take up a lot of time, the use of the timer was implemented to set a limit of 20 minutes for Resident 47's morning care. During a concurrent interview and record review on 3/19/25 at 10:01 a.m. with the Licensed Vocational Nurse (LVN) 4, Resident 47's Progress Note dated 3/3/25 was reviewed, LVN 4 stated Resident 47's Progress note was created by the Interdisciplinary Team (IDT - collaborative group of individuals who work together to achieve a common goal. ) who developed the use of the timer to help staff manage the time spent with Resident 47. LVN 4 stated that no other resident in the facility is using a timer to manage time spent. LVN 4 acknowledged the use of a timer would make Resident 47 feel singled out. During an interview on 3/20/25 at 11:38 a.m. with the Director of Nursing (DON) stated, On, paper, this looks like the first attempt at time management, The DON acknowledged implementing a 20-minute timer for Resident 47's ADL care was an extreme first step. The DON stated best practice is to have all proper documentation in the resident's clinical record. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 02/21, the P&P indicated, .Residents are treated with dignity and respect at all times .Residents may exercise their rights without .discrimination or reprisal from any person or entity associated with this facility .signs indicating the resident's clinical status or care needs are not openly posted .Demeaning practices and standards of care that compromise dignity are prohibited . 51284

Based on observation, interview and record review, the facility failed to administer parenteral fluids (Parenteral fluids administered by injection through the tissue and circulatory system) in accordance with professional standards of practice for two of three sampled residents (Resident 421 and 422), when: 1. Resident 421 was admitted to the facility on [DATE] with a peripherally inserted central catheter (PICC, tube that is inserted into a vein in the upper arm to the heart) for the purposes of administering intravenous (IV - through the vein) antibiotics (medicines that fight bacterial infections). The facility did not have an approved policy and procedure that followed the standards of practice to instruct and guide nurses on the care of the PICC line. Two of Two Registered Nurses (RN [RN 1 and RN 4]) and the Assistant Director of Nursing (ADON) were not trained and did not follow the standards of practice in the care of the PICC line. 2. Resident 422 was admitted to the facility on [DATE]/25 and a midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm) was inserted on 03/20/25 for the purposes of administering intravenous antibiotics. The facility did not have an approved policy and procedure that followed the standards of practice to instruct and guide nurses on the care of the PICC line. Two of Two Registered Nurses (RN [RN 1 and RN 4]) and the Assistant Director of Nursing (ADON) were not trained and did not follow the standards of practice in the care of the Midline line. These failures had the potential to cause Resident 421 and Resident 422 to experience adverse outcomes such as life-threatening blood infection and an air emboli (a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system) due to nursing staff not having the knowledge, training, and competency to safely care for Resident 421 and Resident 422's PICC line and administer their IV antibiotics. Findings: 1. During a review of Resident 421's, Admission Records (AR) dated 3/20/25, the AR indicated Resident 421 was admitted to the facility on [DATE] with a primary diagnosis of late syphilitic oculopathy (an eye condition that can happen if syphilis isn't treated), type two diabetes mellitus (a condition where the body doesn't use insulin [a type of compound that regulates sugar levels in the blood] well and can't keep blood sugar at normal levels), epilepsy (brain disorder that causes recurring, unprovoked seizures [sudden, uncontrolled bursts of electrical activity in the brain that can cause temporary changes in behavior, consciousness, and body movements]), and essential hypertension (high blood pressure that is not due to another medical condition) During a review of Resident 421's Minimum Data Set (MDS-a standardized uniform comprehensive assessment of all residents) dated 3/11/25, the MDS indicated, Resident 421 had a BIMS (Brief Interview for Metal Status-a screening tool used to evaluate a person's cognitive [an individual's thinking, reasoning, and remembering process] ability) score of 15 (a BIMS score of 15 indicated Resident 421 had intact cognitive function). During a review of Resident 421's Order Summary Report (OSR) dated 3/20/25, the OSR indicated, .D/C (discontinue) PICC line after IV (intravenous-in the vein) Antibiotic (medicine to treat bacterial infection) therapy is completed . During a concurrent observation and interview on 3/17/25 at 3:30 p.m., with Resident 421 in his room, Resident 421 had a PICC line on his right upper arm. Resident 421 stated he was here for short term antibiotic therapy for an eye infection. During a concurrent observation and interview on 3/20/25 at 10:27 a.m. with Resident 421 in the facility's lobby, Resident 421 was sitting on a chair waiting for his ride to pick him up. Resident 421's PICC line was removed, and a brown band-aid covered the site where the PICC line had been removed. Resident 421 stated, Registered Nurse (RN) 1 removed his PICC line about 30 to 40 minutes ago and only put a band-aid to cover the site. Resident 421 stated RN 1 did not tell him to lay flat after the PICC line was removed. Resident 421 stated RN 1 did not provide instructions for post PICC line removal. During an interview on 3/20/25 at 10:38 a.m. with the Infection Preventionist (IP), the IP stated she was familiar with what a PICC and Midline were but was not responsible for the care and maintenance for PICC or Midlines. The IP stated, only RNs were allowed to provide care for patients with PICCs and Midlines. The IP stated, RNs must be trained on PICCs and Midlines by their preceptor (a teacher, or someone who trains people how to do a job) before being allowed to provide care and maintenance for PICCs and Midlines. During a phone interview on 3/20/25 at 11:02 a.m. with the Third-Party Vendor Chief Nursing Officer (TPVCNO), the TPVCNO stated the RN should have applied an occlusive dressing (an air and water tight dressing [a piece of material such as a pad applied to a wound]) consisting of petroleum-infused (mixed and saturated[full of]) 2x2 (two inches by two inches-unit of measure indicating size) gauze (a type of cotton cloth used for covering and protecting wounds) covered with a tegaderm (a thin clear sterile dressing that keeps out water, dirt and germs) to seal the site. The TPVCNO stated, the RN should have instructed the resident to remain flat for at least 30 minutes and provided post-removal instructions. The TPVCNO stated, the RN should have informed the resident to keep the dressing on for at least 24 hours. During an interview on 3/20/25 at 11:37 a.m. with the Minimum Data Set Registered Nurse (MDSRN), the MDSRN stated, Resident 421 was in the facility for short term antibiotics and was admitted from [acute care hospital name] with a PICC line on his right arm. The MDSRN stated, RNs were responsible in the care and management of central lines such as PICCs. The MDSRN stated new RNs were paired with experienced RNs to provide their central line management training. The MDSRN stated, there are no official training materials on paper and all training regarding PICCs were verbal in nature. The MDSRN stated, nurses who were not trained in PICC line management should not be allowed to provide care for residents with PICCs, Midlines or any other central lines. The MDSRN stated when a PICC line was removed, pressure and an occlusive dressing was needed to cover the site. The MDSRN stated, RN 1 should not have used a band aid to cover Resident 421's PICC line site.The MDSRN stated this was an incorrect practice and could have caused an air emboli to Resident 421 potentially leading to his death. The MDSRN stated, That's wrong .I've never put a band aid . The MDSRN stated RN 1 did not follow the correct procedure when she removed Resident 421' s PICC line. MDSRN stated RN 1 needed more training. During a concurrent interview and record review on 3/20/25 at 12:18 p.m. with RN 1, RN 1's LVN (Licensed Vocational Nurse)/RN Skills List Orientation (SLO) dated 2/28/25 was reviewed. The SLO indicated, no signatures were present from RN 2 that indicated RN 1 completed the training for .IV/Hydration therapy/antibiotic therapy . RN 1 stated she was trained by RN 2. RN 1 stated RN 2 was her preceptor and was responsible for training her in how to manage PICC lines. RN 1 stated, .there isn't training regarding central line care . RN 1 stated RN 2 should have signed the IV/Hydration therapy/antibiotic therapy as soon as she completed the training. RN 1 stated she was trained by the ADON to change PICC dressings but had to resort back to educational materials from nursing school to familiarize herself with removing a PICC line. RN 1 stated she thought residents should remain laying down for at least two minutes after a PICC was removed. RN 1 stated, .I think the normal is 2-5 minutes . RN 1 stated she made a guess on how long Resident 421 should have laid flat. RN 1 stated no one ever told her how long a resident should have laid flat. RN 1 stated when she removed Resident 421's PICC line, she used a band aid to cover the site. RN 1 stated she should have used an occlusive dressing. RN 1 stated a band aid could have potentially caused an air emboli to develop and could have resulted in Resident 421's death. During a concurrent interview and record review 3/20/25 at 12:48 p.m. with the Assistant Director of Nursing (ADON), RN 1's SLO dated 2/28/25 was reviewed. The SLO stated no signatures were present from RN 2 that indicated RN 1 completed the training for .IV/Hydration therapy/antibiotic therapy . The ADON stated the SLO was not signed by RN 2. The ADON stated she did not see any trainings that were specific to central line care and management. During an interview on 3/21/25 at 5:16 p.m. with the ADON, the ADON stated nurses had been insufficiently trained to care for residents receiving parenteral fluids in central lines and central line care and management. The ADON stated she had not received formal training in central line care and management from the facility. The ADON stated she had relied on her past job experiences to determine her own job competency in caring for residents with central lines and managing parenteral fluid administration. The ADON stated nurses should have been educated, trained, and required to perform a return demonstration to determine their competencies in the care and management of central lines. The ADON stated nurses should not have been assigned to residents with PICCs or central lines if they were not competent. During an interview on 3/21/25 at 5:38 p.m. with the Director of Nursing (DON), the DON stated the facility was not obligated (forced to) offer IV therapy services (a way to give fluids, medicine, nutrition, or blood directly into the bloodstream though a vein [blood vessels located throughout the body] using a central line such as a PICC or midline). The DON stated nurses needed to be competent in central line management. The DON stated nurses should have received trainings from the ADON or DON and completed a return demonstration to determine their competency. The DON stated inadequate training in managing and administering medications through central lines could potentially harm residents, leading to complications such as blood infections or air embolisms, which could have resulted in death. During a review of the facility's policy and procedure (P&P) titled, General Policies For IV Therapy dated 06/18, the P&P indicated, .Only an RN or IV Certified LVN may start intravenous infusion or administer approved IV solutions . During a review of the facility's P&P titled, PICC Removal dated 06/18, the P&P indicated, .to be performed by .RNs according to state law and facility policy .equipment .transparent dressing .sterile gloves .sterile gauze .antimicrobial solution .sterile tape .measuring tape .mask .don clean gloves assess the catheter site for evidence of local complication .remove the tape and dressing .done sterile gloves .apply pressure with sterile gauze until the bleeding stops .secure with sterile occlusive dressing .monitor resident for signs/symptoms of embolism .resident teaching . During a review of the facility's P&P titled, Nursing Personnel Education and Training dated 11/16, the P&P indicated, .nursing personnel education and competency validation is conducted to promote the provision of care and services consistent with professional standards of practice .Competency .means validating acceptable performance and knowledge associated with required skill .care competencies are determined through evaluation of center specific trends, resident populations served, and individual performance evaluation .education provided to new employees .provided as part of orientation and scheduled annually, includes .infection control .state and federal required education . During a review of the Journal of Infusion Nursing The Official Publication of the Infusion Nurses Society Infusion Therapy Standards of Practice, dated January/February 2016, indicated, . Standard 1.1 The Infusion Therapy Standards of Practice is applicable to any patient care setting in which vascular access devices (VADs) [a sterile tube that provides access to your veins for the delivery of intravenous (in the vein) medication such as a PICC (Peripherally inserted central catheter- external device placed in upper arm) line] are placed and/or managed and where infusion therapies are administered. 1.2 Infusion therapy is provided in accordance with laws, rules and regulations . federal and state regulatory and accrediting bodies . 1.3 Infusion therapy practice is established in organizational policies, procedures, practice guidelines, and/or standardized written protocols/orders . 3. SCOPE OF PRACTICE .Practice Criteria . D. Nursing Personnel . 5. Registered Nurse (RN) a. Complete an organized educational program on infusion therapy due to the lack and/or inconsistency of infusion therapy in basic nursing criteria . b. Do not accept assignments and tasks when one . is inadequately prepared to perform the assignment or task . d. Delegate tasks, activities, and components of care after determination of competency to perform the specific task . f. Use critical thinking and nursing judgement to apply the Five Rights of Delegation . 4. INFUSION TEAM . A. Assign vascular access device (VAD) . management and surveillance only to individuals and or teams with infusion therapy education, training, and validated competency . 5. COMPETENCY ASSESSMENT AND VALIDATION Standard . 5.2 The clinician is responsible and accountable for attaining and maintaining competence with infusion therapy administration . 5.3 Competency assessment and validation is performed initially and on an ongoing basis. 5.4 Competency validation is documented in accordance with organizational policy . C. Validate clinician competency by documenting the knowledge, skills, behaviors, and ability to perform the assigned job. 1. Validate initial competency before providing patient care . when the scope of practice changes, and with the introduction of new procedures, equipment, or technology. 2. Validate continuing competency on an ongoing periodic basis . 10. DOCUMENTATION IN THE MEDICAL RECORD Standard 10.1 Clinicians document their initial and ongoing assessments . 10.2 Documentation contains accurate, complete, chronological, and objective information in the patient's medical record regarding the patient's infusion therapy and vascular access with the clinician's name, licensure or credential to practice, date, and time. 10.3 Documentation is legible, timely, accessible to authorized personnel, and efficiently retrievable. 10.4 Documentation reflects the continuity, quality, and safety of care . Practice Criteria A. Documentation includes . 1. Patient . responses to therapy, interventions, and education. 2. Specific site preparation, infection prevention, and safety precautions taken, using a standardized tool for documenting . 3. The type, length, and gauge/size of the vascular access device (VAD) inserted . date and time inserted . 6. peripherally inserted central catheters (PICCs): a. External catheter length and length of catheter inserted. b. Arm circumference: before insertion of a PICC and when clinically indicated to assess the presence of edema [swelling] and possible deep vein thrombosis [DVT-blood clot] . 7. Condition of site, dressing, type of catheter stabilization, dressing change, site care, patient report of discomfort or any pain with each regular assessment of the access site, and patient report of changes related to the VAD or access site. 9. condition of the . access site prior to and after infusion therapy. 10. Results of VAD functionality assessment including patency, absence of signs and symptoms of complications, lack of resistance when flushing, and presence of a blood return upon aspiration. 41. VASCULAR ACCESS DEVICE (VAD) ASSESSMENT, CARE AND DRESSING CHANGES . H. Perform dressing changes . 1. Change transparent semipermeable membrane (TSM) dressings at least every 5 to 7 days and gauze dressing at least every 2 days . 4. Change the dressing . if dressing becomes loose/dislodges . 2. During a review of Resident 422's AR dated 3/21/25, the AR indicated Resident 422 was admitted to the facility on [DATE] with a primary diagnosis of pneumonia, unspecified organism (a disease that causes inflammation and fluid in the lungs caused by an unidentified organism), end stage renal disease (ESRD- a disease, your kidneys no longer work as they should) anemia in chronic kidney disease (a condition where there is not enough red blood cells due to malfunctioning kidneys), and chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys). During a review of Resident 422's MDS dated [DATE], the MDS indicated, Resident 422 had a BIMS score of 15 which indicated Resident 422 had intact cognitive function. During a review of Resident 422's OSR dated 3/21/25, the OSR indicated, .Enhanced Barrier Precautions (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms) .wound/IV atb (antibiotics) .may insert midline .midline dressing to right upper arm .order date . 