Every finding on record at Hanford Post Acute

Based on observation, interview and record review, the facility failed to prepare and distribute food in accordance with professional food service when:1. The food preparation sink was not equipped with a required air gap (a space that helped keep dirty water from getting into clean water). Which had the potential to allow backflow (dirty water flowing backward into clean water) and contaminate (harmful germs or other unsafe substances were present) food, food contact surfaces and equipment. This failure had the potential to expose all 87 residents residing in the facility to contaminated food, food contact surfaces, and an increased risk of foodborne illness. 2. The facility did not follow the required manual ware washing process by removing a clear plastic food storage and a metal measuring cup from the sanitizer (a chemical solution used to reduce harmful germs on food-contact surfaces to a safe level) before the required one-minute contact time, resulting in the items not being sanitized (harmful germs were reduced to a safe level) prior to air drying. This failure had the potential to expose all 87 residents residing in the facility to contaminated (harmful germs or other unsafe substances were present) food-contact equipment and an increased risk of foodborne illness (an illness caused by eating food contaminated with harmful germs or other unsafe substances). Findings:During an observation on 7/15/26 at 8:54 a.m. the food preparation sink was observed with a colander containing food positioned inside the sink basin. Observation of the plumbing underneath the sink revealed the sink drainpipe extended directly into the drain receptor below without a visible air gap between the end of the drainpipe and the drain receptor. During a concurrent observation and interview on 7/15/26 at 9:28 a.m. with Kitchen Staff (KS) 1, KS 1 used the food preparation sink to wash lettuce for lunch meal. KS 1 confirmed the sink was the designated food preparation sink. KS 1 stated an air gap would help prevent backflow so that, if the sink became backed up, contaminated water would not enter the sink and contaminate food. KS1 further stated I don't think this sink has an air gap. During a concurrent observation and interview on 7/15/26 at 4:28 p.m. with the Maintenance Director (MD) and the Registered Dietitian (RD), the MD confirmed the food preparation sink was not equipped with an air gap. The D stated he had worked at the facility for sixteen years and had not been aware of the requirement for an air gap. The RD stated an air gap helped prevent backflow and contamination of food and confirmed food preparation sinks were required to be equipped with an air gap in accordance with the Food Code. During a review of professional reference titled, FDA Food Code 2022, section 5-402.11 Backflow Prevention, (A) A direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. (B) Equipment and fixtures used for food preparation or utensil washing must be installed with an air gap or air brake as required to prevent backflow of sewage into the equipment.During a review of the facilities policy and procedure (P&P) titled Accident Prevention-Safety Precautions, dated 2023, the P&P indicated, an airgap is the most reliable backflow prevention device.all.food preparation sinks.and other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink.an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be the diameter of the water supply inlet and may not be less than one inch.2. During an interview on 7/15/26 at 8:45 a.m. with KS 1, KS 1 stated the dishwasher heater had been inoperable since Monday. KS 1 stated the manual ware washing process required washing items in hot soapy water in the first compartment of the three-compartment sink, rinsing items in clean water in the second compartment, and submerging items in sanitizer in the third compartment for one minute before allowing the items to air dry. KS 1 stated sanitizer concentrations were required to remain between 200-400 parts per million (ppm-a way to measure how much sanitizer was mixed into the water) and were verified using sanitizer test strips prior to use. KS 1 stated if the sanitizer concentration measured less than 200ppm, the Certified Dietary Manager (CDM) would be notified and EcoLab would be contacted. KS 1 further stated the sanitizer, and detergent solutions were premixed by EcoLab and dietary staff did not prepare the sanitizer or detergent mixture. During an interview on 7/15/26 at 9:35 p.m. with the CDM, the CDM stated the dishwasher became inoperable on Monday after dietary staff reported it was not reaching the required wash water temperature. The CDM stated maintenance evaluated the dishwasher and determined the dishwasher heater was not functioning. The CDM stated dietary staff were instructed to discontinue use of the dishwasher and utilize the three-compartment sink for manual ware washing until the dishwasher heater was repaired. The CDM further stated the facility was awaiting a replacement part for the dishwasher heater and had been informed the repair was expected to be completed that day. During a concurrent observation and interview on 7/15/26 at 2:56 p.m. with KS 2, KS 2 manually washed a clear plastic food storage bin and a metal measuring cup in the first compartment of the three-compartment sink, rinsed the items in the second compartment and submerged the items in the sanitizer solution in the third compartment. KS 2 immediately removed the clear plastic food storage bin and the metal measuring cup from the sanitizer solution and placed items in the drying rack without allowing the required one-minute sanitizer contact time. During the interview, KS 2 stated manual ware washing process required wash water maintained at least 100 degrees Fahrenheit (a scale used to measure temperature) in the first compartment, rinsing in the second compartment and submerging items in the sanitizer solution in the third compartment for one minute before allowing the items to air dry. KS 2 stated, that is not the process I did for those dishes. I did not leave them in the sanitizer for one minute. KS 2 stated leaving the items in the sanitizer for one minute was important to kill germs. KS 2 immediately rewashed the clear plastic food storage bin and metal measuring cup and demonstrated the correct manual ware washing process. During an interview on 7/15/26 at 3:39 p.m. with the CDM and the RD, the CDM stated the manual ware washing process required hot soapy water in the first compartment of the three-compartment sink, a clean water rinse in the second compartment and sanitizer in the third compartment followed by air drying. The CDM stated items were required to remain submerged in the sanitizer solution for at least one minute before being removed to air dry and that the three-compartment sink process was required to be completed in the correct order to ensure items were properly sanitized and prevent cross-contamination. The CDM stated kitchen staff were reeducated on the proper manual ware washing process on Monday. The CDM further stated KS 2 washed the clear plastic food storage bin and metal measuring cup incorrectly by removing the items from the sanitizer solution before the required one-minute contact time. The RD confirmed the manual ware washing process described by the CDM and stated the process was important to ensure food-contact items were properly sanitized and to prevent cross-contamination. During a review of the facilities policy and procedure (P&P) titled Sanitization, dated November 2022, the P&P indicated, manual washing ad sanitizing is a three-step process for washing, rinsing and sanitizing: a. scrape food particles and wash using hot water and detergent; b. rinse with hot water to remove soap residue; and c. sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solutions are used according to manufacturer's instructions.During a review of the facilities job description titled Dietary Supervisor, dated February 2024, the job description indicated, directs and supervises all dietary functions and personnel.hires, orients, trains, disciplines and when appropriate, terminates dietary employees.assures that.handling of food and supplies complies with current state and federal guidelines.maintain kitchen and food storage area in a safe, orderly, clean and sanitary manner.ensures continued compliance with all federal, state and local regulations.

Based on observation, interview, and record review, the facility failed to ensure that four out of eight sampled residents (Resident 1, 5, 8, and 57) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behaviors) medications, when.1. Resident 1 was administered aripiprazole and risperidone, two atypical antipsychotics (medications used to treat mental health conditions that makes it hard to tell what is real and what is not) concurrently, leading to duplicate drug therapy, the facility did not ensure adequate monitoring of behaviors and side effects related to use of Resident 1's 3 psychotropic medications, and no Gradual Dose Reductions (GDR- tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose of if the dose or medication can be discontinued) was attempted for Resident 1's antipsychotic medications. 2. Resident 5 was administered risperidone(atypical antipsychotic) and alprazolam (antianxiety medication) and no non-pharmacological interventions (NPI- an activity used to manage mental health symptoms or behaviors without using medications) were attempted, the facility did not ensure adequate monitoring for behavior and side effects related to use of risperidone, venlafaxine, and lorazepam and no GDR were attempted for the use of risperidone, venlafaxine, and lorazepam. These failures had the potential to result in an increased risk of over-sedation (when a medication slows the brain and body more than intended), extrapyramidal symptoms (involuntary muscle movements), and potentially fatal drug to drug interactions.3. Inappropriate diagnosis or indication of Amitriptyline medication (used to treat depression) order. 4. No nonpharmacological intervention implemented for Resident 52's use of sertraline (used to treat depression).These failures placed Resident 8 and Resident 57 at risk for experiencing adverse effects from receiving medications without proper monitoring. 1. During a review of Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/16/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (when the body does not make enough or the hormone insulin or can't use it properly), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry), unspecified hyperlipidemia (high cholesterol), major depressive disorder (a mood disorder causing persistent sadness and loss of interest), unspecified dementia (when confusion or mild cognitive impairment can't be clearly diagnosed as a specific type of dementia). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [ability to think, remember or make decisions] and physical function) Assessment, dated 6/10/26, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 05 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment. During a review of Resident 1's MDS section E-Behavior assessment, dated 6/10/26, the MDS section E indicated no hallucinations, no delusions, no physical behavioral symptoms directed towards others, and no verbal behavioral symptoms directed towards others. During a concurrent observation and interview on 7/16/26 at 1:15 p.m. with Resident 1 in her room, Resident 1 was alert and responsive. Resident 1 stated lunch was delicious and stated she was doing just fine. During a review of the facility document titled, Order Details, dated 5/11/23, the document indicated Resident 1 had current orders for Abilify (atypical antipsychotic) oral tablet 10 mg give 1 tablet by mouth two times a day for Schizophrenia M/B auditory hallucinations (experience that feels completely real but happens entirely within the mind without any external triggers) related to hearing the devil speaking to her causing resident distress. The document indicated an order end date of indefinite. During a review of the facility document titled, Order Details, dated 7/27/23, the document indicated Resident 1 had current orders for Risperdal (atypical antipsychotic) oral tablet 2 mg give 1 tablet by mouth one time a day for Schizophrenia manifested by visual hallucinations: seeing the devil causing distress to resident. The document indicated an order end date of indefinite. During a review of the facility document titled, Order Details, dated 3/29/23, the document indicated Resident 1 had current orders for Xanax tablet 0.25 mg give 1 tablet by mouth every 8 hours for anxiety M/B emotional outburst causing resident distress. The document indicated an order end date of indefinite. During an interview on 7/17/26 at 2:33 p.m. with the Director of Nursing (DON), the DON stated Resident 1's psych note evaluation dated 6/9/26 was completed and indicated to continue both atypical antipsychotic medications (Abilify and Risperdal). During an interview on 7/17/26 at 4:31 p.m. with the Consultant Pharmacist (CP), the CP stated normally a resident should not be on two atypical antipsychotics. During a review of the facility document titled, [Resident 1's name], (undated), the document indicated the name of the medications taken by Resident 1 and the total number of behaviors documented by nursing staff per month. The document indicated, .Xanax. [DATE].[DATE].[DATE]. April 0. May 48. June 0.TOTAL 363.Abilify.[DATE].[DATE].[DATE].April 0.May 39.June 0.Total 389.Risperdal.[DATE].[DATE].