Every finding on record at Golden San Andreas Care Center

Based on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella (a serious lung infection) and other opportunistic waterborne pathogens (a microorganism (bacteria) that exists in water sources or plumbing (pipes required for the water supply, heating and sanitation in a building) systems that can cause serious illness in people over [AGE] years of age and have weakened immune systems) for a census of 82 when:a. The facility did not implement environmental control measures (actions and procedures implemented to reduce or eliminate exposure to risks or hazards) until the day after they were informed of a resident testing positive for legionella infection; and,b. The facility did not update their water management policy to include current Centers for Disease Control (CDC-the national public health agency of the United States) guidelines.These failures put the residents and staff at risk of potential Legionella and other opportunistic waterborne pathogen exposure, threatening their health and well-being.Findings:During an interview on 8/26/26 at 9:18 AM, with the Facility Administrator (ADM), the ADM stated she had called the Department the previous night to report that one of the facility residents had tested positive for legionella's disease.During an observation on 8/26/26 at 9:45 AM, on Unit C, water pitchers were observed on the residents' bedside tables. During an observation on 8/26/26 at 9:47 AM, on Unit A, water pitchers were observed on the residents' bedside tables. During an observation on 8/26/26 at 9:48 AM, on Unit B, water pitchers were observed on the residents' bedside tables. During an interview on 8/26/26 at 10:01 AM, with the infection preventionist (IP), the IP stated Patient 3 had been sent to the hospital with respiratory symptoms on 8/23/26 and returned to the facility on 8/24/26. The IP further stated she received a phone call on 8/25/26 at approximately 5:12 PM, from facility staff, to report Resident 3 had tested positive for legionella. The IP stated she was currently in the process of testing all residents who had respiratory symptoms over the last 30 days. The IP stated the facility had obtained bottled water, and the maintenance department was putting filters on the faucets and shower heads.During an observation on 8/26/26 at 10:15 AM, staff were removing water pitchers from resident rooms and providing bottled water.During an observation on 8/26/26 at 1:28 PM, maintenance staff were observed on Unit B with a rolling cart that contained filters and shower heads.During an interview on 8/26/26 at 4:35 PM, with the ADM, the ADM stated the IP called her at approximately 5:30 PM on 8/25/26, to report Resident 3 had tested positive for legionella. The ADM further stated she then called the Department, the County Public Health office and her corporate office and left voice mails. The ADM stated she notified the residents and their families on 8/26/26. The ADM stated the facility had protocols in place and performed a yearly legionnaires risk assessment. The ADM stated the facility did not implement control measures on 8/25/26 because they were waiting for guidance from the County Public health office.During an interview on 8/28/26 at 9:11 AM, with the ADM, the ADM stated the facility water management policy, dated 5/20/15, was reviewed annually. The ADM further stated she was unaware why the CDC link (a hyperlink pointing to the official CDC website or a data connection used in public health research) included in the policy was from 2003. The ADM stated the facility used the policy that was provided by their corporate office.During an interview on 8/28/26 at 9:33 AM, with the IP, the IP stated legionella was spread through water, ice machines, sinks, and showers, and anywhere there was water. The IP further stated once per year the facility reviewed their water management process and policy. The IP stated the facility had a checklist they used to guide them during this incident. The IP stated at approximately 10 AM on 8/26/26, the shower rooms were shut down, water pitchers were replaced with water bottles, filters were applied to faucets and shower heads, and hand sanitizer and wipes were supplied in all bathrooms and patient rooms. The IP confirmed the facility waited until 8/26/26 to initiate control measures after being informed of Resident 3s positive test result on 8/25/26. The IP stated exposure to the water from the showers and sinks put the residents at risk of respiratory distress caused by pneumonia from legionnaire bacteria.During a review of the facility provided document titled, LEGIONAIRES DISEASE CHECKLIST, dated June 2026, the document indicated, .STEP-ENVIRONMENTAL CONTROL MEASURES.The facility coordinates with the Health Department to conduct an environmental assessment.Shut down water to potential sources of exposure.Showers.Ice Machines.Hand sinks in Resident rooms.Water will remain off until operation is approved by the Health Department.During an interview on 8/28/26 at 10:29 AM, with the Public Health Department (PHD), the PHD stated the IP reached out to them to ensure the facility adhered to the appropriate protocols. The PDH stated they reviewed guidance, expectations, testing protocols and told the facility to review their water management plan to ensure proper protocols were in place. The PHD stated it was important for the facility to have initiated their mitigation protocol initially when they discovered the issue to prevent the potential spread of infection.A review of the facility provided policy titled, Water Supply, dated 5/2015, indicated, .The Center handles and maintains its water supply in accordance with recommendations of the CDC, The Healthcare Infection Control Practices Advisory Committee and the FDA [Federal Drug Administration] to maintain a sanitary water supply and control the spread of waterborne microorganisms.Resources: CDC's Guidelines for Environmental Infection Control In Healthcare Facilities, www.cdc.gov/mmwr/PDF/rr/rr5210.pdf [dated 6/6/2003] .A review of the CDC's online guide titled Overview of Water Management Programs, published March 15, 2024, indicated, .Key Points.Many buildings need a water management program (WMP) for their building water system.WMPs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens.Developing and maintaining a WMP is a multi-step process that requires continuous review.Seven steps of a Legionella WMP are to: 1. Establish a WMP team 2. Describe the building water systems 3. Identify areas where Legionella could grow and spread 4. Decide where to apply and how to monitor control measures 5. Establish interventions when control limits aren't met 6. Ensure the program runs as designed and is effective 7. Document and communicate all activities.the principle of effective water management include: Ensuring adequate disinfection.Maintaining devices to prevent.Sediment, Scale, Corrosion, Biofilm.Maintaining water temperatures to limit Legionella growth, preventing water stagnation.Once established, WMPs require regular monitoring of key areas for potentially hazardous conditions. The programs use predetermined responses to respond when control measures aren't met.Each program has to be tailored for each building at a particular point in time.In some settings, the entire building needs a WMP: Hospitals and long-term care facilities.https://www.cdc.gov/control-legionella/php/wmp/index.html

Based on interview and record review, the facility failed to ensure COVID-19 point-of-care testing (rapid testing performed at the resident location with immediate results) was performed in accordance with manufacturer instructions and applicable federal requirements by using expired iHealth COVID-19/Flu A&B Rapid Test Kits (brand name COVID-19 at home/rapid tests) to evaluate three residents (Residents 1, 2, and 3) for COVID-19, for a census of 84.This failure resulted in resident care decisions being based on test results obtained from expired test kits and had the potential to produce inaccurate COVID-19 test results, including false-positive or false-negative results, which could affect the timely implementation of infection prevention and control measures and resident care.Findings:During a concurrent interview and record review on 8/4/26 at 2:16 PM with the Infection Preventionist (IP), the IP stated the facility did not have any COVID-19 test kits because all available test kits had expired. Record review of a 7/30/26 email from the local health department showed the facility was advised not to use the expired iHealth COVID-19/Flu A&B Rapid Test Kits with lot numbers 242CF10828 and 241CO20924 remaining on hand because neither the local health department nor the California Department of Public Health (CDPH) could authorize the use of test kits beyond their Food and Drug Administration (FDA-a federal agency under the Department of Health and Human Services)-authorized expiration dates. During a phone interview on 8/5/26 at 2:04 PM with the IP, Director of Nursing (DON), Registered Nurse Supervisor (RNS) and Nurse Manager (NM), the IP stated she was unsure whether resident COVID-19 tests were performed using the identified expired iHealth COVID-19/Flu A&B Rapid Test Kits with lot numbers 242CF10828 or 241CO20924. The IP stated she was unsure because the facility documented only the test results and did not document the manufacturer, lot number, or expiration date of the test kits used. The IP further stated the facility did not maintain documentation identifying which COVID-19 test kit was used for each resident. When asked what test kits the facility used to test Residents 1, 2, and 3 listed on the line list (a tracking document used to monitor people with suspected or confirmed COVID-19 cases), the IP stated expired COVID-19 test kits were used to test Resident 1 on 7/26/26, Resident 3 on 7/29/26, and Resident 2 on 7/29/26. The IP stated she personally performed the tests for Residents 2 and 3, while the RNS performed the test for Resident 1. The IP also stated she did not verify whether the identified iHealth COVID-19/Flu A&B Rapid Test kits had an FDA-authorized extended expiration date before using the test kits and believed she first realized the test kits had expired on or about 7/29/26. The IP further stated the test results obtained from the expired COVID-19 test kits were reported to the National Healthcare Safety Network (NHSN-healthcare-associated infection tracking system) and the local health department. During the same interview, the DON stated that resident care decisions were made based on the COVID-19 test results obtained from the expired COVID-19 test kits.During a record review of the same 7/30/26 email from the local health department, the email further indicated that facilities holding a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver (allows a facility to legally perform simple, low-risk diagnostic tests) were required to follow the manufacturer's instructions and that expired COVID-19 test kits should not be used for diagnostic testing, serial outbreak testing, or reportable testing. During a record review of the facility's Clinical laboratory Improvement Amendments (CLIA) Certificate of Waiver, dated 9/1/24, the certificate indicated the facility held a CLIA Certificate of Waiver that was valid at the time the expired COVID-19 test kits were used.During a phone interview on 8/6/26 at 8:27 AM with a representative of the local health department, the representative stated that use of an expired COVID-19 point-of-care test kit could affect the validity and reliability of the test results, potentially resulting in false-positive or false-negative results. During a review of the facility's policy titled, Outbreak of Communicable Diseases, updated 4/22/25, the policy indicated, .The facility identifies and manages infectious outbreaks in accordance with standards of practice as established by federal, state and local guidance.

Based on interviews and record reviews, the facility failed to ensure timely procurement and administration of physician-ordered medications for one of three sampled residents (Resident 1), when the facility did not timely coordinate with the pharmacy, physician, and hospice (comfort-focused care for a person with a terminal illness) staff after Resident 1's ordered medications were unavailable upon admission.This deficient practice resulted in Resident 1 missing three doses of Seroquel (a medication used for mood or behavior symptoms) and two doses of Sertraline (a medication used for mood symptoms) from 9/4/25 through 9/6/25 and placed the resident at risk for unmanaged mood and behavior symptoms.FINDINGS:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility on [DATE] for respite care (short-term facility care provided to give the caregiver temporary relief) with multiple diagnoses including depression (low mood or sadness), delusional disorder (a condition that can affect thoughts or beliefs), and anxiety disorder (worry or nervousness).Review of Resident 1's Order Summary Report, indicated Resident 1 had a physician orders for the following: Sertraline HCl Oral Tablet 50 milligrams (mg; a unit of measurement): Give 1 tablet by mouth one time a day for m/b [manifested by] crying lasting >5 [greater than] minutes related to DEPRESSION . with a start date of 9/5/25. Seroquel Oral Tablet 25 mg: Give 0.25 tablet by mouth one time a day for m/b visual hallucinations [seeing things that are not there] related to DELUSIONAL DISORDERS . with a start date of 9/4/25. Review of Resident 1's September 2025 Medication Administration Record (MAR - a document used to record medications administered or not administered) indicated Resident 1 did not receive the following physician-ordered medications:Seroquel Oral Tablet 25 mg on 9/4/25, 9/5/25, and 9/6/25.Sertraline HCl Oral Tablet 50 mg on 9/5/25 and 9/6/25.During a concurrent interview and record review on 7/7/26, at 1:31 p.m., Resident 1's September 2025 MAR, Progress Notes, and Physician Orders were reviewed with Licensed Nurse (LN 1). LN 1 verified Resident 1 did not receive Seroquel Oral Tablet 25 mg on 9/4/25, 9/5/25, and 9/6/25. LN 1 also verified Resident 1 did not receive Sertraline HCl Oral Tablet 50 mg on 9/5/25 and 9/6/25. LN 1 stated she documented the medications as refused but acknowledged the medications were unavailable at the time. LN 1 reviewed Resident 1's progress notes and verified there was no documentation indicating the physician, hospice staff, or pharmacy was notified of the missed doses. LN 1 stated she should have called the physician, hospice staff, or pharmacy. LN 1 further stated staff could have checked the CUBEX (an automated medication dispensing system) for Sertraline availability and obtained physician direction regarding the missed dose.During an interview on 7/7/26, at 11:18 a.m., the Registered Nurse Supervisor (RN 1) stated medications in the facility's CUBEX could be used for residents when needed. RN 1 verified the CUBEX contained Sertraline 25 mg, with eight tablets available, and Risperidone (medication used for mood or behavior symptoms) 0.5 mg, with eight tablets available. RN 1 stated staff were expected to notify the physician when a medication was unavailable. RN 1 further stated an alternate medication could be ordered by the physician while staff waited for delivery from the pharmacy.During an interview and record review on 7/7/26, at 3:12 p.m., Resident 1's September 2025 MAR and Progress Notes was reviewed with RN 1. RN 1 verified Resident 1 missed doses of Seroquel on 9/4/25, 9/5/25, and 9/6/25 and Sertraline on 9/5/25 and 9/6/25. RN 1 verified there was no documentation that staff notified the hospice team, physician, or pharmacy regarding the missed medications. RN 1 stated the expectation for missed medications was for staff to notify the physician and, if the resident was receiving hospice services, to notify the hospice team and pharmacy. RN 1 stated missed behavior medications placed the resident at risk for uncontrolled behaviors.During a telephone interview and record review on 7/8/26, at 9:34 a.m., Resident 1's September 2025 MAR and Progress Notes were reviewed with the Pharmacy Consultant (PC 1). PC 1 verified missed medications doses for Seroquel and Sertraline. PC 1 also verified there was no documentation that staff notified the physician, pharmacist, or hospice staff regarding the missed doses on the days the medications were not administered. PC 1 stated that when a resident is admitted and an ordered medication is not available, staff are expected to call the pharmacy and physician. PC 1 stated missed behavior medications place residents at risk for recurrence of behavior symptoms. PC 1 further stated missed medications should be administered as soon as possible.Review of facility's policy titled, Medication Ordering and Receiving from Pharmacy, effective 1/22, indicated, .Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt . 3. New medications, except for emergency or 'stat' medications, are ordered as follows: a. If needed before the next regular delivery, inform pharmacy of the need for prompt delivery; b. The emergency kit or emergency drug supply as applicable is used when the resident needs a medication prior to pharmacy delivery .Review of facility's policy titled, Hospice - Provision of Care by Outside Providers, updated 9/17, indicated, . 1. Prior to admission of a resident receiving hospice services by an outside provider, service coordination is agreed upon indicating each party's responsibilities. This may include, but is not limited to: medications .and notifying physicians.4. Medications, medical supplies, and services are provided as indicated by the agreement for coordination of services.

Based on interviews and record reviews, the facility failed to develop person-centered interventions for a fall care plan for one of three sampled residents (Resident 1), when Resident 1 had a witnessed fall from her wheelchair on 9/7/25, struck her head, and the facility revised the care plan to only include alert charting for 72 hours (a documentation process used to track changes in a resident's health) without including an intervention which would address Resident 1's specific fall risk of pitching forward from the wheelchair prior to Resident 1 sustaining a second fall approximately two hours later on 9/7/25. This deficient practice resulted in Resident 1's care plan not including an individualized intervention to address the resident's specific fall risk and had the potential to result in additional falls.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility on [DATE] for respite care (short-term facility care provided to give the usual caregiver temporary relief) while receiving hospice services (comfort-focused care for a person with a terminal illness) with multiple diagnoses including depression (low mood or sadness), delusional disorder (a condition that can affect thoughts or beliefs), and anxiety disorder (worry or nervousness).Review of Resident 1's Progress Note dated 9/7/25, at 9:08 p.m., indicated the Licensed Nurse (LN 2) and Certified Nursing Assistant (CNA) had just readjusted Resident 1 in her wheelchair when the CNA started pushing Resident 1 down the hall in a wheelchair. Resident 1's progress note indicated Resident 1 pitched forward and fell face first onto the floor. The progress note further indicated Resident 1 hit the top of her head and sustained a small cut to the bridge of the nose and a bruise to the top of the forehead.Review of Resident 1's actual fall care plans, both dated 9/7/25 and Resident 1's progress notes related to Resident 1's fall, dated 9/7/25, showed staff added an intervention of alert charting for 72 hours after Resident 1's first fall. Resident 1's care plans and progress notes did not show the facility identified the root cause of the first fall or document how alert charting addressed Resident 1's specific risk of pitching forward from the wheelchair prior to the second fall.Review of Resident 1's progress note dated 9/7/25, at 11:06 p.m., indicated Resident 1 again pitched forward and fell face first onto the floor and hit the top of her head.During a concurrent interview and record review on 7/7/26, at 1:31 p.m., Resident 1's fall risk care plan, initiated 9/4/25 and actual fall care plans, both initiated on 9/7/25, was reviewed with Licensed Nurse (LN 1). LN 1 stated that after a resident fell, staff notified the physician, the family, the Director of Nursing, and the Administrator. LN 1 stated staff would then complete 72-hour charting and update the care plan. LN 1 reviewed Resident 1's fall care plan and stated alert charting for 72 hours was the facility's standard process after a fall. LN 1 stated alert charting documents staff monitoring after a fall but does not, by itself, reduce a resident's risk for another fall.During an interview and record review on 7/7/26, at 3:12 p.m., Resident 1's actual fall care plans, dated 9/7/25, were reviewed with the Registered Nurse Supervisor (RN 1). RN 1 verified the care plan was updated after the first fall on 9/7/25 to include alert charting. RN 1 stated alert charting was already being done because Resident 1 was a new admission for respite care from 9/4/25 through 9/9/25. RN 1 stated she was unsure whether the intervention was effective in preventing the second fall approximately two hours later.During a telephone interview on 7/14/26, at 7:11 p.m., with the Licensed Nurse (LN 2), LN 2 stated Resident 1's first fall on 9/7/25 occurred after both her and the CNA readjusted Resident 1 in her wheelchair because Resident 1 was sloping. LN 2 stated Resident 1 lurched forward while being pushed by the CNA in the hallway and fell out of the wheelchair. LN 2 stated she completed the initial neurological checks ( brief, physical, and cognitive evaluations to quickly assess how well a person's brain and nervous system are functioning), updated Resident 1's fall care plan, and implemented an intervention of alert charting for 72 hours following the fall. LN 2 was unable to explain how alert charting addressed Resident 1's specific risk of pitching forward from the wheelchair or how the intervention was intended to reduce the risk of another similar fall.During a concurrent telephone interview and record review on 7/15/26, at 8:49 a.m., Resident 1's fall risk care plan, dated 9/4/25, Resident 1's actual fall care plans, dated 9/7/25, and Resident 1's progress notes, dated 9/7/25, were reviewed with the Director of Staff Development (DSD). The DSD stated care plans were resident-specific and person-centered. The DSD reviewed the intervention added to Resident 1's actual fall care plan following the first fall which listed Alert Charting for 72 hours. The DSD stated alert charting was a general post-fall intervention and did not address Resident 1's individual fall risk. The DSD further stated staff could have added another intervention, such as close monitoring, following the first fall. Review of facility's policy titled, Fall Management and Neurological Check, updated 1/25, indicated, The center implements a fall management plan based on medical history review and resident evaluation. 5. The LN updates care plans reflecting individualized intervention in an attempt to reduce or prevent falls. 7. The resident's care plan is reviewed quarterly and after a fall to determine effectiveness of current intervention and considers the residents goals, choices and preferences .

Based on observation, interview, and record review, the facility failed to provide meal service in a dignified manner for 13 Residents during the lunch in the assisted dining room (for residents who need staff assistance to consume their meals/drinks) on 6/9/26 when 13 Residents were served their meals on a food tray (a flat tray utilized to carry plates/bowls/drinks/utensils to a dining area) while 23 Residents in the independent dining room had their meals without the food tray and and the food were set on the dining table.This deficient practice had the potential to negatively affect the 13 Residents' psychosocial (involving mental, emotional, social, an spiritual aspects of a person's life) well-being.Findings:During a concurrent observation and interview on 6/9/26, at 12:36 p.m. with Certified Nurse Assistant (CNA) 5 in the assisted dining room during the lunch, 13 residents were observed seated at tables waiting to be served their lunch meal. Staff who were in the dining room started serving the meals to the 13 Residents at each table and placed their food trays on the table in front of each resident. All 13 Residents received their meals on a food tray. CNA 5, who was assisting the residents in the assisted dining room, stated that it was okay to leave the plates, glasses, and silverware on the tray and that they were instructed to do so. CNA 5 went on to say meals were served like this in just this dining room but not the independent dining room. CNA 5 explained that residents who eat their meals in the independent dining room have their meals removed from the food tray and set on the table. CNA 5 stated meals should not be served on a tray and should have been removed to promote dignity and that everybody should be treated with dignity. CNA 5 also stated there should be no difference between the residents having meals in the independent dining room and the residents having their meals in the assisted dining room.During an observation on 6/9/26, at 12 p.m. in the independent dining room, staff were observed serving meals to the residents by removing their food from the food trays, and setting the plates, glasses, and silverware on the table in front of each resident.During an interview on 6/11/26, at 11:12 a.m. with the Director of Staff Development (DSD), the DSD stated there should be no difference between the residents eating in the independent dining room and the residents eating in the assisted dining room. The DSD also stated the plates, glasses, and silverware should have been removed from the tray to promote dignity and a homelike setting.During an interview on 6/12/26, at 1:30 p.m. with the Administrator (ADM), the ADM stated that meals should be served off the tray for dignity, for homelike environment, and implementing residents' rights.During a review of the list of resident rights from the Social Security Administration (SSA) and Social Services published September 2010 and updated July 2015, the list indicated, .To be treated with consideration, respect and full recognition of dignity and individuality.