03/20/2025 .change dressing every 7 days or prn (whenever necessary) .Midline IV Flush Protocol (manual injection of 0.9% (concentration) 5 ml (milliliter-a unit of measure) daily .Ceftazidime (an antibiotic) 1G (gram-a unit of measure) for 30 days . During a concurrent observation and interview on 3/20/25 at 4:55 p.m. with LVN 9 in Resident 422's room, Resident's midline dressing was saturated with blood. LVN 9 stated the dressing was dirty, bloody, and needed to be changed. LVN 9 stated the central line dressing needed to be clean or there was potential for infections to occur. LVN 9 stated RNs were responsible for managing central line care. During a concurrent observation and interview on 3/20/25 at 5:04 p.m. with the ADON, the ADON changed Resident 422's dirty bloody dressing. Resident 422 did not wear a face mask, the uncovered midline actively bled from the insertion site, and the line lay on the bed linens without a sterile barrier between the midline and the linens. The midline's length measured 17 cm (centimeter-a unit of measure). The ADON stated Resident 422 should have worn a mask during the dressing change. The ADON stated the uncovered midline touched the bed linen and was not sterile. The ADON stated she had initially measured the midline at 10cm. The ADON sated the midline was no longer in the proper placement and had to be removed. The ADON admitted to making multiple errors during the procedure which included, not putting a face mask on Resident 422, allowing the midline to touch the nonsterile linens and generally failed to follow appropriate sterile technique (use of practices that restrict microorganisms in the environment and prevent contamination of the procedural area). The ADON stated it was important to follow sterile technique while changing central line dressings so bacteria would not be introduced into the central line which leads directly into the heart, and potentially could have resulted in a life-threatening blood infection. During an interview on 3/21/25 at 8:24 a.m. with RN 1, RN 1 stated she served as the RN for Resident 422 that day and had to be retrained in central line management, including care for his midline, by the DON that morning. RN 1 stated the DON validated her training, and RN 4 provided the retraining for central line management. RN 1 sated she had to explain the procedure and perform a return demonstration to validate her competencies. During an interview on 3/21/25 at 9:13 a.m. with RN 4, RN 4 stated she retrained RN 1 in the central line management this morning. RN 4 stated nurses needed to be competent in central line management before being assigned to care for those residents. RN 4 stated she rarely encountered residents with central lines. RN 4 stated she was unaware of proper positioning for a resident during central line removal. RN 4 stated she was unsure how long a resident had to remain flat after central line removal and estimated about 15 minutes. RN 4 stated inadequate training or competency in dressing change or central line removal could have led to adverse consequences such as infections and air embolisms, both of which could have resulted in death. RN 4 stated her own knowledge in central line management was insufficient and needed to be re-enforced to assure competency. During an interview on 3/21/25 at 11:23 a.m. with the IP, the IP stated the expectation was nurses had to verbalize and had to provide a return demonstration for the trainings they have received to be considered competent. During an interview on 3/21/25 at 5:16 p.m. with the ADON, the ADON stated nurses had been insufficiently trained to care for residents receiving parenteral fluids in central lines and central line care and management. The ADON stated she had not received formal training in central line care and management from the facility. The ADON stated she had relied on her past job experiences to determine her own job competency in caring for residents with central lines and managing parenteral fluid administration. The ADON stated nurses should have been educated, trained, and required to perform a return demonstration to determine their competencies in the care and management of central lines. The ADON stated nurses should not have been assigned to care for residents with PICCs or central lines if they were not competent. During an interview on 3/21/25 at 5:38 p.m. with the Director of Nursing (DON), the DON stated the facility was not obligated (forced to) offer IV therapy services (a way to give fluids, medicine, nutrition, or blood directly into the bloodstream though a vein [blood vessels located throughout the body] using a central line such as a PICC or midline). The DON stated, nurses needed to be competent in central line management. The DON stated nurses should have received trainings from the ADON or DON and completed a return demonstration to determine their competency. The DON stated inadequate training in managing and administering medications through central lines could potentially harm residents, leading to complications such as blood infections or air embolisms, which could have resulted in death. The DON stated sterile technique was supposed to be followed during central line dressing changes. The DON stated if the procedure was not sterile, there was a potential for bacteria and other pathogens to be introduced to the central line which led directly into the heart and could have caused a life-threatening blood infection ultimately leading to death. During a review of the facility's P&P titled, PICC Dressing Change dated 06/18, the P&P indicated, .dressing changes using transparent dressings are performed .if the integrity of the dressing has been compromised (wet, lose or soiled) .equipment .clean gloves .antimicrobial disc .hand sanitizer .mask .antimicrobial solution .label, sterile gauze and tape .transparent dressing .sterile gloves .securement device .measuring tape .procedure .don sterile gloves . During a review of the facility's P&P titled, PICC Removal dated 06/18, the P&P indicated, .to be performed by .RNs according to state law and facility policy .equipment .transparent dressing .sterile gloves .sterile gauze .antimicrobial solution .sterile tape .measuring tape .mask .don clean gloves assess the catheter site for evidence of local complication .remove the tape and dressing .done sterile gloves .apply pressure with sterile gauze until the bleeding stops .secure with sterile occlusive dressing .monitor resident for signs/symptoms of embolism .resident teaching . During a review of the Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf, dated October 2017, indicated, 1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site 2. If the patient is diaphoretic (sweating heavily) or if the site is bleeding or oozing, use a gauze dressing until this is resolved. 3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. 4. Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance. 5. Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower). 6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings. 7. Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. 8. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed 14. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. 15. Encourage patients to report any changes in their catheter site or any new discomfort to their provider. During a review of the Journal of Infusion Nursing The Official Publication of the Infusion Nurses Society Infusion Therapy Standards of Practice, dated January/February 2016, indicated, . Standard 1.1 The Infusion Therapy Standards of Practice is applicable to any patient care setting in which vascular access devices (VADs) [a sterile tube that provides access to your veins for the delivery of intravenous (in the vein) medication such as a PICC (Peripherally inserted central catheter- external device placed in upper arm) line] are placed and/or managed and where infusion therapies are administered. 1.2 Infusion therapy is provided in accordance with laws, rules and regulations . federal and state regulatory and accrediting bodies . 1.3 Infusion therapy practice is established in organizational policies, procedures, practice guidelines, and/or standardized written protocols/orders . 3. SCOPE OF PRACTICE .Practice Criteria . D. Nursing Personnel . 5. Registered Nurse (RN) a. Complete an organized educational program on infusion therapy due to the lack and/or inconsistency of infusion therapy in basic nursing criteria . b. Do not accept assignments and tasks when one . is inadequately prepared to perform the assignment or task . d. Delegate tasks, activities, and components of care after determination of competency to perform the specific task . f. Use critical thinking and nursing judgement to apply the Five Rights of Delegation . 4. INFUSION TEAM . A. Assign vascular access device (VAD) . management and surveillance only to individuals and or teams with infusion therapy education, training, and validated competency . 5. COMPETENCY ASSESSMENT AND VALIDATION Standard . 5.2 The clinician is responsible and accountable for attaining and maintaining competence with infusion therapy administration . 5.3 Competency assessment and validation is performed initially and on an ongoing basis. 5.4 Competency validation is documented in accordance with organizational policy . C. Validate clinician competency by documenting the knowledge, skills, behaviors, and ability to perform the assigned job. 1. Validate initial competency before providing patient care . when the scope of practice changes, and with the introduction of new procedures, equipment, or technology. 2. Validate continuing competency on an ongoing periodic basis . 10. DOCUMENTATION IN THE MEDICAL RECORD Standard 10.1 Clinicians document their initial and ongoing assessments . 10.2 Documentation contains accurate, complete, chronological, and objective information in the patient's medical record regarding the patient's infusion therapy and vascular access with the clinician's name, licensure or credential to practice, date, and time. 10.3 Documentation is legible, timely, accessible to authorized personnel, and efficiently retrievable. 10.4 Documentation reflects the continuity, quality, and safety of care . Practice Criteria A. Documentation includes . 1. Patient . responses to therapy, interventions, and education. 2. Specific site preparation, infection prevention, and safety precautions taken, using a standardized tool for documenting . 3. The type, length, and gauge/size of the vascular access device (VAD) inserted . date and time inserted . 6. peripherally inserted central catheters (PICCs): a. External catheter length and length of catheter inserted. b. Arm circumference: before insertion of a PICC and when clinically indicated to assess the presence of edema [swelling] and possible deep vein thrombosis [DVT-blood clot] . 7. Condition of site, dressing, type of catheter stabilization, dressing change, site care, patient report of discomfort or any pain with each regular assessment of the access site, and patient report of changes related to the VAD or access site. 9. condition of the . access site prior to and after infusion therapy. 10. Results of VAD functionality assessment including patency, absence of signs and symptoms of complications, lack of resistance when flushing, and presence of a blood return upon aspiration. 41. VASCULAR ACCESS DEVICE (VAD) ASSESSMENT, CARE AND DRESSING CHANGES . H. Perform dressing changes . 1. Change transparent semipermeable membrane (TSM) dressings at least every 5 to 7 days and gauze dressing at least every 2 days . 4. Change the dressing . if dressing becomes loose/dislodges .

Based on interview and record review, the facility failed to implement a significant change of condition for Resident 42 when the resident was admitted to the facility on [DATE], was unable to make her needs known and be her own responsible party (RP- health care decision maker) Resident experienced a major improvement in mentation on 3/3/25 and no significant change of condition was completed. This failure had the potential to result in a lack of further improvement for Resident 72 when there were no updates in plan of care to reflect the change in mentation. Findings: During a record review of Resident 72's Admission Record (AR) dated 3/20/25, the AR indicated Resident 72 was admitted into the facility on [DATE]. The AR indicated, .Diagnosis Information . Cerebral Infarction (medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue) . metabolic encephalopathy (condition where brain ' s function is impaired due to an imbalance in the body ' s metabolism) . bipolar disorder . During a record review of Resident 72's Minimum Data Set (MDS - define) section C (cognitive patterns) dated 2/24/25, the MDS section C indicated, . C0100 .0. No (resident is rarely/never understood) . No BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was conducted at this time due to resident scoring a zero in section C0100. During a review of IDT [Interdisciplinary Team] Note dated 3/3/25, the IDT [Interdisciplinary Team] Note indicated, .Resident has a BIMS score of 99 as of 2/24/2025 . resident speaks but it is challenging to understand what she is trying to say . During a review of Social Services Discharge/Preparation Note dated 2/19/25, the Social Services Discharge/Preparation Note indicated, .Welcome Conference held with resident on 2/18/2025, brother and family at bedside. Resident was able to communicate in a limited manner with impaired speech. Resident was able to use a pad of paper and pen to communicate yes and no to some questions. Resident became agitated [related to] difficultly communicating . During a review of Social Services Follow Up Note dated 3/4/2025, the Social Services Follow Up Note indicated, . [Social Services Director] completed a new BIMS assessment due to change in condition, and resident scored a BIMS of 15 [score between 13 to 15 suggests the individual has intact cognitive function]. Writer performed a SLUMS [St. Louis University Mental Status - examination for detecting mild cognitive impairment and dementia] examination with resident, and the resident had a score of 18, which is indicative of dementia [a progressive state of decline in mental abilities] per the scoring guide . During a concurrent interview and record review on 3/20/25 at 4:57 p.m. with the Minimum Data Set (MDS) Coordinator, Resident 72 ' s Social Services Follow up Note dated 3/4/25 was reviewed. The Social Services Follow up Note indicated, . [Social Services Director] completed a new BIMS assessment due to change in condition, and resident scored a BIMS of 15 . The MDS Coordinator was unable to locate a BIMS assessment and a change of condition following this social services visit. The MDS Coordinator stated this change in BIMS can be considered a change of condition. During an interview on 3/21/25 at 2:00 p.m. with the MDS Coordinator, the MDS coordinator stated no formal IDT meeting for change of condition was done for this resident following the social services director's new BIMS scoring of 15. The MDS Coordinator stated, We probably just failed and sounds like we need to do a change of condition for her. During an interview on 3/21/25 at 2:18 p.m. with the Social Services Director (SSD), the SSD stated the IDT should have met on 3/4/25 to discuss the multiple changes in Resident 72's behavior and change in mentation from a BIMS of 99 to a BIMS of 15 and that should have been enough to trigger a change in condition. During an interview on 3/21/25 at 3:46 p.m. with the Director of Nursing (DON), the DON stated it would have been important to conduct a change of condition for Resident 72's change of BIMS from 99 to 15. The DON stated it is important to do a change of condition so new care plan interventions can be implemented to improve the resident's health. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2/2001, the P&P indicated, .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease relation clinical interventions (it is not self-limiting ); . d. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residents medical/mental condition or status .

Based on interview and record review the facility failed to provide adequate supervision (observation, oversight, and guidance of the individual by staff close enough to intervene and protect from harm) to prevent accidents for one of three sampled residents (Resident 1), when the facility failed to develop effective interventions for falls which occurred on 7/1/23, 7/4/23 and 7/8/23. These failures resulted in Resident 1 experiencing another fall on 7/8/23 with injuries of an Intracerebral Hemorrhage (bleeding inside the brain), right zygomatic (bones on upper side of the face that forms the cheek and part of the eye socket) fracture and right clavicle (collarbone) fracture along with pain and hospitalization . Findings: During a review of Resident 1's Admission Record (AR), dated 7/18/23, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included Dementia (loss of cognitive functioning, thinking remembering, and reasoning), Muscle Weakness, Difficulty in Walking and Other Specified Disorders of Bone Density and Structure (disease of the bone). During a review of Resident 1's Minimum Data Set (MDS), dated [DATE], the MDS Section C indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 2 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact). During a concurrent observation and interview on 7/18/23, at 4:05 p.m., with Resident 1, in Resident 1's room, Resident 1 was lying in bed with a purple bruise on the area below her right eye, on the right temple and right forehead. Resident 1 stated, she had fallen twice at the facility. Resident 1 stated, she was attempting to straighten a curtain, lost her balance and fell on to her back. Resident 1 stated, she thought she went to the hospital. Resident 1 stated, she had broken bones in her shoulder. During a review of Resident 1's Progress Notes, dated 7/8/23, the Progress Notes indicated, . [10:16 p.m.] . A loud noise was heard from resident's room. Resident was found on the floor, by the foot of her bed, laying on her right side . During a review of Resident 1's acute hospital record, ED [Emergency Department] Physician Notes (EDPN), dated, 7/9/23, the EDPN indicated, Resident 1 was admitted to the acute hospital on 7/8/23 at 10:55 p.m. The EDPN indicated, Resident 1 was transferred from the facility to the Emergency Department (ED) of the acute hospital for a ground level fall with closed head injury. The EDPN indicated Resident 1 received an Electrocardiography (recording of the heart's electrical activity), Computerized tomography (CT) scan (a series of x-ray images taken from different angels) of the head and spine. Resident 1's EDPN indicated Resident 1 had diagnoses of Ground-level fall, Multiple facial fractures and Intracranial hemorrhage. During a review of Resident 1's acute hospital record, Diagnostic Radiology, dated 7/9/23, the Diagnostic Radiology indicated Resident 1 received an x-ray of the right shoulder for right shoulder injury and pain and was found to have an acute fracture of the right clavicle. During a review of Resident 1's acute hospital record, Admission [History and Physical] dated, 7/10/23, the Admission [History and Physical] indicated, Resident 1 was admitted to the acute hospital for Intracerebral hemorrhage, multiple fractures involving the right zygomatic arch temporal bone, and right clavicular fracture. The Admission [History and Physical], indicated Resident 1 had a sling applied for the right clavicular fracture. During an interview on 7/18/23, at 4:35 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 1 had a history of getting out of bed unassisted. CNA 1 stated, Resident 1 needed assistance when getting up and ambulating. CNA 1 stated, when Resident 1 was in her bed, she wanted to get up. CNA 1 stated, Resident 1 required constant (all the time/one on one) supervision. During a review of Resident 1's MDS, dated [DATE], the MDS Section G indicated, Resident 1 needed one-person physical assistance for transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), walking her in room and walking out of her room, and toilet use. During an interview on 7/18/23, at 4:42 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, I wouldn't say [Resident 1] was a fall risk prior to Resident 1's fall on 7/8/23. LVN 1 stated, she was working when Resident 1 fell in her room around 10 p.m. LVN 1 stated, Resident 1 complained of pain to her back and right ankle after the fall. LVN 1 stated, Resident 1 had injuries of the clavicle and orbital fracture from the fall on 7/8/23. LVN 1 stated, Resident 1 had a history of attempting to get up on her own. LVN 1 stated, Resident 1 needed 1 person assistance when getting up. During a review of Resident 1's Progress Notes, dated 7/8/23, the Progress Notes indicated, . A loud noise was heard from [Resident 1's] room. Resident was found on the floor, by the foot of her bed, laying on her right side . Resident [complained of] head pain, back pain and right ankle pain . [medical doctor] notified . Ordered for [patient] to be sent to ED further evaluation . During a review of Resident 1's Fall Risk Evaluation (FRE), dated 7/1/23, the FRE indicated, . [Resident 1] . Score: 19 . Category: High Risk . During a review of Resident 1's Progress Notes, dated 7/1/23 at 1:17 a.m., the Progress Notes indicated, . [Resident 1] in [Resident 1's room], reports [complaint of] Resident had unwitnessed fall . These symptoms have occurred before . During a review of Resident 1's Progress Notes, dated 7/1/23 at 1:37 a.m., the Progress Notes indicated, . Type: Fall Note . Resident was heard yelling out for help. Upon entering room resident was noted to be sitting upright with back leaned against bed on floor. Resident stated she didn't know where she was heading to, just wanted to get up . During a review of Resident 1's Progress Notes, dated 7/4/23. The Progress Notes indicated, . [Resident 1] in [Resident 1's room] reports [complaint of] Resident had unwitnessed fall. [complaint] of pain to [left] shoulder / [left] cheek noted . During a review of Resident 1's Progress Notes, dated 7/5/23, the Progress Notes indicated, . Type: Fall Note . [7/4/23 11:30 p.m.] Resident was heard screaming out, a loud crash was heard. Upon entering room resident was found on ground at foot of bed . Resident stated she was trying to walk from bed to [wheelchair] when she lost balance and fell . During a review of Resident 1's FRE, dated 7/5/23, the FRE indicated, . [Resident 1] . Score: 18 . Category: Medium Risk . During an interview on 7/18/23, at 5:03 p.m., with the Director of Nursing (DON), the DON stated, everyone in the facility was at risk for falls. The DON stated, the facility had implemented a Falling Star Program for residents that were at higher risk for falls. The DON stated, residents on the Falling Star Program would get a blue armband to help staff identify which residents were at higher risk for falls. During an observation on 7/18/23, at 5:05 p.m., at South Nurses Station, Resident 1 was sitting up in a wheelchair eating dinner. Resident 1 did not have a blue armband on. During an interview on 7/21/23, at 12:27 p.m., with LVN 2, LVN 2 stated, residents on the Falling Star Program were at extra high risk for falls and should have an armband on. LVN 2 stated, the Falling Star program armband was the first thing staff looked for to identify high fall risk residents. LVN 2 stated, if a resident was on the Falling Star Program and was not wearing the armband then the Falling Star Program was not being followed. During an interview on 7/25/23, at 11:00 a.m., with LVN 3, LVN 3 stated, she was working at the facility when Resident 1 fell on [DATE]. LVN 3 stated, when Resident 1 fell on [DATE] she did not have any armband on. LVN 3 stated, she did not know what the Falling Star Program was. LVN 3 stated, she had not received education at the facility on the Falling Star Program. During a review of Resident 1's Care Plan, dated 7/3/23, the Care Plan indicated, . [Resident 1] had an actual witnessed fall . on 7/1/23 . Resident 1's Care Plan indicated, Resident 1's interventions were . Monitor/document/report PRN (as needed) x 72h (for 72 hours) to MD (medical doctor) for s/sx (signs and symptoms): Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation . Neuro (neurological) checks (assessing mental status and level of consciousness, pupil response, motor strength, sensation and gait) x 72 hours . Notify RP (responsible party) and MD of fall incident . placed on Falling Star Program . Resident 1's Care Plan indicated, the interventions were initiated on 7/3/23. During an interview on 7/25/23, at 1:45 p.m., with the DON, the DON stated, it was her expectation for staff caring for Resident 1 knew Resident 1 was a fall risk. The