[DATE].April 0.May 157.June 0.Total 475. During a review of the facility document titled, Care Plan Report, dated 6/19/26, the document indicated, .Focus. [residents name] uses psychotropic medications (Abilify, Risperdal) r/t Behavior management- M/B Auditory hallucinations r/t [related to] Hearing the Devil.Goal.will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date.will reduce the use of psychoactive medication through the review date as indicated. The facility document did not indicate objective measurable goals for the monitoring of behaviors related to psychotropic medications. During an interview on 7/17/26 at 3:52 p.m. with the DON, the DON stated Resident 1's current care plan did not have objective measurable goals and stated it was important to have measurable goals r/t behaviors r/t psychotropic medications because it gave an idea if what was being done for the resident was trending in the right direction. The DON stated the goal was to lower the medication dose and keep behavioral episodes trending down. During an interview on 7/17/26 at 4:31 p.m. with the CP, the CP stated care plans should have objective measurable goals for the number of behavioral episodes for that resident, so staff/providers knew if the medication was working. During a review of the facility document titled, IDT [interdisciplinary team- a group of different healthcare professionals working together to coordinate care for a single patient] PSYCHOTHERAPEUTIC REVIEW, dated 5/26/26, the document indicated, .PSYCHOTHERAPEUTIC REVIEW.Minimal Effective Dosing-Date(s) dose reduction attempted, result of attempted reduction. February 2026: Leave as is, much better when takes meds.November 2025: leave as is Abilify 10 mg. During an interview on 7/17/26 at 3:00 p.m. with the DON, the DON stated Resident 1 was seen by the psychiatric (related to diagnosis and treatment of mental, emotional and behavioral disorders) Physician Assistant on 6/9/26, and stated documentation indicated a GDR was not indicated at the time as benefits of current treatment outweighed the risks. The DON stated there was no documentation of a contraindication of a GDR for the use of Resident 1's three psychotropic medications, was unable to provide documentation of GDR attempts for Abilify, Risperdal, or Xanax. The DON stated it was important to attempt GDRs to keep the medications at the lowest possible dose or possibly discontinue) the medications. During a concurrent interview and record review on 7/17/26 at 3:07 p.m. with the DON, Resident 1's electronic Psychotropic Medication Administration Record (Psych eMAR) dated 7/2026 was reviewed. The Psych MAR indicated, .Xanax.Observe resident closely for significant side effects.Abilify/Risperdal.Observe resident closely for significant side effects.Y/N. and indicated Y for DAY12 (day shift) and NOC12 (night shift) for Xanax and Abilify/Risperdal. The DON stated the process when nurses documented Y (yes) for side effect (S/E) monitoring was to notify the physician of their finding and carry out any orders. The DON stated she believed the staff was interpreting and answering the S/E monitoring question as yes, they were checking off the box. The DON stated she believed the staff was interpreting and answering the S/E monitoring question in this manner because she was unable to find any documentation of actual S/E's that had been documented for Resident 1. During an interview on 7/17/26 at 4:31 p.m. with the Consultant Pharmacist (CP), the CP stated she informed the facility about the trend for documenting behaviors she observed and stated on some months a lot of behaviors were documented and, on some months, low behaviors were documented. The CP stated it was important to have accurate documentation of behaviors so providers knew exactly what was going on and if the resident was not having or was having a lot of behaviors it would affect the dosing. CP stated If behaviors were trending down it was important to monitor behaviors and if Resident 1 was not having many behaviors providers could attempt a GDR. The CP stated it was important not to overmedicate elderly residents because it placed them at risk for falls. The CP stated residents should be on the lowest dose that still worked for that resident. The CP stated If a resident was doing okay on a specific dose of a medication and providers didn't attempt a GDR, then providers would not know if that was the lowest most effective dose for that resident. During an interview on 7/17/26 at 11:55 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she usually worked on the [NAME] Back Side of the building, worked with Resident 1 regularly and was familiar with that resident. LVN 5 stated Resident 1 had episodes of yelling and talking to herself in her room frequently. LVN 5 stated monitoring for Abilify included auditory hallucinations-hearing devil speaking to her causing distress to resident and monitoring for Risperdal included visual hallucinations-seeing the devil causing distress to resident. LVN 5 stated she differentiated auditory hallucination and visual hallucinations by observing Resident 1's behaviors. LVN 5 stated if Resident 1 was looking around and verbally speaking to herself then LVN 5 would document that as auditory hallucinations. LVN 5 stated If resident was talking to herself and looking in a certain direction LVN 5 would document that as visual hallucinations. During a concurrent interview and record review on 7/17/26 at 2:50 p.m. with the DON, Resident 1's Psych eMAR dated May 2026was reviewed. The DON stated the total tally marks for behaviors from the previous month were documented on Resident 1's current Psych eMAR . The DON stated the Psych eMAR indicated how nurses were to document auditory hallucination and visual hallucinations as per eMAR orders. The DON stated tally marks for April 2026 (documented on May 2026 Psych eMAR) for episodes of anxiety m/b emotional outbursts causing resident distress (Xanax), episodes of schizophrenia m/b auditory hallucinations r/t hearing the devil speaking to her (Abilify), and episodes of schizophrenia m/b visual hallucinations seeing the devil causing distress (Risperdal) were tallied as 0. Psych eMAR for Feb. 2026 (documented on March 2026 Psych MAR) indicated tally marks 0 for the month of February. The DON stated it was unlikely that tally marks were exactly the same on the psych eMAR for anxiety m/b emotional outbursts causing resident distress (Xanax), episodes of schizophrenia m/b auditory hallucinations r/t hearing the devil speaking to her (Abilify), and episodes of schizophrenia m/b visual hallucinations seeing the devil causing distress (Risperdal) and stated it was not likely the documentation was accurate. The DON stated inaccurate documentation could change how the physician medicated Resident 1and could affect Resident 1's plan of care. The DON stated if there was continued documentation of high numbers of behaviors, it would keep the providers from attempting to gradually reduce Resident 1's use of psychotropic medications. 2. During a review of Resident 5's AR dated 7/16/26, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, anxiety disorder hyperlipidemia), major depressive disorder dementia with other behavioral disturbance (memory loss or cognitive decline alongside significant, disruptive psychological or behavioral changes), psychosis (a mental state where a person loses touch with reality). During a review of Resident 5's MDS Assessment, dated 4/11/25, the MDS indicated Resident 5 had a BIMS score of 06 indicating Resident 5 had severe cognitive impairment. During a review of Resident 5's MDS section E-Behavior assessment, dated 4/11/25, the MDS section E indicated no hallucinations, no delusions, no physical behavioral symptoms directed towards others, and no verbal behavioral symptoms directed towards others. During an interview on 7/14/26 at 11:43 a.m. with Resident 5, Resident 5 was in the dining room sitting on the wheelchair (WC) alert and responsive. Resident 5 responded to questions appropriately and stated she had no concerns regarding her care. During a review of the facility document titled, Order Details, dated 5/21/25, the document indicated Resident 5 had current orders for Venlafaxine HCL (antidepressant) oral tablet 100 mg give 1 tablet by mouth one time a day for depression M/B sadness over loss of life roles. The document indicated an order end date of indefinite. During a review of the facility document titled, Order Details, dated 6/24/25, the document indicated Resident 5 had orders at that time for Risperdal (atypical antipsychotic) oral tablet0.5 mg give 1 tablet by mouth at bedtime for psychosis m/b verbalizing visual hallucination seeing a man with a gun trying to get her that is not present causing resident distress. During a review of the facility document titled, Order Details, dated 3/25/26, the document indicated Resident 5 had current orders for Risperdal (atypical antipsychotic) oral tablet 1 mg give 0.5 mg by mouth one time a day for unspecified psychosis m/b verbalizing visual hallucinations seeing a man with a gun trying to get her that is not present causing resident distress and give 1 mg by mouth at bedtime for unspecified psychosis m/b verbalizing visual hallucinations seeing a man with a gun trying to get her that is not present causing resident distress . The document indicated an order end date of indefinite. During a review of the facility document titled, Order Details, dated 10/21/25, the document indicated Resident 5 had current orders for Lorazepam (antianxiety agent) oral tablet 0.5 mg give 1 tablet by mouth one time a day for anxiety. The document indicated an order end date of indefinite. During a review of the facility document titled, *PACS-MEDICATION ADMINISTRATION RECORD, dated July 2026, the document indicated, Lorazepam Oral Tablet 0.5 MG.Give 1 tablet by mouth.for ANXIETY DISORDER.m/b repetitive movement.Risperdal Oral Tablet 1 MG.Give 0.5 mg by mouth.for UNSPECIFIED PSYCHOSIS M/B verbalizing visual hallucination.Risperdal Oral Tablet 1 MG.Give 1 mg by mouth. for UNSPECIFIED PSYCHOSIS M/B verbalizing visual hallucination. During a review of the facility provided document titled, [hospital]dated 6/18/25, the document indicated Resident 5 had a urinalysis (a test that checks the urine for infections, kidney problems, diabetes, and liver disease) on 6/18/25. The document indicated, .UA-Appearance. Cloudy.UA-Bacteria. Many. During a review of the facility provided document titled, [hospital] dated 6/18/25, the document indicated Resident 5 had a urine culture (a laboratory test to check the urine for bacteria, yeast, or other microorganisms) on 6/18/25. The document indicated, .Cipro [antibiotic] 500 mg BID [twice a day] x 3 day. During an interview on 7/17/26 at 3:22 p.m. with the DON, the DON stated she was unable to find documentation regarding non-pharmacological interventions (NPI) for Resident 5 prior to starting Risperdal. The DON stated psychosis alone was not an appropriate diagnosis for the use of Risperdal. The DON stated it was important to be cautious with the use of antipsychotics in dementia residents because there was a black box warning (the strictest safety-related alert the federal government requires for prescription drugs) because there was an increased risk for cardiac (relating to the heart) death in dementia residents who were on antipsychotics. The DON stated Resident 5 had a diagnosis of anxiety manifested by repetitive movement and a diagnosis of dementia. The DON stated nurses would not be able to distinguish between repetitive movement as a manifestation of dementia and repetitive movement due to anxiety. The DON stated fidgeting alone/ repetitive movement would not be a good enough symptom for the use of lorazepam. During an interview on 7/17/26 at 4:10 p.m. with the Physician Assistant (PA), the PA stated psychosis was not an indication for chronic use of Risperdal and NPI's should have been implemented prior to starting Risperdal considering Resident 5 was prescribed antibiotics after a urinalysis during the same time the Risperdal was ordered. PA stated it was normal for a resident with dementia to be fidgeting/ have repetitive movement. PA stated fidgeting/repetitive movement alone was not an indication to prescribe lorazepam. During a review of the facility document titled, Care Plan Report, dated 5/13/26, the document indicated, .Focus. [residents name] uses antipsychotic medication for visual hallucinations.Goal. [resident name] will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The facility document did not indicate objective measurable goals for the monitoring of behaviors related to psychotropic medications. During an interview on 7/17/26 at 3:58 p.m. with the DON, the DON stated Resident 5's current care plan did not have objective measurable goals for the use of lorazepam and Risperdal and it was important to have measurable goals for behaviors related psychotropic medications because it gave providers an idea what current goals were and that what was being done for the resident was trending in the right direction. The DON stated the goal was to lower the medication dose and keep behavioral episodes trending down. During an interview on 7/17/26 at 4:18 p.m. with the PA, the PA stated there should be objective measurable goals for Resident 5 and it was important to have less side effects with medications, and that lowering doses of medications minimized the likelihood of side effects. During a review of the facility document titled, IDT PSYCHOTHERAPEUTIC REVIEW, dated 6/23/26, the document indicated, .PSYCHOTHERAPEUTIC REVIEW.4. Minimal Effective Dosing-Date(s) dose reduction attempted, result of attempted reduction. September 2025: Leave as is, meds seem to be helping.June 2025: Continue Venlafaxine 100 mg daily. The DON was unable to provide documentation of GDR attempts for Risperdal, Venlafaxine or Lorazepam, and stated it was important to attempt GDR's to keep the medications at the lowest possible dose or possibly DC the medications. During an interview on 7/17/26 at 12:14 p.m. with LVN 6, LVN 6 stated side effects were documented in the Psych eMAR . LVN 6 stated if a resident had a side effect then staff would click yes indicated by a plus button on the computer system and stated she would then write a change of condition which included monitoring- alert charting, contact the provider and the resident's responsible party. During a concurrent interview and record review on 7/17/26 at 3:50 p.m. with the DON, Resident 5's Psych MAR dated 7/2026 was reviewed. Resident 5's Psych eMar indicated, .Ativan.Observe resident closely for significant side effects.Venlafaxine.Observe resident closely for significant side effects.Risperdal.Observe resident closely for significant side effects.+/-. and indicated Y for NOC12 (night shift) for Risperdal side effect monitoring. The DON stated the process when nurses documented Y (yes) for side effect monitoring was to notify the physician of their finding and carry out any orders. The DON stated she believed the staff was interpreting and answering the side effect monitoring question as yes, they were checking off the box. The DON stated she believed the staff was interpreting and answering the side effect monitoring question in this manner because she was unable to find any documentation of actual side effects that had been documented for Resident 5. During a review of the facility's policy and procedure (P&P) titled, Tapering Medications and Gradual Drug Dose Reduction, dated July 2022, the P&P indicated, .All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions.Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.The staff and practitioner will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident.The physician will order appropriate tapering of medications, as indicated. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated February 2025, the P&P indicated, .Residents do not receive psychotropic medications that are not clinically indicated and necessary. Medications in the following categories are considered psychotropic medications.Anti-psychotics.Anti-depressants.Anti-anxiety medications. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes.determining adequate indications for use.adequate monitoring for efficacy and adverse consequences.determining appropriateness of gradual dose reduction. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction. Diagnosis alone does not necessarily warrant the use of psychotropic medication. If a psychiatric diagnosis is part of the rationale for the use of psychotropic medication, there will be sufficient supporting documentation that the resident meets the criteria for that diagnosis. Duplicate therapy (use of two or more medications of the same pharmacological class or category without a clear distinction of when one medication should be administered over another) is generally not indicated unless there is a documented clinical rationale for the use of multiple medications from the same class or with similar therapeutic effects. Residents receiving psychotropic medication are monitored and the response to treatment is documented. Residents on psychotropic medication receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication. 