Based on observation, interview, and record review the facility failed to ensure safe infection prevention and control practices for census of 87 when:1. Resident 14, Resident 8 and Resident 65's oxygen tubing was not properly stored when not in use,2. Resident 11's indwelling urinary catheter (also known as foley catheter, a flexible, hollow tube inserted into the bladder to continuously drain urine out of the bladder, through the tubing and into an external collection bag) tubing and catheter bag (collects urine drained from the bladder via a catheter, also known as drainage bag) were touching the floor while wheeling herself in the hallway,3. Shared glucometer (a device that measures blood sugar) were not cleaned and sanitized in-between resident care for Resident 98 and Resident 100,4. Pill cutters in the medication cart contained white and yellow medication residue, and5. Medication carts were observed dirty with visible dark specks, debris, fine hairs/fibers, and sticky spills. These failures had the potential to spread infection and cause health problems for the residents in the facility.Findings: 1a. A review of Resident 14's admission RECORD, indicated Resident 14 has a diagnosis of but not limited to dependence on supplemental oxygen. During a concurrent observation and interview with Registered Nurse Supervisor (RNS), on 6/9/26, at 10:51 AM, Resident 14 was observed sleeping in bed with nasal cannula (a flexible plastic device that delivers supplemental oxygen directly into the nostrils) connected to an oxygen concentrator. Resident 14 had a wheelchair on the side of her bed with a nasal cannula wrapped around an oxygen tank that was at the back of the wheelchair. RNS stated when Resident 14 was in the wheelchair, they hook the nasal cannula with the oxygen tank. RNS stated that the nasal cannula should be placed in a plastic bag when not in use. RNS took the nasal cannula and threw it in the trash. A review of Resident 14's physician order dated 4/10/26, indicated, .Change oxygen/nebulizer tubing if it becomes damaged or visible soiled as needed. During a concurrent observation and interview with Resident 14 on 6/11/26, at 2:22 PM, Resident 14's entire oxygen tubing was on the floor while hooked to an oxygen concentrator. Resident 14 was observed pulling her oxygen tubing from the floor and placed it in her nose. Resident 14 stated she had not seen the staff change her oxygen tubing. Resident 14 stated she wanted her oxygen tubing clean because she put it in her nose. During a concurrent observation and interview with License Nurse (LN) 2, on 6/11/26, at 2:25 PM, LN 2 confirmed Resident 14's oxygen tubing was wrapped around the oxygen tank. LN 2 stated it could be contaminated and could be an infection control issue when Resident 14 would use it. LN 2 stated there should be a bag for the oxygen tubing. 1b. A review of Resident 65's admission RECORD, indicated Resident 65 had a diagnosis of, but not limited to dependence on supplemental oxygen, and chronic obstructive pulmonary disease. During an observation on 6/9/26, at 2:20 PM, Resident 65 was observed sitting in a wheelchair and was using oxygen via nasal cannula that was connected to an oxygen tank. During a concurrent observation and interview on 6/9/26, at 2:37 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 confirmed Resident 65's oxygen concentrator at the bedside was on and nasal cannula of the oxygen tubing connected to it was placed inside the drawer of the nightstand. CNA 2 stated the oxygen tubing on the concentrator should not be in the drawer and should be place in the plastic bag when not in use. CNA 2 stated that Resident 65 only used it when he was in bed and he had another one to use while in the wheelchair. A review of Resident 65's physician order dated 5/5/26, indicated, .Change oxygen tubing if it becomes damaged or visibly soiled. as needed . 1c. A review of Resident 8's admission RECORD, indicated Resident 8 had a diagnosis of, but not limited to dependence on supplemental oxygen, and chronic obstructive pulmonary disease (COPD: a progressive, incurable lung disease that restricts airflow and makes it hard to breathe). During an observation on 6/9/26, at 4:40 PM, Resident 8 was observed using oxygen via nasal cannula connected to an oxygen concentrator, and part of the oxygen tubing was on the floor. During a concurrent observation and interview with LN 2, on 6/9/26, at 4:48 PM, Resident 8's oxygen tubing was observed on the floor next to Resident 8's bed while connected to Resident 8's nose. LN 2 stated it should not be on the floor. The DON came into Resident 8's room and instructed LN 2 to replace Resident 8's oxygen tubing. During a concurrent observation and interview with LN 3, on 6/11/26, at 8:38 AM, LN 3 confirmed Resident 8's oxygen tubing was on the floor. LN 3 stated that if the oxygen was being used as needed, it should be coiled and placed inside a bag when not in use. LN 3 stated it was not supposed to be touching the floor because it would become soiled and was not sanitary. The DON came into Resident 8's room and observed Resident 8's tubing on the floor and stated that it should be thrown away and replaced. A review of Resident 8's physician order dated 3/18/26, indicated, .Change oxygen/nebulizer tubing if it becomes damaged or visibly soiled. as needed. During a concurrent interview and record review with Infection Preventionist (IP), on 6/12/26, at 8:33 AM, the IP stated if the oxygen use was for continued use, the staff should transfer the cannula from concentrator to the tank when residents went out of their room. The IP further stated that if the oxygen was used as needed, the cannula should be kept in a bag when not in use. The IP stated if resident was using 2 oxygen tubings, the other one should be place in bag when not in use. The IP stated the oxygen tubing should not be on the floor because it would place the residents at increased risk for infection. The IP stated the oxygen tubing could get contaminated and affect their respiratory system. During an interview on 6/12/2026, at 10:51 AM with the Director of Nursing (DON), the DON stated the oxygen tubing should not be wrapped around the oxygen tank. The DON stated the residents would only need one oxygen tubing. The DON added the oxygen tubing should be stored in a bag when not in use. The DON stated the oxygen tubing should not be on the floor. The DON stated she was not sure if it would pose an infection risk. A review of the facility's policy and procedure titled, Infection Control Policies and Practices, revised 3/19/25, indicated, .Policies and practices are observed to maintaining a safe, sanitary, and comfortable environment and to support infection prevention, identification, and transmission. Policies, protocols, and practices are developed in accordance with the Centers for Disease Control (CDC), Federal and State regulatory requirements, and local health authority guidance. 2. During a review of Resident 11's admission RECORD, dated 6/12/26, the record indicated, Resident 11 was admitted to the facility with diagnoses including obstructive and reflux uropathy (conditions where impaired urinary flow or backward leakage causes pressure and damage to the kidneys). During a review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 5/13/26, the MDS indicated under the Bladder and Bowel section, an indwelling urinary catheter was marked. During a review of Resident 11's Order Summary, dated 5/11/26, the order indicated, .foley cath [catheter] to gravity drainage. Change as needed for clogged or non-functioning related to OBSTRUCTIVE AND REFLUX UROPATHY. During a review of Resident 11's Care Plan Report (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 5/11/26, the care plan indicated, .Potential for infection related to indwelling catheter.Monitor placement and positioning of catheter.Provide catheter care Q [every] shift. During a concurrent observation and interview on 6/11/26, at 11:19 a.m. Resident 11 was up in her wheelchair wheeling herself from her room down the hallway, passed by the nurse's station, where several staff members were working, and down the hallway towards the dining room. Resident 11's catheter bag and part of the catheter tubing were hanging under her wheelchair and were touching the floor as Resident 11 was wheeling herself down the hallway. The Infection Preventionist (IP) passed by the hallway while pushing a food cart stopped next to where Resident 11 was. The IP confirmed that Resident 11's catheter tubing and the drainage bag were dragging on the floor from underneath the wheelchair. The IP stated it should not be touching the floor and went on to say, I'll take her to her room and fix it. During an interview on 6/11/26, at 11:36 a.m. with the IP, the IP stated the catheter tubing, and the drainage bag should never touch the ground due to increased risk for bacteria traveling up the tubing that could potentially cause a bladder infection. During an interview on 6/12/26, at 8:15 a.m. with Certified Nurse Assistant (CNA) 3 who was the assigned staff for Resident 11 during the day shift on 6/12/26, CNA 3 stated Resident 11 had limited functioning for Activities of Daily Living (ADLs, tasks we do to stay alive and well such as bathing, dressing, eating, transferring, and toileting) and she needed assistance with catheter care. CNA 3 explained that catheter care involved emptying the drainage bag and placing it in a privacy bag, monitor the tubing if anything was loose, make sure the tubing was not tangled, properly placed the drainage bag below the bladder, and to secure the tubing. CNA 3 stated that usually the CNAs assisted Resident 11 with placing the drainage bag and securing the tubing underneath the wheelchair. CNA 3 did not mention as part of the catheter care to make sure the drainage bag, and tubing should be off the floor. During an interview on 6/12/26, at 10:34 a.m. with Licensed Nurse (LN) 7, LN 7 stated catheter care would include using a privacy bag for the drainage bag, making sure the indwelling catheter was intact, providing proper peri-care (the washing and cleaning of the genital and anal areas), and making sure the catheter bag and the tubing were not touching the floor. During an interview on 6/12/26, at 1:30 p.m. with the Administrator (ADM), the ADM stated that care for the tubing of an indwelling catheter and the drainage bag included that it should not be dragging on the floor. The ADM further stated that there would be increased risk for infection that could affect the health and well-being of the residents. During a review of the facility's job description titled, Certified Nursing Assistant, dated March 2025, the job description indicated, .Under general supervision performs a combination of following duties in caring for residents in the Community [facility], consistent with the plan of care and established long-term standards and Community policies and processes. During a review of the facility's In-service Training Program (a professional development and learning activities provided to employees while they are actively employed in their field), a lesson plan titled, Peri Care/Catheter Care given by the DSD on 5/19/26 and again on 5/20/26, the Lesson Plan indicated, .Catheter bags need to be below the level of the bladder and placed in a privacy bag with tubing/bag not on the floor. During a review of the facility's Policy & Procedure (P&P) titled, Infection Control Policies and Practices, dated 3/19/25, the P&P indicated, .Policies and practices are observed to maintaining a safe, sanitary, and comfortable environment and to support infection prevention, identification, and transmission. 3. During a medication administration observation, accompanied by Licensed Nurse 1 (LN 1), on 6/9/26 at 11:38 AM, at C wing hallway, LN 1 gathered blood sugar measurement supplies into Resident 98's room. LN 1 placed the glucometer on tabletop next to Resident 98's bed. LN 1 with gloved hand then used the lancet device (sterile needle used to prick the skin and draw a small drop of blood) to prick the right point finger of Resident 98 to collect the blood sample for testing. LN 1 then soaked the test strip (disposable plastic strip coated with special chemicals to measure blood sugar) attached to glucometer with blood and measured the blood sugar. LN 1 stated insulin (injectable drug to treat high blood sugar) administration was required. When out of Resident 98's room, LN 1 removed the gloves and with bare hands used one bleach wipe to quickly wrap the outer surface of the glucometer. LN 1 kept the glucometer wrapped on top of her cart. During a concurrent observation and interview on 6/9/26 at 11:58 AM, with LN 1, at C wing hallway, LN 1 used a second glucometer and prepared the needed supplies to measure Resident 100's blood sugar and entered the room. LN 1 placed the glucometer on tabletop next to Resident 100's bed. LN 1 with gloved hand then used the lancet device to prick the right middle finger of the resident to collect the blood sample for testing. LN 1 then soaked the test strip attached to glucometer with blood and measured the blood sugar. LN 1 stated insulin administration was required for the measured blood sugar. When out of Resident 100's room, LN 1 removed the gloves and with bare hands used one bleach wipe to quickly wrap the outer surface of the glucometer. LN 1 then kept the glucometer wrapped on top of her cart. LN 1 stated she had been trained on how to clean the shared glucometer in-between resident care by first wiping the front and the back of the device, then using a second wipe to further sanitize the glucometer and then wrapping it for a prolonged wetness for four minutes or more. LN 1 acknowledged that she did not wipe the glucometer as described during her training. LN 1 further acknowledged improper cleaning and sanitizing could pose a risk of spreading infection. During an interview on 6/10/26 at 9:45 AM with the Director of Nursing (DON) and the Registered Nurse Supervisor (RNS), the RNS stated improper cleaning and sanitizing of shared glucometer would be an infection control issue that could have caused spread of infection to the residents and staff. During an interview on 6/10/26 at 12:40 PM with the Infection Preventionist (IP), the IP stated that staff must wipe the glucometer with a bleach wipe, one wipe per side and then wrap it with another sheet of bleach wipe. The IP stated the purpose was to prevent the spread of infection. The IP further stated that failure to follow this education could result in the transmission of infection to staff and residents. The IP stated that staff should handle bleach wipes with gloves. During a review of the facility's policy titled, Disinfecting Glucometer.Machine, dated 4/2011, indicated, .The Center disinfects the multiuse glucometer.between each resident use with Centers for Disease Control (CDC) approved .bleach solution.utilizing infection control practices during the disinfecting process. A review of the manufacturer's instruction titled, Cleaning and Disinfecting the Assure Prism multi Blood Glucose Monitoring System (brand name used by facility), revised 9/2024, last accessed on 6/17/26 via https://arkrayusa.com/support/professional-healthcare/cleaning-disinfecting/ , indicated, .The meter should be cleaned and disinfected after use on each patient.Two wipes are needed; one wipe to clean the meter and a second wipe to disinfect the meter.Always wear the appropriate protective gear, including disposable gloves.Wipe the entire surface of the meter using the towelette at least three times vertically and three times horizontally to clean blood and other body fluids from the meter.Meter surfaces must remain wet according to contact times.Once complete, wipe meter dry. 4. During a concurrent observation and interview, on 6/9/26 at 11:58 AM, with LN 1, during medication cart inspection, on wing C, the medication cart stored two pill cutter devices (device that split the pills) with visible white and yellow medication residues. LN 1 stated the pill cutters were not clean and should have been wiped and clean because it presented a potential risk for infection, cross contamination (spread of germs from cart to residents) and allergic reaction. During an interview on 6/10/26 at 9:45 AM with the DON and the RNS, the DON and RNS stated that residue in the pill cutter would make it impossible to identify the medications present and could result in interactions with other medications, posing a risk for allergic reaction. During an interview on 6/10/26 at 12:40 PM with the IP, the IP stated it was not acceptable for the pill cutter to remain unclean because medications could mix, and some residents could experience an allergic reaction. 5. During a concurrent observation and interview, on 6/9/26 at 11:58 AM, with LN 1, LN 1 confirmed medication cart on wing C had visible dark specks, debris and fine hairs or fibers near the back of the bottom drawer. LN 1 stated that they cleaned the cart recently, but it needed to be wiped more frequently. During a concurrent observation and interview on 6/9/26 at 2:24 PM, with LN 2, LN 2 confirmed medication cart on wing B had visible darkish and sticky spots in the bottom drawer of the medication cart. During an interview on 6/10/26 at 9:45 AM with the RNS, the RNS stated that medication carts should be clean for infection control purposes. During an interview on 6/10/26 at 12:40 PM with the IP, the IP stated the medication carts should have been kept clean to prevent bacterial growth and potential cross-contamination. During a review of the facility's policy titled, Infection Control and Practices dated 3/19/25, indicated, .Policies and practices are observed to maintaining a safe, sanitary and comfortable environment and to support infection prevention, identification, and transmission. Policies, protocols, and practices are developed in accordance with the Centers for Disease Control (CDC), Federal and State regulatory requirements. A review of the Centers for Disease Control (CDC) Guidelines, Recommendations 2.b, 2.b.i and 2.b.ii, titled, Infection Control: Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated 2008, indicated, .Meticulously clean patient-care items with water and detergent, or with water and enzymatic cleaners before high level disinfection or sterilization procedures.Remove visible organic residue.Clean medical devices as soon as practical after use. https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html A review of CDC Guidelines, Healthcare- Associated Infections (HAIs): Medication preparation areas.Appendix B2, Table 2. Cleaning Procedure Summaries for Medication Preparation Areas dated 3/19/24, indicated, .Clean and disinfect: countertops, portable carts used to transport or prepare medications. The CDC identified the frequency for this cleaning and disinfection as between uses. https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-b2.html

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment and food-contact surfaces in accordance with professional standards for food safety for 87 residents when:1. Food preparation equipment was not maintained in clean and sanitary conditions in accordance with food safety standards; and,2. The top of the convection oven (a standard oven equipped with a built-in fan and exhaust system) was observed covered with dust and sticky in touch and, the interior surfaces of the convection oven doors were observed to have multiple light brown spots and accumulations of oil/grease residue.3. The top of the dishwasher was observed to be visibly soiled with accumulated debris.These failures had the potential to expose 87 residents to food contamination and foodborne illness (an illness that comes from eating contaminated food. Common signs include nausea, vomiting, watery or bloody diarrhea, abdominal cramps, and fever).Findings: 1a. During a concurrent observation and interview on 6/9/26, during the initial kitchen tour, at 8:15 AM with the Certified Dietary Manager (CDM) in the kitchen, in a shelf, 8 large sheet pans were stored in ready-to-use area with oil/grease buildup that were present throughout the interior surface of the pans, with raised dark brown residue along portions on the inner rims. During a subsequent interview with the CDM, the CDM confirmed the findings, and stated that the sheet pans were not being used for cooking but rather as trays to hold salads and desserts. The CDM further stated that if the sheet pans were used for cooking, the accumulated residue could chip off and potentially fall into the food. However, the sheet pans were stored in the ready-to-use area alongside clean sheet pans, creating the potential for inadvertent use during food preparation and services.During a subsequent observation and interview in the kitchen on 6/10/26, at 10:40 AM with [NAME] (CK) 1, the same 8 large sheet pans previously observed with raised dark brown oil/grease residue were noted to be stored in the ready-to-use area. CK 1 confirmed the findings and stated that those sheet pans should not be stored in the ready-to-use area. CK 1 stated that the residue could chip off and fall into food during use, which could potentially cause residents to become ill. CK 1 further stated that the sheet pans should be thoroughly scrubbed to ensure the cooking surfaces were properly cleaned or, if they could not be adequately cleaned, removed from service and discarded. During an interview on 6/10/26, at 1:43 PM, the Registered Dietitian (RD) stated that 8 sheet pans with oil/grease residue buildup that could not be adequately cleaned should be removed from the ready-to-use shelves in the kitchen when they were not being used as cooking pans. The RD stated that dietary staff should ensure those pans were stored separately to prevent their inadvertent use. The RD further stated using sheet pans with food residue buildup could increase the risk of cross-contamination.2a. During a concurrent observation and interview on 6/9/26, during the initial kitchen tour, at 8:15 AM with the CDM in the kitchen, the interior surfaces of the convection oven doors were observed to have multiple light brown spots and accumulations of oil/grease residue covering the surfaces. The CDM confirmed the findings and stated that the convection oven was old. The CDM began scrubbing the interior door surfaces during the observation and stated that it was unable to remove all the accumulated oil/grease residue due to oven being old. The CDM further stated that dietary staff were responsible for cleaning all food preparation equipment after use and added that continuation of accumulation of food residue might affect sanitary condition of the equipment.During an interview on 6/10/26, at 10:40 AM, CK 1 stated that the interior surfaces of the convection oven doors should be scrubbed thoroughly to remove oil/grease buildup for safety of residents, even though the oven was old. CK 1 further stated that food preparation equipment should be maintained in a sanitary condition.During an interview on 6/10/26, at 1:43 PM, the RD stated that his expectation was for dietary staff to thoroughly clean the interior surfaces of the convection oven doors at the end of each shift. The RD stated that food preparation equipment should be always maintained in a clean and sanitary condition. The RD further stated that accumulated oil/grease residue could dislodge and fall into food items being cooked in the convection oven that could create a risk of cross-contamination and compromising food safety. 2b. During a concurrent observation and interview on 6/9/26, during the initial kitchen tour, at 8:15 AM with the CDM in the kitchen, the top of convection oven observed covered with dust and sticky in touch, the CDM confirmed the findings and stated that dietary staff were responsible for maintaining the cleanliness of food preparation equipment, including the top of the convection oven, and were expected to clean the equipment at the end of each shift. The CDM further stated that dust and food residue could fall into food and potentially cause cross-contamination.During an interview on 6/10/26, at 10:40 AM CK 1 stated that dietary staff were responsible for maintaining the cleanliness of food preparation equipment, including the top of the convection oven. CK 1 stated that exterior surfaces and top of the convection oven should remain free of dust and food residue to prevent those particles from falling into food. CK 1 further stated that dust could contain allergens that might cause residents to become ill.During an interview on 6/10/26, at 1:43 PM, the RD stated that, to remain in compliance with guidelines and adhere to sanitation standards, all food preparation areas and surfaces should be maintained clean and in good condition to prevent contamination of food. The RD stated that dietary staff were expected to maintain the cleanliness of food preparation equipment every day. The RD further stated that the top of the convection oven should be cleaned properly daily to prevent possible cross-contamination.3. During a concurrent observation and interview on 6/9/26, during the initial kitchen tour, at 8:42 AM, a large accumulation of debris was observed on the right side of the top of the dishwasher, where clean dishes exited the dishwasher after washing process. CK 2 confirmed the findings and stated that dietary aides were instructed to clean and remove all food debris and mineral buildup from the top of the dishwasher immediately after completing the dishwashing process. CK 2 further stated that there should not be any visible food debris, food particles, or mineral deposits on the top of the dishwasher, as those materials could fall onto clean dishes and potentially contaminate them.During an interview on 6/9/26, at 8:50 AM, the CDM stated that dietary staff were expected to maintain the cleanliness of the exterior surfaces of the dishwasher during each shift. The CDM further stated that debris and mineral deposits should be removed promptly to prevent them from falling onto clean dishes and potentially causing contamination.During an interview on 6/10/26, at 1:43 PM, the RD stated that dietary staff were expected to wipe down the top of the dishwasher routinely to remove mineral deposits and other debris. The RD further stated that debris and mineral buildup could fall onto clean dishes and potentially cause cross-contamination.During an interview on 6/12/26, at 9:59 AM, the Director of Nursing (DON) stated that some sheet pans and the convection oven were old and had been in use for an extended period, which could result in the accumulation of residue on their inner surfaces over the years. The DON further stated that kitchen and food preparation equipment should be maintained in a clean, sanitary, and good condition to help prevent foodborne illnesses and ensure food safety.During a review of facility's policy and procedure (P&P) titled, Equipment, revised in September 2017, the P&P indicated, .All foodservice equipment will be clean, sanitary, and in proper working order. Procedures. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris.A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, January 18, 2023, version, indicated, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on interview and record review the facility failed to carry out physician orders on two (Resident 1 and Resident 3) out of five residents reviewed for unnecessary drugs.These failures could have contributed to unsafe care and not following the physician orders for the treatment of medical problems. Findings: 1. A review of Resident 1's electronic medical record, titled admission Record; Diagnosis Information indicated Resident 1 had diagnosis of anemia (blood condition where body lacks enough healthy red blood cells to carry adequate oxygen to your tissues), low thyroid level, depression, high blood pressure and fracture of thighbone among others.A review of Resident 1's medical record under laboratory work, titled Complete Blood Count . (blood test for anemia and immune system), dated 3/10/26, the paper record indicated low level of hemoglobin (Hemoglobin, an iron-rich protein in red blood cells that carries oxygen to the rest of the body) in addition to abnormal level of other markers for anemia. The paper record had three handwritten orders for Iron pill (a supplement that helped produce red blood cells), Vitamin C (a vitamin that helped increase Iron absorption) and Vitamin B-12 (an essential vitamin for a healthy red blood cell and nervous system). The paper record for laboratory and drug orders was signed by a provider's Physician Assistant (PA).In a concurrent interview with Nurse Supervisor (RNS), on 6/11/26 at 2:12 PM, and review of Resident 1's electronic medical records, RNS stated she could not find any order entered in electronic health record for these three orders. RNS stated she was not sure why these orders were not communicated to nursing staff to get entered into the computer.In an interview with Physician Assistant (PA), on 6/11/26, at 4:27 PM, the PA stated he was not sure why orders were not carried out. The PA stated facility did not have an order sheet form for new orders, and he acknowledged signing the paper sheet and writing the orders on the lab sheet. The PA stated he often brought up any changes or orders to the attention of nursing staff. The PA stated he did not enter orders on a computer and had a program on his phone to approve the orders.In an interview with Medical Director (MD), on 6/12/26, at 8:40 AM, the MD stated the providers had access to facility's computer system and were able to enter orders in the computer system. The MD stated it was a shared responsibility to make sure all orders were entered into medical records on timely manner and he preferred the provider to enter the orders if feasible.2. A review of Resident 3's electronic medical record, titled admission Record; Diagnosis Information indicated Resident 3 had history of blood clots, morbid (severe) obesity, and arthritis among others.A review of electronic medical record, titled History and Physical (H&P), dated 4/29/26, the handwritten paper record by Medical Doctor 2 (MD 2) indicated a new drug order as follow: Start Zepbound 2.5 mg (or tirzepatide, an injectable prescription medication used for chronic weight management; mg is milligram, a unit of measure) weekly. Further review of the electronic records, including nursing notes, medical providers follow-up notes, did not show if this order was addressed or carried out.In a concurrent interview with Director of Nursing (DON) and RNS, on 6/11/26 at 2:12 PM, Resident 3's electronic medical record was reviewed. RNS stated she could not find any notes or documentation if the order for Zepbound was carried out. RNS stated the nursing staff did not see the new order listed at the bottom of the H&P sheet to address and input in the computer. RNS stated the medical doctor should have informed the nursing of the new order.In an interview with Medical Director (MD), on 6/12/26, at 8:40 AM, the MD stated the providers had access to facility's computer system and are able to enter orders in the computer system. The MD stated it was a shared responsibility to make sure all orders were entered into medical records on timely manner and he preferred the provider to enter the orders if feasible.Facility did not provide a policy on medical provider and director's roles and responsibility.Review of the facility policy, titled Medication administration-General Guidelines, dated 10/2017, the policy indicated, Medications are administered as prescribed in accordance with good nursing principles and practices. The policy under administration indicated Medications are administered in accordance with written orders of the attending physician. Medications are administered without unnecessary interruptions.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were properly labelled and stored in the medication and treatment carts to ensure they remain effective and safe for use with a resident census of 87 when:1. Medication cart in C wing stored an unlabeled insulin glargine pen (Long-acting insulin in pen shape help reduce blood sugar) for Resident 100 which did not have a pharmacy prescription label. The resident's name was handwritten on the product with a permanent marker.2. Medication cart in B wing stored a box of single use eye drops called Dorzolamide-Timolol ophthalmic solution (eye drop used to treat an eye disease called Glaucoma) and was found in the medication cart out of its foil wrap without an opened date marking. 3. Treatment cart at the main station stored opened bottles of sterile normal saline (germ-free salt solution used for wound care) and an open single-use Soft Foam Dressing (wound care item) in the active storage areas of the treatment cart.These failures had the potential to cause medication errors, reduced medication effectiveness, and increase the risk of infection for the residents in the facility.Findings:1. During a concurrent observation and interview with Licensed Nurse 1 (LN 1), on 6/9/26, at 11:58 AM, in the C wing, the medication cart stored insulin glargine for Resident 100 which did not have a pharmacy label with resident name or direction. The insulin pen was marked with a handwritten marking on the side of the pen with a permanent marker. LN 1 stated she was not sure why the insulin pen did not have a patient label and the Ziplock bag used to store the medication was missing from the cart.During an interview with the Director of Nursing (DON) and the RNS, on 6/10/26 at 9:45 AM, the RNS stated that residents should have their own insulin pen with a pharmacy label. The RNS further stated she would not administer an insulin pen without a label because it posed a risk for medication error and infection control. Both the DON and the RNS acknowledged this practice would increase the risk of medication error during medication administration.During a telephone interview on 6/12/26 at 10:34 AM with the Pharmacist (Pharm), the Pharm stated medications should have a label from the pharmacy, and the label may have fallen off or inadvertently been ripped off of the product. Pharm stated they could always ask for a new product if needed.During a review of the facility's undated policy titled MEDICATION ORDERING AND RECEIVING FROM PHARMACY - IC8: MEDICATION LABELS indicated, .Medications are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy can modify or change prescription labels.labels are permanently affixed to the outside of the prescription container.the resident's name, at least, must be maintained directly on the actual product container.Medication containers having soiled, damaged, incomplete, illegible, confusing, or makeshift labels are returned to the dispensing pharmacy for relabeling or destroyed in accordance with the medication destruction policy.2. During a concurrent observation and interview, on 6/9/26 at 2:24 PM, with LN 2, medication cart on B wing was inspected. The cart stored an opened box of an eye drop called Dorzolamide -Timolol that was out of the foil wrap and did not have a marking on it to show when it was opened. LN 2 stated she was unsure when the medication pouch was opened. LN 2 reviewed the manufacturer's instructions on the box, which stated to .Throw away any unused single-use containers 15 days after first opening the pouch .During an interview on 6/10/26 at 9:45 AM with the Director of Nursing (DON) and the RNS, the RNS stated she thought the Dorzolamide HCl-Timolol Maleate eye drops were individually packaged. The RNS further stated that using the medication beyond the manufacturer's 15-day beyond-use date after opening the pouch could result in reduced effectiveness.During a review of the facility's policy titled MEDICATION STORAGE IN THE FACILITY under ID1: STORAGE OF MEDICATIONS dated 4/2008 indicated, .Outdated, contaminated, or deteriorated medications. are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.3. During a concurrent observation and interview, on 6/9/26 at 2:26 PM, with the Registered Nurse Supervisor (RNS), the Treatment cart stationed at the main nursing station was inspected. The treatment cart stored two open and used bottles of normal saline and an opened sterile single-use Soft Foam Dressing inside the active storage areas of the treatment cart. The label on the normal saline bottle and foam dressing packet indicated they were single use and sterile. The RNS stated that the dressing was sterile and should not be used. RNS stated the saline solution should have been tossed after one time use.During an interview on 6/10/26 at 9:45 AM with the Director of Nursing (DON) and the RNS, the RNS stated they did not know when the normal saline bottle and foam dressing had been opened. The RNS further stated that the normal saline was for single use only and would have been discarded after use for safe practice and infection control. The same applied to the foam dressing because it was no longer sterile once opened.During an interview on 6/10/26 at 12:40 PM with the Infection Preventionist (IP), the IP stated that normal saline bottles and single-use foam dressings found in the treatment cart should have been discarded because they were no longer sterile once opened and could increase the risk of infection.During an interview on 6/10/26 at 12:59 PM with the Treatment Nurse (TN) the TN stated, she did not know why the opened normal saline bottle and opened single-use silicone foam dressing were kept in the treatment cart. The TN further stated that these opened items were not supposed to be kept in the treatment cart because they were no longer sterile and posed a risk of infection. During a review of the facility's policy titled PREPARATION AND GENERAL GUIDELINES - IIA3. VIALS AND AMPULES OF INJECTABLE MEDICATIONS, dated 4/2008, indicated . single-use vials (containing no preservatives) are discarded immediately after use.During a review of the facility's policy titled MEDICATION STORAGE IN THE FACILITY - ID1: STORAGE OF MEDICATIONS, dated 4/2008, indicated .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.A review of the Centers for Disease Control (CDC) Guidelines, Recommendations 18.b, 18.e and 18.f titled, Infection Control: Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated 12/7/2023, indicated, .Store sterile items so the packaging is not compromised (e.g., punctured, bent). Evaluate packages before use for loss of integrity (e.g., torn, wet, punctured). The pack can be used unless the integrity of the packaging is compromised. If the integrity of the packaging is compromised (e.g., torn, wet, or punctured), repack and reprocess the pack before use.https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html

Based on interview and record review the facility failed to document and provide clinical justification or expert consultation for switching a blood thinner (rivaroxaban or Xarelto, medication that prevents or slows down the clotting of blood by interfere with the chemical processes that cause blood to clot, helping prevent life-threatening conditions) to an anti-platelet medication (clopidogrel or Plavix, medications that prevent blood cells called platelets from sticking together & primarily used to prevent and treat heart attacks in people with heart disease) for treating recurrent and active blood clot in one out of five residents reviewed for unnecessary drugs (Resident 3). This failure could contribute to ineffective treatment and risk of blood clot formation leading to serious health complications.Findings: Review of Resident 3's clinical record and the admission diagnosis information, dated 6/12/26, the record indicated Resident 3 was admitted with arthritis of the knee with chronic pain, immobility, morbid obesity, history of Pulmonary Embolism (or PE, blood clot in lungs) and recurrent DVT (Deep [NAME] Thrombosis- Blood clot in the legs). The record further indicated Resident 3 was re-admitted to the hospital on [DATE] with another blood clot in left leg and hematoma (localized collection of pooled blood outside of a blood vessel) in her left hip and pelvis area after using enoxaparin injection (a blood thinner in the injection form). Review of Resident 3's clinical record, titled Discharge Summary from the hospital, dated 5/19/26, the record indicated Resident 3 had a nonocclusive thrombus in the left common femoral (an artery in leg) in addition to a left psoas hematoma without evidence of active extravasation (muscle bruise on left side of upper body and hip) and no active bleeding. The record under Discharge Plan indicated to continue rivaroxaban (Xarelto)15 mg twice daily with meals ( mg is milligram, a unit of measurement). Review of Resident 3's medical records including the Medication Administration Record (or MAR) and hospital records, dated 5/2026 and 6/2026, the records indicated the following medication and hospitalizations timelines:Xarelto 20 mg once daily from 4/28/26 to 5/6/26emergency room visit on 5/7/26Enoxaparin 100 mg injection (blood thinner in shot/injection form) Twice daily from 5/8/26 to 5/14/26Hospitalization from 5/14 to 5/19/26 (where hematoma and blood clot discovered) Xarelto 15 mg twice daily from 5/19/26 to 5/28/26Xarelto marked OOO (On Order from Pharmacy) for 5/29, 5/30, 5/31 and 6/1/26, 6/2/26 and 6/3/26.Plavix (clopidogrel) 75 mg daily for blood clot prevention related to personal history of pulmonary embolism from 6/1/26 to current. The records did not have any provider, doctor's note or clinical justification for changing Xarelto to Plavix. During a concurrent interview on 6/11/26 at 2:12 PM, with nurse supervisor (RNS) and review of Resident 3's medical records under Nursing Notes, dated 6/3/26, the note indicated PA [redacted, Physician Assistant] gave order for Therapeutic Interchange (means use of a chemically different medication that is therapeutically equivalent and belongs to the same pharmacological class as the originally prescribed drug) for Rivaroxaban to Clopidogrel. Resident notified and agreeable to the change. the RNS stated the order was placed in the computer through a verbal order (taken by a nurse) and later co-signed by PA. In an interview with PA, on 6/11/26 at 4:27 PM, the PA stated he authorized the change from rivaroxaban to clopidogrel. The PA stated both drugs accomplished the same end results with less bleeding based on his experience. PA stated he was aware of hospital discharge orders to continue rivaroxaban and did not document or write any clinical justification for change. The PA stated he was aware the two drugs were not therapeutically equivalent and they served different indications (used or officially approved to treat multiple, distinct medical conditions). In a telephone interview with Medical Director (MD), on 6/12/26 at 8:40 AM, the MD stated two drugs ( rivaroxaban and clopidogrel) were very different and risk versus benefits should have been documented. MD stated clinical justification should have been documented and the reasoning behind the change due to high-risk nature of the blood clot and the drugs. In a telephone interview with facility's Consultant Pharmacist (Pharm), on 6/12/26, at 10:36 AM, the Pharm stated the two drugs were two different classes of medications and for an active blood clot and recurrent blood clot, the blood thinner as an anticoagulant was recommended. Pharm stated switching rivaroxaban to clopidogrel was not a therapeutic interchange. Pharm was not sure why the change was ordered.Facility did not provide a policy on medical provider and director's roles and responsibility. Review of DailyMed (drug information site by US National Institutes of Health, NIH, which provides trustworthy information about marketed drugs) drug labeling information on clopidogrel, last accessed on 6/15/26 via https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=86ee71f2-850e-4c8e-87f3-c7a618d59d95, the record indicated the approved indication and usage .INDICATIONS AND USAGE: Acute Coronary Syndrome (ACS, a group of heart conditions-including heart attacks that involve sudden, reduced blood flow to the heart muscle) and Recent MI (heart attack), Recent Stroke, or Established Peripheral Arterial Disease (plaque builds up in the arteries that carry blood) . Review of DailyMed drug labeling information on rivaroxaban, last accessed on 6/15/26, via https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=10db92f9-2300-4a80-836b-673e1ae91610, the record indicated the approved indication usage was treatment and prevention of blood clots during DVT, PE and dangerous blood rhythms (when the heart's electrical system malfunctions, causing it to beat too fast, too slow, or irregularly) among others.