DON stated, it was important for staff to know Resident 1 was at risk for falls to prevent further falls and to monitor Resident 1 more frequently. The DON stated, the purpose of the Falling Star Program was to help staff identify which residents were at higher risk for falls. The DON stated, residents qualified for the Falling Star Program if they had more than 3 falls within 90 days or had a fall with injury. The DON stated, one of the ways staff identified residents were on the Falling Star Program was by the resident wearing a blue armband. The DON stated, Resident 1 had a new intervention of being placed on the Falling Star Program on 7/3/23 after she fell on [DATE]. The DON stated, Res 1 was not wearing the blue armband on 7/18/23. The DON stated, Resident 1 returned to the facility from the acute hospital on 7/12/23 after a fall on 7/8/23. DON stated, Resident 1 should have had the blue armband placed when she returned to the facility. The DON stated, it was her expectation that staff know what the Falling Star Program was. The DON stated, if staff did not know what the Falling Star program was, they would not know how to implement it. The DON stated, it was her expectation that a resident on the Falling Star Program would be wearing the blue armband. The DON stated, it was important for Resident 1 to be wearing the blue armband so staff could distinguish the resident as at higher risk for falling. The DON stated, if high fall risk resident was not wearing the blue armband there was a potential for staff not to monitor residents as often as needed. During an interview on 7/25/23, at 2:00 p.m., with the DON, the DON stated, Resident 1 had a new intervention to have a Physical Therapy (PT) and Occupational therapy (OT) evaluation after she fell on [DATE]. The DON stated, the process for the referral for the PT/OT evaluation normally took 2 to 3 days. The DON stated, the facility had not received a referral for PT/OT until 7/8/23. The DON stated, Resident 1 had a fall on 7/8/23 and was transferred to the acute hospital. The DON stated, Resident 1's PT/OT evaluation was not implemented until 7/14/23. The DON stated, a new intervention needed to be implemented every time a resident had a fall. The DON stated, the facility had the ability to provide 1:1 (one on one - constant observation by staff) monitoring which may have taken a couple of hours to arrange. The DON stated, the facility had the ability to provide resident monitoring Q (every) 15 minutes (a visual check of the residents whereabouts every 15 minutes) or monitoring Q 30 minutes which could be arranged in one hour. The DON stated, 1:1 monitoring, Q 15 minute monitoring and Q 30 minute monitoring could have been an appropriate intervention for Resident 1 who was continuing to fall. During a review of Resident 1's Care Plan, dated 7/5/23, the Care Plan indicated, . [Resident 1] had unwitnessed fall with c/o (complaint of) pain to left shoulder and left cheek on 7/4/23 . Resident 1's Care plan indicated Resident 1 had interventions for . Monitor/document / report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation . Notify RP and MD of fall incident . Refer to PT/OT for eval (evaluation) and screen . The Care Plan indicated, the interventions were initiated on 7/5/23. During a review of Resident 1's Medication Review Report (MRR), dated 7/18/23, the MRR indicated, on 7/12/23 Resident 1 had a doctor order for . Occupational therapy evaluation and treatment as indicated . and . Physical Therapy evaluation and treatment as indicated . During a review of Resident 1's Physical Therapy PT Evaluation & Plan of Treatment (PTEPT), dated 7/14/23, the PTEPT indicated, Resident 1 was evaluated for therapy starting on 7/14/23 through 9/10/23. The PTEPT was signed and dated on 7/14/23 by the Physical Therapist. The PTEPT indicated, . Diagnoses . hemorrhage of cerebrum . Zygomatic fracture . Plan of Treatment . Frequency: 5 time(s)/ week Duration: 6 week(s) . Focus of Plan of treatment = Restoration, Compensation, Adaptation . Reason for Referral / Current Illness: . decrease in functional mobility, decrease in strength and falls/fall risk . patient was sent out due to fall (Out of bed) . Precautions / Contraindications: Falls, dementia . During a review of Resident 1's Occupational Therapy OT Evaluation & Plan of Treatment (OTEPT) dated, 7/14/23, the OTEPT indicated, Resident 1 was evaluated for therapy starting on 7/14/23 through 9/10/23. The OTEPT was signed and dated on 7/14/23 by the Occupational Therapist. The OTEPT indicated, . Diagnoses . hemorrhage of cerebrum . Muscle weakness . Plan of Treatment . Frequency: 5 time(s)/week Duration: 8 week(s) . Focus Plan of Treatment = Restoration, Compensation, Adaptation . Reason for Referral / Current Illness: [Resident 1] is a resident of this facility with a [history] of falls and referred to skilled OT services secondary to recent decline in functional status related to an unwitnessed fall on 7/8/23 while attempting to self-transfer . Of note patient had prior fall on 7/4/23 . During an interview on 7/25/23, at 3:42 p.m., with LVN 3, LVN 3 stated, Resident 1 had a fall on 7/1/23, had another fall on 7/4/23, and had another fall on 7/8/23. LVN 3 stated, the interventions in place for Resident 1's fall on 7/1/23 and 7/4/23 were not working because Resident 1 continued to fall. LVN 3 stated, Resident 1 fell 10 minutes after she last saw her on 7/4/23. LVN 3 stated, the facility did not increase the amount of supervision Resident 1 required after fall on 7/1/23 or after fall on 7/4/23. LVN 3 stated, Resident 1 could not get up safely on her own and needed one person assistance. LVN 3 stated, Resident 1 would forget she needed assistance and get up and walk without assistance. LVN 3 stated, Resident 1 had injuries of a cerebral bleed and eye fracture from fall on 7/8/23. During a review of Resident 1's Care Plan, dated 7/8/23, the Care Plan indicated, . [Resident 1] had an unwitnessed fall with [complaint of] head pain, [fracture] of right clavicle, intracerebral hemorrhage, right zygomatic [fracture] . on 07/08/2023 . During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 6/23, the P&P indicated, Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Examples of initial approaches might include . balance training . If falling recurs despite initial interventions, staff will implement additional or different interventions . If underlying causes cannot be readily identified or corrected, staff will try various interventions . once a review is completed Resident may be placed on the Falling Star Program. The individuals that have three or more falls in 90 days or fall with injury will be automatically placed on the Falling Star Program . The Falling Star Program identifies high fall risk residents by Blue arm band . the facility can use the following interventions but not limited to these interventions for the resident. Falling matt, 1:1 (one to one supervision) . toileting program, placing resident on the falling star program or any other interventions that are resident centered . Monitoring Subsequent Falls and Fall Risk . The staff will monitor . each resident's response to interventions intended to reduce falling or the risks of falling .

Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) received adequate supervision and assistance with activities of daily living (ADL- term used in healthcare to refer to people's daily self-care activities such as grooming/personal hygiene, dressing, toileting/continence) care, when Resident 1 required two staff for ADL care per Resident 1's assessed need (care plan- direction on the type of nursing care the individual may need) and Nursing Assistant (NA) 1 turned Resident 1 in bed independently (without the assistance of another staff) on 7/2/21. This failure resulted in Resident 1 falling out of bed and onto the floor on 7/2/21. Resident 1 experienced bleeding from a [CONDITION(S)] (deep cut on the head), pain, required transportation to the acute care hospital for treatment and received nine staples (metal surgical fastener used to hold layers of tissue together) to Resident 1's head. Findings: During a review of Resident 1's Admission Record (document containing resident personal information), dated 7/7/21, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included .Pneumonia (a form of acute [sudden onset] respiratory infection that affects the lung) .Cerebral Infarction (damage to brain tissues from a lack of oxygen) .Severe protein-calorie malnutrition (inadequate intake of food) .muscle weakness (decrease in strength) . During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 6/18/21, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 2 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating severe cognitive deficit. During an interview on 7/7/21, at 1:21 p.m., with Resident 4 (roommate to Resident 1), Resident 4 stated, Last Friday [7/2/21] my roommate fell . I was laying here in bed and next thing I knew he was on the side of me on the floor. Resident 4 stated the curtain between their beds was closed because NA 1 was Cleaning him [Resident 1] up. Resident 4 stated two Certified Nursing Assistants (CNAs) usually provided care to Resident 1 but at the time of the fall, only NA 1 assisted Resident 1. Resident 4 stated when Resident 1 fell , NA 1 yelled for help and two nurses entered the room. During an interview on 7/7/21, at 1:37 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was the assigned nurse for Resident 1 on 7/2/21. LVN 1 stated she was at the South side nurse's station and heard NA 1 yell for help at the end of the hallway. LVN 1 stated she walked down the hall and entered Resident 1's room. LVN 1 stated Resident 1 was on the floor, positioned on his back, and in between two beds (Bed A [Resident 1's bed] and B [Resident 4's bed]). LVN 1 stated Resident 1 had a bleeding wound on the right side of his scalp (skin covering the head except the face), described as bright red blood. LVN 1 stated Resident 1 complained of being cold and in pain but was unable to verbalize exactly where the pain was located. LVN 1 stated Resident 1 was bedbound (unable to get out of bed independently), totally dependent for care (unable to meet own needs) and required two-person assistance for ADLs. During a concurrent interview and record review on 7/7/21, at 1:42 p.m., with LVN 1, Resident 1's care plan dated 6/12/21 was reviewed. Resident 1's ADL care plan indicated, Focus ADL self-care performance deficit (lack or impairment) r/t (related to) muscle weakness, PNA (pneumonia), cer[e][NAME] infarction . Interventions . Bed Mobility . The resident requires extensive assistance (not able to perform or complete the activity of daily living) on 2 staff for repositioning and turning in bed . LVN 1 stated Resident 1's care plan interventions populated from the care plan to the [name of system] (desktop file system that gives a brief overview of each patient) which the CNAs would review before providing care to the residents. LVN 1 stated NA 1 should have known Resident 1 required two staff members to provide care including turn Resident 1 in bed, when he opened the clinical record. LVN 1 stated Resident 1's fall was avoidable if NA 1 waited for a second person to assist with care. During a review of Resident 1's Nursing Note, dated 7/2/21 at 7:11 pm., the Nursing Note indicated, .This writer was alerted to residents @ (at) 1445 [2:45 p.m.] by CNA that resident had fell to the floor during resident ADL care. This writer entered the resident room and noted resident laying on back in between bed A and Bed B. Resident noted to have a laceration about 2 inches long on top of RT (right) side of scalp. Laceration noted to have active bright red blood coming from laceration . Resident bed noted to be at staff member-CNA waist level during fall d/t (due to) staff doing resident care. Obtained statement from the CNA that was doing the resident care . during rounds CNA noted the resident to be soiled and uncomfortable, CNA attempted to get help from other staff however unsuccessful d/t all other staff busy providing resident care to the other resident[s]. CNA then attempted to provide care alone for the resident. CNA was attempting to change an occupied bed d/t it being soiled. CNA rolled resident away from him and resident ended up rolling off the bed . Resident fell to the ground hitting resident head landing on resident back . As resident cont (continued) to lay on the floor while this writer applied pressure to laceration to top of head resident cont to state the resident was 'cold' & 'im in a lot of pain' . Resident transferred to ER (emergency room ) [name of acute care hospital] @ around 1500 [3:00 p.m.] by [name of ambulance service] via stretcher . During a telephone interview on 7/7/21, at 2:06 p.m., with NA 1, NA 1 stated he went through the Nursing Assistant program at the facility and was hired in the middle of May 2021. NA 1 stated he was not certified as a nursing assistant but was scheduled to take the exam the week of 7/12/21. NA 1 stated he was familiar with Resident 1. NA 1 stated he was aware Resident 1 required two staff members for ADL care, including turning in bed. NA 1 stated he worked the evening shift on 7/2/21. NA 1 stated when he performed rounds (an act of visiting each of a number of residents assigned to be cared for) at the beginning of the shift, Resident 1's bed was soaked. NA 1 stated Resident 1 had been incontinent (unable to control excretions) of bowel movement (BM-feces) in bed. NA 1 stated he turned Resident 1 toward him (NA 1) to clean Resident 1, and when he (NA 1) rolled Resident 1 away from him (NA 1) to remove the soiled linen, Resident 1 rolled off the bed and onto the floor. NA 1 stated Resident 1's bed was at his (NA 1) waist level and Resident 1 fell approximately three and a half feet from the bed onto the floor. NA 1 stated Resident 1 bled from his head after he landed on the ground. NA 1 stated he yelled for help and two nurses came into the room. NA 1 stated Resident 1 required extensive two-person for personal care. NA 1 stated he tried to perform extensive assistance alone because Resident 1 was uncomfortable, and he didn't want him to wait until he had help. NA 1 stated he thought he would be able to give Resident 1 care on his own. NA 1 stated I really shouldn't have given him care alone since we are supposed to use two [people]. During an interview on 7/7/21, at 4:20 p.m., with the Director of Staff Development (DSD), the DSD stated, the facility had its own Nursing Assistant program. The DSD stated NA 1 was a recent graduate of the program and was trained on the facility policies and procedures during school. The DSD stated the CNAs and Nursing Assistants (NAs) had the same training and job duties. The DSD stated the CNA and NAs were trained on the importance of following care plan interventions for resident safety during school and orientation. During a concurrent interview on 7/7/21, at 5:15 p.m., with the Administrator (ADM) and the Regional Nurse Consultant (RNC), the ADM stated Resident 1 fell on [DATE] while NA 1 provided care to him in bed. The RNC stated Resident 1 required two staff members for ADL care. The ADM stated NA 1 reported he looked for help and other staff were busy, so he (NA 1) attempted to change Resident 1 by himself. The ADM stated there was no reason for NA 1 to not wait for help with Resident 1's care. The RNC stated NA 1 reported Resident 1 was wet (soiled) and NA did not want to leave him like that while he waited for help. During a review of Resident 1's IDT (Interdisciplinary Team- group of health care professionals with various areas of expertise who work together toward the goals of their patient) Note (from the facility), dated 7/7/21 at 10:37 a.m., the IDT note indicated, .IDT reviewed witnessed fall that occurred on 7/2/21 . full body assessment completed with 2 inch laceration noted to top of right scalp .Laceration had noted active bright red blood coming from laceration . Resident's bed noted to be at waist height of [NA 1] . CNA [NA 1] reported . changing the resident in his bed and the resident's bedding. CNA [NA 1] rolled resident away from them [NA 1] and resident rolled off of the bed. CNA [NA 1] reported that residents head made contact with the floor. Nursing staff applied pressure to the laceration. Resident reported that he was feeling cold and that he was in a lot of pain .Resident is a fall risk r/t (related to) poor safety awareness . IDT identified the root cause of the fall as resident rolling out of bed during being changed . During a concurrent phone interview and record review on 8/17/21, at 3:30 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS Assessment, Section G (Function Status) dated 6/18/21 was reviewed. Resident 1's MDS Assessment, Section G indicated, .A. bed mobility-how resident moves to and from lying position, turns side to side, and positions body while in bed . code 3 (Two+ person physical assist) . B. Transfer- how resident moves between surfaces including to or from : bed, chair, wheelchair, standing position . code 3 . I. toilet use-how resident uses the toilet room, commode, bedpan or urinal . cleanses self after elimination; changes pad . code 3 . The MDSC stated the MDS assessment, Section G assessed Resident 1's ability to perform ADLs and the amount of assistance required. The MDSC stated code 3 for bed mobility, transfers and toilet use indicated Resident 1 required two or more persons assistance. The MDSC reviewed Resident 1's ADL care plan dated 6/12/21 and stated Resident 1 required extensive assistance from two staff members for repositioning and turning in bed. The MDSC stated NA 1 did not follow Resident 1's ADL care plan interventions and if a second person had assisted with Resident 1's care, the second person would have been present to prevent Resident 1 from rolling out of bed. The MDSC stated Resident 1's fall was preventable. During a review of Resident 1's ED (Emergency Department) Physician Notes from the acute care hospital (ACH), dated 7/2/21, at 5:08 p.m., the ED Physician Notes indicated, .Chief Complaint . Fall, Scalp laceration . (patient) is a long term resident of [name of facility] . Pt suffered a Fall while staff was cleaning him. Per EMS (emergency medical services- system that provides emergency medical care), there is a large laceration to the right side of the scalp, bleeding was controlled with a gauze (fabric used in bandages or dressing) dressing . History of Present Illness . [AGE] year old male is BIBA (brought in by ambulance) for a fall . He rates his pain a 6 out of 10 (0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) . Physical Exam . 7 cm (centimeter- unit of measurement) right temporal (temple area of the scalp) . Final Diagnosis . Acute head injury . Disposition . intent to admit .Condition . Guarded (serious and of uncertain outcome) . During a review of Resident 1's Laceration Repair Procedure *ED, from the ACH, dated 7/2/21, the Laceration Repair Procedure * ED indicated, .Procedure . Laceration repair . 7/2/21 17:30:00 [5:30 p.m.] . Description/repair . Laceration 7cm in length. Scalp: tight . Shape: irregular . Depth: multi-layer . Skin closure: #9 staples . During a review of Resident 1's Discharge Summary, from the ACH, dated 7/8/21, the Discharge Summary indicated, .Discharge Summary . DATE OF ADMISSION: 7/2/2021 . DATE OF DISCHARGE: 7/7/2021 . DISCHARGE/DEATH SUMMARY . IMMEDIATE CAUSE OF DEATH: 1. Acute Cardiorespiratory failure (abrupt loss of heart function, breathing and consciousness [the state of being awake and aware]) . 8. Fall with scalp laceration at the nursing home . During a review of the facility document titled Job Description, dated 6/2018, the Job Description indicated, Job title: Certified Nurse Assistant . Essential Job Functions . Perform the following according to policy and procedure . maintain residents' positioning, as needed . Ensure residents' comfort while assisting them in achieving their highest practicable level of functioning as follows: Assist residents with their activities of daily living . Safety . Comply with all company safety policies regulations and requirements involving employee safety and patient safety. This includes . following safe patient handling as required with your specific job position . Physical and sensory requirements . The employee must frequently lift . patients . following the patient care plan and using a variety of equipment, the employee may frequently move, reposition and transfer patients of varying weights . During a review of the facility's policy and procedure (P&P) titled, Quality of Care-Accident Hazards/Supervision/Devices, dated 7/2018, the P&P indicated, Purpose: To provide an environment that is free from controllable accident hazards and provision of supervision . prevent avoidable accidents . Guidelines . 1. The facility will develop a culture of safety and commit to implementing systems that address resident risk and environmental hazard to minimize the likelihood of accidents . 2. The facility recognizes the high-risk nature of the facility population . 6. Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks . 8. Individualized interventions will be developed to reduce the potential for accidents . 10.interventions will be consistent with professional standards . monitoring and modification process may include . 13. a.verifying that interventions are implemented as planned . 14. The facility may use supervision as an intervention to mitigate (reduce) accident risk . Falls . 3. The facility will initiate and implement a comprehensive, residents-centered fall prevention plan for residents at risk for falls or with a history of falls .