3.During a concurrent observation and interview on 7/14/26 at 11:10 a.m. during initial tour in Resident 8'a room, Resident 8 was sitting at bedside and stated he had been in the facility for about five years. Resident 8 stated he goes to dialysis three times a week and was happy with the care he is receiving. During a review of Resident 8's admission Record [AR- a document containing resident profile information], dated 7/16/26, the AR indicated Resident 8 was admitted to the facility on [DATE]with diagnoses which included muscle weakness, end staged renal diseases (ESRD-irreversible kidney failure), and hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided weakness). During a review of Resident 8's Order Details dated 7/15/26, the Order Detail indicated, Amitriptyline HCl Oral Tablet 100 MG . Related Diagnosis: Pain, Unspecified. During a concurrent interview and record review on 7/15/26 at 3:25 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 8's medication orders were reviewed. LVN 1 stated Resident 8 was receiving amitriptyline. LVN 1 stated the medication's indication was for pain. LVN 1 stated Amitriptyline is an anti- depressant medication but the indication in the order is for pain. LVN 1 stated medication's indication was not appropriate. LVN 1 stated it was the responsibility of the licensed nurse receiving the medication order to ensure a proper diagnosis or indication for medication to monitor side effects and monitor effectiveness of medication. During an interview on 7/16/26 at 1:45 p.m. with LVN 3, LVN 3 stated it was important to ensure psychotropic medications had appropriate diagnosis or indication to monitor for side effects of medications. LVN 3 stated it was important to ensure medication was monitored for effectiveness. During an interview on 7/17/26 at 5:22 p.m. with Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON and ADON stated the expectation was for the licensed nurse receiving the medication order to clarify with the Medical Doctor (MD) giving the order of the complete and appropriate diagnosis or indication of medication. The DON stated appropriate diagnosis or indication of medication to ensure residents were ordered and treated with the right medication and to monitor effectiveness of medication. 4. During a concurrent observation and interview on 7/14/26 at 9:20 a.m. during initial tour in Resident 57's room, Resident 57 was lying in bed watching TV. Resident 57 stated she had been in the facility for couple of months. Resident 57 stated she was working with therapy due to a fall at home. Resident 57 stated she uses a wheelchair and a walker for transfer and ambulation. During a review of Resident 57's AR, dated 7/16/26, the AR indicated, Resident 57 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (muscle loss or shrinking muscles), depression (serious mood disorder that causes ongoing sadness and a loss of interest in things you once enjoyed) and muscle weakness. During a review of Resident 57's Medication Review Report [MRR], dated 7/17/26, the MRR indicated, .Sertraline HCl[hydrochloride-an active medicine combined with a safe form of hydrochloric acid to turn it into a stable, water-soluble salt] Oral Tablet 100 MG [milligram-unit of measurement] Give 1 (one) tablet by mouth one time a day .Order date: 6/16/26, Start Date: 6/17/26. During a concurrent interview and record review on 7/15/26 at 2:04 p.m. with LVN 4, LVN 4 reviewed Resident 57's clinical record titled MRR. LVN 4 stated Resident 57 is currently receiving sertraline medication for depression. LVN 4 stated she did not find monitoring order for non-pharmacological intervention and there should be. LVN 4 stated it was important to have monitoring in place for non-pharmacological intervention to provide residents with alternate interventions like listening to them verbalize their feelings and redirecting to activities. LVN 4 stated it was the responsibility of licensed nurses to ensure there was monitoring order for non-pharmacological interventions During an interview on 7/17/26 at 5:32 p.m. with DON and ADON, DON and ADON stated it was important to monitor non-pharmacological interventions to ensure to try something other than medication first. The DON and ADON stated the main goal were to always try to redirect residents' behaviors without medications first. DON and ADON stated the non-pharmacological interventions would be initiated at the time the medication order was received and the nurse receiving the order was responsible in initiating the monitoring. During a review of facility policy and procedure (P&P) titled, Psychotropic Medication Use, revision date 2/25, the P&P indicated, .When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts, and documents an evaluation of the resident. Adequate Indications for Psychotropic Medication Use.an assessment of the resident's condition and therapeutic goals.a determination that non-pharmacological intervention are clinically contraindicated.The clinical rationale for the use of psychotropic medication. Documentation must include that behavioral (non-pharmacological) interventions were attempted but not successful, and these interventions were deemed clinically contraindicated.

Based on observation, interview and record review, the facility failed to prepare food in a form designed to meet an individual resident's needs by preparing pureed zucchini that did not maintain the consistency required for a prescribed pureed diet for one of nine residents (Resident 10). This failure had the potential to increase the risk of aspiration (food or liquid entering the airway instead of the stomach) by not providing food in the consistency required for the residents prescribed pureed diet. Findings:During a concurrent observation and interview on 7/15/26 at 11:41 a.m. with the Certified Dietary Manager (CDM) during lunch tray line, the first pureed meal tray assembled for meal service for Resident 10, contained liquid from the pureed zucchini that had spread throughout the bottom of the clear container. The CDM opened the meal tray for further observation. The pureed zucchini appeared thin, runny and did not maintain its intended shape. When asked how a properly prepared pureed vegetable should appear, the CDM stated it should be smooth, cohesive and hold together, but not be runny. The CDM stated the pureed zucchini observed at that time did not appear as it should. The CDM discarded the pureed zucchini and had it remade to the correct consistency for Resident 10 and the remaining eight residents receiving a pureed diet. During a review of Resident 10's Meal Ticket dated 7/15/26, the Meal Ticket identified Resident 10's diet order as puree, fortified, with nectar thick liquids.During an interview on 7/15/26 at 3:02 p.m. with KS 3, KS 3 stated when preparing pureed foods, she aimed for a nectar-like consistency when blending. KS 3 stated she learned how to prepare pureed foods a long time ago through her experience working in the kitchen. KS 3 stated she did not prepare the pureed zucchini served during the lunch meal service. KS 3 stated pureed foods should hold their form and should not run together. KS 3 stated she believed the pureed zucchini became runny because it sat while in the warmer while waiting for tray line and accumulated additional moisture. KS 3 stated it was important for puree foods to maintain their form because residents would not find runny food appealing. During an interview on 7/15/26 at 3:47 p.m. with the CDM and the Registered Dietitian (RD), the CDM stated pureed foods should be smooth to promote safe swallowing. The CDM stated the pureed zucchini observed during the lunch tray line on 7/15/26 did not meet the required standard because it did not hold its shape. The CDM stated the spoon tilt test should be used to verify the proper consistency of pureed foods rather than relying solely on a visual inspection. The RD conformed pureed foods should maintain their shape and stated foods that are too thin increase the risk of aspiration. During a review of the facilities policy and procedure (P&P) titled, Regular Pureed Diet, dated 2023, the P&P indicated, the pureed diet is a regular diet that has been designed for residents who have difficulty chewing and or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. During a review of the facilities policy and procedure (P&P) titled, Nutritional Management of Thickened Liquids, dated 2023, the P&P indicated, 2. Mildly thick/nectar thick liquids flows off spoon.residents on thickened liquids should avoid foods with mixed consistencies.During a review of facilities Recipe: Pureed (IDDSI Level 4) Vegetables dated 2024, the Recipe indicated, the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests).

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program for two of five sampled residents (Resident 6 and 12) when:1. Licensed Vocational Nurse (LVN) 5 checked Resident 6's blood sugar using a glucometer (a portable medical device used to measure the amount of sugar in the blood) and did not properly disinfect the glucometer after use.2. LVN 5 checked Resident 12's blood sugar using a glucometer and did not properly disinfect the glucometer after use.This failure had the potential to put residents at risk of cross contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) that could result in the transmission of infections and pathogens (germs that invade the body and cause illness) which could lead to infection, hospitalization, or death.1. During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/16/26, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition where the body cannot properly process sugar for energy, causing it to build up in the bloodstream) with diabetic neuropathy (prolonged, high blood sugar from diabetes has caused structural and functional damage to the body's nerves), urinary tract infection, cerebral infarction (stroke), hyperlipidemia (too much cholesterol and fats circulating in the blood). During a concurrent observation and interview on 7/15/26 at 10:53 a.m. with LVN 5 , in Resident 6's room, LVN 5, was observed checking Resident 6's blood sugar using a glucometer. LVN 5 stated Resident 6's blood sugar was 291. LVN 5 administered 8 units (unit of measure) of Novolin R(a form of insulin used to lower blood sugar). After using the glucometer, LVN 5 wrapped the glucometer in a bleach wipe, set a timer, and placed the glucometer on the medication cart. 2. During a review of Resident 12's AR dated 7/16/26, the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, urinary tract infection, hyperlipidemia, chronic kidney disease (when the kidneys are damaged and slowly lose the ability to properly filter waste and extra fluid from the blood). During a concurrent observation and interview on 7/15/26 at 11:08 a.m. with LVN 5, in Resident 12's room, LVN 5 was observed checking Resident 12's blood sugar using a glucometer. LVN 5 stated Resident 12's blood sugar was 256. LVN 5 administered 8 units of Novolin R. After using the glucometer, LVN 5 wrapped the glucometer in a bleach wipe, set a timer, and placed the glucometer on the medication cart. During a concurrent interview and review on 7/15/26 at 11:17 a.m. with LVN 5, the manufacturer instructions for the Bleach Germicidal Wipes were reviewed. LVN 5 stated the process after using a glucometer to check blood sugars, was to wrap the glucometer with the bleach wipe and let stand for 3 minutes. After reviewing instructions on Bleach Germicidal Wipes container with LVN 5, LVN 5 stated she did not wipe the glucometer entirely before wrapping it with the bleach wipe and setting the timer for 3 minutes. LVN 5 stated it was important to clean the glucometer machine to disinfect and to prevent the spread of germs especially since going into another room.During an interview on 7/16/26 at 8:56 a.m. with the Director of Nursing (DON), the DON stated her expectation was for staff to disinfect the glucometer according to manufacturer instructions. The DON stated it was important for staff to disinfect the glucometer according to manufacturer instructions, for infection control. The DON stated staff needed to sanitize glucometers properly before taking it to the next patient. During a review of facility provided document titled, [Brand name] HEALTHCARE .Germicidal Wipes., (undated), the document indicated, .Disinfection.Wipe hard, nonporous surface to be disinfected.Special Instructions for Using This Product to Clean ad Decontaminate.on .Objects Soiled with Blood/Body Fluids.Cleaning Procedure: Blood and other body fluids must be thoroughly cleaned from surfaces and other objects before applying this product. During a review of the facility's policy and procedure (P&P) titled, Blood Sampling-Capillary (Finger Sticks), dated September 2014, the P&P indicated, .The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees.Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of eight sampled residents (Resident 20) when Resident 20's Functional Limitation in Range of Motion was inaccurately coded in the quarterly MDS assessment dated [DATE].This failure had the potential for Resident 20's need not monitored and met which could lead to further decline in function of lower extremities.During a review of Resident 20's admission Record AR-document containing resident profile information], dated 7/16/26, the AR indicated Resident 20 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, atherosclerosis of native arteries of extremities, bilateral legs (hardening and narrowing of the arteries in both legs), muscle weakness and pain.During a review of Resident 20's MDS assessment dated [DATE], the MDS section C indicated Resident 20 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgment) assessment score of 11 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which indicated Resident 20's cognition was moderately impaired. During a concurrent observation and interview on 7/14/26 at 9:35 a.m. during the initial tour in Resident 20's room, Resident 20 was lying in bed and stated he just finished his bed bath. Resident 20 stated he did not take showers because it was too hard for him to sit in the shower chair for a long time. Resident 20 stated he had multiple strokes few years ago and used to be able to move his left leg. Resident 20 stated he cannot move his left leg and his right leg was also getting weaker and not able to bear weight. Resident 20 stated staff had to use a mechanical lift to transfer him out of bed.During an interview on 7/15/26 at 2:43 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 20's care. CNA 1 stated Resident 20 was alert and able to verbalize needs and concerns. CNA 1 stated Resident 20 did not like to get out of bed and had to use a mechanical lift for transfers because his legs are weak. During an interview on 7/15/26 at 3:24 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was familiar with Resident 20's care. LVN 1 stated Resident 20's left leg was weaker than the right leg. LVN 1 stated Resident 20 was always in bed, and it was his choice not to get out of bed. LVN 1 stated she had not seen Resident 20 out of his room and was not sure if staff uses mechanical lift for transfers. During a concurrent observation and interview on 7/16/26 at 1:16 p.m. with Minimum Data Set Regional Consultant(MDSRC), the MDSRC stated the MDS nurse was on vacation, and she was filling in until MDS nurse returns. The MDSRC reviewed Resident 20's quarterly MDS assessment dated [DATE] and stated the assessment indicated Resident 20 did not have limitations on their lower extremities. The MDSRC assessed Resident 20's mobility of his lower extremities. The MDSRC stated the assessment was not accurate, Resident 20 was not able to move his left leg, and the right leg was also weak. The MDSRC stated the assessment should have indicated there was limitation on lower extremities. The MDSRC stated accurate and complete MDS assessment was important for residents to receive proper care.During an interview on 7/17/26 at 5:45 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated her expectation was to ensure MDS assessments are accurate. The DON stated each person completing a portion of the MDS are responsible in ensuring their assessments are complete and accurate. The DON stated MDS was very important because it creates an accurate picture of the residents and ensures proper care was provided. During a review of facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, review date 10/24, the P&P indicated, .Any person who completes a portion of the MDS assessment. is required to sign the assessment certifying the accuracy of portion of that assessment. The information captured on the assessment reflects the status of the resident during the observation [ look-back] period of the assessment.