Based on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services with census of 87 residents when:1. Prescription and narcotic medication delivery manifest or receipts from provider pharmacy were not signed by licensed staff for accountability.2. Resident 24 and Resident 4's prescribed medications were not available and not refilled in a timely manner3. Hazardous drugs (medications that may pose health hazard when not handled appropriately) stored in the medication carts were not labeled alerting staff for safe use and handling.These deficient practices had the potential for unsafe medication exposure, medication errors, risk of drug diversion (drug loss) and residents not receiving prescribed medications as a result of unavailability and delay in refill process. Findings:1. During a concurrent observation and interview with the Registered Nurse Supervisor (RNS), and record review on 6/9/26 at 9:50 AM, the medication delivery sheets from provider pharmacy were reviewed. The medication delivery sheets were kept in a binder in an unorganized manner with no marking for signature or date the medications were received. The unsigned medication delivery sheets, titled CONSOLIDATED DELIVERY SHEETS, included both narcotic (opioid/controlled drugs-medications strictly regulated by the government because of their potential for abuse, misuse, and dependence) and prescription medications. The signature section at the bottom of each page marked Checked By, Received by Print Name and Date/Time was empty and unmarked. RNS acknowledged the findings and stated the staff signed the delivery driver's records only. RNS stated although they have not had any issues with missing medications there was a risk for drug diversion and accountability for resident's medication orders.During a joint interview with RNS and the Director of Nursing (DON), on 6/10/26 at 9:45 AM, the RNS stated they had instructed nurses during an in-service meeting to sign the physical delivery sheets to ensure accuracy of drug delivery and prevent risk of drug diversion.During a phone interview with the Pharmacist (Pharm) on 6/12/26 at 10:34 AM, the Pharm stated the facility should sign the manifest (consolidated delivery sheets) in addition to signing on the pharmacy driver records. The pharm added that the driver should have waited for the nurses to sign and that the current practice needed improvement for accountability purposes. The pharm confirmed the practice was for the nurses to sign the manifest upon receiving.During a review of the facility's policy titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY - IC2: PHARMACY DELIVERY, dated 4/2008, indicated .The dispensing pharmacy will transport medication to the facility in a manner that prevents.diversion of medications.pharmacy provided a method of confirmation of receipt of medications by the courier for each delivery that leaves the dispensing pharmacy.upon arrival at the facility, the courier delivers the medication directly to a licensed nurse.the pharmacy provides a method for both parties to confirm delivery.2a. During a concurrent medication administration observation, and interview with Licensed Nurse (LN) 5 , on 6/9/26, at 8:49 AM, LN 5 was not able to find an eye drop called Artificial Tears (a lubricant eye drop) for Resident 4. LN 5 went to the storage room to get a new supply and could not locate one. LN 5 stated they needed to order the product.The next day, during an interview with LN 4, on 6/10/26 at 9 AM, LN 4 went into the medication storage room to look for the eye drop for Resident 4 and found a different product called Clear Eyes (or Visine, eye drop to reduce eye redness). LN 4 stated they ordered the wrong product. LN 4 stated they did not have the Artificial Tears eye drop to give to Resident 4 for the second day in a row and needed to notify the doctor.2b. During a concurrent medication administration observation, and interview with LN 5, on 6/9/26, at 8:55 AM, LN 5 was not able to find a prescription drug called lactulose (a laxative-it stays in the gut to draw water and soften stools) for Resident 24. LN 5 stated she needed to call the pharmacy for a refill of the prescription.During a follow up interview with LN 5, on 6/9/26, at 12:28 PM, LN 5 stated she had not received the lactulose to administer to Resident 24.The next day, during an interview with LN 4, on 6/10/26 at 9 AM, LN 4 stated he did not have the lactulose yet to give to Resident 24 and was not sure why it was not delivered.During a joint interview with the DON and the RNS, on 6/10/26 at 9:45 AM, the RNS stated that if a delay occurred in the medication delivery, they would call the pharmacy to determine why the medications were not delivered on time. The DON stated the prescription medication should have been delivered already. The RNS stated that central supply staff had ordered the non-prescription (Over the Counter, OTC) medication and that the facility should have had the medications available for the residents use. RNS stated they may have ordered the wrong eye drop product due to name confusion.During a phone interview on 6/12/26 at 10:34 AM with the Pharm, the Pharm stated the facility ordered medications via computer and that the pharmacy needed extra time to prepare and deliver the orders. The Pharm recommended ordering at least 3-5 days in advance when possible and noted that urgent requests can usually be expedited by making phone calls to the pharmacy. The Pharm stated the pharmacy delivered drugs to facility on daily basis.During a review of the facility's policy titled, ORGANIZATIONAL ASPECTS - IA1: PROVIDER PHARMACY REQUIREMENTS, dated 4/2008, indicated, .Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week.3. During a concurrent observation and interview on 6/9/26 at 2:24 PM with LN 2, during the medication cart inspection, for B wing, two bottles of Megace (primarily uses as an appetite stimulant) were stored at the bottom drawer. One bottle had a sticker indicating HD (hazardous Drugs) while the other bottle did not have a hazardous drug sticker. The two bottles had reddish-brownish sticky spills on the outer surfaces of the product.Further inspection of the B wing medication cart and the bubble packs (plastic sheet with individual bubbles each holding one pill) section stored hazardous drugs with no HD labeling alert on the products including Finasteride (a hormone drug for treatment of prostate) and Depakote (a seizure medications). LN 2 stated she did not know what HD meant and how to handle this product. LN 2 stated she followed the order in the MAR .During an interview on 6/10/26 at 9:45 AM with the DON and the RNS, the RNS stated that the pharmacy was not consistent in labeling medications with HD. The RNS stated she would send an email to the pharmacy because this was a risk for the nurses and the residents. The DON stated it was important to label all HD drugs with an eye-catching sticker that the nurses can see for safe handling instructions.During a phone interview on 6/12/26 at 10:34 AM, with the Pharm, the Pharm stated her drug regimen review often alerted the facility to include safe handling with use of gloves when hazardous drugs were handled.During a review of the facility's policy titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY - IC8: MEDICATION LABELS, dated 4/2008, indicated .Medications are labeled in accordance with the facility requirements and state and federal laws.Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/2023, last accessed via https://www.cdc.gov/niosh/docs/2023-130/2023-130.pdf?id=10.26616/NIOSHPUB2023130 and https://www.cdc.gov/niosh/docs/2023-130/default.html , the document indicated Many . drugs intended for individual use can be hazardous to healthcare workers with potential occupational exposure to those who handle, prepare, dispense, administer, or dispose of these drugs. Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. PPE (or Personal Protective Equipment, items like glove or mask) provides worker protection to reduce exposure to hazardous drugs. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. Further review of the document indicated to use single glove for handling intact tablet form and double glove for handling oral liquid form of the hazardous medications as directed.

Based on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment for one of twenty-six sampled residents (Resident 19) when Resident 19's cigarettes and lighter were in her possession and not securely stored.This failure had the potential to affect Resident 19's safety, causing a smoking related injury and fire hazard in the facility, and putting the other residents and staff at risk.Findings:During a review of Resident 19's admission RECORD, dated 6/12/26, the record indicated Resident 19 was admitted to the facility with diagnoses including bipolar (a mental health condition that causes extreme mood swings) and schizoaffective (a mental health condition that causes symptoms like hallucinations or delusions and periods of depression or abnormally elevated mood with intense energy) disorder.During a review of Resident 19's Smoking Safety Evaluation, dated 4/8/26, the evaluation indicated answers to each question as followed: Does Resident have cognitive skill and adequate memory recall noted? No. Resident knows how smoking materials are to be stored? No. Resident can demonstrate proper storage of smoking materials? No. RESIDENT NEED FOR ADAPTIVE EQUIPMENT.Supervision. Notes on Safety from IDT [Interdisciplinary Team, a collaborative group of professionals who work together to manage a patient's care].Reviewed and remains appropriate for supervision. Team Decision.Safe to smoke with supervision.During a review of Resident 19's Care Plan Report (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 11/20/25, the care plan indicated, .Supervised smoking times.During a concurrent observation and interview on 6/10/26, at 10:55 a.m. with Resident 19 in her room, Resident 19 was holding a red lighter in her right hand. Resident 19 stated that she kept her own cigarettes and lighter with her in her room.During an interview on 6/12/26, at 9:21 a.m. with the Activity Director (AD), the AD stated that residents who were supervised with smoking do not keep their own cigarettes and lighter. The AD stated that Resident 19 needed supervision while smoking and should not keep her own cigarette and lighter due to lack of cognitive functioning. The AD also stated that Resident 19's smoking materials should be kept in a box at the activity office and would only be given during smoking scheduled time.During a concurrent interview and record review on 6/12/26, at 10:03 a.m. with the AD, an undated current residents smoking list was reviewed. The list indicated there were 10 residents who smoked and 4 out of the 10 were independent and 6 out of 10 were supervised for smoking. Resident 19 was included on the list for supervised smoking. The AD confirmed that the list was correct.During an interview on 6/12/26, at 10:07 a.m. with Resident 19 in her room, Resident 19 stated that staff were aware that she kept her own cigarettes and lighter. Resident 19 also stated that she used the lighter to light her cigarette and was able to do it.During an interview on 6/12/26, at 10:17 a.m. with Certified Nurse Assistant (CNA) 4, CNA 4 confirmed Resident 19 had her cigarettes and lighter with her and went on to say that she was not aware and did not know if Resident 19 was allowed to keep her own smoking supplies.During an interview on 6/12/26, at 10:21 a.m. with the Registered Nurse Supervisor (RNS), the RNS stated that per the Administrator (ADM) the smoking supplies should have been kept in a locked box and not with her.During an interview on 6/12/26, at 1:30 p.m. with the ADM, the ADM stated that Resident 19 should not have the cigarette and lighter with her because it would be a safety issue and increased the risk for fire hazards, burns, or even death.During a review of the facility Policy & Procedure (P&P) titled, Resident Smoking Safety Independent and Unsupervised, dated January 2025, the P&P indicted, .It is the policy of the center to provide a safe environment for residents, staff and visitors.Residents who do not meet the established criteria to smoke independently are aided/ supervised during smoking activities.All smoking materials, including cigarettes, electronic cigarettes and lighters are locked up including smoking materials for residents who are assessed to be a supervised smoker.

Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for two residents (Resident 25 and Resident 56) who used a low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) in a sample of 26 residents, when Resident 25's and Resident 56's LAL was not correctly calibrated according to Resident 25's and Resident 56's current weight.This deficient practice had the potential to place Resident 25 and Resident 56 at increased risk for developing pressure injury and/or skin breakdown.Findings:a. During a review of Resident 25's admission Record, the record indicated Resident 25 was admitted to the facility with multiple diagnoses including personal history of transient ischemic attack (TIA, is a short period of symptoms caused by a brief blockage of blood flow to the brain) and cerebral infarction (the death of brain tissue caused by a prolonged lack of blood flow and oxygen), cellulitis (potentially serious bacterial infection of deep layers of the skin and underlying tissues), and muscle weakness.During a concurrent observation and interview on 6/9/26, at 9:50 AM, Resident 25 was observed lying in bed on a LAL mattress, and the setting was calibrated to over 400 pounds (LBS-a unit of measurement). Resident 25 stated the mattress was in use due to a history of pressure injuries with the purpose of preventing skin breakdown.During a concurrent interview, and record review conducted on 6/9/26 at 10:04 AM with Licensed Nurse (LN) 1, Resident 25's medical record titled, Weights and Vitals Summary, dated 6/7/26 was reviewed. The record indicated Resident 25's most recent weight documented on 6/7/26, was 114 LBS. LN 1 confirmed Resident 25's most recent weight.During a follow-up observation and interview on 6/9/26, at 10:04 AM, with LN 1 in Resident 25's room, LN 1 confirmed that the LAL mattress was not adjusted to reflect Resident 25's current weight because the mattress pump was set for over 400 LBS, which did not correspond to Resident 25's actual weight. LN 1 stated that Resident 25 had a history of a wound to the coccyx (tailbone) area and that the purpose of the LAL mattress was to prevent further skin breakdown due to fragile skin. LN 1 explained that the LAL mattress pump should be adjusted according to Resident 25's current weight. LN 1 stated that Resident 25's skin was fragile and that failure to properly set the LAL mattress pump could result in the development of new pressure injuries. LN 1 further stated that, rather than providing preventative pressure relief, an improperly adjusted mattress could increase the resident's risk for skin breakdown, pressure injuries, and other skin related complications. During review of Resident 25's, BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK (pressure ulcer, areas of damaged skin typically caused by staying in one position for too long) dated 6/7/26, the scale indicated Resident 25 had a score of 18 (at risk, for the development of pressure ulcer).During an interview on 6/11/26, at 4:36 PM, LN 7 explained that the purpose of a LAL mattress was to serve as an intervention and preventative measure to promote wound healing and reduce the risk of pressure injuries. LN 7 stated that nurses were responsible to adjust the mattress pump setting according to the resident's most recent weight. LN 7 further stated that if the pump was not properly adjusted and was set at a pressure that was too high for the resident's weight, the mattress could become too firm, resulting in increased pressure on the skin. LN 7 further added that this could increase the risk of skin breakdown and pressure injuries rather than helping to prevent or heal them.b. During a review of Resident 56's admission Record, the record indicated Resident 56 was admitted to the facility with multiple diagnoses including hemiplegia (complete or total loss of function of one side of the body) and hemiparesis (partial weakness or reduced muscle strength on one side of the body), personal history of transient ischemic attack, and cerebral infarction, and type 2 diabetes mellitus (a chronic condition leading to high levels of sugar in the blood. People with diabetes could develop skin complications and damage to small blood vessels and nerves that keep skin healthy).During an observation on 6/9/26, at 4:22 PM, Resident 56 was observed lying in bed on a LAL mattress, and the setting was calibrated to over 380 LBS.During an observation and interview on 6/9/26, at 4:27 PM, in Resident 56's room, LN 1 confirmed that the LAL mattress was adjusted to 380 LBS.During a concurrent interview and record review on 6/9/26, at 4:35 PM, with LN 1 Resident 56's medical record titled, Weights and Vitals Summary, dated 6/1/26 was reviewed which indicated, Resident 56's most recent weight documented on 6/1/26, was 183.4 LBS. LN 1 explained that the purpose of LAL mattress was as a preventative measure to relieve pressure on the skin, maintain skin integrity, and help prevent pressure injuries. LN 1 stated that due to Resident 56's diagnoses of hemiplegia and diabetes, and because Resident 56 spent most of his time resting in bed, he was at an increased risk for pressure injuries and skin breakdown LN 1 further stated that nurses were responsible for adjusting the LAL mattress pump according to Resident 56's most current weight. She further stated that lying on an LAL mattress that was improperly adjusted to a pressure setting significantly higher than appropriate for Resident 56's weight could increase the risk of developing pressure injuries and skin breakdown rather than providing the intended pressure relieving benefits.During review of Resident 56's, BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK (pressure ulcer, areas of damaged skin typically caused by staying in one position for too long) dated 2/6/26, the scale indicated Resident 65 had a score of 14 (at moderate risk, for the development of pressure ulcer).During an interview on 6/12/26, at 9:59 AM the Director of Nursing (DON) stated that LAL mattress pumps should be adjusted according to the manufacturer's guidelines and the residents' current weight. The DON further stated that when LAL mattress pumps were adjusted for higher weights than were Resident 25 and resident 56 actual weights, the mattresses became firmer than intended, which might increase pressure on the skin. During a review of the facility provided undated LAL mattress operator's manual for [Brand Name], the review indicated, . INDICATIONS. is indicated for the prevention and treatment of any and all stage pressure ulcers [localized damage to the skin and underlying soft tissue, usually over a bony areas of the body]. PRODUCT FUNCTIONS. Pressure-adjust knob (2) Determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on interview and record review the facility failed to implement non-pharmacological interventions (drug-free approaches and/or resident care interventions without use of drugs that may help with mental health issues) for psychotropic drug use (mind-altering medications) in the plan of care for one out of five residents (Resident 6) reviewed for unnecessary medications. This failed practice may discourage use of drug-free approaches to improve residents' quality of life, reduce distress, and psychotropic medication use.Findings: A review of Resident 6's electronic medical record under admission Record and Diagnosis Information, dated 6/12/26, the record indicated Resident 6 was admitted to the facility on [DATE] with principal diagnosis of rheumatoid arthritis (or RA a chronic immune disease in which the immune system mistakenly attacks the lining of the joints), depression, and obesity among others.A review of Resident 6's electronic medical record under Medication Administration Record (or MAR), dated 6/2026, the MAR record indicated the following:-Fluoxetine (or Prozac, anti-depression drug) 20 mg ( mg is milligram , a unit of measure); give one capsule daily for .statements of hopelessness related to depression .; Start date 4/21/26.The MAR record indicated that the nursing staff were monitoring the residents' depression behavior and the side effects of Prozac in the MAR every shift. A review of Resident 6's electronic medical record under Care Plan Report, dated 4/21/26, the record under the Problem section indicated Resident 6 was taking fluoxetine for depression and the goal was to reduce and manage behaviors. The Plan of Care under the Interventions section did not address non-drug interventions to help with feelings of depression and hopelessness.In a concurrent interview with Nurse Supervisor (RNS), on 6/12/26, at 9:55 AM, and review of Resident 6's plan of care, RNS stated the non-pharmacological interventions were usually part of the care plan and/or MAR for staff to use and document. RNS stated this may have been missed during Resident 6's care planning documentation.In an interview with Certified Nurse Assistant 1 (CNA 1), on 6/12/26, at 1:23 PM, in the C hallway, CNA 1 stated residents liked to be heard and talked to. CNA 1 stated the residents needed kind gestures and smiles to help them feel good.In an interview with Licensed Nurse 3 (LN 3), on 6/12/26, at 1:30 PM, in the C hallway, LN 3 stated even confused residents needed one on one interaction and eye contact to see what was bothering them. LN 3 stated sometimes just fixing their hair or opening the window or curtain helped them feel better. LN 3 stated she did not look at the care plan, but having a place in the chart to see what interventions worked best for each resident was important and helpful.Review of the facility's policy, titled Psychotropic Medication Use, dated 6/2021, the policy indicated Facility staff should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person-centered nondrug and pharmaceutical interventions. Facility staff should provide the residents with a supportive environment promoting comfort, recognizing individual needs and preferences. Staff should become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress, types and the consequences of behavior exhibited by the resident and intervention that may be indicated for specific behavior type. Facility staff should focus on and understanding behavior to enhance communication when the resident is in distress.

Based on interview and record review, the facility failed to ensure informed consent (a process of documenting that a healthcare professional educated a resident about the risks, benefits, and alternatives of a prescribed mental health drug) for psychotropic drug (mind-altering drugs) use followed the facility's policy and resident notification requirements in two (Resident 1 and Resident 3) out of 5 residents reviewed for unnecessary medications.This failed practice may violate residents' rights to be informed of mind-altering medications given to them while in the facility. Findings: 1. A review of Resident 1's electronic medical record, titled admission Record; Diagnosis Information, dated 6/12/26, the record indicated Resident 1 had diagnoses which included depression. The record further indicated Resident 1 had a BIMS score of 13 (BIMS stands for Brief Interview for Mental Status. The test assesses memory and recall, and score is 0 out of 15 points. The total score of 13 to 15 points means resident was cognitively intact with normal thinking and memory.)During an interview with Resident 1, on 6/10/26, at 10:10 AM, Resident 1 stated no one talked to her about medication consent and she did not sign anything. Resident 1 stated she recalled an older guy came to her room and listened to her heart and left without asking any question or giving any comments.2. A review of Resident 3's electronic medical record, titled admission Record; Diagnosis Information, dated 6/12/26, the record indicated Resident 3 had diagnoses which included depression and mood disorder (a category of mental health conditions that primarily affect your emotional state, causing persistent and intense periods of sadness, elation, or both), morbid (severe) obesity, and arthritis among others. The record further indicated Resident 1 had a BIMS score of 15, meaning Resident 3 was cognitively intact with normal thinking and memory.Review of Resident 3's electronic medical record , titled Medication Administration Record or MAR, dated 6/2026, the MAR record indicated Resident 3 was on two mind-altering drugs called Remeron (or Mirtazapine, an anti-depressant) and Cariprazine (or Vraylar, a mood stabilizer).During an interview with Resident 3, on 6/10/26, at 10:21 AM, Resident 3 stated no one talked to her about medication consent and she did not sign anything. Resident 3 stated she had not seen a doctor or anyone explaining anything about her drugs.During a concurrent interview with RNS, on 6/11/26, at 2:12 PM, and review of Resident 3's informed consent form for Remeron and Cariprazine, and Resident 1's informed consent form for Zoloft (or Sertraline, anti-depression drug) the RNS stated the electronic informed consent form was filled out in the computer by a nurse and it did not have an option for the residents to sign it when medication and its side effects were explained to the them. RNS stated the form was printed and given to the doctor or Physician Assistant (PA) for them to sign and talk to residents if needed. RNS stated the nurse was supposed to explain the drug to the resident. RNS stated the form did not have a place for residents to sign the consent even for residents with full mental and physical capacity. RNS acknowledged Resident 3's and Resident 1's informed consents were signed by the PA and the consent form under Prescriber Signature indicated By signing below, I declare that I have personally examined, provided, and discussed with the Resident.the following material information.During an interview with Physician Assistant (PA), on 6/11/26, at 4:27 PM, the PA stated the nursing staff printed the form for him to sign and if needed he would talk to the resident. The PA stated he did not go over side effects, risks or benefits on a regular basis.During a telephone interview with Medical Director (MD), on 6/12/26, at 8:40 AM, the MD stated providers were the ones that give information about drugs as they are more informed of both the drug's effect and the residents medical condition. The MD stated the workflow was that the nurses facilitate the logistics and the providers gave the information and discussed it with the resident. The MD stated the residents should be able to sign the form and acknowledge the information given to them.A review of the facility's policy, titled Psychotropic Medication Use, dated 6/2021, the policy on section 11 indicated .It is the responsibility of attending healthcare practitioner to inform the resident and or resident representative of the initiation, reason for use, and the risk associated with the use of psychotropic medication per facility policy or applicable state regulation. Informed consent will be obtained by the prescriber prior to initiation of psychotropic medication .A review of facility's policy, titled Psychoactive Medications, dated 6/2025, the policy indicated .Written consent is obtained/renewed every six months. If the resident or resident representative cannot sign the form, licensed nurse can sign the form and document the name of the person who gave the consent. The prescriber of the medication can sign using remote technology. A copy is offered to the resident or resident representative .

Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 26 sampled residents (Resident 17) when Resident 17's Documentation Survey Report (form used by Certified Nurse Assistants (CNA) to document patient care and report observations as a proof that required care was provided) did not reflect activities were provided on daily basis from 5/1/26 through 5/31/26.This failure had the potential to not provide sufficient information that reflected Resident 17's activity participation on a daily basis.Findings: During a review of Resident 17's admission RECORD indicated Resident 17 was admitted to the facility with diagnoses including parkinsonism (neurological disorders that cause slowed movement, rigidity, and tremors), difficulty walking, and muscle weakness. During a review of Resident 17's Minimum Data Set (MDS, an assessment tool), dated 5/27/26, the MDS revealed a BIMS (Brief Interview for Mental Status) score of 9 out of 15 indicating a moderate problem with thinking, learning, and memory. During a review of Resident 17's undated Care Plan Report (a form where you can summarize a person's health conditions, specific care needs, and current treatments), the report indicated that Resident 17 needed encouragement and assistance to attend group or social activities. This report also indicated activity staff will visit her to invite, encourage and assist her to group activities she might enjoy. During an observation on 6/10/26, at 10:30 a.m. in Unit A hallway, Resident 17 was taken back to her room and transferred from her wheelchair back to her bed. Resident 17 remained in her room and did not go back to the activities. During a concurrent interview and record review on 6/11/26, at 2:13 p.m. with the Activity Director (AD), Resident 17's Documentation Survey Report, dated from 5/1/26 through 5/31/26 was reviewed. The AD confirmed the report indicated on 5/3/26, 5/4/26, 5/10/26, 5/14/26, 5/20/26, 5/25/26, 5/26/26, and 5/29/26, Resident 17 was recorded to have participated or observed activities. The AD verified all the other days reflected Resident 17 had no activities provided. The AD stated activities were offered every day for 7 days and Resident 17 attended group activities as an observer and seldom as a participant. The AD added that when Resident 17 was not in activities, she spent time with a family member visiting. The AD explained that activities attended, whether in group or family visits, should have been documented on days that it occurred to indicate what Resident 17 did since activities were offered every day. The AD stated there should be activities recorded on those days that reflected with no activity participation because it would mean that no activities were provided which could lead to depression when Resident 17 was left alone, there would be lack of stimulation, and could possibly affect her well-being. The AD stated she expected the activity assistant to record when residents attended activities or offered any kind of activities. During an observation on 6/11/26, at 8:09 a.m. Resident 17 was up in her wheelchair and seated in front of the facility's aviary next to the nurses' station dozing off and did not respond to greetings. During an interview on 6/12/26, at 1:30 p.m. with the Administrator (ADM), the ADM stated there should be documentation or a record of activities on days that activities were offered to give credit to what the activity staff were providing. The ADM further stated that when activities were not documented then activities were not done. During a review of the facility's Policy & Procedure (P&P) titled, Activity Program, dated July 2015, the P&P indicated, .The Center provides an ongoing program of activities designed to meet the interests as well as physical, mental, and psychosocial well-being of each resident.

Based on interview and record review, the facility failed to report the facilities investigation findings to the appropriate parties for an allegation of abuse for two of four sampled residents (Resident 1 and Resident 2), when the results of the investigation for the alleged allegation of abuse that occurred on 4/1/26 was not reported to the Department.This failure had the potential to compromise the facility's ability to ensure that appropriate corrective action was taken as the result of the investigation and could have compromised Resident 1 and Resident 2's safety. Findings:A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses including depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities).A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility with diagnoses including Alzheimer's disease (the most common form of dementia, a progressive and irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), unspecified psychosis (a clinical classification used when an individual experiences symptoms of a disconnect from reality, such as hallucinations or delusions, but the symptoms do not meet the full criteria for a specific psychotic disorder, or there is insufficient information to make a definitive diagnosis), and major depressive disorder (a serious, common mood disorder characterized by a persistent feeling of sadness, emptiness, and a significant loss of interest in activities).During a concurrent interview and record review on 6/4/26 at 11:55 AM with the Administrator (ADM), the facility reported incident folder between Resident 1 and Resident 2 was reviewed. The ADM confirmed that an altercation between Resident 1 and Resident 2 occurred on 4/1/26 and that there was no follow-up report that was submitted to the department. The ADM acknowledged that a report should have been submitted to the department within five days of the incident. The ADM stated that the purpose of conducting follow up investigations after an incident had occurred was to make sure that the facility could substantiate (to provide evidence or facts that prove the truth of a claim or statement) or unsubstantiate (to prove something to be false, invalid, or without evidentiary backing) that a potential abuse situation happened. The ADM also stated that Resident 1 and Resident 2's safety could have been at risk if the investigation was not fully completed. The ADM further stated that the administrator of the facility is the one who is ultimately responsible for carrying out investigations and reporting the findings to the department in accordance with the required timeframes.During a review of the facility's policy and procedure (P&P) titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated 3/25, the P&P indicated, .Resident to resident altercations are reviewed as potential abuse .The Center conducts a thorough investigation of potential, suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source, in accordance with state and federal regulations .During a review of the facility's P&P titled, Abuse Investigation, updated 10/22, the P&P indicated, .The Executive Director is the designated abuse coordinator and is responsible for assigning and overseeing staff that are to assist with investigations .The Center maintains complete and thorough documentation of the investigation .