Based on observations, interviews and record review, the facility failed to provide care in accordance with professional standards of practice when: 1. One of twelve sampled residents (Resident 1) had a wound to his left foot (between the pinky and fourth toe) that was infested (the presence of an unusually large number of insects in a place, typically so as to cause damage or disease) with maggots (larva (an insect at the stage of its life after it has developed from an egg and before it changes into its adult form) of a fly). There was no wound assessment that included documentation of the wound appearance or wound size by licensed nurses on 10/16/20, one day prior to the infestation of maggots; and 2. Three of twelve sampled residents (Residents 2, 4, and 8) were not identified to be at high risk for possible infestation of maggots to their wounds. These failures resulted in Resident 1's left foot wound to be found infested with maggots on 10/17/20 and the potential for Residents 2, 4, 8's wounds to become infested with maggots. Because of the actual harm to Resident 1 and the potential harm to Residents 2, 4, 8, from not having interventions in place to prevent maggot infestation to their wounds, an Immediate Jeopardy (IJ) Situation was called on 10/26/20 at 4:15 p.m. with the facility Administrator (ADM) and Director of Nursing (DON) in the area of CFR (Code of Federal Regulations) 483.25 Quality of Care. The facility submitted an acceptable IJ Removal Plan on 10/28/20 at 11:19 a.m., to conduct assessments of all residents with wounds for maggots or infection, conduct licensed nurse training and education on wound management including performing dressing changes and wounds assessments, wound care documentation and monitoring, conduct environmental assessment of the facility to ensure all screens to windows and doors were closed, additional flytraps in the facility to minimize the number of flies in the facility, implement training and education regarding fly prevention, and address the potential risks flies cause to residents with wounds. The components of the IJ Removal Plan were validated through observations, interviews, and record review. The IJ situation was removed on 10/28/20 at 4:36 p.m. with the ADM and the DON. Findings: 1. During a review of Resident 1's Admission Records, dated 2/20/17, the Admission Records indicated, Resident 1 was admitted to the facility with a [DIAGNOSES REDACTED]. the arteries throughout the body, that can lead to decrease blood supply going to the legs and feet to help with wound healing). During a review of Resident 1's Minimum Data Set (MDS- an assessment of healthcare and functional needs) assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). The MDS section G indicated Resident 1 was totally dependent (requiring assistance) on staff members to transfer from one surface to another. During an observation on 10/22/20, at 11:10 a.m., in Resident 1's room, Resident 1 was lying in bed. Resident 1 had two wound dressings on his left foot, one on his heel and another between the pinky and fourth toe. During an interview on 10/22/20, at 11:13 a.m., with Resident 1, Resident 1 stated he had a wound to his left foot between his pinky and fourth toe. Resident 1 stated he bumped his toes prior to 10/17/20 (when the maggots were discovered). Resident 1 was unable to recall what he bumped his toes on. Resident 1 stated he did not know his left small toe was bleeding until Registered Nurse (RN) 1 informed him. Resident 1 stated RN 1 applied a band-aid (a sticking plaster used to cover wounds) on the wound located between his pinky and fourth toe. Resident 1 stated he had diabetes and had decreased sensation (feeling) to his feet. Resident 1 stated he did not know how often the band-aid needed to be changed. Resident 1 stated he had a shower on Saturday (10/17/20) and Certified Nursing Assistant (CNA) 1 informed Resident 1 there were maggots in the wound. Resident 1 stated Licensed Vocational Nurse (LVN) 1 cleaned his wound and removed the maggots. Resident 1 stated there were a lot of maggots in the wound. Resident 1 stated the facility tried to tell him he got the maggots from staying outside. Resident 1 stated he saw flies inside his room. Resident 1 stated, I guess the fly got inside it (wound between pink and fourth toe). During a review of Resident 1's Order Summary, dated 7/8/20, the Order Summary indicated, Indicate status of the skin surrounding vascular ulcer to (L) (left) heel . Assess for signs and symptoms of infection every shift. During a concurrent interview and record review, on 10/22/20, at 11:30 a.m., with LVN 1, LVN 1 stated she was the licensed nurse assigned to Resident 1 on the morning shift of 10/17/20. LVN 1 stated she did not receive report from the licensed nurse during change of shift handoff (report given during end of shift to the oncoming nurse) that Resident 1 had a wound located on his left foot between his pinky and fourth toe. LVN 1 stated she was not aware of Resident 1's wound between the pinky and fourth toe. LVN 1 stated Resident 1 had a shower on 10/17/20 and CNA 1 notified her Resident 1 had maggots in the wound on his left foot. LVN 1 stated she looked at Resident 1's left foot and saw maggots in the wound located between Resident 1's pinky and fourth toe. LVN 1 stated she notified Resident 1's physician and obtained an order to clean Resident 1's wound with normal saline (NS- a solution mixture of water and salt used to clean wounds) and remove the maggots. LVN 1 stated she carried out the order and removed the maggots from the wound. LVN 1 reviewed Resident 1's chart that contained progress notes, daily nursing assessments, and nursing care plan, and stated she was unable to find documentation regarding Resident 1's wound to his left foot between the pinky and fourth toe. LVN 1 stated the wound located between the pinky and fourth toe should have been assessed and documented, but it was not. During a review of Resident 1's Progress Notes, dated 10/17/20, the Progress Notes indicated, On call (Name of Physician) was called in regards to maggots on patient's feet. Dr. advised wound care to be done. No specific instructions given before dr (doctor). ended the call . patient stated he bumped his foot and had a Band-Aid put on. Patient spent a few hours outside with feet out in the open and believes that might have been when fly landed. Will continue to monitor foot throughout shift . During a review of Resident 1's Order Summary, dated 10/22/20, the Order Summary indicated, Vascular wound to 5th digit of L foot: cleanse with NS, pat dry, apply (brand name of medical grade honey) with calcium alginate (medication for wounds) (between 4th & 5th digits), wrap foot in kerlix (roll of gauze) . During an interview on 10/22/20, at 11:58 a.m., with CNA 1, CNA 1 stated she was the nursing assistant assigned to Resident 1 on 10/17/20 on the day shift. CNA 1 stated she gave Resident 1 a shower and saw maggots in Resident 1's wound that was located between the pinky and fourth toe. CNA 1 stated she notified LVN 1 right away. CNA 1 stated she did not receive report during shift change from the previous CNA if Resident 1 had a wound between his pinky toe and fourth toe. During an interview on 10/22/20, at 2:10 p.m., with RN 1, RN 1 stated she was the nurse assigned to Resident 1 on 10/15/20 on the night shift. RN 1 stated she did not perform a skin assessment on Resident 1, which would have included checking in between Resident 1's toes. During a concurrent observation and interview, on 10/22/20, at 2:21 p.m., with RN 2, in the south hallway, near the exit door, there was a window that had a window screen present. The window screen was not flush against the window, which left a gap between the window and the window screen. Flies were observed entering the building through the gap between the window and the window screen. RN 2 stated, .Yes those are flies RN 2 stated flies inside the building placed residents in the facility at an increased risk for wound maggot infestation. During an interview on 10/22/20, at 2:25 p.m., LVN 1 stated she had seen flies inside the breakroom. LVN 1 stated if flies were inside the building and residents had wounds, the flies could get into the wound bed and cause maggot infestation. During a concurrent observation and interview, on 10/22/20, at 2:30 p.m., with the DON, in the south hallway, near the exit door, the DON validated the window screen was not flush against the window, which caused a gap. Flies were observed entering the building through the gap. The DON stated, Those are flies. The DON went to the north hallway, near the exit doors, and observed a window that had a window screen present. The window screen was not flush against the window, which left a gap between the window and window screen. Resident 1 had access to the patio from his room via a sliding door that contained a door screen. The DON checked Resident 1's door screen. The door screen had a big hole on the screen. The DON stated she would notify maintenance to fix the door screen. During a concurrent observation and interview, on 10/26/20, at 11:25 a.m., with the Maintenance Supervisor/Director (MS), in Dining room [ROOM NUMBER], the flytrap attached to the wall was not functioning. The MS stated the activity staff moved their desk into Dining room [ROOM NUMBER] and unplugged the flytrap from the electrical outlet and used the electrical outlet to plug in their computer. The MS stated he was not aware the flytrap was unplugged in Dining room [ROOM NUMBER]. In the kitchen, the flytrap was not functioning. The MS validated the lights to the flytrap were not turned on, it was not functional. The MS stated he was not aware the flytrap in the kitchen was not functioning. The MS stated he did not know how long the flytraps had not been functioning. The MS stated he did not conduct routine checks in the facility to observe if flytraps were functioning properly. The MS stated he was not aware of the hole in Resident 1's screen door and gaps between the window and window screens on both south and north ends of the hallway until the ADM notified him on 10/22/20. The MS stated the screen doors were important to prevent flies from entering the building. During an interview on 10/26/20, at 1:30 p.m., with RN 3, RN 3 stated she was the licensed nurse assigned to Resident 1 the morning shift of 10/16/20. RN 3 stated when she performed the wound dressing to Resident 1's left heel, she did not assess Resident 1's foot for any new wounds. RN 3 stated she did not check in between Resident 1's toes. During an interview on 10/26/20, at 1:48 p.m., with the ADM, the ADM stated the last time the facility had someone come to the facility to perform Pest Control service was in February 2020, before COVID-19 (a contagious serious respiratory infection transmitted from person to person). The ADM stated the facility did not have a contract with Pest Control to monitor the flytraps to determine if the flytraps were properly functioning, and the facility did not delegate anyone in the facility to monitor the flytraps to ensure if it was functioning properly. During a review of the professional reference from the Centers for Disease Control and Prevention, retrieved on 11/19/20, https://www.cdc.gov/parasites/myiasis/faqs.html, titled, Myiasis (infection of a fly larva in human tissue) FAQs (a list of questions and answers relating to a particular subject, especially one giving basic information for users) dated 10/2020, the professional reference indicated, . Myiasis is infection with a fly larva . There are several ways for flies to transmit their larvae to people . Some flies deposit their larvae on or near a wound or sore, depositing eggs in sloughing-off dead tissue . How can I prevent infection with myiasis . Cover your skin to limit the area open to bites from flies . protect yourself by using window screens and mosquito nets . During a review of the professional reference from the American Society For Microbiology, retrieved on 11/19/20, https://cmr.asm.org/content/25/1/79, titled Myiasis FAQs, dated 2020, the professional reference indicated, . Wound myiasis occurs when fly larvae infest open wounds . Wound myiasis is most often initiated when flies oviposit (lay eggs) in necrotic (dead), hemorrhaging (bleeding), or pus-filled [MEDICAL CONDITION] . The presence of necrosis is also an important factor . In human cases, there is usually only one offending species in the lesion . A lack of hygiene . in the presence of an open wound, are the most important predisposing factors for human wound myiasis . A lack of adequate medical . care of the elderly . and other helpless patients, especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation . Local destruction, invasion into deep tissues, and secondary infection are possible complications of myiasis . Prevention . Individual actions should also be implemented and include . making sure wounds are cleaned and dressed regularly . Appropriate precautions will help avoid infestations. The use of screens and mosquito nets is essential to prevent flies from reaching the skin . Other general precautions include wearing long-sleeved clothing, covering wounds . During an interview on 10/27/20, at 11:20 a.m., with LVN 3, LVN 3 stated she was the licensed nurse assigned to Resident 1 on 10/16/20 on the night shift. LVN 3 stated she was unaware Resident 1 had a wound to his heel. LVN 3 stated she did not assess Resident 1's feet during her shift. During an interview on 10/27/20, at 1:20 p.m., with the Wound Physician (WP), the WP stated when he learned about the wound maggot infestation, he was worried Resident 1's wound may have tunneled (dig or force a passage underground or through something) from the area of the pinky and fourth toe towards the middle of the left foot. The WP stated he assessed Resident 1's left foot for tunneling and luckily, the wound did not tunnel and was only superficial (on the surface). The WP stated he would conduct an in-service for the nurses to perform a thorough skin assessments especially for residents with wounds and diabetes. During an interview on 10/27/20, at 2:05 p.m., with Housekeeper (HK) 2, HK 2 stated she had seen flies inside the building. During an interview on 10/27/20, at 2:18 p.m., with CNA 2, CNA 2 stated she had seen flies inside the building. During an interview on 11/2/20, at 12:50 p.m., with the DON, the DON stated licensed nurses should assess residents with diabetic [MEDICAL CONDITION] (damage to the nerves outside of the brain and spinal cord, often causes weakness, numbness and pain, usually in your hands and feet) for sensation (feeling), presence of pulse, [MEDICAL CONDITION] (swelling), and assess in between residents' toes for wounds. The DON stated residents with [MEDICAL CONDITION] had decreased sensation in their lower extremities and will not know if they have an open wound. During a review of the facility document titled, (Name of Corporation) Healthcare Management, INC. (Incorporated) Job Description, dated 6/2018, the Job Description indicated, .Job Title: Maintenance Director . Ensures the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained in accordance with facility policies and stated and Federal Regulations .Performs minor repairs and supervised the day-to-day repair, improvement and preventative maintenance of the building, equipment . arrange for and manage outside repairs . Ensures safety and sanitation practices and procedures are followed . During a review of (Name of Corporation) Healthcare Management, INC. Job Description, dated 6/2018, the Job Description indicated, Job Title: Administrator . Ensures that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical function status . Responsible for overall management and operations of the facility . During a review of (Name of Corporation) Healthcare Management, INC. Job Description, dated 3/2019, the Job Description indicated, Job Title: Director of Nursing . To plan, organize, develop and direct the overall functions of the Nursing Services Department in accordance, with current federal, state, and local standards governing long term care facilities . to ensure that the highest degree of quality care can be provided to the residents at all times .Responsible for Quality Assurance Activities including: skin integration monitoring system . Schedule daily rounds . to ensure residents are receiving proper care . review nurses' notes to ensure proper documentation is maintained relating to residents' treatment . and conditions . During a review of (Name of Corporation) Healthcare Management, INC. Job Description, dated 6/2018, the Job Description indicated, Job Title: Registered Nurse . Assess resident needs . administer nursing care .Demonstrate ability to perform physical assessment through observation, inspection . During a review of (Name of Corporation) Healthcare Management, INC. Job Description, dated 6/2018, Job Description indicated, Job Title: License Practical Nurse/ License Vocational Nurse . Demonstrate ability to perform physical assessment through observation, inspection . During a review of the facility's policy and procedure (P&P) titled, Quality of Care Foot Care, dated 8/2018, the P&P indicated, To provide the resident with foot care, including treatment to prevent complications from diabetes, [MEDICAL CONDITION] (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) or immobility, that is consistent with professional standard of practice. The facility will provide care and treatment to maintain mobility and good foot health. Foot care and treatment will be in accordance with professional standards of practice, including efforts to prevent complications from resident's medical conditions . Treatments includes preventative care to minimized podiatric complications in residents with diabetes and circulatory disorders . During a review of the facility's P&P titled, Physical Environment Safe, Functional, Sanitary Environment dated 7/2018, the P&P indicated, Purpose: To provide a safe, functional, sanitary and comfortable environment for residents, staff and the public . The facility will maintain and effective pest control program to control pests . During a review of the facility document titled, Foot Assessment in Diabetic Residents undated, the facility documented indicated, .1) Inspect all surfaces of toes, feet and nails paying particular attention to areas of dryness inflammation or cracking. 2) Inspect areas between toes, heels, and soles of feet . 7) Inspect nails, areas between toes and surrounding skin surfaces, 8) When bathing, pay particular attention to drying between the toes . During a review of the National Institute Diabetes and Digestive and Kidney Diseases, retrieved on 11/16/20, from https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/foot-problems, the professional reference indicated, .Overtime, diabetes may cause nerve damage, also called diabetic [MEDICAL CONDITION], that can cause tingling and pain, and can make you lose feeling in your feet. When you lose feeling in your feet, you may not feel a pebble inside your sock or a blister on your foot, which can lead to cuts and sores. Cuts and sores can become infected. Diabetes also can lower the amount of blood flow in your feet. Not having enough blood flowing to your legs and feet can make it hard for a sore or an infection to heal. Sometimes, a bad infection never heals. The infection might lead to gangrene (is a condition that occurs when body tissue dies. It is caused by a loss of blood supply due to an underlying illness, injury, and/or infection. Fingers, toes, and limbs are most often affected). Gangrene and foot ulcers that do not get better with treatment can lead to an amputation (loss of party part) of your toe, foot, or part of your leg. A surgeon may perform an amputation to prevent a bad infection from spreading to the rest of your body, and to save your life. Good foot care is very important to prevent serious infections and gangrene . Checking your feet each day will help you spot problems early before they get worse. A good way to remember is to check your feet each evening when you take off your shoes. Also check between your toes. If you have trouble bending over to see your feet, try using a mirror to see them, or ask someone else to look at your feet. Look for problems such as cuts,sores . During a review of the Advance Foot and Ankle Medicine and Surgery (APMA), retrieved on 11/16/20, from https://www.apma.org/diabeticwoundcare, the professional reference titled, Diabetic Wound Care, dated 2020, indicated, .A [MEDICAL CONDITION] is an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot. Of those who develop a foot ulcer, 6 percent will be hospitalized due to infection or other ulcer-related complication . Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States, and approximately 14-24 percent of patients with diabetes who develop a foot ulcer will require an amputation. Foot ulceration precedes 85 percent of diabetes-related amputations. Research has shown, however, that development of a foot ulcer is preventable . Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as duration of diabetes. Patients who have diabetes for many years can develop [MEDICAL CONDITION], a reduced or complete lack of ability to feel pain in the feet due to nerve damage caused by elevated blood glucose levels over time. The nerve damage often can occur without pain, and one may not even be aware of the problem .Vascular disease can complicate a foot ulcer, reducing the body's ability to heal and increasing the risk for an infection. Elevations in blood glucose can reduce the body's ability to fight off a potential infection and also slow healing . Because many people who develop foot ulcers have lost the ability to feel pain, pain is not a common symptom. Many times, the first thing you may notice is some drainage on your socks. Redness and swelling may also be associated with the ulceration . Learning how to check your feet is crucial so that you can find a potential problem as early as possible. Inspect your feet every day-especially the sole and between the toes-for cuts, bruises, cracks, blisters, redness, ulcers, and any sign of abnormality . 2. During a concurrent observation and interview, on 10/22/20, at 2:21 p.m., with RN 2, in the south hallway, near the exit door, there was a window that had a window screen present. The window screen was not flush against the window, which left a gap between the window and the window screen. Flies were observed entering the building through the gap between the window and the window screen. RN 2 stated, .Yes those are flies RN 2 stated flies inside the building placed residents in the facility at an increased risk for wound maggot infestation. During an interview on 10/22/20, at 2:25 p.m., LVN 1 stated she had seen flies inside the breakroom. LVN 1 stated if flies were inside the building and residents had wounds, the flies could get into the wound bed and cause maggot infestation. During a concurrent observation and interview, on 10/22/20, at 2:30 p.m., with the DON, in the south hallway, near the exit door, the DON validated the window screen was not flush against the window, which caused a gap. Flies were observed entering the building through the gap. The DON stated, Those are flies. The DON went to the north hallway, near the exit doors, and observed a window that had a window screen present. The window screen was not flush against the window, which left a gap between the window and window screen. Resident 1 had access to the patio from his room via a sliding door that contained a door screen. The DON checked Resident 1's door screen. The door screen had a big hole on the screen. The DON stated she would notify maintenance to fix the door screen. During a concurrent observation and interview, on 10/26/20, at 11:25 a.m., with the Maintenance Supervisor/Director (MS), in Dining room [ROOM NUMBER], the flytrap attached to the wall was not functioning. The MS stated the activity staff moved their desk into Dining room [ROOM NUMBER] and unplugged the flytrap from the electrical outlet and used the electrical outlet to plug in their computer. The MS stated he was not aware the flytrap was unplugged in Dining room [ROOM NUMBER]. In the kitchen, the flytrap was not functioning. The MS validated the lights to the flytrap were not turned on, it was not functional. The MS stated he was not aware the flytrap in the kitchen was not functioning. The MS stated he did not know how long the flytraps had not been functioning. The MS stated he did not conduct routine checks in the facility to observe if flytraps were functioning properly. The MS stated he was not aware of the hole in Resident 1's screen door and gaps between the window and window screens on both south and north ends of the hallway until the ADM notified him on 10/22/20. The MS stated the screen doors were important to prevent flies from entering the building. During an interview on 10/26/20, at 1:48 p.m., with the ADM, the ADM stated the last time the facility had someone come to the facility to perform Pest Control service was in February 2020, before COVID-19 (a contagious serious respiratory infection transmitted from person to person). The ADM stated the facility did not have a contract with Pest Control to monitor the flytraps to determine if the flytraps were properly functioning, and the facility did not delegate anyone in the facility to monitor the flytraps to ensure if it was functioning properly. During a concurrent observation and interview, on 10/26/20, at 2:11 p.m., with LVN 2, inside Resident 2's room, a fly was observed. LVN 2 stated, That is a fly. LVN 2 stated Resident 2 had an open wound on her coccyx (is a small, triangular bone resembling a shortened tail located at the bottom of the spine). During a review of Resident 2's Admission Records dated 2/14/20, the Admission Records indicated, Resident 2 was admitted to the facility with [DIAGNOSES REDACTED]. During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 2's BIMS score 3 of 15 points, which indicated Resident 2 was severely cognitively impaired. The MDS section G indicated Resident 2 was totally dependent on staff members to transfer from one surface to another. During a review of Resident 2's Order Summary, dated 2/17/20, the Order Summary indicated, Assess wound site- PU (pressure ulcer) to coccyx for S/SX (signs and symptoms) of infection or other complications QD (daily) . During a concurrent observation and interview, on 10/26/20, at 2:17 p.m., with LVN 2, inside Resident 4's room, a fly observed. LVN 2 stated, Yes that is a fly. LVN 2 stated Resident 4 has an open wound on her coccyx. During a review of Resident 4's Admission Records, dated 6/10/19, the Admission Records indicated, Resident 4 was admitted to the facility with [DIAGNOSES REDACTED]. During a review of Resident 4's MDS dated [DATE], the MDS indicated, Resident 4's BIMS score 1 of 15 points which indicated Resident 4 was severely cognitively impaired. The MDS section G indicated Resident 4 was totally dependent on staff members to transfer from one surface to another. During a review of Resident 4's Order Summary, dated 10/4/20, indicated, Assess wound to coccyx for S/SX of infection or other complication . During a concurrent observation and interview, on 10/26/20, at 2:48 p.m., with RN 4, inside Resident 8's room, a fly was observed. RN 4 stated, Yes that is a fly. That is not the only fly I have seen. I have seen flies here. During a concurrent observation and interview, on 10/26/20, at 2:50 p.m., inside Resident 8's room, Resident 8 stated, Yes, the fly landed on my shoulder, I have seen flies before. During a review of Resident 8's Admission Records, dated 2/14/20, the Facesheet indicated Resident 8 was admitted to the facility with [DIAGNOSES REDACTED]. During a review of Resident 8's MDS dated [DATE], the MDS indicated, Resident 8's BIMS score 3 out of 15 points, which indicated Resident 8 was severely cognitively impaired. Section G of the MDS indicated Resident 8 required two staff members in physical assist to transfer from one surface to another. During a review of Resident 8's Order Summary, dated 2/17/20, the Orders Summary indicated, Assess wound site-PU for S/SX of infection or other complication . During an interview on 10/27/20, at 1:20 p.m., with the Wound Physician (WP), the WP stated when he learned about the wound maggot infestation, he was worried Resident 1's wound may have tunneled (dig or force a passage underground or through something) from the area of the pinky and fourth toe towards the middle of the left foot. The WP stated he assessed Resident 1's left foot for tunneling and luckily, the wound did not tunnel and was only superficial (on the surface). The WP stated he would conduct an in-service for the nurses to perform a thorough skin assessments especially for residents with wounds and diabetes. During an interview on 10/27/20, at 2:05 p.m., with Housekeeper (HK) 2, HK 2 stated she had seen flies inside the building. During an interview on 10/27/20, at 2:18 p.m., with CNA 2, CNA 2 stated she had seen flies inside the building. During a review of the facility document titled, (Name of Corporation) Healthcare Management, INC. (Incorporated) Job Description, dated 6/2018, the Job Description indicated, .Job Title: Maintenance Director . Ensures the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained in accordance with facility policies and stated and Federal Regulations .Performs minor repairs and supervised the day-to-day repair, improvement and preventative maintenance of the building, equipment . arrange for and manage outside repairs . Ensures safety and sanitation practices and procedures are followed . During a review of (Name of Corporation) Healthcare Management, INC. Job Description, dated 6/2018, the Job Description indicated, Job Title: Administrator . Ensures that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical function status . Responsible for overall management and operations of the facility . During a (TRUNCATED)

Based on observations, interviews and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program to prevent, recognize, and control the spread of infections when: 1. Two of four sampled residents (Resident 20 and Resident 21) required the use of a glucometer (a portable machine that checks the blood sugar levels by a skin poke usually for diabetic (a disease which causes high blood sugar)) and Licensed Vocational Nurse (LVN) 4 did not disinfect (clean, especially with a chemical in order to destroy bacteria) the glucometer between resident use with an agent that killed [MEDICAL CONDITION] (C. diff-bacteria that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon); 2. Housekeeper (HK) 1 did not use a disinfectant (chemical liquid that destroys bacteria) that killed [DIAGNOSES REDACTED] when HK 1 disinfected Resident 21's room; 3. The facility did not have a disinfectant that killed [DIAGNOSES REDACTED] available for staff use to disinfect equipment, after the equipment was used for two of two residents (Residents 20 and 21) diagnosed with [REDACTED]. 4. Certified Nursing Assistant (CNA) 3 and HK 1 did not wear an isolation gown (a protective apparel used by medical personnel to avoid exposure to blood, body fluids, and transfer of microorganism (bacteria or virus)) when providing services to Resident 20 and Resident 21; 5. The facility did not have a system in place for resident cohorting (placing a group of individuals with common traits) of residents diagnosed with [REDACTED]. 6. An Ultrasound Technician (US-operates special equipment that uses high frequency sound waves to record images of internal organs) wore an isolation gown at the nurse's station. These deficient practices placed 83 residents and staff at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of communicable (able to be transmitted from one person to another) diseases. An Immediate Jeopardy situation (IJ) was called on 11/4/20, at 3:35 p.m. with the facility Administrator (ADM) and the Director of Nursing (DON). Serious issues were identified with infection control standards not being followed when staff shared the use of a glucometer on residents with isolation precautions (create barriers between people and germs) for [DIAGNOSES REDACTED] and the glucometer was not disinfected with a product that killed [DIAGNOSES REDACTED] after use, a housekeeper did not use a disinfectant that killed [DIAGNOSES REDACTED] when she disinfected the isolation room, residents with isolation precautions for [DIAGNOSES REDACTED] were cohorted with residents with no isolation precautions, and CNA 3 and HK 1 provided services to Resident 20 and Resident 21 that were in isolation for [DIAGNOSES REDACTED] without wearing proper Personal Protective Equipment (PPE- protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection). The facility submitted an Action Plan to address the IJ situation on 11/5/20 at 4 p.m., to address cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of equipment, proper cleaning of surfaces with a disinfectant that killed the bacteria or virus it was intended to kill, availability of bleach disinfectant to staff, implement training and education on [DIAGNOSES REDACTED], disinfectant use, resident cohorting and use of PPE in [DIAGNOSES REDACTED] isolation rooms. The components of the IJ Removal Plan were validated through observations, interviews, and record review. The IJ situation was removed on 11/5/20 at 5:26 p.m. with the ADM and the DON. Findings: 1. During an observation on 11/3/20, at 11:49 a.m., with LVN 4, in the South end hallway, outside Resident 21's room, LVN 4 walked into Resident 21's room and used a glucometer to measure Resident 21's blood sugar level (sugar in the form of glucose in the blood). After LVN 4 obtained Resident 21's blood sugar, LVN 4 disinfected the glucometer with (brand name (non-bleach)) disinfectant. During a review of Resident 21's Admission Record dated 9/24/20, the Admission Record, indicated Resident 21 had a [DIAGNOSES REDACTED]. During a review of Resident 21's Order Summary Report dated 9/27/20, the Order Summary Report, indicated, .Insulin (brand name) Solution (a medication use to lower blood sugar level) 100 unit/ml (units of measurement) Inject 10 unit subcutaneously (under the skin) three times a day for DM (Diabetes Mellitus) Hold for BS (blood sugar) below 70 . dated 11/2/20 .Contact Precaution (types of precautions or interventions implemented to prevent infections due to direct or indirect contact) for possible [MEDICAL CONDITION] . During a review of Resident 21's Care Plan dated 9/28/20, the Care Plan indicated, Fasting (before some kinds of food or drink) Serum Blood Sugar as ordered by the doctor . During a review of Resident 21's Test Toxigenic Difficile (a diagnostic test for [DIAGNOSES REDACTED]) dated 11/2/20, the report indicated, . Result Positive . During a concurrent observation and interview, on 11/3/20, at 12:15 p.m., with LVN 4, in the South end hallway, outside Resident 20's room, LVN 4 walked into Resident 20's room and used the same glucometer that was previously used on Resident 21 to check Resident 20's blood sugar level. After the blood sugar was obtained, LVN 4 disinfected the glucometer with (brand name (non-bleach)) disinfectant. LVN 4 reviewed the disinfectant's label and stated the disinfectant did not contain bleach and the disinfectant did not indicate it killed [DIAGNOSES REDACTED]. LVN 4 stated she did not receive training on the type of disinfectant that was required to be used on equipment (such as glucometers) after resident use for resident with [DIAGNOSES REDACTED]. LVN 4 stated the disinfectant she used (brand name (non-bleach)) was the only disinfectant provided to her. During a review of Resident 20's Admission Record dated 10/1/20, the Admission Record, indicated Resident 20 had a [DIAGNOSES REDACTED]. During a review of Resident 20's Order Summary Report dated 10/25/20, the Order Summary Reported indicated, Contact Precaution for possible [MEDICAL CONDITION] . During a review of Resident 20's Care Plan dated 10/13/20, the Care Plan indicated, (name of resident) has Diabetes Mellitus. She is at risk for diabetes complications . Fasting Serum Blood sugar as ordered by the doctor . During a review of Resident 20's Lab Result Report dated 10/26/20, the report indicated, .Toxigenic Difficile Result Positive . During a concurrent interview and record review, on 11/3/20, at 12:19 p.m., with the Infection Preventionist (IP), the IP stated the facility only used (brand name (non-bleach)) disinfectant throughout the facility. The IP reviewed the label of (brand name (non-bleach)) disinfectant and stated the disinfectant's label did not indicate it kill [DIAGNOSES REDACTED]. The IP stated a disinfectant that contained bleach should be used when disinfecting equipment that was used after residents with [DIAGNOSES REDACTED] to prevent cross-contamination of [DIAGNOSES REDACTED] to other residents. During a review of the facility document titled, Job Description Infection Preventionist, dated 7/2020, the Job Description indicated, .The Infection Preventionist reports to the Director of Nursing . This position is part of the facility leadership team. Responsible for dissemination of infection prevention information, including surveillance data, and policy compliance tracking. Is also accountable for decreasing the incidence and transmission of infectious diseases between patients .essential functions .Trains clinical personnel on implementation of infection prevention practices .Providing the management of infectious patients/residents and other infection prevention issues . Conducts audits regarding the implementation of and compliance with policies . During a concurrent observation, interview, and record review, on 11/3/20, at 12:39 p.m., with Registered Nurse (RN) 3, RN 3 had (brand name (non- bleach)) disinfectant on her medication cart. RN 3 reviewed the disinfectant label and stated the disinfectant did not contain bleach and it would not kill [DIAGNOSES REDACTED]. RN 3 stated the facility had been using (brand name (non-bleach)) disinfectant to disinfect the glucometer after it was used on residents. During a concurrent observation, interview, and record review, on 11/3/20, at 12:39 p.m., with LVN 5, LVN 5 had (brand name) disinfectant on her medication cart. LVN 5 reviewed the disinfectant label and stated the disinfectant did not contain bleach and it would not kill [DIAGNOSES REDACTED]. LVN 5 stated the facility had been using (brand name (non-bleach)) disinfectant to disinfect the glucometer after it was used on residents. During an interview on 11/3/20, at 4:30 p.m., with LVN 3, LVN 3 stated she was the licensed nurse assigned to Resident 21 on 10/29/20 and 10/30/20. LVN 3 stated she collected Resident 21's stool sample on 10/29/20 because Resident 21 had loose stools and placed Resident 21 on contact isolation (infection prevention interventions used to prevent transmission of infectious diseases, which are spread through direct or indirect contact). LVN 3 stated she used (brand name (non-bleach disinfectant)) to disinfect the glucometer after she obtained Resident 20 and 21's blood sugar. During a review of Resident 21's Progress Notes, dated 10/29/20, the Progress Notes indicated, .Resident (name of resident) is on monitor for loose stools. Resident had several episodes of continent (able to control movements) and incontinent (unable to control movements) loose stools. Stool sample collected @ 2119 (9:19 p.m.) . During an interview on 11/3/20, at 4:15 p.m., with LVN 6, LVN 6 stated she was the licensed nurse assigned to Resident 20 on 10/25/20. LVN 6 stated Resident 20 had four episodes of loose stools. LVN 6 stated she notified the physician and obtained an order to placed Resident 20 on contact isolation precaution and obtain a stool sample for [DIAGNOSES REDACTED] testing. LVN 6 stated she used (brand name (non-bleach)) disinfectant to disinfect the glucometer used to check Resident 20's blood sugar level. LVN 6 stated there was no bleach disinfectant available for staff use. During a review of Resident 20's Progress Notes, dated 10/25/20, the Progress Note indicated, .Resident has had 4 episodes of runny light brown diarrhea with abdominal pain. MD notified, new orders to collect stool sample for possible superinfection (infection occurring after or on top of an earlier infection) of [MEDICAL CONDITION] . During an interview on 11/3/20, at 4:38 p.m., with the DON, the DON stated Resident 20 and 21 were still on [DIAGNOSES REDACTED] precautions. The DON stated Resident 21 had loose stools today (11/3/20) and Resident 20's last episode of loose stool was on 11/1/20. The DON stated staff should have used a disinfectant that contained bleach to disinfect equipment (such as glucometers) and environmental (refers to the resident's surroundings) surfaces inside a [DIAGNOSES REDACTED] isolation room and after equipment use, to prevent cross-contamination. During a review of the facility's policy and procedure (P&P) titled, [MEDICAL CONDITION], dated 7/2017, the P&P indicated, .Preventative measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with [DIAGNOSES REDACTED]icile to prevent transmission of [DIAGNOSES REDACTED]icile to others) . The primary reservoirs (causative agent of a disease) for [DIAGNOSES REDACTED]icile are infected people and surfaces. Spores (a unit of sexual or asexual reproduction that may be adapted for dispersal and for survival, often for extended periods of time, in unfavorable conditions) can persist on resident-care items and surfaces for several months and are resistant to common cleaning and disinfection methods . Healthcare workers will wear gloves and gowns upon entering the room of a resident with [DIAGNOSES REDACTED]icile infection . Due to the persistence of [DIAGNOSES REDACTED]icile spores for prolonged periods of time, the environment shall be disinfected with a disinfecting agent recommended for [DIAGNOSES REDACTED]icile . During a review of the facility's P&P titled, Isolation-Categories of Transmission-Based precautions, dated 1/2012, the P&P indicated, .