Number of residents sampled: 8Number of residents cited: 1Based on observation, interview, and record review, the facility failed to timely revise and implement a person-centered comprehensive care plan for one of eight sampled residents (Resident 2) when Resident 2's care plan for enteral nutrition (tube feeding [soft, flexible tube inserted directly into the stomach or small intestine ]- way to get liquid food and nutrients directly into the stomach or small intestine when resident cannot safely eat by mouth) was not updated and did not accurately reflect the physician's order for Resident 2's enteral nutrition.This failure had the potential to result in Resident 20's needs not be met.During an observation on 7/14/26 at 9:29 a.m. during initial tour in Resident 2's room, Resident 2 was observed lying in bed, eyes closed and head of bed elevated. Resident 2 connected to tube feeding machine and feeding formula infusing at 65 milliliter (ml-unit of measurement) per hour. Resident 20 did not answer questions asked. During a review of Resident 2's admission Record [AR- a document containing resident profile information], dated 7/16/26, the AR indicated, Resident 20 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (complete or severe paralysis of one entire side of the body) and hemiparesis (weakness on one side of the body), dysphagia (difficulty swallowing), gastrostomy (small, safe path made into the stomach through the belly to put food, drinks, and medicine straight inside) and anorexia (complete loss of appetite).During a review of Resident 2's Order Details [physician order], undated, the Order Detail indicated . Enteral feeding with [brand name] . at 65 ml [milliliter-unit of measurement]/hr [hour] x16 hrs [hours].During a review of Resident 2's Care Plan, date initiated 03/11/2024, Revision on 03/13/2025, the Care Plan indicated, .Interventions. bolus feed [quick tube-feeding method] & Flush as ordered by MD.During a concurrent interview and record review on 7/15/26 at 3:17 p.m. with Licensed Vocational Nurse (LVN)1, Resident 2's clinical record titled care plan: Enteral nutrition was reviewed. LVN 1 stated Resident 2 is on continuous feeding. LVN 1 stated Resident 2's tube feeding used to be bolus feeding but was changed to continuous. LVN 1 reviewed Resident 2's physician order for enteral feeding and stated the order for continuous feeding was dated 4/1/26. LVN 1 stated it was the responsibility of all licensed nurses to revise and update care plan. LVN 1 stated care plan should be person-centered to meet resident's needs.During an interview on 7/17/26 at 5:22 p.m. with Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated care plan should be updated and revised as soon as a change happens. The DON stated it was every licensed nurse's responsibility to revise and update a care plan. The DON stated it was important to keep care plans up to date to provide proper care and care for residents.During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revision date 3/22, the P&P indicated, . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. When possible, interventions address the underlying source(s) of the problem(s), not just symptoms or triggers. Assessments of residents are on-going, and care plans are revised as information about the residents and the resident 's condition change .

Number of residents sampled: 8Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure nail care was provided for two of eight sampled residents (Resident 11 and Resident 53) when Resident 11 and Resident 53's fingernails were long and dirty with dark brown built up underneath their nails.This failure had the potential for Resident 11 and Resident 53 in sustaining avoidable skin related injuries like cuts, skin tears, scrapes and scratches which can lead to skin infection (invasion and growth of germs in the body).During a concurrent observation and interview on 7/4/26 at 9:28 a.m. during initial tour in Resident 11's room, Resident 11 was lying in bed with eyes open. Resident 11 stated he was in the hospital due to poor circulation in his lower legs and had to amputate both legs above the knee. Resident 11 was observed with several skin tears and scabs on different stages of healing. Resident 11 was observed with long and dirty fingernails. Resident 11 stated his nails are long and dirty and needed to be trimmed and cleaned. Resident 11 stated he did not remember when his nails were last cleaned and trimmed. Resident 11 stated he wanted his nails trimmed and cleaned because he tends to scratch himself.During a review of Resident 11's admission Record [AR-a document containing resident profile information], dated 7/16/26, the AR indicated, Resident 11 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, peripheral vascular disease (a slow, progressive blood circulation disorder), and atherosclerotic heart disease (hardening of arteries cause by hardening of fatty plaque [a sticky gunk made of fat and cholesterol that builds up inside your blood vessels]).During a review of Resident 11's Minimum Data Set ((MDS - a resident assessment tool used to identify cognitive and physical function) assessment, dated 6/29/26, indicated Resident 11's Brief Interview of Mental Status assessment (BIMS- assessment of cognitive status for memory and judgement) scored 9 of 15 (a score of 13-15-indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07-indicates severe impairment). The BIMS assessment indicated Resident 11's cognition was moderately impaired. During a concurrent observation and interview on 7/14/26 at 10:14 a.m. during initial tour of the facility in Resident 53's room, Resident 53 was found sitting in her wheelchair. Resident 53's fingernails were long, thick and yellowish in color with brownish colored built up underneath the nails, Resident 53 stated she would like to have her nails clipped. Resident 53 stated she could not remember when her nails were trimmed last. Resident 53 stated she had mentioned it to several people she wanted her nails clipped but there was no answer from staff.During a review of Resident 53's AR, dated 7/16/26, the AR indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (shrinking and losing muscle size and strength), scoliosis (a sideways curve of the backbone.), and spondylosis without myelopathy, lumbosacral region(the age-related wear and tear of the lower back (lumbar spine) and tailbone (sacrum) area).During a review of Resident 53's MDS assessment dated [DATE], indicated Resident 53's BIMS scored 14 of 15. The BIMS assessment indicated Resident 53 is cognitively intact. During an interview on 7/15/26 at 2:43 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated nail care was provided once a week on Sunday. CNA 1 stated CNAs can only trim non-diabetic residents' nails and licensed nurses take care of diabetic residents. CNA 1 stated long fingernails can cause infection if resident scratches self especially if nails are dirty. During an interview on 7/15/26 at 2:59 p.m. with CNA 2, CNA 2 stated nail care provided to non-diabetic residents and not sure how often they have to trim resident nails. CNA 2 checked Resident 11's nails and stated, needs to be trimmed and cleaned. CNA 2 stated dirty and long nails can get resident sick if he scratches his skin and can lead to infection. During a concurrent observation and interview on 7/15/26 at 3:25 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 11's fingernails are long and dirty. LVN 1 stated licensed nurses trim nails of diabetic residents. LVN 1 stated residents with long nails may scratch self and may lead to infection. LVN 1 stated Resident 11's fingernails should have been cleaned and trimmed. During an interview on 7/16/26 at 11:09 a.m. with Infection Preventionist (IP), the IP stated nail care is provided to residents on their shower days and every Sunday. The IP stated there was no documentation for nail care provided to residents. The IP stated he did not remember any residents complained to him about needing their nails trimmed. The IP stated CNAs may clean, trim or file resident's nails except diabetic residents, only licensed nurses may trim fingernails of diabetic residents.During an interview on 7/16/26 at 11:30 a.m. with CNA 4, she stated, I trim resident fingernails once a week. CNA 4 stated resident fingernails are checked on their shower days making sure nails are cleaned and trimmed. CNA 4 stated long and dirty fingernails could cause infection when a resident scratch self with their long and dirty fingernails. During an interview on 7/16/26 at 1:50 p.m. with LVN 3, she stated CNAs trim and file fingernails of non-diabetic residents and licensed nurses take care of diabetic residents' fingernails. LVN 3 stated she was not sure how often nail care is provided. LVN 3 stated long fingernails could potentially cause injury to residents, they can scratch their skin which could lead to infection especially if their nails are dirty. LVN 3 stated CNAs could let licensed nurses know when a diabetic resident needed their fingernails trimmed. During an interview on 7/17/26 at 5:35 p.m. with Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated her expectation was for staff to keep residents' fingernails trimmed, neat and clean. The DON stated CNAs should be cleaning and trimming residents' nails on their shower days and every Sunday. The DON stated residents could scratch their skin and may lead to infection. During a review of facility's policy and procedure (P&P) titled, Care of fingernails/Toenails, revised date 10/10, the P&P indicated, .Nail care includes daily cleaning and regular trimming. Proper nail care aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Notify the supervisor if the resident refuses the care.