Based on interview and record review, the facility failed to document the administration of controlled drugs (medications that are tightly controlled by the government because they may be abused or cause addiction) for one of five (5) sampled Residents (Resident 5) when, Resident 5's controlled medication count sheet indicated three doses of hydrocodone/APAP (a controlled medication prescribed for pain management) had been signed out (taken out of the medication container) by a licensed nurse but had not been documented as administered to the resident on the medication administration record (MAR). These failures had the potential to cause medication errors and for Resident 5 to be inadvertently overmedicated.Findings: A review of Resident 5's admission RECORD, indicated Resident 5 had been admitted to the facility with diagnoses which included low back pain. During a concurrent interview and record review on 5/29/26 at 11:44 AM with Licensed Nurse (LN) 2, Resident 5's clinical document titled, ANTIBIOTIC OR CONTROLLED DRUG RECORD, dated 5/1/26 through 5/31/26, was compared with Resident 5's MAR, dated 5/1/26 through 5/31/26. The ANTIBIOTIC OR CONTROLLED DRUG RECORD indicated doses of hydrocodone/APAP were signed out by a licensed nurse on the following dates: 5/13/26 at 8 PM5/25/26 at 4 PM5/26/26 at 8 PM LN 2 confirmed the doses were signed out on the ANTIBIOTIC OR CONTROLLED DRUG RECORD, and not documented as administered on the MAR for the dates of 5/13/26, 5/25/26, and 5/26/26. During a concurrent interview and record review on 5/29/26 at 2:18 PM with LN 4, Resident 5's clinical document titled, ANTIBIOTIC OR CONTROLLED DRUG RECORD and the MAR, for the dates of 5/1/26 through 5/31/26 were reviewed. LN 4 confirmed she signed out hydrocodone/APAP on the ANTIBIOTIC OR CONTROLLED DRUG RECORD for Resident 5 on 5/13/26, 5/25/26, and 5/26/26 and did not document it on the MAR. LN 4 stated Resident 5 usually got anxious when he wanted his medication which probably distracted her (LN 4) from documenting the medication as administered in the MAR. LN 4 further stated she had not documented on the MAR that Resident 5 had been given the medication doses, and she should have, to ensure other LNs did not inadvertently administer another dose of medication. LN 4 stated if Resident 5 received an extra dose of hydrocodone/APAP he could experience respiratory depression (slow, shallow breathing pattern), lethargy, (feeling very tired) or experienced an overdose (too much medication given in too short of a time frame could lead to injury or death) of the medication. During an interview on 5/29/26 at 2:20 PM with the Director of Nurses (DON), the DON stated medications should be documented when given to prevent medication errors. The DON further stated there was a risk to Resident 5 of being overmedicated if he received extra doses of hydrocodone/APAP. A review of a facility policy and procedure titled, PREPARATION AND GENERAL GUIDELINES.CONTROLLED MEDICATIONS, dated 8/2014, indicated, .When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR).Date and time of administration.amount administered.Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply.Initials of the nurse administering the dose on the MAR after the medication is administered.

Based on interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for two of three sampled residents (Resident 1 and Resident 2) when:1. Resident 1's low pulse rate (PR) readings of 46 on 3/19/25 were not rechecked and not reported to the medical doctor (MD) in a timely manner; and,2. Resident 2's left knee x-ray result was received and not reported to the MD.These failures had the potential for the facility not to recognize Resident 1 and Resident 2's potential change in conditions which could result in delays in their care and physical harm.Findings:1. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses which included hypertension (a condition with high blood pressure [BP]), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), presence of a pacemaker (a small device that helps maintain a healthy heart beat using electrical impulses) and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood effectively).A review of Resident's 1 medical record titled, Weights and Vitals Summary, for the month of March 2025, indicated Resident 1 had three PR readings on 3/19/25 of 46 bpm (beats per minute) at 8:30 a.m., 8:32 a.m., and 5:08 p.m. which all had a warning message of Low of 60.0 exceeded.During an interview on 7/2/25, at 2:03 p.m., with the Certified Nurse Assistant (CNA), CNA stated that a resident's VS (Vital signs - basic measurements that indicate the body's essential functions that include temperature, pulse, respiration rate, blood pressure, and oxygen saturation) should be checked at least once per shift around 7 a.m. for the morning shift and would be documented on the hall sheet or on the resident's chart. CNA further stated if a resident was on alert charting or on neurological checks (an exam that evaluates brain and nervous system functioning) the vitals needed to be checked more frequently. CNA stated if a resident had an abnormal VS, she would report to the LN and the LN would have assessed the resident to recheck the VS themselves. CNA confirmed that a resident's PR reading of 46 was low and if she had this reading during the first check she would have rechecked again and if it was still low, she would have notified the nurse as soon as possible. CNA stated it was important to report abnormal VS readings because if the readings were too high or too low, the resident could lose consciousness, and it could impact the safety and well-being of the resident. CNA further stated it was also important to keep track of a resident's VS and to have reported any abnormalities to have caught if there was something going on with the resident.During an interview on 7/3/25, at 9:06 a.m., with Licensed Nurse (LN) 3, LN 3 stated that a resident's VS should be checked at least every shift and if they were on alert charting it would be more frequent. LN 3 further stated it was important to check a resident's VS so she would know what the resident's state was at the time. LN 3 stated that if the nurse knew the resident and their baseline, the nurse would be able to tell if there was a potential change of condition just by checking the resident's VS. LN 3 further stated the resident could be at risk of falls, dizziness, hypotension (condition for low BP), bradycardia (heart rate that is slower than normal, typically below 60 beats per minute in adults) or everything could have dropped. LN stated the normal range for a PR would be 60 to 100 bpm. LN 3 further stated if a resident had a PR reading of 46, she would do a full set of VS and would have assessed and monitored the resident to check for any changes. LN 3 stated at that point, she would have rechecked VS every 15 minutes and would have notified the MD and potentially could have sent the resident out to the hospital if they had gotten worse. LN 3 further stated if a resident had a PR reading of 46, she would have initiated alert charting and would have endorsed it to the next shift. LN 3 stated it was important to start the alert charting for a change of condition for abnormal VS readings because it was not the resident's baseline and needed to be communicated to the MD for their suggestions. LN 3 further stated that the residents at the facility are elderly, and their condition could have changed quickly so it would have been important to have reported to the physician right away for abnormal VS readings.During a concurrent interview and record review on 7/1/25, at 1:32 p.m., with LN 1, Resident 1's PR readings on 3/19/25 were reviewed. LN 1 confirmed Resident 1 had three PR readings of 46 entered at 8:30 a.m., 8:32 a.m., and 5:08 p.m. LN 1 stated the first two PR readings on 3/19/25 were taken in the morning shift and the third was taken for evening shift. LN 1 further stated that by looking at Resident 1's overall PR readings, the PR ranged from 60 to 90, and that a PR reading of 46 was low. LN 1 stated if she was the nurse who got the PR reading of 46, she would have monitored Resident 1 and rechecked the PR to have been sure. LN 1 further stated the nurse should have assessed Resident 1 for symptoms and should have notified the MD. LN 1 stated it was important to have checked Resident 1's vitals to have seen if there was a potential change in resident's condition, so the resident needed to be monitored.During a concurrent interview and record review on 7/1/25, at 2:14 p.m., with LN 2, Resident 1's EHR (electronic health record) was reviewed. LN 2 confirmed the PR readings of 46 on 3/19/25 were low and stated she was the LN who entered those PR readings on Resident 1's EHR. LN 2 stated she got Resident 1's vitals from the CNA's vitals on 3/19/25 and was entered in Resident 1's chart. LN 2 further stated she did not recall if she had reported the low PR to the MD or if she questioned the CNA about the low PR readings. LN 2 stated she did not recall if Resident 1 had symptoms or issues on 3/19/25. LN 2 reviewed Resident 1's EHR and confirmed no notes were found for endorsing low PR to the next shift or reporting to the MD.During a concurrent interview and record review on 7/1/25, at 5:09 p.m., with the Director of Nursing (DON), Resident 1's EHR was reviewed. The DON stated the CNA staff were primarily taking vitals for the residents. The DON further stated it was expected for the CNA to have reported abnormal vital signs to the LN and the LN to have reviewed the resident's vitals. The DON confirmed the three 46 PR readings on 3/19/25 were all the same and stated it was her expectation for the LN to have rechecked these PR readings. The DON stated it was important to check resident's vitals so the staff could follow the physician's orders for medication administration and to follow the correct MD order.2. A review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility in 2018 with diagnoses that included generalized muscle weakness, rheumatoid arthritis (a chronic autoimmune disease that causes inflammation and damage to the joints), subluxation of the left knee (a partial or incomplete dislocation of the kneecap) and lumbosacral scoliosis (lower part of the spine is curved sideways).A review of Resident 2's progress notes for alert charting following Resident 2's fall on 3/1/25 indicated no noted injuries from the fall incident.A review of Resident 2's physician orders indicated Resident 2 had an order dated 3/5/25 for left knee x-ray due to fall.A review of Resident 2's left knee x-ray result, dated 3/5/25, via fax received on 3/6/25 at 3:55 a.m., indicated, .IMPRESSION: Arthroplasty [surgical replacement of a joint] is seen however the prostheses [artificial joint] appear to be dislocated at the knee joint . with handwritten noted with staff initials and dated 3/5/25.During an interview on 7/3/25, at 9:06 p.m., with LN 3, LN 3 stated she was the LN who completed the change of condition when Resident 2 had an unwitnessed fall on 3/1/25. LN 3 further stated she did not recall if Resident 2 had any injuries when she had the fall on 3/1/25. LN 3 stated she did not recall Resident 2 complaining of knee pain when she had the fall and was just complaining of her usual hip or leg pain which was routine for Resident 2. LN 3 further stated she was not aware that Resident 2 had a left knee x-ray ordered on 3/5/25 and of the result. LN 3 stated if the x-ray result was abnormal, the LN would call the MD and then fax the result. LN 3 further stated if the MD or the physician assistant could not be reached then the x-ray result would be faxed over. LN 3 stated once an x-ray result was faxed over to the physician, the staff would use a stamp to note that it was sent and then would be sent to medical records and the LN would also add a progress note in the resident's chart to document the call and fax to the MD. LN 3 further stated it was important to report any test result to the MD because the MD would dictate or determine the plan of care for the resident. LN 3 stated the risk of not reporting x-ray results to the MD including the potential to worsen or if there was a fracture it could impact the resident's care and reduce the resident's quality of life.During a concurrent interview and record review on 7/3/25, at 1:18 p.m., with LN 4, Resident 2's medical record was reviewed. LN 4 stated she was the one who obtained the physician's order for Resident 2's left knee x-ray because Resident 2 was complaining of left knee pain on 3/5/25. LN 4 confirmed there were no progress notes indicating the MD was notified about the left knee x-ray results. LN 4 stated it was important to report diagnostic results to the MD because they oversaw Resident 2's care. LN 4 further stated if x-ray results were not reported to the MD, it could potentially put Resident 2's health at stake or her condition could get worse.During a concurrent interview and record review on 7/1/25, at 3:50 p.m., with UM 2, Resident 2's medical record was reviewed. UM 2 stated the expectation was for the LN to have noted the result and faxed to the MD if there were no abnormalities. UM 2 further stated if there were abnormalities in the x-ray then the LN should have called the MD to have reported the result. UM 2 confirmed that Resident 2's left knee x-ray result dated 3/5/25 should have been reported to the MD and faxed over. UM 2 further confirmed Resident 2's left knee x-ray result did not indicate that it was faxed over and there were no notes found indicating it was sent to the MD. UM 2 confirmed Resident 2 was seen by the MD on 3/7/25 at the facility and there was no note that the left knee x-ray result was reviewed. UM 2 stated the LN should have contacted the MD and documented if the result was relayed to the MD.During a concurrent interview and record review on 7/1/25, at 5:09 p.m., with the DON, Resident 2's medical record was reviewed. The DON stated that her expectation was that the MD would have already reviewed the diagnostic result if the LN already noted that the result was received. The DON reviewed Resident 2's left knee x-ray dated 3/5/25 and confirmed it was received by the LN based on the date and initials on it. The DON stated that usually a result report with a similar note would have meant that the LN would have reported it to the MD. The DON further stated the importance of reporting any normal or abnormal diagnostic results to the MD was for the MD to prescribe treatment if needed.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 1) when, Resident 1's Activity of Daily Living (ADL - refer to the basic self-care tasks essential for independent living, like bathing, dressing, eating and toileting) charting tasks for July of 2024 had multiple shifts that lacked Certified Nursing Assistant (CNA) entries. This failure had the potential to provide insufficient information regarding the condition, care, and services provided to Resident 1. Findings: 1. A review of Resident 1's clinical document titled Documentation Survey Report v2, a report that lists all the ADL areas that CNAs are to chart on each shift had missing documentation for the following care areas and dates: Behavior:10 PM-6 AM shift for July 2,3,7,8,17,20,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 Bladder Continence:10 PM-6 AM shift for July 2,3,7,8,17,23,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,9,11,13,15,17,18,19 Bowel Continence:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 Bowel Movements:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19,29; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 Fall Interventions:10 PM-6 AM shift for July 2,3,7,8,12,17,24,26,30,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 Fluid Intake:10 PM-6 AM shift for July 2,3,7,8,12,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19,29; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG (A section of an assessment tool related to a resident's functional abilities and goals)-1 Step (Curb):10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-12 Steps:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-4 Steps:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Car Transfer:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 Chair/Bed-to-Chair Transfer:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Eating:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Lower Body Dressing:10 PM-6 AM shift for July 2,3,7,8,17,24,26,31,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Lying to Sitting on Side of Bed:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Oral Hygiene:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Personal Hygiene:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Picking Up Object:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Pulling On/Taking Off Footwear:10 PM-6 AM shift for July 2,3,7,817,24,27,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13,15,17,18,19 GG-Roll Left and Right:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Shower/Bathe Self:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Sit to Lying:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Sit to Stand:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18, 19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Toilet Transfer:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG- Toileting Hygiene:10 PM-6 AM shift for July 2,3,4,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Tub/Shower Transfer:10 PM-6 AM shift for July 2,3,4,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 GG-Upper Body Dressing:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13, 15, 17, 18, 19 GG-Walk 10 Feet:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13, 15, 17, 18, 19 GG-Walk 150 Feet:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13, 15, 17, 18, 19 GG-Walk 50 Feet with Two Turns:10 PM-6 AM shift for July 2,3,7,8,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13, 15, 17, 18, 19 GG-Walk 10 Feed on Uneven Surfaces:10 PM-6 AM shift for July 2,3,7,8,12,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13, 15, 17, 18, 19 GG-Wheel 150 Feet:10 PM-6 AM shift for July 2,3,7,8,12,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13, 15, 17, 18, 19 GG-Wheel 50 Feet with Two Turns:10 PM-6 AM shift for July 2,3,7,8,12,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13, 15, 17, 18, 19 GG-Wheelchair/Scooter Use:10 PM-6 AM shift for July 2,3,7,8,12,17,24,26,30,31; 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11, 13, 15, 17, 18, 19 Amount Eaten: 2 PM-10 PM shift for July 4,9,11,17,18,19; and 6 AM-2 PM shift for July 4,11,13,15,17,18,19 Bath/Shower Monday/Thursday AM (time on the form also indicated 1700 and is assigned to 2 PM-10 PM shift): 2 PM-10 PM shift for July 4,11,15,18.22,25; There was no documentation option for entry by the 6 AM-2 PM shift. Bowel and Bladder Training: 10 PM-6 AM shift for July 1,3,4,7,8,9,18,25,27,28,31; 2 PM-10 PM shift for July 2,3,4,5,7,8,9,10,11,13,14,15,17,18,19,20,21,22,24,25,26,27,27,30,31; and 6 AM-2 PM shift for July 4,5,9,10,11,13,14,15,17,18,19,20,21,22,24,25.26,27 During a phone interview with CNA 1 on 5/23/25, at 11:55 AM, CNA 1 stated that there were times she would complete the ADL task but was not able to complete the documentation. CNA 1 stated she was aware of the facility's expectation that CNAs would complete their charting by the end of their shift. CNA 1 stated that the risk of not completing the assigned documentation could have placed Resident 1 at risk for not receiving proper care by the following shift or receiving unnecessary care. CNA 1 stated, If I don't chart a resident had a bowel movement when they actually did, then the charge nurse might give the resident a laxative [medication to help someone have a bowel movement] they didn't need. During a phone interview with Licensed Nurse 1 (LN) on 5/23/25, at 10:30 AM, LN 1 stated that CNAs were supposed to complete documentation on resident specific CNA tasks every shift. LN 1 further stated that it was part of a charge nurses' responsibility to hold the CNAs accountable and ensure that they had completed their documentation before they left at the end of their shift, but she did not always complete that task. During a concurrent interview and record review on 5/22/25 at 4:15 PM, with the Director of Staff Development (DSD), the DSD confirmed that there were multiple missing CNA documentation entries on Resident 1's document titled Documentation Survey Report v2 for July 2024. The DSD stated that the risk of CNAs not documenting in the Electronic Health Record (EHR) could have placed Resident 1 at risk for miscommunication of care between shifts, placed the CNA and/or facility at risk for not being able to prove that a task or tasks had been completed, and would have made it difficult for other departments to have accurately assessed Resident 1. The DSD further stated that the expectation was for all CNAs to complete all assigned documentation in full before the end of their shift. During a concurrent interview and record review on 5/22/25, at 4:30 PM, the Director of Nurses (DON) verified there were multiple missing entries for multiple CNA tasks in Resident 1's document titled Documentation Survey Report v2, dated 7/24. The DON stated the expectation was that CNAs would document throughout their shift and ensure that all required charting was completed before they left the facility. The DON also stated that she expected the LN would have reviewed all CNA documentation by the end of the shift to ensure it was completed. The DON stated that the risk of nurses not ensuring all documentation was completed by the end of the shift had the potential to place Resident 1 at risk for not receiving the care and services required in a timely and accurate manner. A review of an undated facility provided policy and procedure (P&P) titled Charting and Documentation, the P&P indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .Documentation in the medical records will be objective (no opinionated or speculative), complete and accurate .