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have a communicable disease or infections that can be transmitted to others . Transmission-Based precaution will be used whenever measures more stringent than Standard Precaution are needed to prevent or control the spread of infection. Based on Centers for Disease Control and Prevention (CDC) definitions, three types of Transmission-Based Precautions .Contact .implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items . When possible, dedicate the use of non-critical equipment items . to avoid sharing items, if use of common items is unavoidable, then adequately clean and disinfect them before use for other residents . During a review of the professional reference retrieved on 11/19/20, from https://www.cdc.gov/hai/prevent/cdi-prevention-strategies.html titled, Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities, dated 8/7/19, the professional reference review indicated, .Purpose: This document provides information on the basic principles and interventions recommended for the prevention of Clostridioides (formerly known as ,[MEDICAL CONDITION].) difficile infection (CDI) in acute care facilities. The strategies are intended to facilitate implementation of CDI prevention efforts by state and local health departments, quality improvement organizations, hospital associations, and healthcare facilities. Core strategies for the prevention of CDI in acute care facilities include: 1. ISOLATE AND INITIATE CONTACT PRECAUTIONS FOR SUSPECTED OR CONFIRMED CDI. Create nurse-driven protocols to facilitate rapid isolation of patients with suspected or confirmed CDI. For suspected patients, ensure rapid evaluation by healthcare personnel and infection prevention. Place symptomatic patients on contact precautions, in a single-patient room with a dedicated toilet. If single-patient rooms are not available, cohort like patients. Use dedicated patient-care equipment (e.g., blood pressure cuffs, stethoscopes) . 3. PERFORM ENVIRONMENTAL CLEANING TO PREVENT CDI. Create daily and terminal cleaning protocols and checklists for patient-care areas and equipment. Perform daily cleaning of CDI patient rooms using a [DIAGNOSES REDACTED]icile sporicidal agent (EPA List K agent). Clean and disinfect the patient-care environment (including the immediate vicinity around a CDI patient and high touch surfaces) at least once a day, including toilets. Clean and disinfect all shared equipment prior to use with another patient (e.g., wheelchairs, gurneys) . During a review of the professional reference retrieved on 11/19/20, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf titled, 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, . the professional reference indicated .C. difficile is a spore-forming gram positive anaerobic bacillus .This pathogen is a major cause of healthcare-associated diarrhea and has been responsible for many large outbreaks in healthcare settings that were extremely difficult to control. Important factors that contribute to healthcare-associated outbreaks include environmental contamination, persistence of spores for prolonged periods of time, resistance of spores to routinely used disinfectants and antiseptics, hand carriage by healthcare personnel to other patients, and exposure of patients to frequent courses of antimicrobial agents .Prevention of transmission focuses on syndromic (approach of treating) application of Contact Precautions for patients with diarrhea, accurate identification of patients, environmental measures (e.g., rigorous cleaning of patient rooms) . and a bleach-containing disinfectant (5000 ppm (parts per million)) for environmental disinfection . 2. During a concurrent observation, interview, and record review, on 11/3/20, at 9:40 a.m., HK 1 disinfected Resident 21's room. Resident 21's room had a sign on the door that indicated Resident 21 was on contact precautions. During a review of the sign posted on the door, the signed indicated Contact Precautions undated, indicated, STOP Contact Precautions Everyone must . Put on gown before entry .Use dedicated or disposable equipment, clean and disinfect reusable equipment before use on another person . HK 1 stated she used (brand name) (did not contain bleach) to disinfect Resident 21's room. During a review of Resident 21's Order Summary Report dated 9/27/20, the Order Summary Report, indicated, .dated 11/2/20, indicated, Contact Precaution for possible [MEDICAL CONDITION] . During a review of Resident 21's Test Toxigenic Difficile (a diagnostic test for [DIAGNOSES REDACTED]) dated 11/2/20, the report indicated, . Result Positive . During an interview on 11/3/20, at 11:30 a.m., with the IP, the IP stated Resident 21 was on contact precautions due to [DIAGNOSES REDACTED]. During an interview on 11/3/20, at 11:45 a.m., with HK 1, HK 1 stated she was not aware of the type of isolation precaution Resident 21 was on. HK 1 stated she only used (brand name (non-bleach)) disinfectant, to disinfect surfaces in Resident 21's room. During an interview on 11/3/20, at 3:20 p.m., with the Account Manager (AM), the AM stated he was in charge of providing education to the housekeepers on proper disinfection of environmental surfaces throughout the facility. The AM stated (brand name) (did not contain bleach) disinfectant was use for disinfecting residents' rooms. The AM stated the housekeepers needed to use bleach to disinfect a room with a resident who had [DIAGNOSES REDACTED]. The AM stated it was his responsibility for housekeepers to know when to use bleach and when to use (brand name) (did not contain bleach) disinfectant. The AM stated HK 1 should have used bleach when she disinfected Resident 21's room because bleach killed [DIAGNOSES REDACTED] and (brand name) (did not contain bleach) does not. During an interview on 11/3/20, at 4:38 p.m., with the DON, the DON stated the facility staff should use a disinfectant that contained bleach to disinfect equipment, and environmental surfaces inside a [DIAGNOSES REDACTED] isolation room in order to prevent cross-contamination. During an interview on 11/4/20, at 10:35 a.m., with the ADM, the ADM stated he needed to ensure housekeeping had the appropriate tools and resources to carry out their duties. The ADM stated the housekeeping staff needed to be educated on proper use of a disinfectant for [DIAGNOSES REDACTED] residents. The ADM stated he needed to coordinate with the AM, to ensure education was provided to housekeeping staff to use bleach when disinfecting positive [DIAGNOSES REDACTED] residents' rooms. The ADM stated it was the ADM's responsibility to oversee all functions of the facility. During a review of the facility's P&P titled, [MEDICAL CONDITION], dated 7/2017, the P&P indicated, .Preventative measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with [DIAGNOSES REDACTED]icile to prevent transmission of [DIAGNOSES REDACTED]icile to others) . The primary reservoirs for [DIAGNOSES REDACTED]icile are infected people and surfaces. Spores (a unit of sexual or asexual reproduction that may be adapted for dispersal and for survival, often for extended periods of time, in unfavorable conditions) can persist on resident-care items and surfaces for several months and are resistant to common cleaning and disinfection methods . Due to the persistence of [DIAGNOSES REDACTED]icile spores for prolonged periods of time, the environment shall be disinfected with a disinfecting agent recommended for [DIAGNOSES REDACTED]icile . During a professional reference review, retrieved on 11/19/20, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf titled, 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, .the professional reference indicated, .C. difficile is a spore-forming gram positive anaerobic bacillus .This pathogen is a major cause of healthcare-associated diarrhea and has been responsible for many large outbreaks in healthcare settings that were extremely difficult to control. Important factors that contribute to healthcare-associated outbreaks include environmental contamination, persistence of spores for prolonged periods of time, resistance of spores to routinely used disinfectants and antiseptics, hand carriage by healthcare personnel to other patients, and exposure of patients to frequent courses of antimicrobial agents .Prevention of transmission focuses on syndromic application of Contact Precautions for patients with diarrhea, accurate identification of patients, environmental measures (e.g., rigorous cleaning of patient rooms) . and a bleach-containing disinfectant (5000 ppm (parts per million)) for environmental disinfection . 3. During a concurrent observation and interview, on 11/3/20, at 12:51 p.m., with the ADM, the ADM stated he did not know how long the facility staff have conducted the practice of not using a bleach disinfectant for residents on isolation for [DIAGNOSES REDACTED]. The ADM went into the supply room and was unable to find any forms of bleach disinfectants in the supply room. During an interview on 11/3/20, at 2:42 p.m., with the Central Supply (CP), the CP stated, .To tell you honestly, I have been struggling to order bleach . The CP stated she did not order any products that contained bleach. The CP stated she was not aware there were [DIAGNOSES REDACTED] positive residents in the facility. The CP stated the IP or nursing staff should have communicated to her if the facility required products that contained bleach to clean equipment and surfaces of the positive [DIAGNOSES REDACTED] residents. During an interview on 11/4/20, at 9:40 a.m., with the IP, the IP stated the process to ensure bleach wipes were available to licensed nurses (LN) was to verbally communicate the need to central supply. The IP stated it was the LNs responsibility to inform nursing management for the need of bleach wipes once the medications carts needed to be restocked. The IP stated verbal communication between central supply and LNs was not an appropriate process to ensure bleach wipes were always available . During an interview on 11/4/20, at 10 a.m., with the DON, the DON stated verbal communication with central supply needed to be done to ensure bleach wipes were available for LNs to disinfect medical equipment. The DON stated she conducted observations of the medication carts daily to ensure LNs had proper supplies stocked in the carts, which included bleach wipes to disinfect glucometers and blood pressure cuffs (device used to measure pressure that is exerted by the blood upon the walls of the blood vessels). The DON stated she does not know how bleach wipes were not available for LNs from 10/25/20 to 11/3/20. The DON did not comment on if she conducted daily observations, how the LNs did not have bleach wipes available from 10/25/20 to 11/3/20. During an interview on 11/4/20, at 10:35 a.m., with the ADM, the ADM stated his responsibility was to ensure nursing staff and management staff had appropriate tools and resources to carry out their duties. The ADM stated there needed to be an appropriate process to ensure bleach wipes were available to all nursing staff and not just a verbal communication with the central supply department. During a review of (Name of Corporation) Healthcare Management, INC. Job Description, dated 6/2018, the Job Description indicated, Job Title: Administrator . Ensures that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical function status . Responsible for overall management and operations of the facility . 4. During a concurrent observation and interview on 11/3/20, at 9:40 a.m., near Resident 21's room, HK 1 was cleaning Resident 21's room. Resident 21's room had a sign on the door which indicated Resident 21 was on contact precautions. During a review of the sign posted on the door, Contact Precautions undated, the signed indicated, STOP Contact Precautions Everyone must . Put on gown before entry . HK 1 did not wear an isolation gown when she cleaned Resident 21's room. HK 1 stated she had forgotten to put on a gown when she cleaned Resident 21's room. HK 1 stated she should have worn a gown to protect herself from Resident 21's infectious (likely to spread infection) disease and to prevent cross contamination. During an interview on 11/3/20, at 11:30 a.m., with the IP, the IP stated housekeepers needed to wear a gown when they cleaned in room with contact isolation. The IP stated Resident 21 was on contact precautions for [DIAGNOSES REDACTED]. During a review of Resident 21's Order Summary Report dated 9/27/20, the Order Summary Report, indicated, .dated 11/2/20, indicated, Contact Precaution for possible [MEDICAL CONDITION] . During a review of Resident 21's Test Toxigenic Difficile dated 11/2/20, the report indicated, . Result Positive . During a concurrent observation and interview, on 11/3/20, at 12:12 p.m., with CNA 3, in South side hallway, outside Resident 20's room, Resident 20's room had a sign on the door which indicated Resident 20 was on contact precautions. During a review of the sign posted on the door, Contact Precautions undated, the signed indicated, STOP Contact Precautions Everyone must . Put on gown before entry .CNA 3 went into Resident 20's room and did not don (put on) a gown prior to entering. CNA 3 stated he provided Resident 20 and Resident 22 their meal tray. CNA 3 stated he does not need to wear an isolation gown inside an isolation room when he is passing out meal trays. CNA 3 stated he received education that he did not have to wear a gown when passing meals out to residents with isolation precaution. CNA 3 stated he could not recall who provided him that education. During a concurrent interview and record review, on 11/3/20, at 12:19 p.m., with the IP, the IP stated facility staff should wear an isolation gown while inside an isolation room, to prevent cross-contamination. During an interview on 11/3/20, at 4:38 p.m., with the DON, the DON stated facility staff should wear appropriate PPE when entering isolation precaution rooms to prevent cross-contamination. During a review of the facility's P&P titled, [MEDICAL CONDITION], dated 7/2017, the P&P indicated, .Preventative measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with [DIAGNOSES REDACTED]icile to prevent transmission of [DIAGNOSES REDACTED]icile to others) . Healthcare workers will wear gloves and gowns upon entering the room of a resident with [DIAGNOSES REDACTED]icile infection . During a professional reference review, retrieved on 11/19/20, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf, dated 11/4/19, titled, Prevent the Spread of [DIAGNOSES REDACTED], the professional reference indicated, .How do I make sure I don't spread [DIAGNOSES REDACTED]? In a healthcare setting . Make sure all doctors, nurses, and other healthcare providers . caring for you and other patients with [DIAGNOSES REDACTED], doctors, nurses and other healthcare providers will use certain precautions, such as gowns and gloves, to prevent the spread of [DIAGNOSES REDACTED] to themselves and to other patients . 5. During an interview on 11/3/20, at 3:16 p.m., with the IP, the IP stated when Resident 20 and Resident 21 tested positive for [DIAGNOSES REDACTED], both residents remained in their respective rooms together with their roommates Resident 22 and Resident 23 that were [DIAGNOSES REDACTED] negative. The IP stated she assessed Resident 20 and Resident 21's roommates for risk of contracting the [DIAGNOSES REDACTED] infection. The IP stated she did not use an assessment tool for Cohorting C.diff negative residents with [DIAGNOSES REDACTED] positive residents. The IP stated she did not document her assessment. The IP stated, .Just critical thinking. It's all in my head . During an interview on 11/3/20, at 4:30 p.m., with LVN 3, LVN 3 stated she was the licensed nurse assigned to Resident 21 on 10/29/20 and 10/30/20. LVN 3 stated she collected Resident 21's stool sample on 10/29/20 because Resident 21 had loose stools and placed Resident 21 on contact isolation. During a review of Resident 21's Progress Notes, dated 10/29/20, the Progress Notes indicated, .Resident (name of resident) is on monitor for loose stools. Resident had several episodes of continent (able to control movements) and incontinent (unable to control movements) loose stools. Stool sample collected @ 2119 (9:19 p.m.) . During a review of Resident 21's Order Summary Report dated 11/2/20, the Order Summary Report, indicated, .Contact Precaution for possible [MEDICAL CONDITION] . During a review of Resident 21's Test Toxigenic Difficile dated 11/2/20, the report indicated, . Result Positive . During an interview on 11/3/20, at 4:15 p.m., with LVN 6, LVN 6 stated she was the licensed nurse assigned to Resident 20 on 10/25/20. LVN 6 stated Resident 20 had four episodes of loose stools. LVN 6 stated she notified the physician and obtained an order to placed Resident 20 on contact isolation precaution and obtain a stool sample for [DIAGNOSES REDACTED] testing. During a review of Resident 20's Progress Notes, dated 10/25/20, the Progress Note indicated, .Resident has had 4 episodes of runny light brown diarrhea with abdominal pain. MD notified, new orders to collect stool sample for possible superinfection (infection occurring after or on top of an earlier infection) of [MEDICAL CONDITION] . During a review of Resident 20's Order Summary Report dated 10/25/20, the Order Summary Reported indicated, Contact Precaution for possible [MEDICAL CONDITION] . During a review of Resident 20's Lab Result Report dated 10/26/20, the report indicated, .Toxigenic Difficile Result Positive . During a review of Resident 22's Admission Records, dated 5/23/19, indicated, Resident 22 is an [AGE] year old female, with a [DIAGNOSES REDACTED]. During a review of Resident 23's Admission Records, dated 1/4/18, indicated, Resident 23 is an [AGE] years old male, with a [DIAGNOSES REDACTED]. During an interview on 11/4/20, at 10 a.m., with the DON, the DON stated she was not involved in the decision making process for Cohorting Residents 20 and 21 with other residents that were not on isolation precautions for [DIAGNOSES REDACTED]. The DON stated the facility practice was for the IP to make the decision if resident room changes were needed. The DON stated nursing decisions that included resident Cohorting were ultimately the DON's responsibility and she should have been involved in the decision-making process for Residents 20 and 21. During a review of the facility document titled, Job Description Infection Preventionist, dated 7/2020, indicated, The Infection Preventionist reports to the Director of Nursing . This position is part of the facility leadership team. Responsible for dissem(TRUNCATED)