Based on interview and record review, the facility failed to ensure the environment was free of hazards and adequate supervision was provided to prevent accidents for one of three residents, Resident 96, when nursing staff had assessed Resident 96 as a high risk for falls, were aware of Resident 96's history of falls, and previous Left hip fracture and failed to provide the level of supervision necessary to meet Resident 96's needs. The Occupational Therapy and Physical Therapy evaluation indicated Resident 96 required moderate assistance with toileting and was not independent with transfers between the bed and wheelchair. Nursing staff failed to implement supervision and interventions to address Resident 96's needs. The Minimum Data Set (MDS - a health assessment used in nursing homes to track patient needs, care plans, and health changes.) assessment indicated staff were to provide contact assistance with Activities of Daily Living (ADL - the basic self-care tasks people do every day, such as eating, bathing, and dressing etc.) and interventions were not implemented.These failures resulted in unwitnessed falls on [DATE] and [DATE] inside Resident 96's room, and [DATE] on the hallway, outside Resident 96's room. The fall of [DATE] approximately at 5:28 a.m. occurred after Resident 96 slid out from her wheelchair and was found sitting next to her wheelchair. After complaining of severe pain in the Right Hip and Right leg, Resident 96 was later sent to the hospital via ambulance following the fall incident. Resident 96 was diagnosed with Right hip fracture in the Emergency Department (ED). Ortho surgeon consulted on [DATE] and underwent surgery for an Open Reduction and Internal Fixation (ORIF - is a type of surgery used to stabilize and heal a broken bone) and pin placement. Resident 96 was hospitalized from [DATE] to [DATE] for 15 days and with limitations of movement, mobility, pain and suffering. Resident 96 was discharged back to the skilled nursing facility with hospice care following hospitalization.FINDINGS:During a review of Resident 96's admission Record (AR - a document with personal and medical information), dated [DATE], the AR indicated Resident 96 was a female, 83-years-old and was admitted [DATE] to the facility with diagnoses which included Displaced Fracture of Greater Trochanter of Left Femur, subsequent encounter for closed fracture with routine healing ( a resident in the recovery phase for a broken left hip bone, where the broken piece moved out of place but is healing normally), Disorder of bone density and structure (the bones lose their solid inner strength, becoming thin, fragile, and porous like a sponge or an open honeycomb), and Dementia (a progressive state of decline in mental abilities).During an interview on [DATE] at 3:15 p.m. with Licensed Vocation Nurse (LVN)7, LVN 7 stated Resident 96 had an unwitnessed fall on [DATE] approximately 5:28 a.m. and LVN 7 was the nurse in charge of Resident 96. LVN 7 stated Certified Nursing Assistant (CNA) 9 notified LVN 7 of Resident 96's unwitnessed fall. LVN 7 stated Resident 96 fell in the hallway outside of Resident 96's room, next to the door. LVN 7 stated Resident 96 was lying on her right side and right arm supporting the body. LVN 7 stated Resident 96 reported she slid out of her wheelchair in the hallway. LVN 7 stated Resident 96 was evaluated, a head-to-toe assessment was done, and Resident 96 did not complain of pain or discomfort at the time of fall. LVN 7 stated Resident 96 was transferred to her wheelchair with the assistance of CNA 9. LVN 7 stated Resident 96 kept saying and repeating why did this happen again. LVN 7 stated Resident 96 did not complain of pain until after being transferred to the wheelchair. LVN 7 stated Resident 96 complained of severe pain while sitting upright in her wheelchair and movement of her right leg. LVN 7 stated Resident 96 was administered pain medication as needed but was ineffective. LVN 7 stated on [DATE] the physician was notified and ordered Resident 96 to be transferred to acute care hospital for further evaluation. LVN 7 stated Responsible Party (RP) and Director of Nursing (DON) were made aware of the fall incident. LVN 7 stated Resident 96's fall could have been prevented with nonskid surface pad on seat of wheelchair. LVN 7 stated before the fall incident, Resident 96 was alert and consistently seated in her wheelchair. LVN 7 stated Resident 96 self-transferred from bed to wheelchair, used the wheelchair to access the toilet and propel self around the facility. LVN 7 stated Resident 96 enjoyed spending time with other residents, singing and visiting in the front lobby during her free time. During an interview on [DATE] at 5:01 p.m. with CNA 9, CNA 9 stated she was the CNA assigned to care for Resident 96 on [DATE], the day of the fall from the wheelchair. CNA 9 stated Resident 96 was found in a seated position on the floor in the hallway outside of Resident 96's room on [DATE] at approximately 5:28 a.m. CNA 9 stated she assisted the Charge nurse in transferring Resident 96 back into the wheelchair. CNA 9 stated Resident 96 was a fall risk, and CNAs were instructed to monitor her closely. CNA 9 stated Resident 96 required supervision when transferring from bed to wheelchair. CNA 9 stated Resident 96 sometimes forgot to use the call light for assistance and independently transferred from bed to wheelchair without first calling for assistance. CNA 9 stated Resident 96 was non ambulatory and used a wheelchair to go to the toilet for toileting and mobility throughout the facility. CNA 9 stated Resident 96 liked to do things independently. CNA stated Resident 96 was toileted before 5:28 a.m. CNA 9 stated the use of a chair alarm could have helped prevent the fall.During a concurrent interview and record review on [DATE] at 9:38 am with LVN 4, Resident 96's NURSING-FALL RISK OBSERVATION/ASSESSMENT(NFRA), dated [DATE] was reviewed. The NFRA indicated Resident 96 had a high fall risk score of 16. LVN 4 stated she had provided care to Resident 96 many times. LVN 4 stated Resident 96 had a history of falls at home and had been placed on fall precautions while in the facility. LVN 4 stated Resident 96 had experienced repeated falls in the facility on [DATE], [DATE] and [DATE]. LVN 4 stated Resident 96 had not consistently used the call light for assistance and preferred to do activities independently. LVN 4 stated Resident 96's required supervision or touching assistance (a staff provides verbal cues and or contact guard assistance as the resident completes activity) during transfers between surfaces. LVN 4 stated Resident 96 experienced a mental and physical decline after the Right hip surgery following the unwitnessed fall on [DATE] and upon returning to the facility on [DATE] under Hospice care (a comfort-focused medical treatment and support). LVN 4 stated when Resident 96 was first admitted to the facility on [DATE], Resident 96 was alert and oriented to person, place and time with occasional forgetfulness, verbally interactive with other residents and staff, and able to self-propelled in her wheelchair. LVN 4 stated following the Right hip surgery, Resident 96 had been oriented only to person, had become very weak and fatigued easily. LVN 4 stated Resident 96 complained of pain during repositioning and had wanted to sleep more. LVN 4 stated Resident 96's fall was not preventable because Resident 96 was noncompliant with using the call light for assistance and preferred to do activities independently.During a concurrent interview and record review on [DATE] at 10:42 a.m. with the Occupational Therapist (OT), Resident 96's Occupational Therapy Medicare OT Evaluation & Plan of Treatment (OTME), dated [DATE] was reviewed. The OTME indicated Resident 96's bilateral upper extremities strength was graded three out of five (the resident can independently move bilateral upper extremities, but it is weak and cannot lift heavy things). Resident 96's standing balance during ADL was poor. Resident 96's toileting transfer was minimal to moderate assistance and facility staff assistance was necessary because Resident 96 was unable to complete the task safely without assistance. The OT stated he performed OTME for Resident 96 on [DATE]. The OT stated Resident 96 needed reinforcement regarding safety awareness and the importance of using the call light for assistance. The OT stated Resident 96's therapy treatment goals were provided to improve independence with ADL, increase safety awareness, improve standing balance and activity tolerance, reinforce safe techniques, and reduce the risk of falls. The OT stated Resident 96 showed deficits in strength, balance, mobility, and cognition which affected daily activities, mobility, and safety.During a concurrent interview and record review on [DATE] at 2:17 p.m. with the Physical Therapist (PT), Resident 96's Physical Therapy Medicare PT Evaluation and Plan of Treatment (PTME), dated [DATE] was reviewed. The PTME indicated, Resident 96's bilateral lower extremity was graded three out of five (the resident can move their legs against gravity but cannot resist any extra pressure or resistance). Resident 96's sitting and standing balance was poor, and her coordination was impaired. Resident 96 was not independent and required minimal assistance to perform bed mobility and transfer task safely. The PT stated he performed PTME for Resident 96 on [DATE]. The PT stated Resident 96 was not supposed to self-transfer and required staff assistance with transfers. The PT stated Resident 96's therapy treatment goals were to improve safety awareness, balance, emphasize standing and transfer task.During an interview on [DATE] at 5:22 p.m. with the DON, the DON stated Resident 96 had an unwitnessed fall on [DATE] at 9:30 p.m. The DON stated CNA 3 found Resident 96 sitting on the floor and was not wearing nonskid socks. The DON stated during the interview with Resident 96, Resident 96 reported she was trying to reach something in the drawer and her feet slipped out from underneath her, causing her to fall. The DON stated Resident 96 was assessed as high fall risk prior to the fall on [DATE]. The DON stated Resident 96 should have called for help but did not call for help. The DON stated Resident 96 was toileted 10mins before the fall. The DON stated Resident 96 was independent with transfer and toileting. The DON stated Resident 96 was on fall risk precaution. The DON stated the immediate actions taken after the fall were keeping the bed low, Call light within reach, keeping personal belongings within reach. The DON stated the fall care plan was updated and a new intervention was added with a nonskid sock every evening as tolerated. The DON stated the fall care plan was effective in preventing falls. The DON stated the fall was not preventable because every fall was a different scenario and with different new fall interventions implemented. The DON stated Resident 96 was non-compliant with using the call light for assistance and Resident 96 could self-transfer from bed to wheelchair. The DON stated on [DATE] at 2:15 p.m. Resident 96 had a second unwitnessed fall. The DON stated CNA 7 found Resident 96 was seated on the floor, facing the bathroom. The DON stated Resident 96 reported to the charge nurse she slipped during self-transfer from bed to wheelchair and hit her head. The DON stated Resident 96 sustained a reddish discoloration on her right forehead. The DON stated Resident 96 was transferred to the acute care hospital for a higher level of care. The DON stated Resident 96 returned to the facility on the same day with no new orders and to continue with care plan. The DON stated Resident 96's fall care plan was updated, and new interventions were added, including monitoring bowel and bladder needs every two hours and enrolling Resident 96 on the falling star program (a falling safety system used in health care facility to identify residents who have a high risk of falling). The DON stated Resident 96's falling star program which included the following interventions such as a star to be placed on name plate next to the door and on wheelchair, Staff to assist Resident 96 to the bathroom before meals, after meals, bedtime and as needed, offer to lay resident down after all meals, encourage residents to attend activities of choice and resident not to be left alone in room while out of bed. The DON stated a falling star program was like putting an extra set of eyes on Resident 96 and there was no documentation on how often the staff monitored Resident 96. The DON stated the fall care plan was effective in preventing falls. The DON stated the fall was not preventable because every fall was with a different scenario and with different new fall interventions. The DON stated Resident 96 required supervision and assistance with transfers and toileting but Resident 96 was noncompliant with using the call light for assistance. The DON stated Resident 96 could self-transfer from bed to wheelchair and could toilet independently. The DON stated on [DATE] at approximately 5:28 a.m. Resident 96 had a third unwitnessed fall. The DON stated CNA 9 found Resident 96 on the floor in the hallway outside the resident's room. The DON stated when LVN 7 assessed resident 96 there were no visible injuries. The DON stated Resident 96 reported to LVN 7, Resident 96 slid down from her wheelchair and fell to the floor. The DON stated Resident 96 was transferred back to her wheelchair by the nursing staff. The DON stated Resident 96 continued to experience pain in the Right hip and Right leg and her pain medication was ineffective. The DON stated LVN 7 notified the physician and Resident 96 was transferred to the acute care hospital for further evaluation. The DON stated Resident 96 was diagnosed with a Right hip fracture. The DON stated the fall was not preventable because every fall was with a different scenario and with different new fall interventions. The DON stated one on one supervision and the use of tab alarm was not considered as a fall intervention because Resident 96 was alert, independent with bed mobility and transfer. The DON stated one on one supervision and the use of tab alarm would have limited Resident 96's ability to move freely within her room and throughout the facility. The DON stated Resident 96 had the right to move freely and independently. The DON stated Resident 96's fall care plan was updated, and a new intervention was added including non-skid pad to the wheelchair seat, medication review by pharmacy, falling star program and a room change to a room near the nurse's station upon return from the acute care hospital. During a concurrent interview and record review on [DATE] at 3:10 p.m. with the Minimum Date Set Regional Consultant (MDSRC - a specialized nurse in skilled nursing facilities who oversees the mandated resident assessment), Resident 96's Section GG - Functional Abilities (SGFA), dated [DATE] was reviewed. The SGFA indicated toileting hygiene, toilet transfer and chair/bed to chair transfer scores were four. The MDSRC stated a score of four means supervision or touching assistance. The MDSRC stated nursing staff must stay with Resident 96 to provide verbal cues or contact guard assistance (a caregiver keeps one or two hands on a resident's body to steady balance or prevent a fall) as Resident 96 completes activity. The MDSRC stated Resident 96's fall care plan was reflected on the Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment and was communicated to the staff, Resident 96 required supervision and physical assistance during transfers.During a review of Residents 96's MDS assessment dated [DATE], indicated Resident 96's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 10 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 96's cognition was moderately impaired.During a record review of Resident 96's Hospital record titled History and Physical (H&P), dated [DATE], the H&P indicated, . Date of service [DATE]. Chief Complaint Episode of fall. 83-years-old Hispanic female brought in from. post-acute skilled nursing facility after an episode of fall. baseline history of hypertension and dementia. Patient is oriented to herself only. Right hip x-ray and CT of hip. reported right hip intertrochanteric fracture. Orthopedic physician. has been consulted. surgery has been scheduled. tomorrow.During a review of Resident 96's Hospital record titled Ancillary Notes - OT (ANOT), dated [DATE], the ANOT indicated, . The patient is a [AGE] year-old Hispanic female brought in. from skilled nursing facility after an episode of fall. baseline history. dementia. Pt is now s/p right femoral trochanteric nailing. Rehab reason for referral: Evaluation and treatment. Not oriented to time, not oriented to situation. Evaluation assessment: Co-treated with PT due to concerns of fatigue. Pt demonstrated poor condition throughout due to the frequent verbal cues and repeated instructions the therapist provided. dementia which impedes her ability to be independent. Pt's family came in during the therapy session to observe. Pt was transferred to EOB [Edge of bed] and attempted to stand. unsuccessful. Pt will benefit from continued skilled therapy. to address functional mobility deficits, safety and independence.During a review of Resident 96's Hospital record titled Ancillary Notes - PT (ANPT), dated [DATE], the ANPT indicated, . Evaluation assessment: Patient received in room, agreeable to PT/OT. She presents with impaired functional mobility associated to pain elicited on R hip during mobility tasks. patient would benefit from continued skilled therapy. to address functional mobility deficits, safety and independence.During a review of Resident 96's Hospital record titled Discharge Summaries Notes (DSN), dated [DATE], the DSN indicated, .admit date : [DATE]. Reason for admission: Intertrochanteric fracture of right hip. Final Diagnosis. Intertrochanteric fracture of right hip. Fall. Encounter for palliative care. Leg pain. Hospital Course. patient is a [AGE] year-old Hispanic female. brought in from. skilled nursing facility after an episode of fall. Patient is status post ORIF. on [DATE]. postoperative patient had an episode of blood loss anemia, Acute Kidney Injury (AKI - sudden loss of kidney function) on Chronic Kidney Disease Stage IV (CKD stage IV - severe kidney damage) requiring starting hemodialysis (a life-saving medical treatment that uses a machine and a special filter to clean your blood when your kidneys have failed) in the hospital. recommended hospice which the family accepted. Patient is cleared to go back on [DATE] with hospice in the