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care to prevent the development of pressure ulcers/injuries (PU/PI - areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface (bony prominence)) when: 1. Resident 1 was at risk for developing pressure ulcers and worsening of a shearing wound (a force that causes the skin and underlying tissues to move in opposite directions, often due to pressure and friction) on the coccyx (tailbone). Resident 1's skin assessments and wound documentation were incomplete, the physician was not notified the wound had worsened, and PU preventative measures were not correctly identified and implemented upon admission; and, 2. Resident 2 was at risk of developing pressure ulcers and worsening of a shearing wound on the coccyx and blanchable redness (a temporary reddening of the skin that disappears when pressure is applied) to both heels. Resident 2's skin assessments and wound documentation were incomplete and measures to prevent PU development were not implemented. These failures resulted in Resident 1 having wound pain and required surgical intervention at a hospital with the placement of a wound vacuum (VAC -a medical treatment that uses negative pressure to help severe wounds heal). In addition, these failures resulted in Resident 2 developing a deep tissue injury (DTI - deep skin and tissue loss where the extent of the damage cannot be determined because it is covered by eschar (black dead tissue)) to the left heel and had the potential to result in increased pain, infection (the invasion and growth of germs in the body), and muscle or bone loss. Findings: 1. A review of Resident 1's ADMISSION RECORD, indicated Resident 1 was admitted to the facility in Spring 2025 with diagnoses which included but not limited to: sepsis (a life-threatening infection), arthritis (swelling and tenderness where two or more bones meet, causing joint pain and/or stiffness) due to other bacteria (an infection in the joint fluid and tissues caused by bacteria), chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty breathing), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS -an assessment tool), dated 4/22/25, in the section, M -Skin Conditions, indicated, Resident 1 was at risk of developing pressure ulcers. During a concurrent interview and record review on 5/13/25, at 1:19 PM, Resident 1's electronic health record (EHR) was reviewed with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was admitted with two wounds, one on the left hand, and a shearing wound on the coccyx. Resident 1's Admission -Readmission Nursing Evaluation . dated 4/18/25, indicated, .Indicate Pressure Ulcers and/or other wound types .Sacrum [triangular shaped bone in the lower back located between the hip bones] .Type: Pressure [injury to skin and underlying tissue resulting from prolonged pressure on the skin] .Length 1.8 [cm- centimeter -a metric unit of length], Width 0.8 [cm], Depth 0.1 [cm], Stage II [2 -partial-thickness skin loss, presenting as a shallow open wound; wounds are classified into stages to indicate the depth of tissue damage and includes stages 1 through 4 and unstageable (when dead tissue is covering the wound making it unable to determine the depth of the wound)] . LN 1 stated the nurse who completed Resident 1's Admission-Readmission Nursing Evaluation was not a wound nurse. LN 1 stated he updated the description of the wound on the order he entered after he assessed Resident 1's wounds. LN 1 confirmed he entered .Cleanse [clean] shearing wounds to coccyx . to Resident 1's orders on 4/18/25 which changed the type of wound listed on the order from pressure ulcer to shearing wound. LN 1 stated he did not document in a progress note (a written record that documents a resident's health status, treatment progress, and any changes in their condition over time) the measurements, location, and description of what the wound looked like after his initial assessment. LN 1 further stated he needed to get better at documentation, and he tried to make weekly progress notes but stated he missed the charting. LN 1 confirmed Resident 1's BRADEN SCALE [a widely used tool in healthcare to assess and predict a patient's risk for developing pressure ulcers] FOR PREDICTING PRESSURE SORE RISK, dated 4/18/25, indicated, .MOISTURE .Rarely Moist [the degree to which skin is exposed to moisture ranging from rarely moist to constantly moist], .MOBILITY [the ability to move or be moved freely and easily] .Very Limited: Makes occasional slight changes in body or extremity [arms and/or legs] position but unable to make frequent or significant changes independently .[Resident 1 was] AT RISK [risk levels for pressure ulcer development range from at risk, moderate risk, high risk, or very high risk based off of the score obtained from the Braden scale assessment tool] . for pressure ulcers. LN 1 stated he disagreed with Resident 1's initial Braden scale assessment risk level since Resident 1 was fully incontinent of bowel and bladder (involuntary loss of urine or feces), had a high moisture risk, was immobile (not capable of movement), and required assistance to turn or reposition in bed. LN 1 stated Resident 1's Braden Scale assessment should have been assessed as a high risk for pressure ulcer development. LN 1 further stated it was his expectation for Resident 1 to be turned and repositioned every two hours to prevent the wound from worsening. LN 1 explained he completed Resident 1's wound care based on the treatment listed on the treatment administration record (TAR - a document used to track the administration of various treatments, including medications, therapies, and procedures). LN 1 stated he noted on 4/24/25 Resident 1's wound to the coccyx worsened and the wound size increased. LN 1 reviewed Resident 1's Progress Notes, dated 4/24/25, written by LN 1, which indicated, .LATE ENTRY .Provided wound care for resident with shearing wound to coccyx .Wound size went from 3.5x1.5x0.1 [length, width, depth in cm] on admission to 6.2x3x0.1 .discolored sheared skin. Periwound [around the wound] is macerated [softening and breaking down of the skin resulting from prolonged exposure to moisture] .Resident complains of discomfort wound pain 6/10 [pain scale 0-no pain to 10-worse pain] with wound care . LN 1 confirmed that the late entry for the worsening of Resident 1's wound was written in Resident 1's EHR on 5/7/25. LN 1 stated he forgot to document Resident 1 had a worsening condition of the wound on 4/24/25 and confirmed he did not notify the doctor. LN 1 further stated it was facility policy to notify the doctor and to document worsened conditions immediately to obtain new physician orders for wound treatment. Resident 1's EHR was reviewed by LN 1, and he was unable to locate any further documentation regarding Resident 1's worsening wounds. During a follow up interview on 5/13/25 at 2:49 PM, LN 1 stated documentation in a resident's medical record was important because it provided accurate and efficient documentation on what was happening with the resident. LN 1 further explained it was important to document timely and notify the doctor of a change in a resident's medical condition to keep the doctor and care team up to date, and the doctor could give new orders to prevent wounds from getting worse. LN 1 stated the risk to a resident not being turned every two hours (q2h -a patient care practice where a patient is repositioned every two hours) was it increased skin breakdown, decreased circulation (inadequate blood flow through the body's blood vessels), was not good for anyone to stay in one position too long, and for comfort of the resident. LN 1 reviewed Resident 1's medical record but could not find evidence Resident 1 was turned every 2 hours, or where Resident 1 refused to be turned. During a concurrent telephone interview and record review on 5/14/25, at 1:16 PM, LN 4 (a nurse from the hospital Resident 1 was sent from and back out to), confirmed she wrote Resident 1's Progress Note, dated 4/18/25 (day Resident 1 discharged from the hospital and was admitted to the facility) and took photos of the wound to Resident 1's coccyx during her stay at the hospital. LN 4 further stated Resident 1's Progress Note, indicated, .Coccyx continues to have an area of friction [force of rubbing between two surfaces] to left coccyx, wound bed is pink with red frayed [ragged] edges, blanchable erythema [a reddening of the skin that disappears when pressure is applied and returns to normal color when pressure is released], hyperpigmentation [areas of skin that appear darker than the surrounding areas] is noted at gluteal cleft [the deep groove or crease that separates the two buttocks] .skin intact .goals are to .reduce friction and pressure .turn q2hours . LN 4 further stated when Resident 1 returned to the hospital on 4/27/25, Resident 1's wound was re-evaluated and confirmed Resident 1's coccyx had worsened. LN 4 stated the wound covered both sides of Resident 1's buttocks creating an unstageable pressure ulcer with a foul odor (likely indicating infection). LN 4 confirmed Resident 1 required surgical debridement (removal of damaged tissue from a wound) on 5/3/25 and Resident 1 had to have a wound vacuum placed on the coccyx to help close the wound. A review of Resident 1's, Care Plan Report, dated 4/19/25, indicated, . [Resident 1] has skin sheering to her coccyx upon admit .Goal [Resident 1's] skin will show signs of improvement .Interventions/Tasks .Monitor for s/sx [signs and symptoms] of infection .Notify MD [medical doctor] of s/sx of infection . A review of Resident 1's, Nursing Progress Note, dated 4/24/25 (late documentation on 5/7/25), indicated, .LATE ENTRY .Provided wound care for resident with shearing wound to coccyx, increase in size r/t [related to] persistent watery stools. Wound size went from 3.5x1.3x0.1 on admission to 6.2x3x0.1. Wound bed is 100% [percent] granulation [pink or red, fleshy skin growth] with discolored sheared skin. Periwound is macerated. Resident complains of discomforting wound pain 6/10 with wound care . A review of Resident 1's Order Details, order date 4/18/25, indicated, .Cleanse shearing wounds to coccyx with NS [normal saline -salt water], pat dry .every day shift for skin shearing . A review of Resident 1's Order Details, order date 4/18/25, indicated, .Monitor shearing wounds to coccyx for s/s [signs/symptoms] of infection until resolved . A review of Resident 1's Order Details, order date 4/19/25, indicated, .Cleanse shearing wounds to coccyx with NS, pat dry .cover with foam dressing [an absorbent wound covering to promote wound healing] .every day shift for skin shearing AND as needed for soiled, lifting or missing [dressing] . A review of Resident 1's Nursing Progress Note, dated 4/26/25, indicated, . [Resident 1] transferred to ER [emergency room ] . [Resident 1] was having hallucinations [sensing things such as visions, sounds, or smells that seem real but are not] and thinking people were in bed with her, nurse noted grayish appearance . Review of an online version of a published book titled NURSING FUNDAMENTALS SECOND EDITION, dated 2024, in the section 10.5 Braden Scale, indicated, .Each risk factor on the Braden Scale is rated from 1 to 4 based on the client's assessment findings. When using the Braden Scale, start with the first category and review each description listed across the row for each of the ratings from 1 to 4, and choose the one that best describes the client's current status. Continue this process for all rows. Add all six numbers to determine a total score, and then use the total score to determine if the client is at mild, moderate, high, or severe risk for developing a pressure injury. The lower the score, the higher the risk of developing a pressure injury. Additionally, customized nursing interventions are implemented based on the rating in each category. The lower the score, the more aggressive actions are taken to prevent or heal a pressure injury . (https://wtcs.pressbooks.pub/nursingfundamentals/chapter/10-5-braden-scale/) 2. A review of Resident 2's ADMISSION RECORD indicated Resident 2 was admitted to the facility in the Summer of 2022 with diagnoses which included but not limited to: Cerebral Infarction (otherwise known as Ischemic Stroke -the death of brain tissue due to a lack of blood supply), difficulty in walking, muscle weakness, and heart failure (when the heart is unable to pump enough blood to meet the body's needs). A review of Resident 2's Minimum Data Set (MDS -an assessment tool), dated 3/02/25, in the section, M -Skin Conditions, indicated, Resident 2 was at risk of developing pressure ulcers. During a concurrent interview and record review on 5/13/25 at 2 PM, Resident 2's EHR was reviewed with LN 1. LN 1 stated Resident 2's shearing wound to the coccyx was first documented on 3/11/25 and confirmed Resident 2 obtained the wound while residing in the facility. LN 1 confirmed Resident 2 also had blanchable redness (a red or discolored area that turns white or pale when pressed) documented to both the right and left heels on 4/5/25. LN 1 confirmed monitoring of Resident 2's coccyx and heels was placed on the TAR and began on 4/5/25. LN 1 confirmed Resident 2 was immobile, depended on staff for all care, and stated Resident 2 needed to be turned q2h and had heel lift boots (a type of boot or device designed to elevate the heel) applied to both heels to prevent worsening redness and pressure ulcer development. LN 1 further stated the heel lift boots were required anytime Resident 2 was in bed. LN 1 further stated the care plan indicated Resident 2 was to be turned every 2 hours and was incontinent of bladder and bowel. LN 1 further explained it was important that these interventions were implemented to prevent pressure ulcers or other skin wounds from worsening. LN 1 confirmed Resident 2 should be turned every 2 hours by the CNA's (Certified Nursing Assistants). LN 1 confirmed Resident 2's EHR showed no evidence she had been turned every 2 hours per the care plan. During a concurrent interview and record review on 5/13/25 at 2:31 PM, CNA 3 stated the CNA's do not turn residents every 2 hours because they did not have any residents that required it. CNA 3 reviewed Resident 2's EHR and confirmed the care plan for Resident 2 indicated for her to be turned at least every 2 hours, however, CNA 3 stated she would have no way of knowing what was in resident's care plans. CNA 3 further stated she relied on the nurses to tell them, and she stated she had never been told any resident's required being turned or repositioned every 2 hours. During a concurrent observation and interview on 5/13/25 at 2:09 PM, with LN 1, in Resident 2's room, Resident 2 was observed lying in bed on her back. LN 1 exposed Resident 2's legs by removing the covers. Resident 2 had on the right sided heel lift boot; however, the left heel was lying on the bed and not in the boot. LN 1 then proceeded with wound care to the left heel. LN 1 removed a foam bandage on Resident 2's left heel. Resident 2's left medial (situated toward the middle of the body) heel where the foam bandage was removed was indented with the bandage and exposed a 2-3 cm dark black puffy circle. LN 1 stated when he last saw the left heel on 5/10/25 it was not like this. LN 1 further stated it was unusual for the wound to turn from just redness to black calling it a deep tissue injury with eschar (dry, leathery, black or brown dead tissue that forms over a wound). LN 1 further explained he was off for the last 2 days and was not notified of any changes, and did not see any documentation in Resident 2's medical record to indicate worsening to the left heel. LN 1 cleansed the wound and replaced the bandage. LN 1 then rolled Resident 2 directly onto her right side exposing her back and buttocks. LN 1 removed the foam bandage covering the wound to Resident 2's coccyx. Resident 2's coccyx had two opened areas actively bleeding and just above on the sacrum was a round opened, and bleeding wound consistent with a Stage 3 pressure ulcer (full-thickness skin loss that extends into the deepest layer of skin) circular in size on a bony prominence, surrounded by non-blanchable redness (a red or discolored area that does not turn white or pale when pressed). LN 1 stated he still believed the wound to the coccyx and sacrum was a shearing wound due to the odd shape and stated it was not a pressure ulcer because it was not circular, but did state the wound was larger. During a concurrent interview and record review on 5/13/25 at 2:49 PM, LN 1 stated the last measurement of the wound was 1.9 x 1.2 cm that he had documented on a written piece of paper that listed each resident with wounds for the week of 4/24/25. LN 1 confirmed there was not any additional written documentation of the wound to Resident 2's coccyx or left heel other than checking off the wound care was completed in the TAR. LN 1 confirmed his documentation was lacking due to time restraints and could be better, but would document the changes he observed today, including getting the wound care clinic involved in treating Resident 2 since the wounds worsened. LN 1 reviewed Resident 2's EHR and stated the only documentation of the skin was done on 5/11/25 on the Long Term Care Weekly Evaluation . form and stated the nurse who completed the evaluation checked the box that indicated, .No New Impairment. Skin clean, dry and intact . LN 1 confirmed the skin was not intact and stated it was his understanding the wounds to the coccyx and left heel were healing and not worsening. During a concurrent interview and record review on 5/13/25 at 2:39 PM, LN 2 stated the expectation for residents who are unable to turn themselves or adjust their own body position in bed was to turn them every 2 hours. LN 2 explained that the CNA's were responsible for this task. Review of Resident 2's, Care Plan Report dated 8/25/22, indicated, . [Resident 2] has an ADL [activities of daily living] performance deficit related to s/p [status post] CVA [Cerebral Vascular Accident; otherwise known as stroke] . [Resident 2] requires substantial/maximal assistance by staff to turn and reposition in bed . In addition, LN 2 confirmed the same care plan report indicated . [Resident 2] was at risk for skin breakdown/pressure injury . [Resident 2] needs assistance to turn/reposition at least every 2 hours, more often as needed . LN 2 stated the residents were turned every two hours because it was a known standard of care. LN 2 further explained she was unable to find evidence in Resident 2's EHR which showed Resident 2 was turned every 2 hours per Resident 2's care plan. LN 2 stated it was important to document the residents turns to help prevent further skin breakdown and it allowed everyone to capture the whole picture of care being provided. LN 2 further stated the risk of not being turned every 2 hours was further skin breakdown or the creation of a new skin wound that could cause pain or infection. During a concurrent interview and record review on 5/15/25 at 8:46 AM, LN 3 confirmed she wrote Resident 2's Long Term Care Weekly Evaluation ., dated 5/11/25. LN 3 stated she did not recall the status of Resident 2's coccyx or left heel but stated if there was a change she would have documented the change instead of checking the box that indicated, .No new Impairment. Skin clean, dry and intact . LN 3 stated she did not take measurements of the wound on 5/11/25 and did not document the condition of the wounds. During an interview on 5/13/25 at 3:53 PM, the Director of Nursing (DON) stated they do not document in the EHR when residents were turned. When asked if she had a way to know if the residents were being turned, the DON stated she did not know, because turning the residents was not charted, but stated they should since it was her expectation. The DON further stated they only document when a resident refused care. The DON stated her expectation to document and chart a change in condition or wound, would be to document the worsened condition, put the resident on 72-hour alert charting (typically consists of nursing staff documenting on the change of condition every shift, three times a day, over a 72 hour period), and document the doctor was notified after the assessment was done by the nurse. The DON explained notifying the doctor was important so he can give further orders for care. During an interview on 5/13/25, at 5:09 PM, the Administrator (ADM) stated her expectation for documenting an assessment was for the assessment to be documented by the end of the nurse's shift. The ADM confirmed documentation of an assessment several days after an assessment and change in condition, did not meet her expectation. The ADM stated her expectation to notify the doctor of a change in condition was about 24 hours. The ADM further stated the risk to the resident if the doctor was not notified in a timely manner would be the resident not getting the treatment needed to improve. The ADM explained the importance of turning and repositioning a resident was to change pressure points. A review of Resident 2's care plan dated 3/11/25, indicated, . [Resident 2] has a sheering wound on coccyx .Goal . [Resident 2] will not have any complications related to sheering wound .Interventions .Assist pt [patient] or remind her to change positions when in bed .Monitor for worsening condition daily . A review of Resident 2's care plan dated 4/7/25, indicated, . [Resident 2] has blanchable redness to her left heel .Goal .Redness will resolve without complications .Interventions .Heel protectors while in bed .Monitor for increased redness, swelling, drainage or open areas and report any adverse changes [undesired effects] to MD/PA [medical doctor/physician's assistant] until resolved . A review of Resident 2's care plan dated 8/25/22, indicated, .[Resident 2] is at risk for skin breakdown/pressure injury development related to malnutrition [lack of sufficient nutrients in the body], incontinence and requires staff assistance with ADL's .Goal .[Resident 2 will have intact skin, free of redness, blisters or discoloration .Interventions .[Resident 2] needs assistance to turn/reposition at least every 2 hours, more often as needed or requested .Monitor/document/report PRN [as needed] any changes in skin status: appearance, color, wound healing, s/sx [signs/symptoms] of infection, wound size . A review of Resident 2's Order Details, dated 3/11/25, indicated, .Monitor sheering wound to coccyx for s/s of infection or worsening condition until resolved .every day and evening shift . A review of Resident 2's Order Details order date 4/5/25, indicated, .Cleanse open area to coccyx with normal saline, pat dry with gauze, apply [brand name bandage] to wound bed, cover with dry dressing .every day shift Change dressing PRN [as needed] if soiled or dislodge . A review of Resident 2's Order details, dated 4/5/2025, indicated, .Monitor left heel blanchable redness for skin breakdown .every shift . A review of Resident 2's Order details, dated 5/13/25, indicated, .Apply skin prep to L [left] heel DTI .every day and evening shift for DTI pressure injury . A review of a facility policy and procedure (P&P) titled, Charting and Documentation, revised 7/17, indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record .treatments or services performed .changes in the resident's condition .progress toward or changes in the care plan goals .documentation of procedures and treatments will include care-specific details .The date and time the procedure/treatment was provided .The assessment date and/or any unusual findings obtained during the procedure/treatment .How the resident tolerated the procedure/treatment .Notification of family, physician or other staff . A review of a facility P&P titled, Change in a Resident's Condition or Status, revised 11/15, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician .of changes in the resident's medical .condition and/or status .A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .notifications will be made within twenty-four (24) hours of a change . A review of a facility P&P titled, Goals and Objectives, Care Plans, revised 4/09, indicated, .Care plan goals and objectives are defined as the desired outcome for a specific resident problem .When the goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved .Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . A review of an undated facility P&P titled, Wound Prevention, indicated, .The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds .Upon admission .and when a significant change in the resident status occurs, the resident's skin will be evaluated head-to-toe by licensed nurse .Weekly skin checks will be conducted by the licensed nurse. This will be documented in the resident's Electronic Medical Record (EMR) . A review of an undated facility P&P titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, indicated, .The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers .the nurse shall describe and document/report .full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .pain assessment .Resident's mobility status .current treatments, including support surfaces . A review of an online John Hopkins Medicine article, copyright 2024, titled, Bedsores [pressure ulcers], indicated, .Bedsores can happen when a person is bedridden or otherwise immobile .Bedsores are ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a prolonged time. Bedsores are also called pressure injuries, pressure sores, pressure ulcers, or decubitus ulcers. Bedsores can be a serious problem among frail older adults. They can be related to the quality of care the person receives. If an immobile or bedridden person is not turned, positioned correctly, and given good nutrition and skin care, bedsores can develop .A bedsore develops when blood supply to the skin is cut off for more than 2 to 3 hours. As the skin dies, the bedsore first starts as a red, painful area, which eventually turns purple. Left untreated, the skin can break open and the area can become infected. A bedsore can become deep. It can extend into the muscle and bone. Once a bedsore develops, it is often very slow to heal. Depending on the severity of the bedsore, the person's physical condition, and the presence of other diseases .bedsores can take days, months, or even years to heal . The most severe sores may require a hospital stay to fight infection or surgery may be needed . (https://www.hopkinsmedicine.org/health/conditions-and-diseases/bedsores#:~:text=A%20bedsore%20develops%20when%20blood,A%20bedsore%20can%20become%20deep.) Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care to prevent the development of pressure ulcers/injuries (PU/PI - areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface (bony prominence)) when: 1. Resident 1 was at risk for developing pressure ulcers and worsening of a shearing wound (a force that causes the skin and underlying tissues to move in opposite directions, often due to pressure and friction) on the coccyx (tailbone). Resident 1's skin assessments and wound documentation were incomplete, the physician was not notified the wound had worsened, and PU preventative measures were not correctly identified and implemented upon admission; and, 2. Resident 2 was at risk of developing pressure ulcers and worsening of a shearing wound on the coccyx and blanchable redness (a temporary reddening of the skin that disappears when pressure is applied) to both heels. Resident 2's skin assessments and wound documentation were incomplete and measures to prevent PU development were not implemented. These failures resulted in Resident 1 having wound pain and required surgical intervention at a hospital with the placement of a wound vacuum (VAC -a medical treatment that uses negative pressure to help severe wounds heal). In addition, these failures resulted in Resident 2 developing a deep tissue injury (DTI - deep skin and tissue loss where the extent of the damage cannot be determined because it is covered by eschar (black dead tissue)) to the left heel and had the potential to result in increased pain, infection (the invasion and growth of germs in the body), and muscle or bone loss. Findings: 1. A review of Resident 1's ADMISSION RECORD, indicated Resident 1 was admitted to the facility in Spring 2025 with diagnoses which included but not limited to: sepsis (a life-threatening infection), arthritis (swelling and tenderness where two or more bones meet, causing joint pain and/or stiffness) due to other bacteria (an infection in the joint fluid and tissues caused by bacteria), chronic obstructive pulmonary disease (COPD -a chronic lung disease causing difficulty breathing), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS -an assessment tool), dated 4/22/25, in the section, M -Skin Conditions, indicated, Resident 1 was at risk of developing pressure ulcers. During a concurrent interview and record review on 5/13/25, at 1:19 PM, Resident 1's electronic health record (EHR) was reviewed with Licensed Nurse (LN) 1. LN 1 stated Resident 1 was admitted with two wounds, one on the left hand, and a shearing wound on the coccyx. Resident 1's Admission -Readmission Nursing Evaluation . dated 4/18/25, indicated, .Indicate Pressure Ulcers and/or other wound types .Sacrum [triangular shaped bone in the lower back located between the hip bones] .Type: Pressure [injury to skin and underlying tissue resulting from prolonged pressure on the skin] .Length 1.8 [cm- centimeter -a metric unit of length], Width 0.8 [cm], Depth 0.1 [cm], Stage II [2 -partial-thickness skin loss, presenting as a shallow open wound; wounds are classified into stages to indicate the depth of tissue damage and includes stages 1 through 4 and unstageable (when dead tissue is covering the wound making it unable to determine the depth of the wound)] . LN 1 stated the nurse who completed Resident 1's Admission-Readmission Nursing Evaluation was not a wound nurse. LN 1 stated he updated the description of the wound on the order he entered after he assessed Resident 1's wounds. LN 1 confirmed he entered .Cleanse [clean] shearing wounds to coccyx . to Resident 1's orders on 4/18/25 which changed the type of wound listed on the order from pressure ulcer to shearing wound. LN 1 stated he did not document in a progre [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received adequate supervision and that care plan (an individualized set of goals and interventions specific to the Resident 1 ' s needs) interventions were implemented to prevent an injury when, Resident 1 ' s care plan interventions of a fall mat (a soft pad at the side of the bed to soften a fall) and two person staff assist with activities of daily living (ADL ' s; a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) were not implemented and Resident 1 fell from the bed on 9/24/24. This failure led to Resident 1 sustaining multiple skin tears, pain, a broken clavicle (also called collarbone; is a long, slightly curved bone that connects your arm to your body and located in your upper chest area), and a decline in ability to feed herself. Findings: During a review of Resident 1 ' s undated clinical record titled ADMISSION RECORD, (a document that contained Resident 1 ' s demographic information) indicated, Resident 1 ' s diagnosis included encephalopathy (a brain dysfunction that caused confusion, memory loss, and personality changes), muscle weakness, and Parkinson ' s disease (a long-term brain disorder that caused involuntary body movements, stiffness, and difficulty with balance and coordination). A review of Resident 1 ' s clinical record titled, Brief Interview of Mental Status, (BIMS - an interview that assessed Resident 1 ' s mental function), dated 6/26/24, indicated Resident 1 ' s BIMS score was 11 (8 to 12 points suggests moderate cognitive impairment; Problems with a person's ability to think, learn, remember, use judgement, and make decisions). A review of Resident 1 ' s clinical record titled, Morse Fall Scale, (an assessment tool that determined Resident 1 ' s fall risk factors and targeted interventions to reduced fall risks), dated 1/12/24, indicated Resident 1 ' s fall risk score was 55 (45 and higher indicated a high risk for falls). Resident 1 ' s contributing factors for falls included a history of falls, use of a wheelchair, overestimated or forgot physical limits, and had more than one medical diagnosis. A review of Resident 1 ' s clinical record titled, [FACILITY NAME] Progress Notes *New* Post Fall Evaluation, dated 9/10/24, at 4:42 p.m., by the Licensed Nurse (LN 1), indicated the Certified Nursing Assistant (CNA 1) witnessed Resident 1 fall on 9/10/24, at 4:07 p.m., in Resident 1 ' s room. At the time of the fall, CNA 1 was changing Resident 1 ' s brief (adult diaper). After the fall, Resident 1 was sent to the Emergency Department (ED) at [ACUTE CARE HOSPITAL NAME] where it was determined Resident 1 had a fractured (broken) left clavicle. A review of Resident 1 ' s clinical record titled, [ACUTE CARE HOSPITAL NAME] Progress Notes *New*, dated 9/10/24, at 9:06 p.m., by LN 5, indicated Resident 1 rolled out of bed and had complaints of pain scored at 10 out of 10 using the Numerical Rating Pain Scale (assessment tool 0 through 10; 0 = no pain and 10= the worst pain). A review of Resident 1 ' s fall risk care plan, initiated on 8/29/22, indicated Resident 1 was at risk for falls related to her diagnosis of Parkinson's disease, weakness, urinary incontinence (unable to hold urine), use of antianxiety and antidepressant medications, history of falls, and required staff assistance with transfers and toileting. Interventions included fall mats at the bedside which was initiated on 9/1/2022. A review of Resident 1 ' s clinical record titled, Post Fall Evaluation, dated 9/10/24, at 4:42 p.m., indicated there was no fall mat in place at the time of the fall. A review of Resident 1 ' s clinical record titled, Interdisciplinary Team [IDT - a group of health care providers and other staff members that work together to discuss the care of Resident 1] Post Fall Meeting, dated 9/11/24, at 9:55 a.m., by LN 1, indicated Resident 1 rolled out of bed on 9/10/24, at 4:07 p.m. and sustained a fracture to her left clavicle, skin tears to the right and left side of her wrists, skin tears to the right index (finger next to the thumb) finger, a knot (bump) to the left side of her head, and complained of severe left shoulder pain that radiated (sent out) down to the elbow. At 4:45 p.m., Resident 1 was sent to [ACUTE CARE HOSPITAL NAME] for further evaluation. A review of Resident 1 ' s clinical record titled, [ACUTE CARE HOSPITAL NAME] Progress Notes *New*, dated 9/11/24, at 2:12 a.m., by LN 4, indicated Resident 1 returned to the facility from [ACUTE CARE HOSPITAL NAME] on 9/11/24, at 1:31 a.m. During a concurrent observation and interview on 10/16/24, at 11:50 a.m., in Resident 1 ' s room, Resident 1 had skin tears on her right hand that had steri-strips (thin, sticky bandages that are applied to the skin to help small cuts or wounds stay closed as they heal) in place, and a scabbed wound (a rough surface made of dried blood that forms over a cut or broken skin while it is healing) on her left fourth finger. There was no fall mat on either side of the bed. Resident 1 stated she was unsure how she fell out of bed on 9/10/24. During a concurrent observation and interview on 10/16/24, at 11:57 a.m., with LN 2, LN 2 stated Resident 1 required two staff members on each side of the bed when Resident 1 was turned and/or her brief was changed because Resident 1 was very fragile. LN 2 acknowledge there was not a fall mat at the bedside and that Resident 1 required a fall mat as part of her fall precaution interventions. During an interview on 10/15/24, at 12:05 p.m., with CNA 2, CNA 2 stated Resident 1 was a one person assist with brief changes and transfers (move from bed to wheelchair). CNA 2 stated she was unsure if Resident 1 needed a fall mat and was not sure where to look in Resident 1 ' s clinical record to verify if Resident 1 needed a one person or a two person assist with care needs. CNA 2 was unsure where to locate Resident 1 ' s care plan. During an interview on 10/15/24, at 12:10 p.m., with LN 3, LN 3 stated Resident 1 was a two person assist with brief changes (staff assistance to remove and replace an absorbent cloth or disposable products which is worn by humans who are incapable of, or have difficulty, controlling their bladder or bowel movements) and transfers because of her limited ability to assist with cares and because Resident 1 was very weak. During a phone interview on 10/15/24, at 12:36 p.m. with CNA 1, CNA 1 stated before Resident 1 ' s fall on 9/10/24, Resident 1 sometimes required a one person assist and sometimes required a two person assist with cares (depending on Resident 1 ' s strength on a given day). CNA 1 stated on the day of the fall, CNA 1 rolled Resident 1 ' s body away from her on the bed and then CNA 1 turned to grab the brief off of the nightstand. CNA 1 stated that was when Resident 1 fell out of bed. CNA 1 stated after the fall, Resident 1 declined in her physical ability to be helpful with her own cares. CNA 1 stated after the fall Resident 1 complained her head and shoulder hurt and Resident 1 was later transferred to [ACUTE CARE HOSPITAL NAME]. During a concurrent interview and record review on 10/15/24, at 1:20 p.m., with the Minimum Data Set (MDS - standardized assessment of Resident 1) Nurse, Resident 1 ' s clinical record titled, Section GG - Functional Abilities and Goals (a section of a comprehensive assessment that reviewed Resident 1's physical abilities), dated 6/30/24 and Section GG - Functional Abilities and Goals, dated 9/16/24, were reviewed. Section GG, dated 6/30/24 (before the fall), indicated Resident 1 required supervision or touch assistance (the helper provided verbal cues and/or touching/steadying assistance and the helper set up or cleaned up, but Resident 1 completed the activity) when she ate her meals. Resident 1 was dependent on staff when she rolled to the right and to the left (the helper did all the effort) and with all other ADLs. Section GG - Functional Abilities and Goals, dated 9/16/24 (after the fall), indicated Resident 1 was dependent on assistance when she ate her meals (the helper did all the effort and Resident 1 did none of the effort to complete the activity). Resident 1 remained dependent on staff when she rolled to the right and to the left and with all other ADLs. The MDS Nurse stated before the fall, Resident 1 was able to feed herself most of the time and after the fall she needed total assistance with eating. The MDS Nurse stated Resident 1 ' s care plan was supposed to be read and followed by all CNAs, Licensed Vocational Nurses (LVN), Registered Nurses (RNs), and the entire care team to guide them in how to specifically care for Resident 1. During an interview on 10/15/24, at 2:04 p.m., with the Occupational Therapist (OT), the OT stated before the fall, Resident 1 was able to feed herself independently more often than she was not able to feed herself independently and Resident 1 had started Occupational Therapy on 10/7/24 to increase independence with ADLs. The OT stated before the fall Resident 1 had use of both of her arms (Resident 1 was right-handed). The OT stated after the fall, Resident 1 had increased trouble with feeding and did not have use of her left arm (arm was in a sling; a device used to support and keep still (immobilize) an injured part of the body). The OT stated all health care professionals were supposed to read and follow Resident 1 ' s care plan to ensure safety during cares and treatments. A review of Resident 1 ' s clinical record titled, Occupational Therapy (exercises designed to increase independence with Activities of Daily Living (ADLs - brushing teeth, getting dressed, toileting, eating) Treatment Encounter Note(s), dated 10/11/24, at 2:24 p.m., by the Occupational Therapist (OT - health care provider who assisted Resident 1 with Occupational Therapy), indicated Resident 1 attempted therapy and then immediately requested to lay back down in bed. A two-person assist (two health care providers assisted Resident 1) was used when Resident 1 was repositioned. Resident 1 ' s body movements led to pain (as evidenced by Resident 1 yelled out) and limited her functional activities. During a phone interview on 10/15/24, at 2:39 p.m., with the Medical Director (MD), the MD stated the facility should have provided the correct number of staff while providing cares to Resident 1 to ensure quality care was delivered. During a follow-up interview on 10/15/24, at 2:50 p.m., with CNA 1, CNA 1 stated on 10/15/24, the Director of Staff Development (DSD) showed CNA 1 (for the first time) that the information regarding the amount of assistance Resident 1 required was located in Resident 1's care plan in the Electronic Heath Record ( a digital version of a patient's medical history that can be used to improve patient care) and in the Kardex (a system that nurses used to organize and access resident ' s information for care planning). CNA 1 stated prior to 10/15/24, CNA 1 was unsure where to find information regarding the amount of assistance Resident 1 required during cares. CNA 1 stated after Resident 1 ' s fall, Resident 1 had a decline in her ability to feed herself. CNA 1 stated before the fall, Resident 1 used to call CNA 1 by name and after the fall Resident 1 did not recall CNA 1 ' s name. During a concurrent phone interview and record review on 10/16/24, at 12:27 p.m., with the Director of Nursing (DON), Resident 1 ' s Medication Administration Record (MAR - a document that indicated when and what medication was administered to Resident 1), dated 9/24, was reviewed. The DON stated Tramadol (a government regulated pain mediation used to treat moderate pain (4 through 6 on the Numerical Rating Pain Scale) to severe pain (7 through 9 on the Numerical Rating Pain Scale) 50 milligrams (mg - unit of measurement) was ordered to be given every 6 hours following the fall on 9/10/24. The DON verified Resident 1 was given Tramadol 54 times for pain control in the month of September 2024. A review of Resident 1 ' s left clavicle fracture care plan, initiated on 9/11/24, in the section titled Interventions, indicated for Resident 1 to use a sling to her left arm at all times and was not supposed to put weight on the left arm. During a concurrent interview and record review on 10/15/24, at 3:25 p.m., with the DON, the following documents were reviewed: - Resident 1 ' s care plan related to ADL deficits, initiated on 8/30/22, - [Resident 1 ' s] Kardex, undated, - Certified Nursing Assistant Job Description, dated 10/20, - The facilities Fall and Fall Risk, Managing Policy and Procedure (P&P), dated 9/23, and - The facilities Care Plan, Comprehensive Person-Centered P&P, dated 3/22. The DON confirmed Resident 1 ' s ADL deficit care plan, initiated on 8/30/22, indicated Resident 1 ' s ADL interventions, also initiated on 8/30/22, included: extensive assistance by two staff members when Resident 1 was turned in bed and toileted. The DON confirmed Resident 1 ' s clinical record titled, Kardex, indicated Resident 1 required two staff members to assist Resident 1 when she was repositioned in bed, turned in bed, and with brief changes. A concurrent interview and record review with the DON continued with a review of the facility ' s document titled, Certified Nursing Assistant Job Description, indicated, . Duties and Responsibilities .review care plans daily to determine if changes in the resident ' s daily care routine have been made on the care plan The facility ' s P&P titled, Fall and Fall Risk, Managing, indicated, . 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 complications from falling . The facility ' s P&P titled, Care Plan, Comprehensive Person-Centered, indicated, . The . team . develops and implements a . person centered care plan for each resident . After reviewing Resident 1 ' s ADL deficit care plan, Resident 1 ' s Kardex, the Certified Nursing Assistant Job Description, the Fall and Fall Risk, Managing P&P, and the Care Plan, Comprehensive Person-Centered P&P, the DON stated that CNA 1 should have used a two person assist to turn Resident 1 and two persons assist to change Resident 1 ' s brief. The DON stated Resident 1 ' s care plan was created to ensure Resident 1 received safe care from the healthcare team. The DON stated her expectation was that all the staff members would have read and followed Resident 1 ' s care plan. The DON verified Resident 1 ' s care plan, the CNA Job Description, and the above listed P&Ps were not followed. A review of the facility ' s undated educational power point titled, Lifting and Transferring, indicated, .WHEN CHANGING A RESIDENT-TIPS AND REMINDERS . Ensure there are appropriate staff to assist. For example, if the resident requires a 2 person assist, be sure to have 2 CNAs to assist . Ensure that all supplies are within reach, so you do not have to leave the resident ' s side. Always review the Care Plan or Kardex prior to providing care to ensure proper plan of care is maintained . A review of the facility ' s P&P titled, Repositioning, dated 5/13, indicated, .check the care plan, . or the communication system to determine resident ' s specific positioning needs including Resident level of participation and the number of staff required to complete the procedure .