Based on observations, interviews and record review, the facility failed to maintain an effective pest control program when flytraps in the facility were not functioning, window screens were not secured on the window leaving a gap, a door screen had a hole on the screen, and the facility did not delegate an individual to monitor the flytraps when pest control services were stopped in February 2020. This failure resulted in Resident 1's left foot wound to be found infested (the presence of an unusually large number of insects in a place, typically so as to cause damage or disease) with maggots (larva (an insect at the stage of its life after it has developed from an egg and before it changes into its adult form) of a fly) on 10/17/20 and the potential for Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12's wounds to become infested with maggots. Findings: During a review of Resident 1's Facesheet (a document containing resident profile information), dated 2/20/17, the Facesheet indicated Resident 1 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident 1 had a [DIAGNOSES REDACTED]. Resident 1 had a [DIAGNOSES REDACTED]. During a review of Resident 1's Minimum Data Set (MDS- an assessment of healthcare and functional needs) assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). The MDS section G indicated Resident 1 was totally dependent (requiring assistance) on staff members to transfer from one surface to another. During an observation on 10/22/20, at 11:10 a.m., in Resident 1's room, Resident 1 was lying in bed. Resident 1 had two wound dressings on his left foot, one on his heel and another between the pinky and fourth toe. During an interview on 10/22/20, at 11:13 a.m., with Resident 1, Resident 1 stated he had a wound to his left foot between his pinky and fourth toe. Resident 1 stated he bumped his toes prior to 10/17/20 (when the maggots were discovered). Resident 1 was unable to recall what he bumped his toes on. Resident 1 stated he did not know his left small toe was bleeding until Registered Nurse (RN) 1 informed him. Resident 1 stated RN 1 applied a band-aid (a sticking plaster used to cover wounds) on the wound located between his pinky and fourth toe. Resident 1 stated he had diabetes and had decreased sensation (feeling) to his feet. Resident 1 stated he did not know how often the band-aid needed to be changed. Resident 1 stated he had a shower on Saturday (10/17/20) and Certified Nursing Assistant (CNA) 1 informed Resident 1 there were maggots in the wound. Resident 1 stated Licensed Vocational Nurse (LVN) 1 cleaned his wound and removed the maggots. Resident 1 stated there were a lot of maggots in the wound. Resident 1 stated the facility tried to tell him he got the maggots from staying outside. Resident 1 stated he saw flies inside his room. Resident 1 stated, I guess the fly got inside it (wound between pink and fourth toe). During a concurrent interview and record review, on 10/22/20, at 11:30 a.m., with LVN 1, LVN 1 stated she was the licensed nurse assigned to Resident 1 on the morning shift of 10/17/20. LVN 1 stated she did not receive report from the licensed nurse during change of shift handoff (report given during end of shift to the oncoming nurse) that Resident 1 had a wound located on his left foot between his pinky and fourth toe. LVN 1 stated she was not aware of Resident 1's wound between the pinky and fourth toe. LVN 1 stated Resident 1 had a shower on 10/17/20 and CNA 1 notified her Resident 1 had maggots in the wound on his left foot. LVN 1 stated she looked at Resident 1's left foot and saw maggots in the wound located between Resident 1's pinky and fourth toe. LVN 1 stated she notified Resident 1's physician and obtained an order to clean Resident 1's wound with normal saline (a solution mixture of water and salt used to clean wounds) and remove the maggots. LVN 1 stated she carried out the order and removed the maggots from the wound. LVN 1 reviewed Resident 1's chart that contained progress notes, daily nursing assessments, and nursing care plan, and stated she was unable to find documentation regarding Resident 1's wound to his left foot between the pinky and fourth toe. LVN 1 stated the wound located between the pinky and fourth toe should have been assessed and documented, but it was not. During a review of Resident1's Progress Notes, dated 10/17/20, the Progress Notes indicated, On call (Name of Physician) was called in regards to maggots on patient's feet. Dr. advised wound care to be done. No specific instructions given before dr. ended the call . patient stated he bumped his foot and had a bandaid put on. Patient spent a few hours outside with feet out in the open and believes that might have been when fly landed. Will continue to monitor foot throughout shift . During a review of Resident 1's Order Summary , dated 10/22/20, the Order Summary indicated, Vascular wound (breaches in the skin caused by problems with blood flow to particular parts of the body) to 5th digit of L foot: cleanse with NS (mixture of salt and water used to clean wounds) , pat dry, apply (brand name of medical grade honey) with calcium alginate (water-insoluble, gelatinous, cream-coloured substance that promotes wound healing) (between 4th & 5th digits), wrap foot in kerlix (roll of gauze) . During an interview on 10/22/20, at 11:58 a.m., with CNA 1, CNA 1 stated she was the nursing assistant assigned to Resident 1 on 10/17/20 on the day shift. CNA 1 stated she gave Resident 1 a shower and saw maggots in Resident 1's wound that was located between the pinky and fourth toe. CNA 1 stated she notified LVN 1 right away. CNA 1 stated she did not receive report during shift change from the previous CNA if Resident 1 had a wound between his pinky toe and fourth toe. During a concurrent observation and interview, on 10/22/20, at 2:21 p.m., with RN 2, in the south hallway, near the exit door, there was a window that had a window screen present. The window screen was not secured against the window, which left a gap between the window and the window screen. Flies were observed entering the building through the gap between the window and the window screen. RN 2 stated, .Yes those are flies RN 2 stated flies inside the building placed residents in the facility at an increased risk for wound maggot infestation. During an interview on 10/22/20, at 2:25 p.m., LVN 1 stated she had seen flies inside the breakroom. LVN 1 stated if flies were inside the building and residents had wounds, the flies could get into the wound bed and cause maggot infestation. During a concurrent observation and interview, on 10/22/20, at 2:30 p.m., with the Director of Nursing (DON), in the south hallway, near the exit door, the DON validated the window screen was not secured against the window, which caused a gap. Flies were observed entering the building through the gap. The DON stated, Those are flies. The DON went to the north hallway, near the exit doors, and observed a window that had a window screen present. The window screen was not secured against the window, which left a gap between the window and window screen. Resident 1 had access to the patio from his room via a sliding door that contained a door screen. The DON checked Resident 1's door screen. The door screen had a big hole on the screen. The DON stated she would notify maintenance to fix the door screen. During a concurrent observation and interview, on 10/26/20, at 11:25 a.m., with the Maintenance Supervisor/Director (MS), in Dining room [ROOM NUMBER], the flytrap attached to the wall was not functioning. The MS stated the activity staff moved their desk into Dining room [ROOM NUMBER] and unplugged the flytrap from the electrical outlet and used the electrical outlet to plug in their computer. The MS stated he was not aware the flytrap was unplugged in Dining room [ROOM NUMBER]. In the kitchen, the flytrap was not functioning. The MS validated the lights to the flytrap were not turned on, it was not functional. The MS stated he was not aware the flytrap in the kitchen was not functioning. The MS stated he did not know how long the flytraps had not been functioning. The MS stated he did not conduct routine checks in the facility to observe if flytraps were functioning properly. The MS stated he was not aware of the hole in Resident 1's screen door and gaps between the window and window screens on both south and north ends of the hallway until the ADM notified him on 10/22/20. The MS stated the screen doors were important to prevent flies from entering the building. During an interview on 10/26/20, at 1:48 p.m., with the ADM, the ADM stated the last time the facility had someone come to the facility to perform Pest Control service was in February 2020, before COVID-19 (a contagious serious respiratory infection transmitted from person to person). The ADM stated the facility did not have a contract with Pest Control to monitor the flytraps to determine if the flytraps were properly functioning, and the facility did not delegate anyone in the facility to monitor the flytraps to ensure if it was functioning properly. During a concurrent observation and interview, on 10/26/20, at 2:17 p.m., with LVN 2, inside Resident 4's room, a fly observed. LVN 2 stated, Yes that is a fly. LVN 2 stated Resident 4 has an open wound on her coccyx. During a concurrent observation and interview, on 10/26/20, at 2:48 p.m., with RN 4, inside Resident 8's room, a fly was observed. RN 4 stated, Yes that is a fly. That is not the only fly I have seen. I have seen flies here. During a concurrent observation and interview, on 10/26/20, at 2:50 p.m., inside Resident 8's room, Resident 8 stated, Yes, the fly landed on my shoulder, I have seen flies before. During an interview on 10/27/20, at 2:05 p.m., with Housekeeper (HK) 2, HK 2 stated she had seen flies inside the building. During an interview on 10/27/20, at 2:18 p.m., with CNA 2, CNA 2 stated she had seen flies inside the building. During a review of the facility document titled, (Name of Corporation) Healthcare Management, INC. (Incorporated) Job Description, dated 6/2018, the Job Description indicated, .Job Title: Maintenance Director . Ensures the building(s), equipment and utilities are maintained in good working order and facility grounds are properly maintained in accordance with facility policies and stated and Federal Regulations .Performs minor repairs and supervised the day-to-day repair, improvement and preventative maintenance of the building, equipment . arrange for and manage outside repairs . Ensures safety and sanitation practices and procedures are followed . During a review of (Name of Corporation) Healthcare Management, INC. Job Description, dated 6/2018, the Job Description indicated, Job Title: Administrator . Ensures that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical function status . Responsible for overall management and operations of the facility . During a review of the facility's policy and procedure (P&P) titled, Physical Environment Safe, Functional, Sanitary Environment dated 7/2018, the P&P indicated, Purpose: To provide a safe, functional, sanitary and comfortable environment for residents, staff and the public . The facility will maintain and effective pest control program to control pests .

Based on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 76) were free from accidents and injury when Certified Nursing Assistant (CNA) 1 and CNA 6 used a mechanical lift sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) past its manufactured recommended safe used by date of six months. The sling ripped during transfer and Resident 76 fell from the mechanical lift onto the floor and sustained a fracture (broken bone) of the right foot fifth toe. As a result of this failure, Resident 76 suffered a broken bone to the right foot fifth toe and was afraid to get out of bed in case of another fall. Findings: During a concurrent observation and interview with Resident 76, on 4/9/19, at 2:30 p.m., in Resident 76's room, Resident 76 laid in bed and stated, I stay in my bed because I fell from the sling way back. I can't remember the date I fell . During a review of the clinical record for Resident 76, the face sheet (a document containing resident profile information) undated, indicated Resident 76 was admitted to the facility with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 76, the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment dated [DATE], indicated Resident 76's Brief Interview for Mental Status (BIMS- assessment of cognitive (pertaining to reason, memory and judgement) status) score of 14 of 15 points indicated Resident 76 was cognitively intact. The MDS assessment also indicated Resident 76 required extensive assistance of two staff members to transfer from one surface to another. During an interview with CNA 6, on 4/10/19, at 9:28 a.m., CNA 6 stated she and CNA 1 used a mechanical lift with a sling to transfer Resident 76 back to bed from her wheelchair on 3/31/19 around 2 p.m. CNA 6 stated Resident 76 was suspended above the floor when the sling ripped and Resident 76 fell to the ground and landed on the floor on her bottom. CNA 6 stated, (The sling) ripped completely and was torn on both sides. (Resident 76) landed on her bottom. Our slings are universal. We check the sling every time we use it. (Resident 76) is 200 plus pounds. I'm not sure why it snapped. She was in her wheelchair and we were transferring her to the bed, maybe she was 5 feet high (from the floor). When we were transferring over, that's when it snapped. It just snapped out of nowhere. The bottom part of the sling is where it snapped. She fell downwards on the floor . During a review of the clinical record for Resident 76, the progress notes dated 3/31/19, at 2:14 p.m., indicated, . CNA reported that (Resident 76) fell during transfer in the mechanical lift when the sling broke. This nurse immediately went to (Resident 76's) room, wherein resident was lying on the floor at the foot of residents bed with 2 other CNAs. The mechanical lift was in front of resident with legs of lift still underneath her . CNA's stated loops on sling broke during transfer and resident's feet hit floor and CNA immediately grabbed resident in bear-hug type hold . (Resident 76) stated, I fell , the sling broke. I'm uncomfortable. I'm on the floor. It's cold. Get me off the floor . During a review of the clinical record for Resident 76, the foot x-ray dated 3/31/19, indicated, . Findings . Right foot: there is a nondisplaced (sic)(force causes the bone to crack or break but maintain its alignment) oblique (bone breaks diagonally) hairline fracture through the midportion of the fifth metatarsal (toe) . Impression . non displaced [MEDICAL CONDITION] metatarsal. Soft tissue swelling of the midfoot and the forefoot . During a concurrent interview and record review with the Maintenance Supervisor (MS), on 4/10/19, at 9:59 a.m., the MS reviewed the undated maintenance log for the slings used in the facility and stated the maintenance log did not identify the sling number for all the slings in the facility, dates when inspection occurred, the date the slings were new to the facility and the date the sling needed to be removed from use as indicated by the manufacturer's instructions. The MS stated he did not know the number of the sling that ripped while transferring Resident 76. The MS stated he did not know the date the sling was opened and used for the first time. The MS stated he did not know when the sling used on Resident 76 should have been discarded. The MS stated, I've been here a year. We have different sizes of sling. We bring in the new slings. I order some, central supply order some. The MS stated the facility policy was to discard the sling after 6 months of use as indicated by the manufacturer's instructions. The MS stated, (The facility) threw the sling (away). The (Director of Nursing) notified me when (the sling) broke. We don't have a process in place to check for the slings. I just check the sling, there is no process. There's no identifying mark which sling got checked. The MS stated it was important to track all the slings used in the facility to ensure they were not past the manufacturer's guidelines. The MS stated, the facility did not date the slings and did not have a process to check when the slings were past the manufactures specified period of safe recommended use (six months). During a review of the mechanical lift sling manufacturers recommendations titled Sling Maintenance Best Practices, dated 5/3/17, indicated, .Check condition before each use if there is any fraying or visible wear and tear, do not use .slings should be replaced every six months . During an interview with Central Supply Staff (CSS), on 4/10/19, at 11:22 a.m., the CSS stated, We have several slings in the building. My role is to order slings. I saw it broken (the sling that ripped). It was broken on the bottom . (after Resident 76's fall) I said, I hope it's not mine (sling). I still don't know if the (sling that ripped was a sling I ordered). During an interview with the Administrator (ADM), on 4/10/19, at 2:14 p.m., the ADM stated prior to Resident 76's fall, the facility did not have a process in place or documented assessment for the facility to track and identify the slings used during a mechanical lift transfer. The ADM stated he did not know the sling number of the sling that ripped during Resident 76's transfer or the date when the sling was first used in the facility. The ADM stated he did not know if the sling that ripped during Resident 76's transfer was past the date of manufacturer's recommended use. The MS stated the facility did not have a process to date slings and track the six month manufactures recommended safe use. The ADM stated, There is no system in place .It (sling that ripped with Resident 76) was one of the slings we were looking to replace. The ADM stated, The system was flawed. I could not prove that we logged the (sling) number. When we look at maintenance log, there is a flaw in the system . There is no system in place. I know we have to have a system. The ADM stated there was a total of 22 slings being used in the facility. The ADM stated he recognized it was very important to track and identify all the slings used in the facility to ensure slings were not being used past the manufacturer's recommendations (six months). The facility policy and procedure titled, Safe Lifting and Movement of Residents dated 12/13, indicated, . In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . 1. Resident safety . will be incorporated into goals and decisions regarding the safe lifting and moving of residents . 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . 8. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings. 9. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 10. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints . During an interview with CNA 1, on 4/10/19, at 2:26 p.m., CNA 1 stated he was one of the CNA's who assisted Resident 76 with the transfer from the wheelchair to the bed. CNA 1 stated, . It happened on the morning shift . We got her up from her bed in the chair around 9:30 am. We used the universal sling. Universal sling is used for residents who weigh up to 400 or 450 lbs. (while Resident 76 was being transferred and was dangling in the air) It ripped in the bottom. I can't recall right now if there is a date (on the sling). (Resident 76) was more frightened after the fall. She was scared because she screamed. The two metal hooks were on her feet, the sling loops were the two that gave out and her feet were on the ground. She was about 3 feet off the floor when she fell . CNA 1 stated it was the CNA's responsibility to inspect the slings used to transfer residents that they were not used past the date on the manufacturer's recommendation. CNA 1 stated the slings were not labeled with a date. During an interview with the Director of Staff Development (DSD), on 4/10/19, at 3:14 p.m., the DSD stated she saw the sling that was ripped during Resident 76's transfer. The DSD stated she did not know the date when the sling was new. The DSD stated it was important for all the slings to be dated to ensure slings were not past the manufacturer's recommended date of use. The DSD stated, I did see the sling (that ripped during Resident 76's transfer). It looked like it was cut in half . During an interview with the Director of Nurses (DON), on 4/10/19, at 3:31 p.m., the DON stated she threw the ripped sling away after Resident 76's transfer and fall. The DON produced a picture she stated she took of the sling on 3/31/19 which she showed to the surveyor. The DON stated there was no date on the sling that ripped to indicate when it was new and used for the first time. There was no identifier mark on the sling that ripped to differentiate the sling from other slings. The DON stated prior to Resident 76's fall, the facility did not have a system or process in place to track all the slings to ensure they were not past the manufacturer's recommended date of use (six months). The DON stated, There was no actual system in place. We noticed there was a flaw. We made a list of all the slings. We started replacing the old ones. I don't remember if there was a number on the sling. Honestly I don't know. I marked all the (slings) I wanted to keep. I'm not sure if it was one of the slings that I marked. There was no way to know how old the slings are. The manufacturer recommends 6 months. We follow the manufacturer's recommendations. I've never had a sling that ripped before so I was very surprised of what happened. The DON stated it was very important to have a system and process in place to determine and track all the slings used in the facility. The DON stated the slings used in the facility should be documented, inspected, dated when opened and discarded after six months per manufacturer's recommendations to ensure resident safety during transfers with the sling. During a telephone interview with the Medical Supplies Sales Representative (MSR), on 4/10/19, at 4:37 p.m., the MSR stated, I've never experienced a sling ripped . The MSR stated he was unable to find the date the sling was purchased by the facility. During an interview with CNA 2, on 4/11/19, at 8:17 a.m., CNA 2 stated, The charge nurse will let us know if there are new slings. I don't remember exactly when was the last time the slings were replaced. CNA 2 stated slings should have a date when it was first opened and the slings did not have dates. During an interview with Licensed Vocational Nurse (LVN) 1, on 4/11/19, at 8:32 a.m., LVN 1 stated, I have been an RNA (Restorative Nursing Assistant-helps with rehabilitation exercises) for [AGE] years and I have been an LVN for 3 years. New slings go straight to the laundry to be washed and that's where they are kept. That's where they store them. They don't usually tell me if there's a new sling. I don't know how many slings there are in the facility. The only way I would know is to ask central supply. During an interview with CNA 4, on 4/11/19, at 8:37 a.m., CNA 4 stated, I don't remember the last new sling that was purchased by the facility. I have been here since (YEAR). (Some of the slings), you can't read the tag on the slings because the slings are old. Nobody tells us if there is a new sling in the building. We had old slings . it's (sling) worn out. One time the standup slings did not have hooks to fasten so I just tied it (sling edges) around the mechanical lift so the resident won't fall. During a review of the mechanical lift sling manufacturers recommendations titled Sling Maintenance Best Practices, dated 5/3/17, indicated, .Check condition before each use if there is any fraying or visible wear and tear, do not use .slings should be replaced every six months . The facility policy and procedure titled, Falls and Fall Risk, dated 12/07, indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling . The facility policy and procedure titled, Safe Lifting and Movement of Residents dated 12/13, indicated, . In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents . 1. Resident safety . will be incorporated into goals and decisions regarding the safe lifting and moving of residents . 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . 8. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings. 9. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 10. All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints .

Based on staff, resident and family interviews, clinical record and administrative document review, the facility failed to review and revise the comprehensive plan of care for 1 of 2 Residents sampled (Resident 2) after Resident 2 had a change in functional status which required staff assistance when using a wheelchair. This failure resulted in a fall of Resident 2 from the wheelchair, while unassisted outdoors, and sustained a fracture to the lower leg. Findings: Review of Entity Reported Incident (ERI) dated 8/27/14, indicated an event which occurred on 8/24/14 at 9:36 a.m. as follows: Passerby came into facility stating that resident who is wheelchair (w/c) bound was on the ground outside the facility. Resident was found flat on back and complaining of lower extremity (leg) pain. Resident stated she was outside on the paved sidewalk getting sunshine when her wheelchair went straight instead of turning left, gaining momentum she fell from the wheelchair when it reached the curb which caused resident to fall into street. The document indicated an Xray showed acute fracture (break in bone) of the tibia (lower leg bone) with no displacement. Review of the facility investigation documented as an ERI the form indicated an interview with the Director of Nursing (DON) on 8/27/14 had revealed: DON stated .Resident had an electric w/c up until last month when the resident hit a sliding glass door in the facility and staff felt she was unable to control the electric wheelchair so they gave her a manual (w/c). Resident has left sided [MEDICAL CONDITION] (one sided [DIAGNOSES REDACTED]) due to [MEDICAL CONDITIONS] (stroke-damage to the brain caused by a disruption of the blood supply to a part of the brain). Resident developed a blood clot in the leg and is now in the (Acute Care Hospital 2) for monitoring . The facility, Verification of Investigation Report (VIR) indicated Resident 2 can't remember why she went straight on the sidewalk instead of left toward the front door. The VIR indicated Resident 2 stated the pavement had a decline and Resident 2's wheelchair veered toward the area of the decline, the resident rolled off and fell from the chair. The VIR indicted a passerby entered the facility and called out to staff, Resident 2 had fallen outside. The VIR indicated Licensed Nurse (LN) 4 and LN 5 responded and found Resident 2 lying on her back, on the pavement at the curb. The VIR indicated Resident 2 thought the Activity Associate (AA) was assisting her by pushing the wheelchair from behind, but when she noticed her wheelchair was going too fast she informed the AA and received no response, realizing the AA was not behind her. The VIR indicated Resident 2 complained of pain to the LLE. The VIR indicated an X-ray of Resident 2's Left Ankle revealed a proximal tibia fracture. The VIR indicated, Resident 2 was wheelchair bound, had decreased activity tolerance, with left sided weakness due to late effects of a [MEDICAL CONDITION]. Review of Resident 2's Annual Minimum Data Set Assessment (MDS) (an assessment tool used in nursing homes to identify functional abilities and health problems) dated 5/1/14, and 8/1/14, Quarterly Assessment was done. On the annual assessment, dated, 5/1/14, Section C, Brief Interview for Mental Status (BIMS) documented a score of 15 (a score of 15 indicated no cognitive impairment) which indicated Resident 2 had the ability to recall without cues. The MDS dated [DATE], Resident 2's BIM score was 11 which indicated Resident 2 had declined in the mental status score. The MDS dated [DATE] indicated Resident 2 required two or more persons for physical assistance. On 8/1/14 the MDS indicated Resident 2 required total dependence with full staff performance which reflected a decline in functional status. On 5/1/14, in the section of the MDS titled, Care Area Assessment (CAA) (items which indicated if a new or revised care plan would be necessary) indicated all areas were checked under activities of daily living, physical function, and falls that indicated the care plan should have been reviewed and revised. Review of the Care Plan (CP), undated, indicated Resident 2 had a history of [REDACTED]. Review of Resident 2's Fall Risk Assessment dated 6/14/14 indicated Fall Risk Score of 11. Score of 10 or more indicates higher risk for falls and must be care planned. On 8/9/14 a Fall Risk Score of 15 was documented. On 8/27/14 at 3:15 p.m., during an interview, Interim DON (IDON) stated Resident 2 was outside the facility unsupervised on the day of the fall from the wheelchair, No one is scheduled to be out here to watch residents. The IDON stated Resident 2 was Lying on the street with the wheelchair next to her. On 8/27/14 at 4:40 p.m., during an interview, Resident 4 stated she observed Resident 2 fall from her electric wheelchair about a month ago. Resident 4 stated, No one comes out to supervise the residents outside. On 9/4/14 at 4 p.m., during an interview, Resident 2's Responsible Party (RP) stated, They (facility staff) took (Resident 2's) electric wheelchair away . they did not think she was safe in it .I was told (Resident 2) had been leaving the premises I was called whenever she went to (fast food restaurant). Review of Resident 2's Social Service notes dated 8/6/14 at 10:31 a.m., indicated, . Nursing staff has suggested (Resident 2) not use the electric wheelchair . (Resident 2) has been using a manual wheelchair since the elopement. (Resident 2) has left sided weakness and staff assist with propelling (Resident 2) around the facility as (Resident 2) chooses. On 9/4/14 at 4:10 p.m., during a concurrent interview, Resident 2 stated she went to (fast food restaurant) (across the street). Resident 2 stated she thought (Activities Aide) was behind her when she fell outside. The RP stated she had been notified when Resident 2 had crossed the street at the facility to go to the (fast food restaurant). On 6/16/15 at 12:45 p.m., during an interview, Certified Nursing Assistant (CNA) 3 stated, I was the one that found her .a car stopped to block other cars and to see if (Resident 2) was alright. CNA 3 stated she became aware of Resident 2's fall when a passerby stopped, came into the facility and called for help because one of the residents was on the road. CNA 3 stated she found Resident 2 outside on the pavement. CNA 3 stated she used her cell phone to call LN 4. CNA 3 stated (Resident 2) told me something hurt. CNA 3 stated (Resident 2) would always go outside .everyday . (Resident 2) wasn't supervised . On 6/16/15 at 1:15 p.m., during an interview, License Nurse 2 (LN 2) stated (Resident 2) would let me know if she was going out .before the fall (Resident 2) would have little memory lapses . (Resident 2) was already forgetting time, days .and was already forgetful . LN 2 stated Resident 2 had a history of [REDACTED]. LN 2 stated, One time (Resident 2) got stuck in the garden area . We had to pull her out. LN 2 stated a staff member called her once telling her (Resident 2) was at the fast food restaurant parking lot unattended. LN 2 stated there had been no revision of the nursing care plan to reflect a change of status of Resident 2 in functional and cognitive ability which would have required staff assistance with mobility. Upon inquiry of Resident 2's fall into the public street on 8/24/14, LN 2 stated I assessed (Resident 2) .(Resident 2) had some soft tissue swelling on the left leg so she got an order for [REDACTED]. On 6/16/15 at 2 p.m., during an interview and concurrent record review, the Unit Manager stated (Resident 2) would go outside unsupervised. The care plan for Resident 2 was reviewed. The Unit Manager stated, I do not recall doing anything with Resident 2's care plan .there is no revision dates on the care plan except for the dates after the fall from the wheelchair when the resident fell and fractured her leg. On 6/18/15 at 4:29 p.m., during a telephone interview, Resident 2's Responsible Party (RP) stated, Resident 2 was always allowed to go outside unsupervised. Resident 2's RP stated, After I picked up her electric wheelchair, they told me they (facility) were going to put the alarm on and supervise her and they never did. The RP stated before the fall, the staff told her Resident 2 wasn't capable of having the motorized wheelchair.

Based on staff and resident interview, clinical record and administrative document review, the facility failed to ensure 1 of 1 sampled residents (Resident 1), who was identified as a high risk for falls was provided the 2 person assistance needed to prevent her from falling out of bed, when Resident 1 fell out of bed as Certified Nursing Assistant (CNA) 1 provided care unassisted. This failure caused Resident 1 to sustain a hip fracture and laceration to the forehead which required an emergency transport to the hospital for sutures, a surgical procedure, and increased pain. Finding: On 8/11/14 at 2:50 p.m., during an interview, Licensed Nurse 1 (LN) stated she had investigated Resident 1's fall which occurred on 8/9/14. LN 1 stated, CNA 1 was performing personal care and a bed linen change while the resident was in bed when Resident 1 fell out of bed and sustained injuries. LN 1 stated, I think she is a two person assist. On 8/13/14 at 2:10 p.m., during a telephone interview, Resident 1's family member stated, They (facility) had one CNA handling (Resident 1) and they need two CNAs for a woman of her size. On 8/13/14 at 2:45 p.m., during a telephone interview, CNA 1 stated, she worked at the facility for approximately 1 month. CNA 1 stated No one (staff) ever told me (Resident 1) was a two person assist (required two people to provide resident care). CNA 1 stated, (CNA 2) told me she cares for (Resident 1) by herself. CNA 1 stated, a sign posted on Resident 1's door indicated Resident 1 required staff assistance or how many staff were required to provide Resident 1's care, It doesn't (indicate) 1 person assist or 2 person. CNA 1 stated, during the new-hire orientation, the CNA trainer told CNA 1, Residents which require 2 person assistance for care can be done by 1 person,You can do (Residents requiring 2 person assistance) on your own. CNA 1 stated, I asked (LN 1) for help before I went in (Resident 1's room) .(LN 1) said she would send someone to help me but she never did .no one ever showed up to help me CNA 1 stated on 8/9/14 while Resident 1 was in her bed, CNA 1 attempted to change Resident 1's bedding and brief without another person's assistance, using a technique of turning Resident 1 from side to side, when Resident 1 fell out of bed, I started on the right side, got the sheets (under Resident 1) and (turning Resident 1) to the left, I rolled (Resident 1) closer to me on her right side, (Resident 1's) back was facing me, (Resident 1) reached for the dresser on the right side of her bed with her right arm .I had my arm on her, but she fell . face down to the floor. On 8/27/14 at 2:32 p.m., during an interview, Resident 1 stated she had fallen and broken her hip. Resident 1 stated, the facility should have sent two people to help CNA 1. Resident 1 stated, I can't remember them ever sending two people to help me. I am a large woman. On 8/27/14 at 3 p.m., during an interview, CNA 1 stated she did not receive training on repositioning residents in bed. CNA 1 stated during orientation, you see how (other CNAs) do it (repositioning) and that's how you do it. On 8/27/14 at 3:30 p.m., during an interview, LN 1 stated CNA 1 asked (LN 1) for help with providing care for Resident 1 about a half hour before Resident 1's fall. LN 1 stated I did convey (the message to help CNA 1) to another CNA (CNA 2), I'm not sure if she went to help her. Review of Resident 1's Quarterly Minimum Data Set Assessment (MDS) (a federally mandated assessment of residents in a nursing home to identify cognitive , functional abilities and health problems), dated 4/22/14, in the section under, Brief Interview for Mental Status (BIMS) indicated a score of 9. (A score of 9 indicated Resident 1 had the ability to recall without cues given by the staff performing the assessment.) The assessment indicated Resident 1's functional status for bed mobility scored a 3. A score of 3 indicated extensive assistance was needed by Resident 1 and two or more persons were needed for physical assistance. The assessment indicated Resident 1 weighed 224 pounds. Resident 1's Fall Risk Assessment, dated 6/29/14, indicated Resident 1 had a fall risk score of 12. A score of 10 or more indicated a higher risk for falls and a care plan must be initiated. On 8/9/14 a Fall Risk Assessment was completed for Resident 1 which indicated Resident 1 was at a higher risk for falls as indicated by a score of 15. On 8/27/14 at 4:30 p.m., during an interview, CNA 2 stated LN 1 did not ask her to help CNA 1 the day Resident 1's fell . CNA 2 stated she was in a nearby resident room when she heard a scream from Resident 1's room. CNA 2 stated she went into Resident 1's room to help and she saw Resident 1 on the floor. Resident 1's Clinical Notes, dated 8/9/14, indicated LN 1 found Resident 1 lying on the floor face down and bleeding from her forehead. The document indicated at 9:15 a.m., LN 1 called for help, assessed Resident 1 for injuries and applied a pressure dressing to the forehead to stop the bleeding. The unit manager then called 911. The document indicated, Possible of fracture as resident complained pain to lower extremity. On 8/9/14 at 9:35 a.m., Resident 1 was transferred to the acute care hospital (ACH 1) ER (emergency room ) by ambulance. Resident 1's report from ACH 1, titled, Meditech Report 0809-0105, dated 8/9/14, dictated by the Medical Doctor (MD), indicated under Medical Decision Making, The patient presents status [REDACTED]. The patient had CT's (Computerized Tomography - specialized three dimensional X-ray) of the head, cervical spine, and bilateral (both sides) hands and pelvis ordered because she has a large laceration on her forehead which is approximately 5 cm (centimeters-a method of measurement) horizontal which was sutured up with 3-0 nylon, approximately 10 sutures sewn by myself .and she does have a right hip fracture . Under the section Disposition, the document contained, In serious condition, she will be transferred to ( .ACH 2) for further evaluation for Ortho (orthopedics, bone specialty). Resident 1's transfer report from ACH 2 indicated, Resident 1 was admitted on [DATE] for a right hip fracture. The X-ray result dated 8/10/14 indicated, Impression: Right hip severe acute comminuted fracture (A fracture in which the bone is splintered, crushed, or broken into pieces). Resident 1 had a surgical procedure, Open Reduction Internal Fixation (ORIF) (hip surgery to repair fracture) of right hip on 8/12/14. Resident 1 was discharged from ACH 2, back to the facility on [DATE] . Review of Resident 1's Medication Administration Record (MAR) dated 8/1/14 to 8/8/14 indicated Resident 1's pain level: 0 which indicated No pain. Review of Resident 1's MDS readmission assessment dated , 8/28/14 indicated under Pain Frequency .almost constantly . Under Pain Intensity Resident 1's pain level was rated a 10 (0 being no pain and 10 being worst pain). Pain Effect on Function indicated, Resident 1's pain made it hard to sleep. The facility's administrative document titled, Prevention & Minimization of Serious Accidents, dated, 12/09 indicated, The facility must ensure that the resident's environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent/minimize serious accidents .