SNF. She is medically stable.During a concurrent observation and interview on [DATE] at 9:22 a.m. with Resident 96 inside Resident 96's room, Resident 96 was in bed and eyes closed. Resident 96 was interviewed by utilizing translating service California Department of Public Health Translator (CDPHT - a language professional who helps people with limited English skills understand health information) via phone. Resident 96 stated her first name, was unable to answer what happened to her and took a long time to respond. Resident 96 was falling asleep during the interview, and no other questions were asked.During a review of Resident 96's Care Plan Report (CPR), the CPR indicated, on [DATE] the following fall interventions were implemented such as keeping bed in low position with brakes locked, keeping call light and personal items frequently used within reach, monitoring changes in condition affecting risk for falls and notify physician if observed. On [DATE] fall intervention to provide proper, well-maintained footwear as indicated (Non-skid Socks etc.) On [DATE] room change was initiated for Resident 96 to be closer to the nurse's station. On [DATE] fall interventions were to apply nonskid tape to left side of bed, and red tape to wheelchair brakes. On [DATE] Resident 96 was encouraged to wear nonskid socks every night as tolerated. On [DATE] Resident 96 to be enrolled in the Falling star program (a fall safety system used in health care facility to identify residents who have a high risk of falling).During an interview on [DATE] at 8:38 a.m. with CNA 3, CNA 3 stated she was the CNA assigned to Resident 96 when Resident 96 had an unwitnessed fall on [DATE] at 9:30 p.m. CNA 3 stated Resident 96 was found sitting on the floor between the bed and the wheelchair. CNA 3 stated she immediately notified the charge nurse, who assessed Resident 96 and Resident 96 was assisted back to her bed. CNA 3 stated Resident 96 was on Fall precaution but did not remember if she was on the falling star program. CNA 3 stated Resident 96's fall intervention was to ensure call light was within reach while in bed. CNA 3 stated Resident 96 does not consistently use the call light to ask for assistance. CNA 3 stated Resident 96 was independent with transfers, could walk to the bathroom and use the toilet by herself.During an interview on [DATE] 10:03 am with LVN 2, LVN 2 stated Resident 96 had an unwitnessed fall [DATE] at 2:15 p.m. and LVN 2 was the nurse in charge of Resident 96. LVN2 stated Resident 96 was found on the floor sitting between her bed and wheelchair facing the bathroom. LVN 2 stated Resident 96 reported she wanted to go to the bathroom and did not say how she fell. LVN 2 stated a discoloration on right side of the forehead was observed and Resident 96 stated she hit her head. LVN 2 stated the physician was notified and Resident 96 was sent out to acute care hospital for further evaluation. LVN 2 stated Resident 96 previous fall care plan was not effective. LVN 2 stated Resident 96's new fall intervention added bowel and bladder every two hours to check if Resident 96 needed to use the restroom and Resident 96 was enrolled in the falling star program. LVN 2 stated the Falling Star program was a Facility Fall Safety program which enrolled residents who had two or more falls within the previous 30 days. LVN 2 stated on [DATE] was her first day working in the facility and was not told by the outgoing nurse Resident 96 was a high fall risk. LVN 2 stated Resident 96's falls could have been prevented if nursing staff performed frequent checks and provided bowel and bladder every two hours to Resident 96 but did not. LVN 2 stated Resident 96 was readmitted to the facility on [DATE].During an interview on [DATE] at 11:02 a.m. with CNA 8, CNA 8 stated she was assigned to care for Resident 96 on [DATE] when Resident 96 had an unwitnessed fall. CNA 8 stated Resident 96 was able to self-propelled in her wheelchair, independent with transfer and able to ambulate to the toilet. CNA 8 stated Resident 96 would get out of bed without using the call light to ask for assistance.During an interview on [DATE] at 1:12 p.m. with CNA 7, CNA 7 stated Resident 96 had an unwitnessed fall on [DATE] at 2:15 p.m. during morning and afternoon shift change. CNA 7 stated both morning and afternoon CNA staff were to report to the Charge nurse during a shift change. CNA 7 stated she was not the CNA in charge of resident 96 but CNA 7 had established rapport with Resident 96 and was familiar with her bedside care. CNA 7 stated after the shift report was done, she went to check on Resident 96 and said goodbye before leaving and found Resident 96 sitting on the floor inside her room. CNA 7 stated she immediately notified the charge nurse, who assessed Resident 96. CNA 7 stated Resident 96 was assisted back to bed. CNA 7 stated Resident 96 is alert, pleasant and can keep a conversation. CNA 7 stated Resident 96 was on supervision for transfers and toileting and had to be observed and provided with verbal guidance because Resident 96 was able to self-transfer from bed to a wheelchair and perform toileting independently. CNA 7 stated Resident 96 liked to do things on her own. CNA 7 stated Resident 96's fall may have been preventable with supervision and continuous monitoring for her safety.During an interview on [DATE] at 2:47 p.m. with LVN 7, LVN 7 stated he was the Charge Nurse assigned to Resident 96 when Resident 96 had an unwitnessed fall on [DATE] at 9:30 p.m. LVN 7 stated Resident 96 was found sitting on the floor beside her bed barefoot without a nonskid sock. LVN 7 stated upon interviewing Resident 96 reported Resident 96 was trying to reach her drawer to get something when her feet slipped out from under her. LVN 7 stated Resident 96 required supervision with transfers and toileting and did not call for assistance. LVN 7 stated Resident 96 was able to transfer from the bed to the wheelchair and used the wheelchair to self-propel around her room and the facility. LVN 7 stated Resident 96's Nursing-Fall Risk Observation/Assessment (is an evaluation used by healthcare professionals to identify a resident's likelihood of falling - low, moderate, and high-risk falls) was assessed as a moderate fall risk. LVN 7 stated fall precaution interventions included keeping the bed in a low position, ensuring the call light and belongings were within reach and ensuring proper footwear was worn. LVN 7 stated Resident 96 does not use the call light for help or assistance when transferring from bed to wheelchair, from a wheelchair back to bed, or when going to the toilet, because of her preference for independence. LVN 7 stated Resident 96's fall could have been prevented if resident 96 had worn nonskid socks and called for help. LVN 7 stated Resident 96's care plan was updated to include wearing nonskid socks when out of bed to prevent slipping.During a review of the facility's policy and procedure (P&P) titled Falls, dated 12/2007, the P&P indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try prevent. from falling.minimize complications from falling. If underlying causes cannot be readily identified or corrected, staff will try various interventions. until falling is reduced or stopped. If the resident continues to fall, staff re-evaluate the situation and whether it is appropriate to continue or change current interventions.

Based on observation, interview and record review the facility failed to ensure the daily nurse staffing information publicly posted for a facility with a census of 89 residents reflected the actual hours worked by nursing staff. This failure had the potential to provide residents, resident representatives, visitors and the public with inaccurate information regarding the facilities' daily nurse staffing levels, limiting their ability to make informed decisions based on the facilities' actual staffing. Findings:During an observation on 7/16/26 at 2:49 p.m. the facilities publicly posted staffing document titled Staffing Information 2026 was reviewed. The posting reflected staffing information for Thursday, July 16, 2026, including a census of 89 residents and staffing hours by shift. The posting did not indicate the staffing hours reflected actual hours worked. During a concurrent interview and review of the facilities Staffing Information 2026 sheet, dated 7/16/26 and Appendix PP Tag F732, dated 2/3/23, on 7/16/26 at 3:17p.m. with the Director of Staff Development (DSD), the DSD stated she prepared and posted the daily staffing sheet using the monthly certified nursing assistant (CNA) and licensed vocational nurse (LVN) schedules and the facility census. The DSD stated the staffing sheet was posted the evening before for the following day and updated only if scheduled staffing changes occurred. When asked whether the publicly posted staffing sheet reflected the days actual hours worked, the DSD stated the posting reflected projected staffing and acknowledged the information could change throughout the day. The DSD stated actual hours worked were maintained by the human resources/payroll department after staff completed their shifts and were not reflected on the publicly posted staffing sheet. The DSD further stated the facility had always posted staffing information using this process. After review of Appendix PP Tag F732, the DSD verbalized understanding the regulation requires the facility to publicly post actual hours worked rather than projected staffing hours. During a concurrent interview and review of the facilities Staffing Information 2026 sheet, dated 7/16/26 and Appendix PP Tag F732, dated 2/3/23, on 7/16/26 at 3:17p.m. with the Director of Nursing (DON), the DON stated the facility had been posting projected staffing hours because staff believed that was the required process and the federal requirement to post actual hours worked came as a surprise. The DON stated responsibility for ensuring the daily nurse staffing information was posted in accordance with federal requirements belonged to the DSD. The DON acknowledged the federal requirement was to publicly post actual hours worked and stated accurate staffing information was important for residents, visitors and the public to know the facility had sufficient staff to safely care for residents. Following review of Appendix PP Tag F732, the DON verbalized understanding the facility was required to publicly post actual hours worked rather than projected staffing hours. During a review of facilities policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers dated August 2022, the P&P indicated, The information recorded on the form shall include the following: g. the actual time worked during that shift for each category and type of nursing staff.

Based on observation, interview and record review, the facility failed to ensure a psychiatric consultation recommendation was reviewed, communicated to the interdisciplinary team (IDT) and the attending physician and appropriately followed up for one of eight sampled residents (Resident 56). This failure had the potential to delay the evaluation and implementation of a recommended intervention intended to address the residents emotional and psychosocial needs and could have affected the facilities ability to ensure timely behavioral health services. Findings:During an interview on 7/14/26 at 9:10 a.m. with Resident 56 in her room, Resident 56 disclosed her husband of thirty-six years had passed away a few months prior. Resident 56 became tearful while discussing her loss. Resident 56 stated she had not been seen by psychiatric services while residing at the facility. During a review of Resident 56's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 7/16/26 , the AR indicated Resident 56 had the following diagnoses: depression (a medical condition that caused a person to feel sad, hopeless, or lose interest in things they usually enjoyed for a long time) and anxiety (a medical condition that caused a person to feel excessive worry, fear or nervousness, even when there was little or no danger). During a review of Resident 56's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 7/2/26, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of fifteen (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 56 had no cognitive impairment.During an interview on 7/16/26 at 10:53 a.m. with Certified Nursing Assistant (CNA) 10, CNA 10 stated Resident 56's husband had passed away while the resident was residing at the facility. CNA 10 stated she believed Resident 56 needed emotional support related to her loss and periodically checked on her, offered conversation and companionship and encouraged food and snacks when the resident had decreased appetite. CNA 10 stated Resident 56's family visited frequently and provided support. CNA 10 stated she had not observed any Resident 56 experiencing any crying episodes or any significant changes in behavior. CNA 10 stated she would report any concerns regarding Resident 56 to the nurse. During an interview on 7/16/26 at 11:00 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she became aware of Resident 56's husband's death through resident monitoring documentation. LVN 5 stated Resident 56 was being monitored for sleep patterns, episodes of anxiety and sadness.During a concurrent interview and review of Resident 56's electronic health record on 7/16/26 at 11:15 a.m. with the Social Services Director (SSD), the SSD stated Resident 56's husband passed away on 5/4/26 while Resident 56 resided at the facility. The SSD stated she met with Resident 56 on 5/6/26 and on one additional occasion. The SSD stated a psychiatric physician assistant evaluated Resident 56 on 6/9/26 and recommended initiation of sertraline (an antidepressant [medication used to help improve a person's mood and reduce symptoms of depression] medication used to treat depression). The SSD stated Resident 56 had not received sertraline and there was no physician order for the medication. The SSD stated the psychiatric consultation note did not indicate Resident 56 declined the recommendation and Resident 56 had never received sertraline. The SSD stated an IDT meeting was not conducted to review the psychiatric consultation recommendations related to Resident 56's husbands' death. The SSD stated she was unaware Resident 56 wanted someone to talk to regarding her loss. The SSD stated Resident 56 was encouraged to participate in activities of her choice and received frequent family visits. The SSD stated she believed psychiatric consultation recommendations should have been followed up regarding the psychiatric recommendation to initiate sertraline being missed. Resident 56 was seen for a psychiatric follow up and psychotropic medication review. The consultation indicated Resident 56 reported her spouse had recently passed away and endorsed feeling sad. The assessment concluded a diagnosis of depression and anxiety disorder. The treatment plan documented start sertraline 50 milligrams (mg-a unit of measurement used to measure a very small amount of medication) tablet once daily, continue behavioral monitoring by staff, and continue routine psychiatric follow-up, and indicated no criteria for psychiatric hospitalization at the time. The attached medication orders included sertraline 50 mg by mouth once daily for depression related to verbalization of sadness and alprazolam 0.25 mg by mouth three times daily for anxiety related to repetitive anxious health concerns. During a review of Resident 56's Medication Review Report, dated 7/16/26, the Medication Review Report indicated, no active orders for sertraline. During an interview on 7/17/26 at 12:10 p.m. with the Director of Nursing (DON), the DON stated that the psychiatric provider communicated consultation findings and recommendations to the SSD, who was responsible for presenting the recommendations to the IDT for review and discussion. The DON stated the recommendation documented in the psychiatric consultation dated 6/9/26 to consider starting sertraline was not brought to the IDT for discussion and was not communicated to the attending physician. The DON stated there was no tracking process beyond the SSD receiving the consultation and believed the psychiatric provider's recommendation may not have been communicated because an order was not sent. The DON stated psychiatric recommendations were intended to support residents emotional and psychological well-being and quality of life. When asked about the potential impact of not following up on a psychiatric recommendation, the DON stated it could have affected the resident's day to day functioning, but noted the SSD had followed up with Resident 56 after the episode of crying. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention, and Monitoring, dated 3/2015, the P&P indicated, the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly.if the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood and function.During a review of the facility's policy and procedure (P&P) titled, Depression-Clinical Protocol, dated 9/2012, the P&P indicated, with consultative support as needed, the physician will order appropriate non-pharmacological and pharmacological interventions, based on the preceding assessments.the staff and physician will monitor the residents response to treatment for depression and will document approaches, timetables, and goals of treatment in the interdisciplinary care plan and progress notes.During a review of the facility's policy and procedure (P&P) titled, Behavioral Health Services, dated 2/2019, the P&P indicated, behavioral health services are provided to residents as needed as part of the interdisciplinary, person centered approach to care.residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care.During a review of the facility's policy and procedure (P&P) titled, Social Services, dated 9/2021, the P&P indicated, the director of social services is a qualified social worker and is responsible for b. providing for the social and emotional needs of the resident and family.the facility staff is able to identify and address factors that have potentially negative effect on psychosocial functioning of a resident, for example e. difficulty coping with change or loss, g. behavioral problems (confusion, anxiety, loneliness, depressed mood, anger, fear, wandering, psychotic episodes), i. bereavement or unresolved grief.During a review of the facility's Social Services Director Job Description, dated 12/2025, the document indicated provide medically related social services so that the highest practicable physical, mental and psychosocial wellbeing of each resident is attained or maintained.