Based on interview and record review, the facility failed to protect the right of Resident 45, 1 of 25 female residents in the facility with a diagnosis of dementia (impaired ability to remember or make decisions) to be free from sexual abuse, when interactions of a sexual nature occurred between a male resident (Resident 36) who had a history of known sexual behaviors directed towards females in the facility, and Resident 45; and the facility lacked a process to evaluate the capacity for residents in the facility to consent to sexual activity. This deficient practice resulted in three instances of sexual contact between Resident 36 and Resident 45 on 12/15/23, 12/17/23, and 12/23/23, and placed other vulnerable residents in the facility at risk of sexual abuse due to the facility's inadequate response to sexual activities and lack of a process to evaluate capacity to consent to sexual activity. This created a likelihood serious physical and/or psychosocial harm (negative impact on physical, emotional, and/or mental wellness) would occur, if not corrected immediately. The Immediate Jeopardy (IJ-a threat to resident health or safety which requires immediate corrective action due to the likelihood of serious injury or harm) began on 12/15/23, when the facility failed to assess Resident 45's ability to consent to sexual activity and did not identify the sexual contact by Resident 36 as possible abuse. The Administrator (ADM) and Director of Nursing (DON) were notified of the IJ on 1/26/24, at 11:18 AM. On January 26, 2024, at 5:19 PM, a removal plan was provided by the facility. The State Agency verified the facility's implementation of the removal plan while onsite at the facility. On 1/26/24, at 5:58 PM, the ADM and DON were notified the IJ immediacy was removed. There was no non-compliance identified at a lower level upon removal. Findings: A review of Resident 45's Admission Record indicated Resident 45 was admitted to the facility with a primary diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 36's Admission Record indicated Resident 36 was admitted in Spring of 2023 and was his own Responsible Party (RP - able to make medical and personal decisions for himself). A review of Resident 36's Brief Interview for Mental Status (BIMS) showed a score of 8, indicating moderate cognitive (mental process involved in knowing, learning, and understanding things) impairment. A review of Resident 36's clinical record titled, Progress Notes: Type: Alert Note, dated 10/4/23, at 4:02 PM, indicated, Resident has been placed on alert charting for monitoring for inappropriate/sexual behaviors with staff and peers. Resident has been moved from A Wing to C Wing in result of demonstrating unwarranted inappropriate behaviors with a female peer. The residents were immediately separated and placed on continuous monitoring for further interactions .collected witness statements from staff members/witnesses. Resident is currently residing in bed .Will continue to monitor. A review of Resident 36's Care Plan, dated 10/19/23, indicated .Focus [Resident 36] will not share a bathroom or any joined bathrooms with any females .Goal [Resident 36] will not have no [sic] incidents with sharing a bathroom with a female .Intervention/Tasks Room change with unshared bathroom with females and will be redirected to his own room when trying to use other bathrooms . A review of Resident 36's Care Plan, dated 12/15/23, indicated, .Focus [Resident 36] is going into female peer rooms and engaging in personal contact .Goal [Resident 36] will not go into female residents rooms unsupervised .Interventions/Goals resident educated on not going into female patients room unsupervised and/or without consent .resident is on alert charting for inappropriate gestures with female staff and peers .staff will provide redirection as needed when in close personal contact with female peers . A review of Resident 36's clinical records titled, Progress Notes, ranging 12/15/23 through 1/8/24 indicated Resident 36's behavior with other residents as follows: .12/15/2023 11:26 [AM] Note Text: CNA [certified nursing assistant] reported to writer that she witness [sic] [Resident 36] in female peers room touching and kissing peer . .12/19/2023 17:00 [5 PM] patient noted following female peer around facility. patient [sic] unreceptive to redirection. patient stated im [sic] not gonna stop, do you know how many times ive [sic] kissed her? . attempted to counsel patient however patient continued to be non-redirectable . .12/20/2023 16:15 [4:15 PM] . pt [Patient] was observed attempting to kiss [Resident 45] on the cheek . .12/23/2023 14:49 [2:49 PM] .patient observed kissing and touching peer. staff attempted to provide redirection and counsel however patient became agitated and was unreceptive. patient asked, how am i [sic] supposed to get a girlfriend in this place then. writer again reminded that boundaries and personal space should be maintained and respected. patient [sic] did not respond . .12/24/2023 13:12 [1:12 PM] . Resident had inappropriate language towards staff and peers . .12/27/2023 12:55 . Resident had personal contact with female peer . .01/03/2024 13:05 [1:05 PM] . Staff member reported to writer, that [Resident 36] was seen with inappropriate touching with female residents at 1300 [1 PM] . .01/03/2024 13:15 [1:15 PM] . He [Resident 36] was found going down the hallway B towards [Resident 45's] room . .01/08/2024 13:21 [1:21 PM] . [Resident 36] was trying to hold hands with another resident. Redirected several times . A review of Resident 45's clinical records titled, Progress Notes, ranging 12/15/23 through 12/23/23 indicated as follows: .12/15/2023 11:26 [AM] .CNA reported that a male resident was in room with patient and both patients were seen kissing. Writer asked male resident to leave the room . .12/17/23 17:46 [5:46 PM] . Resident caught kissing [Resident 36] in front of the nurses station at dinner time. No inappropriate touching with hands. Female resident is confused and both residents were separated. .12/23/23 14:49 [2:49 PM] . patient observed kissing peer. patient consenting however patient is not self-responsible . A review of Resident 36's clinical document titled, IDT [Interdisciplinary Team - ADM, DON, ADON [Assistant Director of Nursing], Infection Preventionist, Licensed Nurses, etc.,] Care Conference, dated 1/4/24, indicated, .Topics Discussed at Resident . Request: resident's inappropriate behaviors towards staff and a ressident [sic] [Resident room number] [Resident 45] .Psychosocial Mood/behavior risk and interventions to manage: resident has particiapated [sic] in the meeting. he has acknowledged that he did touch staff. he was advised not to do so. he understood that this type of behavior is not appropriate and it is unacceptable. he was advised to ask staff or reach out to staff via verbal queue [prompt] such as by saying excuse me, can you help me instead of trying to touch them to get their attention .describe additional care areas and person-centered approaches: he was also advised on his approaches to resident [45] and/or to any other female peer in the facility. he has been advised not to touch his female peers or to go in their rooms even if invited .additional comments: resident will be reminded and redirected when he is in his peers or [Resident 45's] personal space. staff will focus on the approaches they use to redirect resident wothout [sic] trying to upset him. staff can redirect him to social services or other areas . A review of Resident 36's clinical document titled, Nursing Weekly Observation, dated 1/20/24, indicated, .M. Mental/Emotional/Behavioral Status .2. Mood and behavior patterns .Alert .Oriented .Friendly .Sexually inappropriate . During an interview with Resident 45 on 1/25/24, at 9:26 AM, Resident 45 could not verbalize her name when asked. During an interview with CNA 2 on 1/25/24, at 9:56 AM, CNA 2 stated Resident 36 wandered all day and went into other rooms. CNA 2 further stated she had only seen him went into Resident 45's room. CNA 2 explained Resident 36 made inappropriate jokes and showed nude photos on his telephone. During an interview with Licensed Nurse (LN) 5 on 1/25/24, at 10:05 AM, LN 5 stated she thought Resident 45 was vulnerable. LN 5 explained she did not believe Resident 45 had the capacity to consent to sexual activity. During an interview with LN 2 on 1/25/24, at 10:11 AM, LN 2 stated Resident 45 did not have the capacity to make decisions and she was forgetful. LN 2 further stated Resident 45 was alert and oriented to self only. LN 2 stated she informed the DON and ADM and asked if the incident on 12/15/23 should be reported to the authorities as possible abuse. LN 2 explained she was informed by the ADM and DON it was not necessary as Resident 45 was engaging and welcoming the behavior exhibited by Resident 36. During an interview with LN 4 on 1/25/24, at 10:37 AM, LN 4 stated she was told to be careful of Resident 36 as he was inappropriate. LN 4 explained she was informed he was to be monitored for inappropriate comments and to redirect him. During an interview with the Psychiatric Nurse Practitioner (PNP) on 1/25/24, at 11:34 AM, the PNP stated she evaluated Resident 45 on 1/5/24. The PNP stated Resident 45's Responsible Party (RP) wanted Resident 45 assessed due to inappropriate contact with a male resident and the facility requested an evaluation of Resident 45's mental status changes. The PNP stated she was not asked to evaluate Resident 45's ability to consent to sexual activity and stated Resident 45 did not have the capacity to consent to sexual interactions due to dementia. During an interview with Family Member (FM) 2 on 1/25/24, at 2:27 PM, FM 2 stated Resident 45 did not have the ability to consent to a sexual relationship. FM 2 stated Resident 45 had a history of sexual abuse as a child. During an interview with Family Friend (FF) 1 on 1/25/24, at 2:48 PM, FF 1 stated when she visited Resident 45 in December, Resident 45 expressed that a couple of men were making sexual advances and she was upset about it and wanted to be left alone. During an interview with the Medical Director (MD) on 1/25/24, at 3:03 PM, the MD stated Resident 45's dementia would impact her informed decision-making capacity. MD explained if someone lacked the capacity to give informed consent that would be a concern, and if someone were being taken advantage of that would be wrong. The MD stated, .I don't know what the facility process is for establishing consent .there should be some kind of procedure for that . During an interview with the ADM on 1/25/24, at 3:38 PM, the ADM stated they had not seen any indication that Resident 45 did not want the sexual interactions and did not view the incidents as potential abuse. The facility could not provide documented evidence of Resident 45's decisional capacity to consent to the sexual advances from Resident 36 on 12/15/23, 12/17/23, and 12/23/23. During an interview with Resident 45 on 1/26/24, at 10:14 AM, Resident 45 stated she would not want a man kissing or touching her. During an interview with the Director of Nursing (DON) and the Administrator (ADM) on 1/26/24, at 11:36 AM, neither could confirm whether Resident 45 had been assessed for the ability to consent to sexual contact. A review of the facility policy titled, FREEDOM FROM ABUSE, NEGLECT and EXPLOITATION Abuse, dated 11/2017, the policy indicated, PURPOSE: To keep residents free from abuse, neglect and corporal punishment of any kind by any person. POLICY: The facility will provide a safe resident environment and protect residents from abuse .This includes freedom from .sexual or physical abuse .GUIDELINES: .For allegations of abuse, the facility will: a. immediately implement safeguards to prevent further potential abuse b. Immediately report the allegation to appropriate authorities c. Conduct a thorough investigation of the allegation d. Document and report the result of the investigation of the allegation .Resident to resident abuse: .Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions (e.g .sexual or verbal aggression .wandering into another's room/space) .Types of Abuse: .4. Sexual Abuse a. Non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent or a resident who does not want the contact to occur. b. Investigations of an allegation of sexual abuse will start with a determination of whether the sexual activity was consensual or not, taking into consideration the cognitive ability of the resident to consent. c. Residents without the ability to consent will not engage in sexual activity .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that two of twenty-one sampled residents (Resident 64 and Resident 49) functional abilities did not diminish when: 1. Resident 64 had a decline in her ability to feed herself and services were not provided to determine the cause and/or maintain her abilities. 2. Resident 49 was not provided Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services per her care plan interventions. These failures resulted in Resident 64's decline in range of motion (ROM, the full movement potential of a joint) to her right arm, left arm and hand, increased pain, and a loss of the ability to feed herself; and in a decline in Resident 49's ability to transfer from a sit to stand position, requiring substantial to maximum assistance when transferring from a bed or chair. Findings: 1. A review of Resident 64's ADMISSION RECORD, indicated, Resident 64 was admitted to the facility in May of 2023, with diagnoses which included Alzheimer's disease (a progressive disease that affects the parts of the brain that control thought, memory and language) and muscle weakness. During a concurrent observation and interview, in Resident 64's room, on 1/23/24, at 8:58 AM, Certified Nurse Assistant (CNA) 1 stated Resident 64 had been able to move both of her arms and feed herself. CNA 1 further stated Resident 64 declined and stopped moving her arms after she had COVID-19 (a respiratory virus which can cause serious health complications and requires 10 days isolation) in June 2023. During an observation on 1/24/24, at 9:02 AM, Home Health Aide (HHA-a hospice staff who provides personal care) 1 was observed putting a t-shirt on Resident 64. Resident 64 was grimacing and gasping when HHA 1 moved her arms and attempted to uncurl her fingers from her palm. A review of Resident 64's MDS (minimum data set, a resident assessment and screening tool) Section GG, dated October 17, 2023, indicated, .Functional limitation in Range of Motion .upper extremity [arm] . no impairment .lower extremity [leg] .no impairment .Eating .Supervision or touching assistance . A review of Resident 64's MDS Section GG, dated December 12, 2023, indicated, .Functional limitation in Range of Motion .upper extremity . Impairment on both sides .lower extremity .impairment on both sides .Eating .Dependent . A review or Resident 64's care plan, revised on 8/18/2023, indicated, .Goal . [Resident 64] will remain free of complications related to immobility, including contractures [a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff] . During an interview on 1/24/24, at 3:12 PM, the Hospice Case Manager (CM) stated Resident 64's arms had no, obvious contractures on admission to hospice on 12/5/23. During an interview on 1/30/24, at 8:04 AM, the Director of Staff Development (DSD) stated staff should have informed the charge nurse or unit manager of the change in Resident 64's condition so they could intervene and request occupational therapy or RNA services. During a concurrent observation and interview, in Resident 64's room, on 1/30/24, at 9:27 AM, Licensed Nurse (LN) 2 confirmed Resident 64 had contractures to both arms and her left hand. LN 2 stated Resident 64 had been able to feed herself with set up assistance previously. LN 2 further stated when a resident's condition declined the physician and the responsible party should be informed. LN 2 stated social services should have been contacted and a care conference (a meeting with everyone involved in the person's care) should have occurred when Resident 64's mobility had significantly changed. LN 2 further stated the decline should have been documented to indicate the changes in her mobility. LN 2 confirmed there was no documentation in Resident 64's clinical record indicating her upper extremity contractures. LN 2 stated had the issue been addressed there would have been opportunities to increase her ROM and prevent the contractures from getting worse, prevent pain and further decline. LN 2 further stated Resident 64 should have a hand roll (device placed in the palm of the hand to prevent skin breakdown) to prevent her nails cutting into her hand. LN 2 stated the lack of documentation and follow up put resident 64 at risk of more severe contractures. During a telephone interview on 1/30/24, at 2:51 PM, the Medical Director (MD) stated RNA services would have helped Resident 64 with her mobility and made her more comfortable. The MD further stated the goal of care was to emphasize comfort and quality of life. 2. A review of Resident 49's ADMISSION RECORD, indicated Resident 49 was admitted to the facility in October of 2023 with diagnoses which included hydronephrosis (swelling of one or both kidneys) and muscle weakness. A review of Resident 49's MDS Section GG, dated November 27, 2023, indicated, .03 Partial /moderate assistance-Helper does LESS THAN HALF the effort .Sit to stand: the ability to come to a sitting position from sitting in a chair, wheelchair, or side of the bed .Chair/bed-to-chair transfer .Toilet transfer .Tub/shower transfer . A review of Resident 49's MDS Section GG, dated December 8, 2023, indicated, .02. Substantial/maximal assistance-Helper does MORE THAN HALF the effort . Sit to stand: the ability to come to a sitting position from sitting in a chair, wheelchair, or side of the bed .Chair/bed-to-chair transfer .Toilet transfer .Tub/shower transfer . During an interview on 1/22/24, at 11:34 AM, Resident 49 stated, .I can't move my legs, they don't exercise them . During an interview on 1/25/24, at 7:47 AM, LN 3 stated Resident 49 was unable to move her lower extremities. A review of Resident 49's care plan initiated on 11/26/21 with a revised date of 11/9/2023., indicated, [Resident 49] has limited physical mobility .Interventions .NURSING REHAB/RESTORATIVE: ACTIVE ROM [active range of motion, moving a part of your body by using your muscles] Program to both legs, 5x/week [5 times per week] . A review of Resident 49's Progress Note dated 11/9/2023, indicated, .RNA meeting held this AM with DSD and RNAs in attendance. Resident will continue RNA for AROM [active range of motion, moving a part of your body by using your muscles] and walking . A review of facility documents titled, RNA program assignment sheet, dated December 1-31, 2023, indicated Resident 49 did not receive RNA services in the month of December 2023. A review of facility documents titled, RNA program assignment sheet, dated January 1-24, 2024, indicated, Resident 49 refused RNA services on January 1, 2024, and received them on January 2, 2024. Resident 49 did not receive RNA services January 3 through January 24, 2024, During an interview on 1/30/24, at 7:42 AM, the DSD confirmed Resident 49's care plan indicated she was to receive RNA services 5 times per week. The DSD stated the purpose of the RNA services was for Resident 49 to receive ROM to maintain her level of function and decrease her risk of contractures. The DSD stated it was her expectation that residents on the RNA program would be provided services. A review of a facility policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised July 2017, indicated, .Residents will not experience an avoidable reduction in range of motion (ROM) .Residents with a limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM . A review of a facility P&P titled, Activities of Daily Living (ADL's-essential basic self care tasks), Supporting, revised March 2018, indicated, .Residents will be provided with care treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Interventions .will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice . A review of a facility P&P titled, Restorative Nursing Services, revised July 2021, indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services .

Based on interview and record review the facility failed to evaluate resident specific risk factors and changes in health conditions that caused the development of pressure ulcers (an injury that breaks down the skin and underlying tissue caused by being in one position for too long) for two of three residents (Resident 1 and Resident 2) when: 1. Resident 1's person centered risk factors to prevent and treat pressure ulcers were not documented on a risk for skin breakdown care plan, risk factor interventions were not implemented to prevent/heal pressure ulcers, and Resident 1's nursing assessment was not completed on 8/3/23 upon the discovery of a stage three pressure ulcer (affecting the deepest layer of your skin) to Resident 1's ischial tuberosity (also known as the sitting bone, as this is where the weight of the body is held when seated); and, 2. Resident 2's person centered risk factors to prevent and treat pressure ulcers were not documented on a risk for skin breakdown care plan, risk factor interventions were not implemented to prevent/heal pressure ulcers, and Resident 2's nursing assessment done on 8/8/23 was not completed upon the discovery of a stage two pressure ulcer (Partial thickness loss of the middle layer of skin presenting as a shallow open ulcer) to Resident 2's tailbone. These failures resulted in the development of a stage three pressure ulcer to Resident 1's right ischial tuberosity and the development of a stage two pressure ulcer to Resident 2's tailbone. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included weakness on the right side of the body, hyperglycemia (an abnormal amount of sugar in the blood which can affect the eyes, kidneys, and nerves of the body ) chronic wounds (a wound that does not heal in a predictable amount of time), edema (swelling caused by too much fluid trapped in the body's tissues) to both lower legs and nicotine dependence. A review of Resident 1's Quarterly Minimum Data Set (MDS, an assessment tool), dated 7/9/23, revealed a score of 12 on the Brief Interview for Mental Status which indicated slight cognitive impairment (BIMS, a score of 0-15, zero being significant impairment and fifteen being no impairment.) Further review of the MDS indicated Resident 1 was at risk for developing pressure ulcers and was not on a turning/repositioning program. Resident 1's mobility documented on the 7/9/23 MDS indicated Resident 1 did not walk, needed the assistance of two people for bed mobility and transfers, and used a wheelchair. The MDS also revealed Resident 1 was frequently incontinent of bowel and bladder (little or no control of bowel and bladder function) and was not on a toileting program (scheduled or prompted use of the bathroom for bowel or bladder retraining.) A review of Resident 1's assessment titled, .Bowel and Bladder Screener ., dated 7/3/23, revealed a score of 9 which indicated Resident 2 was a .good candidate for retraining [bladder retraining] . During a concurrent interview and record review on 11/10/23, at 12:38 p.m., LN 1 confirmed Resident 1 had not been on a toileting program and incontinence was a risk factor for pressure ulcers. A review of Resident 1's assessment titled, BRADEN SCORE FOR PREDICTING PRESSURE SORE RISK [an assessment used to determine if a resident is at risk for developing pressure ulcers], dated 4/19/23, revealed a score of 18 which indicated Resident 1 was at risk of developing pressure ulcers on admission to the facility. The next Braden completed was dated 7/3/23 and revealed a score of 13 which indicated a moderate risk for developing pressure ulcers (at risk 15-18, moderate risk 13-14, high risk 10-12, very high risk 9 or below). During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's meal intake for the months of July, August, and September of 2023 were reviewed. LN 1 confirmed Resident 1 was on a low salt, double portioned diet and that in July facility staff did not document Resident 1's meal intake for breakfast 7 times, for lunch 8 times, and for dinner 3 times. Resident 1 refused three meals, ate 0-25 percent of his meals 10 times, and ate 26-50 percent of his meals 12 times. In August facility staff did not document Resident 1's meal intake for breakfast 11 times, and for lunch 12 times. Resident 1 refused 11 meals, ate 0-25 percent of his meals 11 times, ate 26-50 percent of his meals 5 times, and N/A (non-applicable) was documented 2 times. In September Resident 1 was in the facility for 12 days. Facility staff did not document Resident 1's meal intake for breakfast 5 times, and for lunch 7 times. Resident 1 ate 0-25 percent of his meals 6 times and ate 26-50 percent of his meals 2 times. LN 1 confirmed Resident 1 consumed 50 percent or less of his meals over half the time and there was no offer of an alternative meal documented or any type of calorie replacement supplements ordered. LN 1 confirmed the findings and verified poor nutrition was a risk factor for the development of pressure ulcers. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's weights were reviewed. On 4/25/23 (six days after admission) Resident 1 weighed 235.4 pounds, on 8/1/23 (three months after admission) Resident 1 weighed 202 pounds. LN 1 stated Resident 1's weight loss was attributed to a medication used to reduce the fluid accumulation in his lower legs. LN 1 confirmed Resident 1 was admitted to the facility with 2-3+ pitting edema (a score given to measure how long it takes for the skin to rebound after being pressed) to both lower legs according to his admission assessment dated [DATE]. A review of Resident 1's daily nursing monitors to measure the edema revealed from 8/1/23-8/14/23 Resident 1 continued to have 2-3+ pitting edema. From 4/25/23-8/1/23 Resident 1 lost 33.4 pounds (a 14 percent loss). During an interview on 11/10/23, at 12:38 p.m., LN 1 stated pressure ulcer risks for Resident 1 included being a daily smoker, refusal of care, incontinence, right sided weakness, right sided hand, and knee contractures (a fixed tightening of muscle, tendons, and ligaments which prevents normal movement of the associated body part) and a decline in mobility. LN 1 stated on admission in early 2023 Resident 1 was able to transfer himself from bed to his wheelchair, and around June of 2023 Resident 1 was no longer able to transfer himself and required staff to use a lift device to transfer Resident 1. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's care plans and clinical record were reviewed with LN 1. The first care plan reviewed, dated 4/27/23, indicated, .Focus .alteration in skin integrity due to: edema, PVD [peripheral vascular disease, a disease affecting the veins], stasis ulcers [a wound that takes longer to heal due to vein and blood flow issues] .Interventions .Assess/record changes in skin status .avoid pressure .complete skin report weekly . LN 1 confirmed during the nurses required weekly summary of Resident 1, the summary should include a skin report. LN 1 verified in June 2023 two summaries were completed (out of 4), and one summary in August 2023 (out of 4) was completed. An additional care plan reviewed, dated 5/1/23, indicated, .[Resident 1] has potential for impairment to skin integrity r/t [related to] .venous stasis ulcers .to lower extremities, with episodes of incontinence .he is at risk for further skin breakdown .Interventions .Monitor for skin breakdown/pressure ulcer formation daily . LN 1 confirmed on both of Resident 1's at risk for skin breakdown care plans the care plans did not include other identified risk factors such as being a daily smoker, poor mobility, refusal of care, weakness on the right side, and contractures. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's nurses notes were reviewed with LN 1. LN 1 confirmed there was not a progress note, a change in condition note, or any other type of entry from a nurse that Resident 1's pressure ulcer to his right ischial tuberosity was assessed for cause, location, stage, size (length, width, depth), odor, or necrotic/eschar tissue (dead skin tissue) but should have been to monitor if the pressure ulcer was improving or worsening. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 1's care plans were reviewed with LN 1. LN 1 confirmed on 8/3/23 a care plan was initiated which read, .Focus .[Resident 1] has cellulitis (a skin infection) to wound right ischium UTD [unable to determine, unable to see the wound entirely due to dead skin tissue] PU [pressure ulcer] .Goal .The resident will have no complications resulting from the cellulitis through the review date .Interventions .Educate the resident that prevention of cellulitis starts with good hygiene .importance of compliance with showers and turning and repositioning .give antibiotics .monitor/document and report to MD [medical doctor] the following symptoms of Cellulitis .WOUND/DRESSING per MD order . LN 1 confirmed the care plan was geared towards the potential infection of the pressure ulcer as opposed to person centered interventions to treat/heal the pressure ulcer. LN 1 confirmed there was never a specific care plan initiated for the pressure ulcer discovered on 8/3/23 to Resident 1's right ischial tuberosity outlining interventions to prevent worsening of the pressure ulcer. A review of Resident 1's Physician Assistant's (PA) note, dated 8/9/23, indicated the PA examined Resident 1 on 8/9/23 (six days after the discovery of the pressure ulcer) which read, .complaints: none .Skin .exam .yes . Further review of the note revealed under the area for the PA to write a Plan the area was blank. A review of Resident 1's wound physician's note, dated 8/10/23, indicated, .Patient has a large pressure injury on right ischium. He now spends most of his time in his wheelchair. I discussed repositioning with him. I also am recommending a LAL mattress [an air mattress that redistributes pressure] and a Roho cushion [a chair cushion designed to relieve pressure] for his wheelchair .Initial wound encounter measurements are 7cm [centimeters, a unit of measure] length x 6.5cm width with no measurable depth, with an area of 45.5 sq [square] cm .wound bed has 100% eschar .surgical debridement .removed .necrotic/eschar .used .scalpel .post debridement measurements: 7cm length x 6.5cm width x 3cm depth . A review of Resident 1's wound physician's note, dated 8/17/23, indicated, .Right Ischium is a Stage 3 Pressure Injury .no change in the wound progression . During an interview with Certified Nursing Assistant (CNA) 1 on 10/26/23, at 5:24 p.m., CNA 1 stated Resident 1 would get up into his wheelchair on the day shift and not go back to bed until approximately 9 p.m.[Resident 1] would just want to stay in his chair .we told nurses every time he did not want to go back to bed. Sometimes he won't let us change him either . During an interview with the Director of Nursing (DON) on 11/1/23, at 11:29 a.m., the DON stated Resident 1 should have had a Roho cushion prior to the pressure ulcer forming because he shifted to one side due to his right sided weakness and was up in his wheelchair most of the time which put him at risk for skin injury or further skin injury. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., LN 1 confirmed Resident 1 spent more time up in his wheelchair than in bed. LN 1 stated there was no documentation to verify that Resident 1 was being repositioned in his wheelchair or in bed. LN 1 confirmed Resident 1's Roho cushion and LAL mattress were not added to a care plan. LN 1 added care plans were the documented plan of care the resident should receive. Prior to 8/10/23, LN 1 verified Resident 1 did not have any other pressure relieving devices to help prevent pressure ulcers except for the same mattress every resident had in the building. A review of Resident 1's change in condition nurse's note, dated 9/12/23, indicated, .Resident [1] presented with .foul odor from wound to R [right] ischium, lethargic [drowsy], pale and clammy .MD advised to send resident to acute for further evaluation for .sepsis [your body's extreme reaction to an infection. Without prompt treatment, it can lead to organ failure, tissue damage and death] . 2. Resident 2 was admitted to the facility in mid-2023 with diagnoses which included diabetes (an abnormal amount of sugar in the blood which can affect the eyes, kidneys, and nerves of the body), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs which can cause fatigue, constipation, and dry skin), overactive bladder (causes a frequent and sudden urge to urinate that may be difficult to control), and had a history of urinary tract infections (UTI, a common infection which happens when bacteria, often from the skin or rectum, enter the urinary system.) A review of Resident 2's Quarterly MDS, dated [DATE], revealed a score of 4 on the BIMS which indicated significant cognitive impairment. Further review of the MDS indicated Resident 1 was at risk for developing pressure ulcers, had a stage two pressure ulcer (developed three months after admission), and was not on a turning/repositioning program. Resident 2's mobility documented on the 8/13/23 MDS indicated Resident 2 needed the assistance of one person for bed mobility and transfers and used a wheelchair. The MDS also revealed Resident 2 was frequently incontinent of bowel and bladder and was not on a toileting program. A review of Resident 2's assessment titled, .Bowel and Bladder Screener ., dated 8/10/23, revealed a score of 9 which indicated Resident 2 was a .good candidate for retraining . During a concurrent interview and record review on 11/10/23, at 12:38 p.m., LN 1 confirmed Resident 2 had not been on a toileting program and incontinence was a risk factor for pressure ulcers. A review of Resident 2's assessment titled, BRADEN SCORE FOR PREDICTING PRESSURE SORE RISK, dated 5/17/23, revealed it was blank (not done on admission to the facility.) The next Braden was completed on 8/10/23 and revealed a score of 16 which indicated Resident 2 was at risk for developing pressure ulcers. During a concurrent interview and record review on 10/26/23, at 4:49 p.m., LN 1 confirmed Resident 2's 5/17/23 Braden assessment was incomplete. LN 1 stated the Braden should be completed upon admission to the facility, so staff are able to properly identify pressure ulcer risk for each resident. LN 1 stated the Braden should be done on admission and quarterly thereafter. A review of Resident 2's nurse progress note dated 8/5/23, indicated, .coughing and fine crackles [a series of short, explosive sounds that can also sound like bubbling, rattling, or clicking] noted during shift. Resident appears to have increased confusion .MD notified of findings .This writer requested order for chest x-ray . During an interview on 10/4/23 at 11:47 a.m., CNA 3 stated she could not remember the exact date but when she took over care for Resident 2 one morning, she was soaked with urine and her bed was wet. CNA 3 added Resident 2 had a rash on her bottom, and she notified the nurse. CNA 3 went on to say Resident 2 would not drink much water. During an interview on 10/31/23 at 2:44 p.m., LN 4 stated he witnessed Resident 2 up in her recliner a couple times on the PM shift (shift between AM shift and Night shift.) LN 4 added Resident 2 was not eating well, would not drink enough water, and stayed in bed while she was sick. LN 4 stated these factors contributed to Resident 2 developing a pressure ulcer. During an interview on 11/1/23 at 11:29 a.m., the DON stated Resident 2 developed a pressure ulcer because Resident 2 was not repositioned frequently or often enough. The DON added Resident 2's nutrition was not good. During an interview on 11/10/23 at 12:38 p.m., LN 1 stated Resident 2 would get up to her wheelchair for meals then transfer to the recliner in her room each day. LN 1 confirmed Resident 2 did not have any other pressure relieving devices to help prevent pressure ulcers except for the mattress every other resident had in the building. LN 1 verified there was no documentation to indicate Resident 2 was on a turning/repositioning program. A review of Resident 2's care plans indicated, .Focus .[Resident 2] has bladder incontinence and requires extensive assistance with toileting .She is at risk for skin breakdown .date initiated 5/25/2023 .Interventions .Briefs [used for incontinence in adults] .encourage fluids . An additional care plan indicated, .[Resident 2] has potential for pressure ulcer development r/t [related to] bowel and bladder incontinence, immobility and she requires extensive assistance with bed mobility .date initiated 5/23/2023 .Interventions .Encourage and assist patient to turn and reposition frequently .monitor nutritional status .provide good .care with each incontinent episode . A review of Resident 2's change of condition nurse's note, dated 8/8/23, indicated, .pressure ulcer on [tailbone] . A subsequent review of Resident 2's care plans revealed staff did not initiate a care plan for Resident 2's pressure ulcer with interventions to treat/heal the pressure ulcer. During an interview on 11/1/23 at 11:29 a.m., the DON stated staff should have initiated a care plan after the pressure ulcer was identified. During a concurrent interview and record review on 11/10/23, at 12:38 p.m., Resident 2's nurses notes were reviewed with LN 1. LN 1 confirmed there was not a progress note, a change of condition note, or any other type of entry from a nurse that verified Resident 2's pressure ulcer to her tailbone was assessed for cause, location, stage, size (length, width, depth), odor, or necrotic/eschar tissue (dead skin tissue) but should have been. A review of Resident 2's Physician Assistant's (PA) note indicated the PA examined Resident 2 on 8/9/23 (one day after the pressure ulcer was discovered) which read, .complaints: none .Skin .exam .yes . Further review revealed under the area for the PA to write a Plan the area was blank. A review of the facility's policy and procedure titled, Prevention of Pressure Injuries, revised 4/2020, indicated, .Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment [The facility uses the Braden Scale] weekly and upon any changes in condition .inspect the skin on a daily basis .identify any signs of developing pressure injuries .inspect pressure points .[tailbone] .ischium .reposition resident as indicated on the care plan .Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team [team of professionals providing day to day care of the resident] .Choose a frequency for repositioning based on the resident's risk factors .Evaluate, report and document potential changes in the skin .Review the interventions and strategies for effectiveness on an ongoing basis . A review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, Revised 4/2018, indicated, .The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example immobility, recent weight loss .Full assessment of pressure sore [ulcer] including location, stage, length, width and depth, presence of .necrotic tissue .pain assessment .mobility status .current treatment, including support surfaces .all active diagnoses .The physician will help identify factors contributing .to skin breakdown .medical instability .friable [fragile] skin .the physician will order .pressure reduction surfaces .During resident visits, the physician will evaluate and document the progress of wound healing .The physician will guide the care plan as appropriate .Current approaches should be reviewed for whether they remain pertinent to the resident .medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident .

Based on interview and record review the facility failed to ensure quality care was provided to one of three sampled residents (Resident 2) when: 1. Staff were notified on [DATE] that Resident 2 had signs and symptoms of a urinary tract infection (UTI, a common infection which happens when bacteria, often from the skin or rectum, enter the urinary system) by Resident 2's family member but assessment and monitoring of Resident 2's condition was not done; and, 2. Resident 2 had a lung infection which began on [DATE]. Resident 2's physician examined her on [DATE] and did not document an assessment of Resident 2's lung infection was done; and, 3. Resident 2 had one instance of bleeding from her rectum with a medium sized blood clot on [DATE] and the nurse removed hard stool from the rectum without a physician's order, the physician was never notified, and monitoring of Resident 2's condition was not done. These failures resulted in Resident 2 being sent to acute care hospital (ACH) 1 on [DATE] with diagnoses of pneumonia (an infection that affects one or both lungs. It causes the air sacs of the lungs to fill up with fluid or pus), UTI, and anemia (when your blood produces a lower-than-normal amount of healthy red blood cells) then transferred to ACH 2 the next day ([DATE]) with diagnoses of septic shock (most severe form in which the infection causes low blood pressure, resulting in damage to multiple organs, Sepsis), pneumonia, and UTI which ultimately contributed to her death on [DATE]. A review of Resident 2's Face Sheet was admitted to the facility in mid-2023 with diagnoses which included diabetes (an abnormal amount of sugar in the blood which can affect the eyes, kidneys, and nerves of the body), overactive bladder (causes a frequent and sudden urge to urinate that may be difficult to control) and had a history of urinary tract infections. A review of Resident 2's Quarterly MDS, dated [DATE], revealed a score of 4 on the BIMS which indicated significant cognitive impairment. Resident 2's mobility documented on the [DATE] MDS indicated Resident 2 needed the assistance of one person for bed mobility and transfers. The MDS also revealed Resident 2 was frequently incontinent of bowel and bladder and was not on a toileting program (scheduled or prompted use of the bathroom for bowel or bladder retraining.) 1. A review of Resident 2's assessment titled, .Bowel and Bladder Screener ., dated [DATE], revealed a score of 9 which indicated Resident 2 was a .good candidate for retraining . During a concurrent interview and record review on [DATE], at 12:38 p.m., LN 1 confirmed Resident 2 had not been on a toileting program. A review of Resident 2's care plans indicated, .[Resident 2] has bladder incontinence [little or no control of bladder] .at risk for .UTI's .Date initiated [DATE] .risk for septicemia [the body's most extreme response to an infection, Sepsis] will be minimized/prevented via prompt recognition and treatment of symptoms of UTI .monitor/document for s/sx [signs and symptoms] of UTI: pain, burning .deepening of urine color .foul smelling urine .altered mental status [confusion] . During an interview on [DATE] at 11:47 a.m., CNA 3 stated she could not remember the exact date but when she took over care for Resident 2 one morning, she was soaked with urine and her bed was wet (large amounts of urine can be a symptom of UTI called polyuria.) CNA 3 added Resident 2 would not drink much water but would complain about going more frequently but then she won't pee, but she had the feeling to go. I think it was happening for days . During an interview on [DATE] at 9:32 a.m., Certified Nursing Assistant (CNA) 4 remembered Resident 2's urine had a strong odor but was unsure of the date. She was not drinking enough water. A review of Resident 2's nurse progress note dated [DATE] indicated, .This writer received in report that resident [2] had one episode of emesis [vomit, throwing up] during lunch . A review of Resident 2's nurse progress note dated [DATE] at 6:53 a.m., indicated, .Resident appears to have increased confusion .all information endorsed to oncoming shift . A review of Resident 2's nurse progress note dated [DATE] indicated, .notified charge nurse resident [2] was found on the floor . A review of Resident 2's nurse progress note dated [DATE] at 2:29 p.m., indicated, .Per resident's [family member], the way her mom has been acting is like when she has a UTI. Resident has no symptoms of UTI [symptoms can include poor appetite, drowsiness, frequent falls, foul smelling urine, dark colored urine, vomiting, and confusion] .will place on alert charting [charting done by nurses on all shifts to monitor a change of condition] to increase water intake and monitor for s/sx of UTI . During an interview on [DATE], at 12:38 p.m., with Licensed Nurse (LN) 1, LN 1 verified a nurse documented Resident 2 would be placed on alert charting for signs and symptoms of a UTI. LN 1 confirmed Resident 2 was never put on alert charting to monitor for signs and symptoms of a UTI. During an interview with the Administrator (ADM) on [DATE] at 4:15 p.m., the ADM stated if family was concerned about Resident 2 having a UTI, they (staff at the facility) should have notified the doctor and should have followed up on the family's concern. Staff should follow up if there was any concern from the resident or the family. During an interview with the Director of Nursing (DON) on [DATE] at 11:29 a.m., the DON stated if staff were alerted that a resident had symptoms of a UTI staff should monitor for temperature changes, urinary symptoms, vital sign changes, color of urine, and if they are retaining (urine is unable to leave the body). Interventions could have been cranberry supplements and forcing fluids. I expect them (staff) to monitor for a UTI. The risk of not monitoring for symptoms would be the infection could travel to the kidneys. It could lead to worsening infection. She should have been tested for a UTI if she had a history of UTI's. A review of Resident 2's ACH 2 records dated [DATE]-[DATE] indicated, .Discharge Diagnosis .septic shock .Likely secondary combination of underlying pneumonia and UTI .acute [sudden] encephalopathy [alteration of mental status] .very likely secondary to hypercapnic respiratory failure [when you have too much carbon dioxide (CO2), a gas waste product from the lungs when breathing out] and UTI .Acute hypercapnic respiratory failure: Very likely secondary to decompensated CHF [congestive heart failure, a weakened heart condition that causes fluid buildup in .lungs], and possibly underlying pneumonia .due to patients advanced age, being very frail, in septic shock and CHF as well, respiratory failure, patients prognosis is guarded .afternoon of [DATE], patient expired peacefully 1850 [6:50 p.m.] . 2. A review of Resident 2's nurse progress note dated [DATE] indicated, .coughing and fine crackles [a series of short, explosive sounds that can also sound like bubbling, rattling, or clicking] noted during shift. Resident appears to have increased confusion .MD notified of findings .This writer requested order for chest x ray (an image of the lungs and heart to diagnose disease) .all information endorsed to oncoming shift . A review of Resident 2's nurse progress note dated [DATE] indicated, .reports .crackles all lung bases [bottom of the lungs] .anxious .[physician assistant] notified and made aware of the resident's current status .orders were received: Levaquin [antibiotic], Duoneb [an inhaled medication used to treat breathing problems], Robitussin [cough medicine] . A review of Resident 2's nurse progress note dated [DATE] indicated, .productive cough [a cough that brings up mucus], sputum [mucus/spit] is light yellow in color. Expiratory wheezes [a whistle type sound when breathing out] heard to upper lobes [upper lungs] . A review of Resident 2's Physician Assistant's (PA) note indicated the PA examined Resident 2 on [DATE] which read, .complaints: none .lungs .exam .yes . Further review revealed under the area for the Physician Assistant (PA) to write a Plan the area was blank. During an interview on [DATE] at 2:12 p.m., with Resident 2's PA, the PA stated if a nurse notified him or the physician that a resident had signs and symptoms of an infection, one of us would go and see the patient the same day. The PA explained for respiratory infections he would listen to residents' lungs, heart and throat and make a diagnosis and treat them. I saw her (Resident 2) on [DATE] (no documentation was found) and she had no complaints that day. On [DATE] her chest was clear. When asked why antibiotics were ordered on [DATE] if Resident 2's chest was clear, the PA stated she had crackles. The PA confirmed he did not order an x-ray of Resident 2's chest and told staff We will see if that medicine helps. The PA stated when he visits the facility Everyone wants to talk to me, and I forget to document. She [Resident 2] was getting better on [DATE], there is no documentation because I was busy. During an interview on [DATE], at 12:38 p.m., with Licensed Nurse (LN) 1, LN 1 confirmed a transfer form (outlining Resident 2's basic information for the ACH) was done on the day of discharge ([DATE]) but there was not a nurse's progress note/change in condition note done that outlined Resident 2's signs and symptoms or the reason she was sent to the ACH. A review of Resident 2's ACH 2 records dated [DATE]-[DATE] indicated, .Discharge Diagnosis .septic shock .Likely secondary combination of underlying pneumonia and UTI .acute [sudden] encephalopathy [alteration of mental status] .very likely secondary to hypercapnic respiratory failure [when you have too much carbon dioxide (CO2), a gas waste product from the lungs when breathing out] and UTI .Acute hypercapnic respiratory failure: Very likely secondary to decompensated CHF [congestive heart failure, a weakened heart condition that causes fluid buildup in .lungs], and possibly underlying pneumonia .due to patients advanced age, being very frail, in septic shock and CHF as well, respiratory failure, patients prognosis is guarded .afternoon of [DATE], patient expired peacefully 1850 [6:50 p.m.] . 3. A review of Resident 2's nurse progress note dated [DATE] indicated, .Called to room by CNA, pt [patient] having moderate amount of blood coming out of rectum with a medium size blood clot, I could see hard stool inside of rectum, I removed what I could see and noticed the rest was soft. Pt tolerated procedure well with minimal discomfort. I notified RN [registered nurse] on duty and will endorse to Day shift to let MD know if bleeding continues . During an interview on [DATE] at 10:09 a.m., LN 5 stated the amount of blood from Resident 2's rectum was moderate, enough to soak a peri pad (a soft absorbent pad worn in the underwear used to catch urine or blood) and there was a large blood clot. When asked, LN 5 stated she should have notified Resident 2's physician and completed a change of condition assessment for Resident 2. If the assessment was done the CNAs would have done vital signs and if any changes were noted Resident 2 would have been sent to the hospital. During an interview with the DON on [DATE] at 11:29 a.m., the DON stated the risk of the physician not being notified of a change in condition was the condition could get worse. The DON confirmed bleeding from the rectum was a change in condition and the physician should have been notified immediately. The DON stated, You can't guess where it's [blood] coming from. The DON added Resident 2 should have been put on alert charting because her hemoglobin (Hgb, red blood cells that are responsible for delivery of oxygen to the body) could have dropped (due to abnormal bleeding), and harm could have come to Resident. The DON confirmed a nurse should not have removed stool from Resident 2's rectum without a physician's order. A review Resident 2's ACH 1 records dated [DATE] indicated, .Hgb 8.1 L [low, normal Hgb is 12XXX,d+[DATE].0] .OB [occult blood, a test used to detect blood in the stool] positive stool .worsening anemia 8.1 now, 11 in March this year . A review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, revised ,d+[DATE], indicated, .Our facility promptly notifies the .physician .resident representative of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's .physician .when there has been a(an) .significant change in the resident's physical .mental condition .need to alter the resident's medical treatment significantly .A significant change of condition is a major decline .in the resident's status that .will not normally resolve itself without intervention by staff .Prior to notifying the physician or healthcare provider, the nurse will make detailed observation and gather relevant and pertinent information for the provider .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . A review of the facility's policy and procedure (P&P) titled, .Surveillance for Infections, revised ,d+[DATE], indicated, .The infection preventionist will conduct ongoing surveillance for healthcare-associated infection .that have substantial impact on potential resident outcome .and that may require .other preventative interventions .clinically significant .mortality [death] associated with infection .pneumonia, UTI's .nursing staff will monitor residents for signs and symptoms that may suggest infection .and will document and report suspected infections to the charge nurse .The charge nurse will notify the attending physician .of suspected infections . A review of an article by the National Library of Medicine published [DATE] indicated, .Urinary tract infection (UTI) is a common infection in the elderly, mainly due to age-related risk factors like .inadequately controlled diabetes mellitus, poor bladder control leading to urinary retention or incontinence .and altered mental state .UTIs are responsible for around 25% of all geriatric hospitalization s attributing to almost 6.2% of deaths due to infectious diseases and repeated emergency department and office visits yearly .UTI usually presents with localized symptoms like painful urination, new onset or worsening urinary urgency or frequency .but symptoms of UTI are atypical in the elderly population. UTI manifests more atypically for this age group as delirium, confusion, dizziness, drowsiness, falls, urinary incontinence, or poor appetite . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9827929/#:~:text=Symptoms%20of%20UTI%20are%20atypical,the%20absence%20of%20a%20fever.

Based on interview and record review, the facility failed to maintain acceptable parameters of nutrition for one of three sampled residents (Resident 1) when Resident 1's decreased food intake and 18-pound weight loss was not recognized, addressed, or reported to the physician in a timely manner. This failure resulted in a delay of treatment and Resident 1 being hospitalized . Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included tongue cancer and dysphagia (difficulty swallowing). Review of Resident 1's POLST (Physician Orders for Life Sustaining Treatment: care directives during life threatening situations) dated [DATE], indicated, .Attempt Resuscitation/CPR [cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating] . was checked. A review of Resident 1's electronic health record titled, Weight Summary, indicated the following: [DATE]-118.2 Lbs (pounds) [DATE]-100 Lbs During a concurrent interview and record review on [DATE], at 3:41 p.m., Certified Nursing Assistant (CNA) 1 reviewed Resident 1's medical record for meal intake, Task:Nutrition-Amount Eaten . and confirmed Resident 1 refused all his meals from [DATE] through [DATE], with the exception of one meal on [DATE], when Resident 1 ate ,d+[DATE]% of the morning meal. CNA 1 stated it was dangerous to Resident 1's health to continuously refuse his meals, and this was an important issue to report to the nurse. During a concurrent interview and record review on [DATE], at 4:55 p.m., Resident 1's medical record was reviewed with Licensed Nurse (LN) 1. LN 1 stated she did not know the resident had refused his meals during this time period, and she expected the CNA to report it to the nurse. LN 1 further stated she did not know about Resident 1's weight loss, but 18 pounds lost in four days was a lot and the physician should have been notified by the nurse. LN 1 stated there was no documentation to indicate the physician was notified about Resident 1's refusals to eat or his 18-pound weight loss. During a concurrent interview and record review on [DATE], at 5:49 p.m., Resident 1's medical record was reviewed with the Director of Nursing (DON). The DON acknowledged Resident 1's weight loss of 18 pounds and stated Resident 1 was dehydrated. The DON stated she considered it a significant weight loss. The DON stated she was unaware Resident 1 refused his meals between [DATE] and [DATE]. The DON further stated there was no documentation to show if the physician was notified about Resident 1's weight loss and his refusal of meals. The DON stated she expected the CNA to report it to the nurse and the nurse should have reported it to her. The DON further stated Resident 1's refusals to eat should have been addressed and better coordination of care should have been provided. The DON reviewed Resident 1's medical record and stated a Skin and Nutrition review was held to address Resident 1's weight loss on [DATE] and confirmed Resident 1 was hospitalized as of [DATE] and was not in the facility on [DATE]. During an interview on [DATE], at 3:15 p.m., Medical Doctor (MD) 1 stated he was not notified Resident 1 had refused to eat from [DATE]-[DATE] and was also unaware Resident 1 had lost 18 pounds. MD 1 further stated the nursing staff should have notified him, so he could have addressed these issues. MD 1 explained it was not acceptable for a resident to lose 18 pounds in 4 days. MD 1 stated the risk of this decline in food intake and weight was serious including metabolic (chemical reactions in the body that breakdown food into energy) problems, dehydration (body loses too much water) and the resident would suffer serious medical problems. During an interview on [DATE], at 4:33 p.m., LN 2 stated she was aware Resident 1 was refusing meals but did not know he had an 18-pound weight loss. LN 2 further stated she did not address Resident 1's refusal to eat or weight loss to the physician. LN 2 stated Resident 1 experienced a significant change of condition with refusals of all meals and a further assessment of Resident 1 should have been completed. LN 2 stated Resident 1 had an appointment on [DATE] with an Oncologist (cancer doctor). LN 2 indicated she should have sent Resident 1 to the hospital for an evaluation, rather than to his appointment on [DATE], and indicated it was not safe for Resident 1 to be sent out of the facility for his appointment. During a concurrent interview and record review on [DATE], at 11:06 a.m., the Registered Dietician (RD) confirmed she was not notified by the facility about Resident 1's 18-pound weight loss. The RD stated nursing should have called her in order to address the weight loss. The RD further stated Resident 1's 18-pound weight loss was considered a significant weight loss because the resident had lost 15 percent in four days. The RD explained significant weight loss could be harmful because Resident 1 was losing weight drastically. During an interview on [DATE], at 12:37 p.m., the Oncology Nurse (ON) 1 stated Resident 1 arrived for his oncology appointment from the facility on [DATE]. ON 1 further stated Resident 1's eyes were closed, he was cyanotic (bluish discoloration of the skin from poor circulation or lack of oxygen in the blood), his nail beds were gray, and all his extremities were cold. ON 1 explained she could not get any vital signs on him and considered Resident 1 in an unstable condition. During an interview on [DATE], at 12:44 p.m., the Oncologist (ON MD) stated Resident 1 arrived for his appointment on [DATE] and was found to be unresponsive. A sternal rub (the application of a painful response with the knuckles of closed fist to the center chest of a person who is not alert and does not respond to verbal commands) was performed with no response. The ON MD further stated he ordered Resident 1 to be taken to the emergency room . The ON MD explained he did not understand why Resident 1 was brought to his office when Resident 1 looked out of it and needed to go to the hospital. The ON MD stated he was not notified about Resident 1's weight loss and expected the facility to communicate with him. The ON MD further stated Resident 1 was at risk for malnutrition (lack of proper nutrition), dehydration, delirium (a disturbed state of mind or consciousness), and kidney failure. A review of the hospital document titled, History and Physical, dated [DATE], indicated, .REASON FOR ADMISSION/ CHIEF COMPLAINT: Worsening mentation [mental activity] .In the ER [emergency room ] the patient [Resident 1] has been unresponsive. He is hypothermic [the body gets very cold and can't warm up on its own], hypotensive [low blood pressure]. Lab work shows severe hyponatremia [sodium level in the blood is low] . A review of the hospital document titled, Emergency Department Reports, dated [DATE], indicated, .[Resident 1] presents for evaluation of worsening mentation. Over the past few days the patient's become increasingly less interactive and nonverbal. They note he has not been eating and has had weight loss. He was at the infusion center here and directed here because he was looking more ill per staff .I spoke with [Resident 1's responsible party] who would like to continue fluids and antibiotics but agrees would not be appropriate for dialysis [a process by which blood is filtered to remove toxins when kidneys don't work properly]. I explained that the patient is gravely ill and will likely likely [sic] not survive this. [RP] voiced good understanding of this and would like the patient to be admitted here . A review of the hospital document titled, Discharge Summaries Notes, dated [DATE], indicated, HOSPITAL COURSE .The patient [Resident 1] was admitted to the hospitalist service. He was given IV [intravenous, in the vein] fluid hydration and antibiotics without improvement in his sodium level or mentation. Given his advanced age, protein, nutrition with cachexia [weakness and wasting of the body] acute kidney injury, I discussed the patient's prognosis with his son and decision was made to transition [Resident 1] to comfort measures . Review of the facility policy titled, Resident Rights . dated [DATE], indicated, .The facility will promptly inform the resident, consult with the resident's physician .when there is .A significant change in the resident's physical, mental, or psychosocial status . Review of an undated facility policy titled, Nutrition and Hydration, indicated, .Residents who experience weight loss will be reviewed during the Skin and Nutrition meeting .

Based on interview, record review, and facility policy review, the facility failed to consistently manage and treat pain for one of four sampled resident's to the extent possible in accordance with the resident's preferences when a resident (Resident 1) was admitted to the facility without a pain management plan, the resident's pain was not consistently monitored, and additional medication to treat pain was not ordered and administered until three days after admission. This failure caused Resident 1 to experience prolonged pain and suffering without intervention, and prevented her from working with physical therapy immediately after admission, potentially extending rehabilitation time. Findings: Review of Resident 1's acute care hospital records indicated a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication record indicated the resident received the pain medication as much as every four hours each day. Review of Resident 1's clinical record revealed the following documents: A Discharge Summary from an acute care hospital, dated 10/25/2021, indicated due to the resident's prolonged hospital stay, the resident became physically deconditioned and was evaluated by rehabilitation medicine with recommendations for skilled nursing facility upon discharge. An Admission Record, indicated Resident 1 was admitted to the facility in October of 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Order Summary Report indicated an order, dated 10/13/2021, to question the resident about the presence of pain or burning including pressure points every shift. The order indicated to monitor for pain using the 0-10 scale, where 0 is for no pain and 10 is for the worst pain possible. A Weights and Vitals Summary, dated October 2021, indicated pain levels were recorded on 10/25/2021 at 10:38 p.m., 10/26/2021 at 9:15 p.m., and 10/28/2021 at 12:37 a.m., 1:47 p.m., 1:48 p.m., 4:08 p.m., and 5:15 p.m. The pain level summary contained no documented evidence a pain level was assessed more frequently than every 24 hours between 10/25/2021 and 10/28/2021. The pain level summary contained no documented evidence a pain level was assessed on 10/27/2021. A Social Services Note, dated 10/26/2021 at 7:25 a.m., indicated the resident's focus for being here will be to work with our physical and occupational therapy services. A Pain Evaluation, dated 10/26/2021, indicated Resident 1 was able to verbalize pain, was currently taking pain medications, did experience pain within the last 5 days, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An Order Summary Report indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physical Therapy (PT) Evaluation and Plan of Treatment, dated 10/26/2021, indicated a pain assessment where Resident 1 experienced pain at a level of 8 (out of 10) constantly in the lower back and right lower leg. The PT evaluation further indicated Prescribed Medications helped to relieve the pain. A Physical Therapy Treatment Encounter Note(s), dated 10/26/2021, indicated Resident 1's response to Session Interventions: Patient reports increased pain and has not had her pain medication prior to PT. Paint declined sitting EOB [Edge of Bed] today due to fatigue and pain, will begin tomorrow. A Physical Therapy Treatment Encounter Note(s), dated 10/27/2021, indicated Resident 1's response to Session Interventions: Patient participates well with PT. declined sitting EOB today due to not receiving her pain medication x2 [times two] days. An Alert Note Progress Note, dated 10/28/2021 at 2:12 a.m., indicated Resident 1 was complaining of severe pain to right leg and arm and back, asking for a pain pill, resident was told no pain medication, needs a script. A Physical Therapy Treatment Encounter Note(s), dated 10/28/2021, indicated Resident 1's Behaviors Exhibited: Patient report she has not received any pain meds aside from tylenol. Reported issue to nursing staff and negative impact on therapy. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] A History and Physical (Amended), date of visit 10/29/2021, contained no documented evidence the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A plan of care, dated 11/1/2021, with a focus Resident 1, has a potential for discomfort/pain r/t [r/t - related to] Fibro-myalgia [sic], with the use of narcotics. An interview was conducted with Resident 1 on 11/5/2021 at 10:16 a.m. Resident 1 indicated she suffered from chronic pain, and a pain management plan was not discussed with her at the facility until four days after she was admitted . Resident 1 stated when she complained of pain and requested pain medication, nursing staff told her either no pain medications were ordered, or they were unable to get them ordered, or they did not have access to the facility emergency kit where they were kept. Resident 1 stated she was told a physician ordered [MEDICATION(S)] (a pain medication) on 10/28/2021 so she could work with physical therapy, and she was not given the pain medication until 10/29/2021 at about one o'clock in the morning. Resident 1 indicated she was unable to work with physical therapy at times due to her uncontrolled pain, and felt in despair. An interview was conducted with Licensed Nurse (LN) 1 on 11/5/2021 at 10:43 a.m. LN 1 indicated staff had difficulty getting Resident 1's pain medications ordered from the physician, and then pharmacy was slow to fill the prescription. LN 1 further stated most registry staff do not have access to the emergency kit medications, so they were unable to give Resident 1 the ordered pain medications. An interview was conducted with LN 3 on 11/10/21 at 3:05 p.m. LN 3 indicated nurses always had problems getting medications from the pharmacy if the physician did not order them prior to resident admission to the facility. LN 3 stated if the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Physical Therapist (PT) on 11/18/2021 at 7:36 a.m. PT indicated Resident 1 was initially admitted to the facility for physical rehabilitation. PT confirmed an initial physical therapy evaluation was conducted the day after Resident 1's arrival to the facility, and Resident 1 reported constant pain at a level of 8 out of 10 on the pain scale. PT indicated the resident stated she could not work with physical therapy because she had not had pain medication since she left the hospital and it was too painful to get out of bed. PT indicated the resident's unrelieved pain was immediately reported to nursing staff, but the resident did not receive pain medication until a couple of days later. An interview was conducted with the Director of Staff Development (DSD) on 11/23/2021 at 10:15 a.m. The DSD indicated not all registry staff are able to access facility emergency kit medications, such as pain medication, right away but they will eventually get a pharmacy code. The DSD stated registry staff without a code can request assistance from other nurses on duty that have access, or call administration staff to come in to access the emergency kit. The DSD indicated registry staff would not necessarily know to do this because they were not told this in orientation. An interview was conducted with the Administrator and Unit Manager (UM) on 12/02/2021 at 9:14 a.m. The Administrator and UM indicated Resident 1 had not complained of pain until 10/28/2021 when the additional pain medications were ordered. The UM indicated the order for [MEDICATION(S)] was entered on 10/28/2021 at noon by the doctor. The UM confirmed the first dose of [MEDICATION(S)] was not given until 10/29/2021 at 1:10 a.m. The Administrator and UM stated pharmacy had to obtain a hard copy of the prescription before they could fill it, and that is why it took so long to get to the resident. An interview was conducted with the Administrator and UM on 12/03/2021 at 10:06 a.m. The Administrator and UM confirmed a pain level for Resident 1 was not documented for date 10/27/2021, and a pain level was only entered once for dates 10/25/2021 and 10/26/2021. The UM indicated newly admitted residents with chronic pain conditions should have a plan of care instituted to address pain management. The UM stated the initial pain evaluation was not completed to trigger a pain care plan. A facility policy entitled Quality of Care Pain Management, dated 11/2017, was reviewed. The policy indicated, Residents are assessed and evaluated to identify pain and manage pain/symptoms with appropriate non-pharmacologic and pharmacologic interventions to assist the resident to attain or maintain his/her highest practicable level of well-being. The policy further indicated, Strategies for the prevention and management of pain may include but are not limited to the following: .Develop and implementing both non-pharmacological and pharmacological interventions/approaches to pain management.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one of four sampled residents (Resident 1) to address immediate pain management needs when the resident went three days without medication to treat uncontrolled pain. This failure prevented Resident 1 from fully participating in physical therapy for three days and caused the resident to experience prolonged pain and suffering without intervention. Findings: Review of Resident 1's acute care hospital records indicated a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication record indicated the resident received the pain medication as much as every four hours each day. Review of Resident 1's clinical record revealed the following documents: A Discharge Summary from an acute care hospital, dated 10/25/2021, indicated due to the resident's prolonged hospital stay, the resident became physically deconditioned and was evaluated by rehabilitation medicine with recommendations for skilled nursing facility upon discharge. An Admission Record, indicated Resident 1 was admitted to the facility in October of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pain Evaluation, dated 10/26/2021, indicated Resident 1 was able to verbalize pain, was currently taking pain medications, did experience pain within the last 5 days, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An Order Summary Report indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A PT Evaluation and Plan of Treatment, dated 10/26/2021, indicated a pain assessment where Resident 1 experienced pain 8/10 (a pain level of an 8 out of a possible 10 point scale where 0 is no pain and 10 is the worst pain ever experienced) constantly in the lower back and right lower leg. The PT evaluation further indicated Prescribed Medications helped to relieve the pain. An IDT (Interdisciplinary Team) Care Plan Conference/Welcome Meeting Form, dated 10/29/2021 (four days after the resident was admitted to the facility), indicated a resident care plan was discussed and reviewed with Resident 1, the resident's son, and facility staff including the Director of Nurses (DON). A plan of care, dated 11/1/2021 (six days after the resident was admitted to the facility), with a focus Resident 1, has a potential for discomfort/pain r/t [r/t - related to] Fibro-myalgia [sic], with the use of narcotics. The facility was unable to provide documented evidence a pain management care plan was implemented within 48 hours of Resident 1's admission to the facility. An interview was conducted with Resident 1 on 11/5/2021 at 10:16 a.m. Resident 1 indicated she suffered from chronic pain, and a pain management plan was not discussed with her at the facility until four days after she was admitted . Resident 1 indicated she was unable to work with physical therapy at the beginning of admission to the facility due to her uncontrolled pain. An emailed response was received from the Interim Director of Nurses (IDON) on 11/15/2021 at 11:15 a.m. In the response, the IDON indicated the IDT Care Plan Conference/Welcome Meeting Form was the resident's baseline care plan. An emailed response was received from the Administrator at 11/22/2021 at 2:03 p.m. The Administrator confirmed per the interim IDON, no baseline care plan was created for Resident 1 prior to 10/29/2021. An interview was conducted with the Administrator and Unit Manager (UM) on 12/03/2021 at 10:06 a.m. The UM indicated newly admitted residents with chronic pain conditions should have a plan of care instituted to address pain management. The UM stated the initial pain evaluation was not completed to trigger a pain care plan. A facility policy entitled, Comprehensive Care Plan Baseline Care Plan, dated 11/2017, was reviewed. The policy indicated, Facilities are required to develop a baseline care plan within the first 48 hours of admission which provides for the provision of effective and person-centered care to each resident and their representative. The care plan is a balance between conditions and risks affecting resident's health and safety, and the resident's goals and choices.