Based on observation and interview, the facility failed to account for and periodically reconcile controlled drugs (medications or chemicals that the government tightly regulates because they carry a risk of being misused, causing addiction, or leading to dependence) when the facility was unable to provide documentation indicating periodic reconciliation of controlled drugs was being completed.This failure had the potential to result in controlled drug discrepancies and medication diversion (the illegal transfer, theft, or misuse of prescription medications from their intended path). During a concurrent observation and interview on 7/16/26 at 8:28 a.m. with the Director of Nursing (DON), in her office, the DON was observed with the Consultant Pharmacist (CP) actively destroying controlled medications. The DON stated controlled medications for destruction were kept in the DON's office in a locked container.During an interview on 7/16/26 at 8:45 a.m. with the DON, the DON stated there was no single process for periodically reconciling medications but rather many processes were in place such as keeping count in the narcotic book and verifying the count against the medication cards at the beginning of the shift and before the leave of shift to ensure the narcotic count was correct. The DON stated another process for verification of controlled drugs included if medications were needing to be refilled and pharmacy was unable to refill the medication because it was too soon to be refilled, that would raise concern and cause an investigation into those circumstances. The DON stated she did not have a process to reconcile controlled medications periodically. The DON acknowledged those processes were not adequate for periodic reconciliation and accounting of all controlled drugs and stated it was important to have a process to reconcile controlled medications periodically to help prevent diversion. During an interview on 7/16/26 at 8:47 a.m. with the CP, the CP stated she was aware of the State Operations Manual (SOM- is an official federal guidebook that provides rules, instructions, and policies for state inspectors to check if healthcare facilities follow safety and health laws) mandate to have a process in place to reconcile medications and the need for periodic review to reconcile narcotic (potent, often addictive drugs that dull senses, relieve severe pain, and induce sleep or stupor) medications. CP stated it was important to have a process in place to periodically reconcile narcotics and account for all controlled medications so that nurses could not divert the medications.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was eight percent. There were 25 opportunities for errors and two medication errors occurred for two of five sampled residents (Resident 6 and Resident 12) when:1. Licensed Vocational Nurse (LVN) 5 administered 8 units of Novolin R (a short-acting insulin used to decrease blood sugar) instead of the prescribed Humulin R (a short-acting insulin) to Resident 6.2. LVN 5 administered 8 units of Novolin R instead of the prescribed Humulin R to Resident 12.This failure resulted in two medication errors and had the potential to result in dosing mistakes from concentration differences, unexpected blood sugar fluctuations, and possible allergic reactions.1. During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/16/26, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition where the body cannot properly process sugar for energy, causing it to build up in the bloodstream) with diabetic neuropathy (prolonged, high blood sugar from diabetes has caused structural and functional damage to the body's nerves), urinary tract infection, cerebral infarction (stroke), hyperlipidemia (too much cholesterol and fats circulating in the blood).During a concurrent observation and interview on 7/15/26 at 10:53 a.m. with LVN 5, in Resident 6's room, LVN 5 was observed checking Resident 6's blood sugar. LVN 5 stated Resident 6's blood sugar was 291. LVN 5 administered 8 units (unit of measure) of Novolin R.During a review of the facility document titled, Resident: [Resident 6's name] Order Details, dated 12/22/25, the document indicated Resident 6 had current orders for Humulin R injection Solution 100 unit/ML (unit of measure) inject as per sliding scale(sliding scale provided- a personalized chart that tells the nursing staff how much short-acting insulin to inject) subcutaneously (under the skin) three times a day for type 2 diabetes mellitus Fingerstick Blood Sugar (FSBS) check with insulin sliding scale coverage at AC (before meals) and HS (at bedtime).During a review of the facility document titled, *PACS-MEDICATION ADMINISTRATION RECORD, dated July 2026 the document indicated, .HumuLIN R injection Solution 100 UNIT/ML.subcutaneously three times a day for Type 2 DIABETES MELLITUS [DM]. During a concurrent interview and record review on 7/15/26 at 1:32 p.m. with LVN 5, Resident 6's current insulin orders were reviewed. LVN 5 stated Resident 6's current insulin orders included Lantus 34 units one time at 9 p.m. and Humulin R TID (three times a day)-breakfast lunch dinner and HS (at bedtime). LVN 5 stated she had administered 8 units of Novolin R to Resident 6 LVN 5 stated Resident 6's insulin order did not match the insulin medication that she had, on hand. LVN 5 stated the insulin on hand and administered, should match the insulin order prescribed because if staff administered the wrong insulin, it could severely hurt somebody. 2. During a review of Resident 12's AR dated 7/16/26, the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, urinary tract infection, hyperlipidemia, chronic kidney disease (when the kidneys are damaged and slowly lose the ability to properly filter waste and extra fluid from the blood). During a concurrent observation and interview on 7/15/26 at 11:08 a.m. with LVN 5, in Resident 12's room, LVN 5 was observed checking Resident 12's blood sugar. LVN 5 stated Resident 12's blood sugar was 256. LVN 5 administered 8 units of Novolin R to Resident 12.During a review of the facility document titled, Resident: [Resident 12's name] Order Details, dated 6/17/21, the document indicated Resident 12 had current orders for Humulin R Solution inject as per sliding scale (sliding scale provided) subcutaneously before meals and at bedtime.During a review of the facility document titled, *PACS-MEDICATION ADMINISTRATION RECORD, dated July 2026 the document indicated, .HumuLIN R Solution (Insulin Regular Human).subcutaneously before meals and at bedtime for Type 2 DM.During a concurrent interview and record review on 7/15/26 at 1:40 p.m. with LVN 5, Resident 12's current insulin orders were reviewed. LVN 5 stated Resident 12's current insulin orders included Glargine (Lantus- a long-acting insulin) one time a day at 8:00 p.m.-15 units and Humulin R TID-breakfast, lunch, dinner and HS. LVN 5 stated she administered 8 units of Novolin R to Resident 12 and acknowledged Resident 12's current short acting insulin order did not match the insulin she had on hand. LVN 5 stated insulin on hand and administered should match the insulin order prescribed, because giving the wrong insulin could severely hurt someone. During an interview on 7/16/26 at 9:01 a.m. with the Director of Nursing (DON), the DON stated her expectations were that the insulin on hand and available at the facility for administration match the prescriber's orders. The DON stated nurses should have identified the medication error; the nurse receiving the medication should have verified the medication upon delivery and should not have accepted the insulin medication, and instead returned the drug to pharmacy. The DON stated it was the nurses' responsibility that prior to administering medications they completed checks that included verifying the right patient, the right medication, the right dosage etc. before administering that medication. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program for three of six sampled residents (Residents 3, 5 and 6) when: 1. Resident 5 ' s oxygen concentrator (a device that concentrates the oxygen from the ambient air) was being used without a filter. 2. Resident 3 and Resident 6 ' s oxygen concentrator filters were covered with dust and lint. These failures placed Residents 3, 5 and 6 at an increased risk to develop respiratory and healthcare-associated infections. Findings: 1. During a review of Resident 5's Admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/12/25, the AR indicated, Resident 5 was admitted from an acute care hospital on 4/27/25 to the facility, with diagnoses that included Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), and Generalized Muscle Weakness. During a review of Resident 5's Order Summary Report (OSR), dated 5/12/25, the OSR indicated, . Order Summary . Oxygen at 2 LPM (liters per minute- unit of measurement) via nasal cannula (a device used to deliver supplemental oxygen) . Order Date 4/27/25 . During a review of Resident 5's Nursing Care Plan (CP), dated 5/8/25, the CP indicated, . [Resident 5] has COPD . Interventions/Tasks . Give oxygen therapy as ordered by the physician . Date Initiated: 4/27/25 . During an observation on 5/12/25, at 11:58 a.m., inside Resident 5 ' s room. Resident 5 was lying in bed, asleep and had an oxygen cannula connected to an oxygen concentrator. The oxygen was being given at 2L/min continuously. The oxygen concentrator filter was operating without the filter installed on the left side of the machine. During a concurrent observation and interview, on 5/12/25, at 12:35 p.m., inside Resident 5 ' s room with the Infection Preventionist (IP), the IP looked at Resident 5 ' s oxygen concentrator and stated the oxygen concentrator was operating without a dust filter and it should. The IP stated, Resident 5 ' s respiratory condition could worsen. The IP, stated maintaining the cleanliness of oxygen concentrator was the responsibility of the licensed nurses. During an interview on 5/12/25, at 2:13 p.m., with the Director of Nursing (DON), the DON stated using an oxygen concentrator without a filter was not acceptable and could potentially cause residents to become ill. The DON stated the purpose of the oxygen concentrator was to improve resident's oxygen level. The DON stated she expects the oxygen concentrator to be inspected and cleaned twice a week, and as needed for the safety and well-being of all residents receiving oxygen. The DON stated residents using dirty oxygen concentrators could have respiratory infection such as Pneumonia (lung infection caused by bacteria) and Bronchitis (inflammation of the airways). During a review of the facility ' s document titled, Job Description: Licensed Practical Nurse/Licensed Vocational Nurse, dated 11/2018, the document indicated, . Drug Administration Functions . Prepare and administer medications as ordered by the physician . Nursing Care Functions . Review the resident ' s chart for specific treatments, medication orders . Safety and Sanitation . Ensure that your unit ' s resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner . Participate in the development, implementation, and maintenance of infection control program . During a review of the facility's Policy and Procedure (P&P), titled, Oxygen Administration, dated 10/2010, the P&P stated, . Preparation . 3. Assemble the equipment and supplies as needed . Steps in the Procedure . Check the mask, tank, humidifier, etc., to be sure they are in good working order and are securely fastened . During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 12/2018, the P&P indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2009, the manual indicated, . Routine Maintenance. Cleaning the Cabinet Filter. CAUTION. DO NOT operate the concentrator without the filter installed . 1. Remove each filter and clean at least once a week depending on environmental conditions . 2. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filters thoroughly before installation . 2. During a review of Resident 6's AR, dated 5/12/25, the AR indicated, Resident 6 was admitted from an acute care hospital on 2/20/25 to the facility, with diagnoses that included COPD, Generalized Muscle Weakness, Hypertension, and Cerebral Infarction (stroke). During a review of Resident 5's OSR, dated 5/12/25, the OSR indicated, . Order Summary . Oxygen at 2 LPM via nasal cannula continuously . Order Date 2/20/25 . During a review of Resident 5's CP, dated 2/21/25, the CP indicated, . [Resident 6] has Oxygen Therapy r/t [related to] COPD . Interventions/Tasks . Oxygen 2LPM via nasal cannula continuously every shift . Date Initiated: 2/21/25 . During a review of Resident 3's AR, dated 5/12/25, the AR indicated, Resident 3 was admitted from an acute care hospital on 4/16/25 to the facility, with diagnoses that included COPD, Generalized Muscle Weakness, Hyperlipidemia (high cholesterol) and Morbid Obesity (overweight). During a review of Resident 3's OSR, dated 5/12/25, the OSR indicated, . Order Summary . Oxygen 2 LPM via nasal cannula every shift for SOB [shortness of breath] . Order Date 4/16/25 . During a review of Resident 3's CP, dated 2/21/25, the CP indicated, . [Resident 3] has COPD . Interventions/Tasks . Give oxygen therapy as ordered by the physician . Date Initiated: 4/17/25 . During a concurrent observation and interview, on 5/12/25, at 12:37 p.m., inside Resident 3 and Resident 6 ' s rooms, with the IP. Resident 3 and Resident 6 were in bed and being given oxygen through nasal cannulas connected to the oxygen concentrator. The IP looked at Resident 3 and Resident 6 ' s oxygen concentrators and stated the oxygen concentrator filters were covered with dust and lint. The IP stated, using a dirty oxygen concentrator was not acceptable. The IP stated, Resident 3 and Resident 6 were not getting the full benefit of supplemental oxygen and their respiratory condition could worsen. The IP stated, residents receiving supplemental oxygen from oxygen concentrator with dirty filter could cause respiratory infections. The IP stated, the oxygen concentrator filters should be cleaned once a week and as needed. During an interview on 5/12/25, at 2:18 p.m., with the DON, the DON stated using a dirty oxygen concentrator was not acceptable and could potentially cause residents to become ill. The DON stated, the purpose of the oxygen concentrator was to improve resident's oxygen level. The DON stated, residents using a dirty oxygen concentrator could have respiratory infection. The DON stated, she expects the oxygen concentrator to be cleaned twice a week and as needed by the licensed nurses for the safety and well-being of all residents receiving oxygen. During a review of the facility ' s document titled, Job Description: Licensed Practical Nurse/Licensed Vocational Nurse, dated 11/2018, the document indicated, . Drug Administration Functions . Prepare and administer medications as ordered by the physician . Nursing Care Functions . Review the resident ' s chart for specific treatments, medication orders . Safety and Sanitation . Ensure that your unit ' s resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner . Participate in the development, implementation, and maintenance of infection control program . During a review of the facility's P&P titled, Oxygen Administration, dated 10/2010, the P&P stated, . Preparation . 3. Assemble the equipment and supplies as needed . Steps in the Procedure . Check the mask, tank, humidifier, etc., to be sure they are in good working order and are securely fastened . During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 12/2018, the P&P indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2009, the manual indicated, . Routine Maintenance. Cleaning the Cabinet Filter. CAUTION. DO NOT operate the concentrator without the filter installed . 1. Remove each filter and clean at least once a week depending on environmental conditions . 2. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filters thoroughly before installation .