Based on interview and record review, the facility failed to recognize the cumulative side effects of multiple [MEDICAL CONDITION] medications and ensure provider/prescriber was notified of resident reponse and behaviorial assessments for 1 of 3 sampled residents (Resident 1). This failure caused a deterioration of health status resulting in severe illnes and hospitalization of Resident 1. Findings: According to the admission record, Resident 1 was admitted to the facility in early (YEAR) with [DIAGNOSES REDACTED]. Resident 1's admission assessment stated he was alert, confused, and able to walk with the assistance of a walker. Resident 1 was discharged from the facility on 3/14/17. Review of the clinical record for Resident 1 included: A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Physician Assistant 1 (PA 1) progress note dated 2/20/17 documented, Increased agitation, [MEDICAL CONDITION], danger to himself and to others with trying to (and hitting) staff, threatening other patients. The plan for Resident 1 was to, Resume his [MEDICATION NAME] (an antipsychotic medication) - will need this up to long term until other medical treatment can be used and he is stabilized without being a danger to himself or others. Will start [MEDICATION NAME] (an antipsychotic medication) and do a taper up until he is stable and may then consider gradual dose reduction of the [MEDICATION NAME]. PA 1's next assessment dated [DATE] documented, (Resident) was a little over-sedated this a.m. [MEDICATION NAME] was held for 2/27/17, and reduced from 10 mg a day to 5 mg a day. A clinician order on 3/1/17 indicated the [MEDICATION NAME] order was increased back to 10 mg a day, and [MEDICATION NAME] was maintained at 15 mg a day. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A nursing progress note dated 3/02/17 at 10:33 p.m. documented, Slept until approximately (7:00 p.m.). A nursing progress note dated 3/04/17 at 12:02 a.m. documented, Patient was not alert and was difficult to rouse. He did not eat dinner or drink fluids this shift. A nursing progress note dated 3/04/17 at 11:02 p.m. documented, (Resident) in bed all evening shift and refused meal. A nursing progress note dated 3/07/17 at 10:26 p.m. documented, Resident slept throughout (evening) shift waking for short time at approximately (7:30 p.m.). A nursing progress note dated 3/08/17 at 10:20 p.m. documented, Sleeping through afternoon. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Of the 41 scheduled doses between 3/1/17 and 3/14/17 to administer [MEDICATION NAME], the medication was given 35 times and held 6 times. The documentation stated the medication was held twice for resident sleeping, twice refused by the resident, once for unidentified reason, and once because the resident was, Not alert and difficult to rouse. The (MONTH) (YEAR) documentation of monitoring for behaviors related to [MEDICATION NAME] indicated that between 3/1/17 and 3/14/17 there were 40 opportunities to document behavior and 39 were marked, No Behaviors Exhibited. The documentation for 3/8/17 indicated, See Nurses Notes, however a review of the nurses notes for 3/8/17 made no reference to anxiety, agitation or restlessness. The (MONTH) (YEAR) MAR for [MEDICATION NAME] indicated, Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Of the 14 scheduled doses between 3/1/17 and 3/14/17 to administer [MEDICATION NAME], the medication was given 12 times and held two times. The documentation stated the medication was held once for the resident sleeping, and once due to the resident refusal. The (MONTH) (YEAR) MAR for [MEDICATION NAME] indicated, Give 5 tablet (sic) by mouth two times a day related to [MEDICAL CONDITION]. Of the 27 scheduled doses during (MONTH) to administer [MEDICATION NAME], the medication was given 22 times and held five times. The documentation stated the medication was held 3 times for the resident sleeping and twice due to resident refusal. The (MONTH) (YEAR) documentation of monitoring for behaviors related to [MEDICATION NAME] and [MEDICATION NAME] indicated that between 3/1/17 and 3/14/17 there were 40 opportunities to document behavior ([MEDICAL CONDITION]) and 37 were marked, No Behaviors Exhibited, and three were left unmarked with no indication of behavior. The (MONTH) (YEAR) documentation of monitoring for adverse reactions for antipsychotic ([MEDICATION NAME] and [MEDICATION NAME]) medication indicated that between 3/1/17 and 3/14/17 there were 40 opportunities to document adverse reactions and 37 were marked, No adverse reactions. On 3/12/17 the documentation indicated all three shifts (day, evening, and night) marked, Excessive sedation. There was no documented evidence of staff notifying a clinician of Resident 1's condition. Between 3/2/17 and 3/14/17, the progress notes and MAR monitoring for behavior indicated 0 episodes of aggressive behavior, agitation, or restlessness. There was no documented evidence of clinician notes from 2/27/17 through the discharge date of [DATE]. A 3/14/17 clinical note from General Acute Care Hospital (GACH) indicated Resident 1, Was found to [MEDICAL CONDITION] (a complication caused by the body's overwhelming and life threatening response to an infection) . (a lung infection) along with right heel (skin infection). Patient (has) dehydration along with . (kidney) failure. Patient will be started on . antibiotics. Patient already has received (3 liters of intravenous fluid) in emergency room . Patient has generalized rigidity, patient was on [MEDICATION NAME] as well as [MEDICATION NAME] ([MEDICATION NAME]) at skilled nursing facility most likely he is having extrapyramidal side effects .Overall prognosis for this patient is poor, patient is critically sick at this point of time. A 3/15/17 nursing note from the GACH Intensive Care Unit indicated that, (Patient) mentation (mental activity) improved throughout the day. Patient (alert and oriented) to self only but is alert and answers many questions appropriately. The 3/18/17 GACH Discharge Summary indicated, All antipsychotics and sedatives were held patient's mentation eventually return (sic) to patient's baseline .At baseline patient does confabulate (false memory) quite a bit occasionally gets agitated however patient has not required any sedatives. Patient's behavior is amenable to reorientation and reassurance by family and nursing staff (sic) Previous medications including [MEDICATION NAME] and [MEDICATION NAME] have been discontinued. Patient was started on low-dose [MEDICATION NAME] switches (sic) tolerated very well. Review of Lexi-comp, an on-line source of professional medication information, accessed on 1/29/18, at http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7019 included the following concerns related to adverse effects of [MEDICATION NAME]; (MONTH) cause [MEDICAL CONDITION] .may cause CNS (central nervous system) depression, which may impair physical or mental abilities .aspiration (inhaling foreign material, e.g. liquid, food); use with caution in patients at risk of pneumonia. The warning also included, Extrapyramidal symptoms (EPS) (various nervous system abnormalities) .Risk of [DIAGNOSES REDACTED] (uncontrollable repetitive or twisting movements of the affected body part, i.e. the neck) may be greater with increased doses .Factors associated with greater vulnerability to tardive dyskinesia (involuntary uncontrollable movements especially of the mouth, tongue, trunk, and limbs and occurring especially as a side effect of prolonged use of antipsychotic drugs) include older in age .alcoholism, poor treatment responses, and use of high doses of antipsychotics. Consider therapy discontinuation with signs/symptoms of tardive dyskinesia. The warnings also included, (MONTH) increase the risk for falls due to somnolence .Use may be associated with [DIAGNOSES REDACTED] (NMS) (a life-threatening reaction to antipsychotic drugs characterized by fever, altered mental status and muscle rigidity). Review of Lexi-comp, an on-line source of professional medication information, accessed on 1/29/18, at http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7391, included the following concerns related to adverse effects of [MEDICATION NAME]; (MONTH) cause [MEDICAL CONDITION] .may cause CNS (central nervous system) depression, which may impair physical or mental abilities .aspiration (inhaling foreign material, e.g. liquid, food); use with caution in patients at risk of pneumonia. The warning also included, Extrapyramidal symptoms (EPS) (various nervous system abnormalities) .Risk of [DIAGNOSES REDACTED] (uncontrollable repetitive or twisting movements of the affected body part, i.e. the neck) may be greater with increased doses .Factors associated with greater vulnerability to tardive dyskinesia (involuntary uncontrollable movements especially of the mouth, tongue, trunk, and limbs and occurring especially as a side effect of prolonged use of antipsychotic drugs) include older in age .alcoholism, poor treatment responses, and use of high doses of antipsychotics. Consider therapy discontinuation with signs/symptoms of tardive dyskinesia. The warnings also included, (MONTH) increase the risk for falls due to somnolence .Use may be associated with [DIAGNOSES REDACTED] (NMS) (a life-threatening reaction to antipsychotic drugs characterized by fever, altered mental status and muscle rigidity). Review of Lexi-comp, an on-line source of professional medication information, accessed on 1/29/18, at http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7195, included the following concerns related to adverse effects of [MEDICATION NAME]; (MONTH) cause CNS depression, which may impair physical or mental abilities. Review of Lexi-comp, an on-line source of professional medication information, accessed on 1/29/18, at http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7804, included the following concerns related to adverse effects of Trazadone; (MONTH) cause CNS depression, which may impair physical or mental abilities. In an interview with family member 1 (FM 1) on 9/28/17 at 2:55 p.m., FM 1 stated Resident 1 entered the facility with confusion, but decent health, and was able to walk on his own. Resident 1 declined every week, and before he was discharged he could no longer walk, eat, or go to the bathroom on his own. Resident 1 was unable to hold a phone to his ear, and couldn't talk. FM 1 stated that on the day Resident 1 left the facility, he was observed sitting in wheelchair, shaking, and not responding. In an interview with Licensed Vocational Nurse 1 (LVN 1) on 12/28/17 at 11:10 a.m., LVN 1 stated that any change of condition would be reported to PA 1. LVN 1 confirmed a change of condition would include any resident who was previously active that became sleepy and difficult to rouse. In an interview with LVN 2 on 12/28/17 at 11:25 a.m., LVN 2 stated that any change of condition would require notification of the physician. LVN 2 confirmed that a change of condition would include any resident who became less active and sleeping during the day when previously awake. Review of a (MONTH) (YEAR) facility policy titled, Change in a Resident's Condition or Status indicated that, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A significant change in the resident's physical/emotional/mental condition. The policy defined, Significant change of condition as a decline in the resident's status that, Will not normally resolve itself without intervention by staff. Review of a (MONTH) (YEAR) facility policy titled, Antipsychotic Medication Use indicated that, Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician: (including) sedation .extrapyramidal effects .[DIAGNOSES REDACTED]. The policy also included, The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. In an interview with the Director of Nursing (DON) on 12/28/17 at 9:50 a.m., the DON stated that if a resident has a change in condition her expectation was for the nurse to perform an assessment of the resident and notify the clinician (MD or PA). The DON confirmed that a resident sleeping more often and being difficult to rouse would qualify as a change of condition, and also confirmed that there was no documentation to show that a clinician was notified of Resident 1's condition following PA 1's final documented assessment on 2/27/17.

Based on observation, interview, and record review, the facility failed to supervise 1 resident (1) in a census of 87 to prevent falls when: 1. The facility's policy for fall prevention was not implemented when a fall trend investigation was not conducted after the resident fell on [DATE]. Because of this failure the facility did not implement additional measures to prevent further falls, and 2. The resident's care plan was not followed when she was left unattended without a safety device on and fell on [DATE]. This failure resulted in the resident sustaining a hip fracture requiring surgical repair. Findings: Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. She was readmitted to the facility on [DATE]. Review of the clinical record for Resident 1 included: A physicians order, dated 10/3/14, for, "Front open alarm belt on at all times while resident is in (wheelchair)..." A care plan for Risk of Falls, initially dated 8/8/14, included, as the first approach to prevent falls, "Do not leave resident unattended without safety device." A Minimum Data Set (MDS, an assessment tool), dated 10/23/14, described the resident as having moderately impaired cognitive function, with both short-term and long-term memory problems. The resident's functional status was described as requiring "extensive assistance" for all activities of daily living, including transferring to and from the toilet. A Fall Risk Evaluation, dated 11/24/14, described the resident as having decreased muscle coordination, a loss of balance, and needing assistive devices, such as a wheelchair. The resident was described as being unable to walk and needing safety devices, such as bed and chair alarms to alert staff when she attempted to get up. The resident's fall risk was assigned a score of 20. The form described, "Score 10 or more indicates higher risk of falls." A Departmental Note, dated 11/28/14 at 9:34 p.m., indicated, "Resident found on floor by her (wheelchair)...at 9 PM...Her safety belt was unbakled (sic). She is able to unbakle (sic) herself. Small abrasion to back of her head...." The clinical record did not contain a Fall Trend Investigation Report regarding the fall on 11/28/14. A Departmental Note, dated 12/20/14 at 11:18 a.m., indicated, "Resident was using the restroom when she fell off the toilet landing on her right hip side. (Certified Nursing Assistant (CNA)) witness the fall just couldn't get to her quick enough." The note further indicated the resident was sent to the local hospital for x-rays. An "addendum" to the note on the same date, at 11:20 a.m., described, "Resident was attempting to stand while on the toilt (sic) and this is the reason she proceeded to fall. Other injuries happened along with the hip, resident had a hematoma (bruise) to the right side of her forehead (sic) and a discoloration to the right shoulder. Sent to (emergency room )..." In an interview with the Administrator on 12/26/14 at 8:45 a.m., he stated Resident 1 had a hip fracture as a result of the fall on 12/20/14 and had surgical repair. The resident was readmitted to the facility on [DATE]. In an interview with CNA 1 on 12/26/14 at 10:20 a.m., CNA 1 stated that on 12/20/14 she was across the hall when another CNA saw Resident 1 attempt to get out of bed. Then the two staff members took Resident 1 to the toilet connected to her room. CNA 1 stated, "To get her (clean) clothes, I had to close the bathroom door, then open the closet." She indicated she did this while the resident remained on the toilet on the other side of the doors. In a concurrent observation of Resident 1's room, along with CNA 1, on 12/26/14 at 10:20 a.m., the toilet was observed to have armrests affixed to the seat. It was located approximately 3 feet from the resident's closet. CNA 1 demonstrated closing the bathroom door and opening the closet. When both doors were moved to get into the closet, the toilet could not be seen. In a second interview with CNA 1, on 12/26/14 at 11:20 a.m., CNA 1 stated, "I heard the fall seconds after she was put on the toilet." Review of the facility's Fall Prevention Program policy, dated 5/10, included, "Purpose: To ensure consistency in the implementation of preventive measures to assists (sic) with reduction of falls." The policy also included, "The Director of Nursing/designee will be responsible for ensuring that residents...who have experienced a recent fall have recommended interventions in place as well as current assessments...If the trend indicates multiple falls by one or more residents, the Interdisciplinary Team (IDT) will complete a Fall Trend Investigation Report that further reviews circumstances that may contribute to the resident's repeated falls." In an interview with the Unit Manager (UM) on 12/26/14 at 11:25 a.m., the UM verified the IDT did not meet after Resident 1's fall on 11/28/14 to investigate the fall and did not complete a Fall Trend Investigation Report. The UM also confirmed the facility had not followed its care plan prior to the 12/20/14 fall by leaving Resident 1 unattended on the toilet.

Based on observation, interview, and record review, the facility failed to ensure the environment was free from hazards and failed to ensure adequate supervision for 1 of 4 sampled residents (Resident 1) when she was left unattended in her room within reach of a lamp she was known to try and pick up. Resident 1 attempted to pick up the lamp which resulted in a TV falling onto her lower leg. She sustained a deep 7 centimeter laceration to her shin which required a trip to the emergency room and sutures. This failure resulted in injury to Resident 1 that caused pain and an increased potential for infection. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) described her as alert with short-term memory problems and moderately impaired decision-making abilities. She was also described as having disorganized thinking. She required moderate assistance with transferring, walking, bathing, dressing and toileting. Review of a "Fall Trend Investigation Report", dated 6/16/14, indicated Resident required "frequent observation" and "Pt (patient) to not be left in room unattended. To be out in hallway in line of site(sic)." Review of a care plan titled, "[DIAGNOSES REDACTED]", dated 7/4/14, indicated, "Be sure that vase looking lamp not in Pt's room as Pt. likes to pick up & move." Review of the "Facility Reported Event", dated 7/31/14, noted that on the evening of 7/31/14 at 8 p.m., a Certified Nursing Assistant (CNA) heard a crashing sound in Resident 1's room and found Resident 1 in her wheelchair with a deep laceration to the right shin. Resident 1's TV was observed to be laying on the floor in front of a bed. When asked what happened, Resident 1 stated, "My TV fell on me as I was trying to reach my lamp." Resident 1 was noted to have an approximately 7 centimeter (cm) long laceration to her right shin. She received emergency services from 911 personnel and was transferred to an acute care facility. Observation of the location of Resident 1's TV was done by the Department, Administrator, and Maintenance Supervisor on 8/8/14 at 7:40 a.m. The TV had been positioned on a chest of drawers belonging to Resident 1. The chest had two heights: the height on the left (when viewing the chest from the front) was approximately level with a standard wheelchair. The height on the right extended upward approximately to a 2 drawer height. The TV had been positioned on the lower height of the chest level with Resident 1's arms when sitting in a wheelchair. The TV was a modern flat screen measuring 20 inches high and 30 inches wide with a lightweight base. The lamp had been positioned behind the TV within reach of Resident 1. CNA 1 was interviewed on 8/8/14 at 7:50 a.m. regarding the location of Resident 1's TV. CNA 1 stated she had noticed the TV sitting diagonally on the lower portion of the chest "closer to the edge a few days ago", and had pushed it back against the wall. She stated she did not remember telling anyone about it. Observation of three random resident rooms (Residents 2, 3, and 4) in the facility containing TVs, was done with the facility Administrator on 8/8/14 at 8:15 a.m. The selection of TVs varied from large, modern flat screens affixed to the wall, to small boxy, bulky old TVS. The furniture holding these TVs was primarily privately owned (by residents or their families) and varied from solid wooden chests or cabinets to small chests or cabinets. The Administrator was interviewed on 8/8/14 at 8:30 a.m., regarding the varied selection of TVs and bases for TV placement. He stated his goal was to eventually replace all non-flat screen TVs with wall mounted flat screen TVs. He acknowledged that various TV cabinets in resident rooms presented potential safety issues. Licensed Nurse 1 (LN 1) was interviewed on 8/8/14 at 9 am, and stated she had observed that Resident 1 became more confused and disoriented in the evening. LN 1 stated she had not witnessed the incident but thought she knew what may have happened. Resident 1's TV was located on a chest that was level with her when she was sitting in a wheelchair. LN 1 stated CNA 1 had not mentioned to her about previously moving TV back toward wall. An old lamp resembling a vase was sitting behind the TV. LN 1 felt that Resident 1 reached for the lamp and pulled the TV over by accident. LN 1 stated she was not aware that Resident 1 was not supposed to be in her room alone. She stated she had just given Resident 1 her medication in the hallway and was walking back to the medication cart when she heard the crash. An observation of Resident 1's wound care to her right lower extremity was done by the Department on 8/8/14 at 9:30 a.m. Resident 1's entire right lower extremity appeared swollen from below the knee to the toes. A large laceration was visible mid-shin with edges approximated (lined up) and sutured. The surrounding skin was red and warm. Scant bloody drainage the size of a dime was noted on the dressing. LN 1 was observed cleansing the laceration and applying a clean dressing. Resident 1 complained of discomfort and was unable to rate the pain. She stated, "That really hurts." LN 1 stated she had been requesting pain medication at least every four hours. CNA 2 was interviewed on 8/8/14 at 9:50 a.m., regarding the care issue that Resident 1 was not to be left alone in her room. CNA 2 stated she was aware of this. CNA 1 was interviewed on 8/8/14 at 9:55 a.m., and stated she knew that Resident 1 was not to be left alone in her room because of a history of falls. The Director of Staff Development (DSD) was interviewed on 8/20/14 at 10:05 a.m., and stated the intent of the "Fall Trend Investigation Report" approach was to frequently observe Resident 1 and to keep her in the line of sight as much as possible.

Based on observation, interview, and record review, the facility failed to protect 1 of 3 sampled residents (Resident 1) from injury when a hot pack (a treatment applied to reduce pain) was improperly applied to Resident 1's knee. This failure resulted in an open wound from a 2nd degree burn that caused pain and increased potential for infection. Findings: Resident 1 was initially admitted to the facility in the Summer of 2013 and most recently readmitted to the facility in the Spring of 2014. [DIAGNOSES REDACTED]. A review of the Minimum Data Set (an assessment tool) completed in July 2014, indicated Resident 1 could "usually understand" and had "modified independence" in cognitive skills for daily decision making. Resident 1's functional status indicated, "extensive assistance" needed with "one person physical assist" in transfer, toilet use, and personal hygiene. A review of the care plan for skin, updated 7/25/14, identified Resident 1 was at risk for skin breakdown and pressure ulcer. The care plan specified approaches to implement as, "Monitor for skin breakdown/pressure ulcer formation daily..." and to notify the physician for any signs and symptoms of skin breakdown. A review of the care plan for Alzheimer dementia, updated 7/25/14, identified Resident 1 had the problem of decreased safety awareness. The care plan documented Resident 1 had impaired cognition "...as manifested by...decreased safety awareness..." A review of Resident 1's clinical records contained following: The "Treatment Record," dated 8/11/14, indicated, "Apply heat pack (hot pack) to R (right) knee as needed for joint pain every 8 hrs (hours)." LN 3 initialed in the treatment record which indicated she carried out the order on 8/11/4. The "Departmental Notes," nurses' progress notes, dated 8/12/14. indicated, "Resident noted to have 6x8cm reddened area with outer area of redness with fluid filled blister." The "physician progress notes [REDACTED]. The PA documented, "Staff txed (treated) R (right) knee pain/...(with) heat pad which caused burn (with) blistering." The injury identified as a 2 degree burn with mild pain. The "Emergency Physician Record" from the acute hospital, dated 8/16/14, documented, "Burn of R knee from heating pack...R knee 2nd degree burn 6 x 4.5 cm (centimeter)." The "Departmental Notes," contained no documented evidence Resident 1 was monitored during the hot pack treatment on 8/11/14. There was no documented evidence Resident 1's skin was assessed or skin condition was monitored before, during or after the hot pack application. There was no documented evidence when the hot pack was applied and/or removed. The nurses' notes did not contain any documented evidence of the duration of application, or the manner in which the hot pack was applied to Resident 1. A review of the facility provided policy and procedure, "Lippincott Nursing Procedures" the 5th edition, under "Heat and Cold," implementation of "Direct Heat Application," stipulated, "Check the practitioner's order...For a chemical hot pack (disposable): Absorbent, protective cloth covering...Place the pack in a protective cloth covering, and secure the covering with tape or roller gauze." The policy and procedure further instructed, "Documentation: Record the time and date of the heat application...duration, and site of application... and skin condition...signs of complications; and patient's tolerance of treatment." A review of the undated hot pack manufacturer's instruction on the back of the product had a warning statement: "Do not apply against unprotected skin. Wrap in soft cloth and apply." In a concurrent observation and interview on 8/22/14 at 9:50 a.m., Resident 1 was observed to be transferred by two staff from the wheelchair to the bed. Resident 1's right knee was observed covered with a white gauze bandage. Resident 1 communicated with a nod and a shake of the head and was able to answer in simple sentences such as, "It hurts." When asked if she was in pain, Resident 1 nodded her head pointing to her right knee with her finger circling over the knee cap area. During the dressing change observation on 8/22/14 at 10:05 a.m., Resident 1 was observed to have an open wound to her right inner knee about the size of a lemon. The wound bed was red pink with greenish blue eschar (dead skin that sheds off from healthy skin) present. The eschar was surrounded by thick yellow discharge. Licensed Nurse 1 (LN 1) explained the yellow discharge was due to (Brand name), an enzymatic debriding ointment applied onto the wound bed (enzymatic debridement is the use of an enzyme to remove dead tissue from a wound). During the dressing change which lasted approximately 10 minutes, LN 1 did not address any pain issues or assess Resident 1's pain level. Meanwhile, Resident 1 was constantly grimacing with intermittent moaning, "...ahh...ahh..." and "...hurt...hurt." LN 2, who stated she was on the job orienting, was present holding Resident 1's hand to comfort her during the dressing change. In a telephone interview on 8/22/14 at 2:15 p.m., LN 3 stated, on 8/11/14, the physician was contacted and a message was left to request the hot pack order but LN 3 did not receive a return call from the physician to confirm the order. LN 3 explained that she applied the hot pack to Resident 1 before the physician confirmed the order because she thought applying a hot pack to ease the knee pain was a nursing judgement as in applying an ice pack. LN 3 acknowledged she did not document the time and duration of the hot pack application or the skin condition before, during, and after the application. LN 3 acknowledged there was no documented evidence to verify how the hot pack was applied. LN 3 stated the physician signature for the hot pack order was obtained on 8/12/14 when the PA was in the facility to examine Resident 1's burn injury. Certified Nurse Assistant 1 (CNA 1) was interviewed via telephone on 8/22/14 at 2:35 p.m., and interviewed on 8/27/14 at 10:20 p.m. CNA 1 stated, on 8/11/14 around 8 a.m., Resident 1 complained of knee pain during her morning care. CNA 1 stated she reported Resident 1's knee pain to LN 3 and observed LN 3 brought a disposable hot pack and a cold pack into Resident 1's room shortly after. CNA 1 stated LN 3 placed the cold pack into Resident 1's drawer stating she would apply the cold pack later. CNA 1 stated she witnessed LN 3 activate the hot pack and directly applied to Resident 1's right knee and wrapped it with "(Brand name) (a bandage)" to hold the hot pack. CNA 1 confirmed she witnessed no barrier cloth placed between Resident 1's skin and the hot pack. CNA 1 further stated she witnessed the whole procedure while she was holding Resident 1's hand at the bedside because Resident 1 cried. CNA 1 stated Resident 1 had the hot pack on throughout the a.m. shift and witnessed the hot pack remained on the resident's knee approximately 2 p.m. In an interview on 8/27/14 at 10:33 a.m., CNA 2 stated she witnessed LN 3 apply the hot pack directly onto Resident 1's skin without any barrier cloth on 8/11/14. CNA 2 stated she was assisting Resident 1's roommate with her breakfast and witnessed LN 3 applying the hot pack when she took the breakfast tray out of the room. CNA 2 verified CNA 1 was present during the procedure. In an interview with CNA 1 and CNA 2 on 8/27/14 at 12:10 a.m., CNA 1 stated since the burn injury to her knee, Resident 1 had difficulty to get up in the morning and often did not want to get up at all. CNA 1 stated she noted Resident 1 had increased complaints of pain and observed Resident 1 guarding and/or protecting her burn area frequently. CNA 2 stated Resident 1 was grimacing and moaning when repositioning her and got uncomfortable easily. CNA 2 described Resident 1 became more cautious when care was provided, and worried about what the CNA was doing. In an interview on 8/27/14 at 12 p.m., the Administrator and the Director of Nursing acknowledged the heat pack caused a 2nd degree harm to Resident 1. The Administrator stated the incident was, "Disheartening."