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one of six sampled residents (Resident 4) when Resident 4 was administered 4.5 L/min (liters-unit of measurement)/min (minute) of oxygen via Nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 2L/min of oxygen per physician's order. This failure had the potential to put Resident 4 at risk to oxygen toxicity (a lung damage that happens from breathing too much supplemental oxygen; it can cause coughing and trouble breathing; in severe cases it can even cause death). Findings: During a Review of Resident 4's Admission Record, (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/12/25, the AR indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included Congestive Heart Failure (CHF- weakness in the heart where fluid accumulates in the lungs), Hypertension (high blood pressure), Dyspnea (shortness of breath, difficulty breathing), and Asthma (a chronic lung condition making it difficult to breathe). During a concurrent observation and interview on 5/12/25 at 12:30 p.m., with the Infection Preventionist (IP), inside Resident 4's room, Resident 4 was lying in her bed, sleeping and with supplemental oxygen via nasal cannula receiving 4.5L/min. IP stated, she needs to check the physician order to verify if Resident 4 was supposed to receive 4.5L/min of supplemental oxygen. During a concurrent interview and record review on 5/12/25 at 12:45 p.m. with the IP, Resident 4's Physician Order Summary (POS) was reviewed. The POS indicated , . Oxygen 2LPM (liters per minute) via Nasal Cannula Continuously . Order Date 4/23/25 . The IP stated, Resident 4 current oxygen setting was incorrect and could potentially cause harm if not corrected immediately. The IP stated, the higher flow of oxygen could have a negative effect on Resident 4's overall health. The IP stated, she expect the licensed nurses to routinely check the oxygen setting during medication pass and as needed, and it was not done. During a concurrent interview and record review on 5/12/25 at 2:04 p.m. with the Minimum Data Set Nurse (MDSN), Resident 4's Progress Note (PN) was reviewed. The MDSN stated, she was unable to find any documentation indicating Resident 4 ' s oxygen level dropped below 90% (percent- unit of measurement) and a physician ' s order to increase the oxygen delivery from 2LPM to 4.5LPM. The MDSN stated, Resident 4 could get hurt from receiving too much oxygen. During an interview on 5/12/25, at 2:13 p.m., with the Director of Nursing (DON), the DON stated oxygen was considered a medication and physician's order should be followed to prevent oxygen toxicity for Resident 4. During a review of the facility's policy and procedures (P&P) titled, Oxygen Administration, dated October 2010, the P&P indicated, .Verify that there is a physician's order .review the physician's orders or facility protocol for oxygen administration .after completing the oxygen setup or adjustment, the following information should be recorded .the rate of oxygen flow, route and rationale . During a review of the facility ' s document titled, Job Description: Licensed Practical Nurse/Licensed Vocational Nurse, dated 11/2018, the document indicated, . Drug Administration Functions . Prepare and administer medications as ordered by the physician . Nursing Care Functions . Review the resident ' s chart for specific treatments, medication orders .

Based on interview and record review, the facility failed to ensure residents receive necessary treatment and care in accordance with facility's policies and procedures and professional standards of practice for one of thirteen residents (Resident 12) when Resident 12 who had a known history of constipation, with infrequent bowel movements and refusing continence care for several days and nursing staff did not notify the doctor and implement interventions to prevent complications. This failure resulted in Resident 12 experiencing avoidable impaction of stool, life-threatening symptoms of altered mentals status and low blood pressure that required transfer to higher level of care to an acute care hospital where the emergency department (ED- is the part of the hospital where patients get treated for serious or sudden health problems) physician digitally removed 2.205 pounds of hardened stool. Resident 12 was treated for acute septic shock (is a severe, life-threatening form of sepsis characterized by dangerously low blood pressure and organ dysfunction due to an infection),admitted to the intensive care unit 3/6/25 and later the same day passed away. Findings: During a review of Resident 12's Admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 12 was admitted to the facility on [DATE] with diagnoses which included Parkinsonism (a brain disorder that makes it hard to control body movements), Adult Failure to Thrive (a medical condition characterized by a decline in physical and cognitive function, often including weight loss, decreased appetite, and a general lack of vigor), abnormalities of gait (a condition characterized by walking in an unusual or unsteady way), Osteoarthritis (is a condition when the cushion between the bones breaks down and the bones rub together and the joints hurts and become stiff) and constipation (fewer bowel movements (BM) or the stool is hard, dry and painful). During a review of Resident 12's Minimum Data Set (MDS- a standardized assessment tool used in nursing homes) assessment dated [DATE], The MDS Section GG (focuses on assessing a resident's functional abilities, particular in areas of self-care and, mobility) indicated Resident 12 was not capable of going to the toilet and was dependent with staff with activities of daily living (ADLs). The MDS Section H (focuses on Bladder and Bowel health- This section is crucial for assessing resident's continence status) indicated Resident 12 could not control her Bladder (the part of the body that holds urine) and Bowel (the part of the body responsible for storing and eliminating stool) and was not on an incontinent program (it's a plan to help residents go to he bathroom more regularly or with assistance). During a review of Resident 12's Brief Interview of Mental status assessment (BIMS - a test used in the nursing homes to check how well a resident is thinking and remembering things) dated 2/16/25, Resident 12's BIMS score was 13 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 12 was cognitively intact (thinking, memory, and understanding are normal). During a review of Resident 12's Progress Notes (PN), dated 3/6/25 the PN indicated, .upon med pass [medication administration] writer noted to be unresponsive and lethargic resident [Resident 12] unable to verbalize what was wrong writer obtained vitals [BP] 89/50, [HR] 60, [RR] 17, [Temperature] 97.3 writer notified [name of doctor] via phone new order to be sent out to [name of acute hospital] for further evaluation for AMS [altered mental status] orders noted and carried out care plan updated RP [Responsible Party] notified. During a review of Resident 12's Acute Care Hospital (ACH) document titled, ED [Emergency Department-is a part of the hospital where people go when they need urgent medical help] Physicians Notes (EDPN), dated 3/6/25, at 1:25 a.m. The EDPN indicated .patient is a 78 y.o. [year old] female . presents to the ED with altered mental status and Hypotension (Low Blood Pressure) . During the initial triage vital signs taken at the ED, resident was noted with a Blood Pressure (BP-how hard your blood is pushing inside your body when it moves through your veins and arteries) 62/50, Heart Rate (HR-how fast of slow the heart is beating) 139, Respirations Rate (RR-how fast you're breathing) 26, and Oxygen Saturation (how much oxygen your blood is carrying to your body) of 93% . During an evaluation by the ED physician, he noted resident had a high probability of imminent (likely to happen soon) or life-threatening deterioration due to the low B/P . CT (Computed tomography- medical device that takes picture of the inside of the body, like brain, lungs, or bones, so the doctor can see of anything is wrong) was performed and indicated the lung bases were poorly seen due to severe distention (swelling ) with abundant fecal material (stool) in the left colon (part of the large intestine) .a massive digital (using fingers) removal of feces [stool] procedure on this patient after giving 4 mg [milligrams-unit of measurement] morphine (a drug used to treat moderate to severe pain) IV [intravenous - when medicine or fluids are given through a needle or tube directly into a vein] .massive amounts of stool was coming up the vagina and out of the rectum[IL7] (It is where the body stores stool before a person is ready to have a bowel movement) .physician noted to have removed 1000 g (grams) (unit of measure) 2.205 pounds of hard rocky poop [stool] .Patient [Resident 12] is s/p [status post] fecal disimpaction (removing hard, stuck stool) 1 kg [kilogram- unit of measurement] [2.205 pounds] of fecal [stool] matter evacuated . While initially responsive to 1.5L [liters-unit of measurement] bolus (a quick large dose of medication or fluids directly into a vein through an IV) patient quickly decompensated (the body or an organ is no longer able to cope of function properly after trying to manage a problem for a while) . These findings suggest poor prognosis (low chances of recovery) . after speaking with patient's son, [name of son] and daughter, explaining the patient's current prognosis along with her status, family would like to change the patient's code status (tells healthcare worker what to do if a patient's heart stops or they stop breathing) to DNR/DNI [Do not Resuscitate -do not try to bring them back if a the heart stops beating or they stop breathing]/ [Do not intubate - if a person has trouble breathing, they don't wasn't a breathing tube] . on 3/6/25 at 12:55 p.m. resident passed away under comfort care (keeping a patient comfortable at end of life) .Cause of Death, Septic Shock and colitis[IL8] (inflammation of the colon) . During a concurrent interview and record review on 3/24 /25 at 11:40 a.m. with the Assistant Director of Nursing (ADON), Resident 12's Bowel Continence (BC), dated 2/2025 and 3/2025 was reviewed. The BC indicated, On 2/23/25 at 1:59 p.m. and 9:34 p.m. Resident 12 refused care. On 2/24/25 Resident 12 refused care. On 2/25/25 at 9:59 p.m. and 10:58 p.m. Resident 12 had no BM. On 2/26/25, 2/27/25, 2/28/25, 3/1/2025, 3/2/25 Resident 12 refused care. The ADON stated stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 3/3/25 at 5:20 a.m. Resident 12 had no BM, and at 1:52 p.m. and 9:59 p.m. Resident 12 refused care. The ADON stated stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 3/4/25 at 3:52 a.m. Resident12 had incontinence [urine and bowel], and at 1:51 p.m. and 9:59 p.m. Resident 12 refused care. The ADON stated stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. The ADON stated, they did not know how often or how much Resident 12 was having BM. The ADON stated they could not accurately track Resident 12's BM because she often refused brief changes. The ADON stated Resident 12 did not have regular BM that staff could track by shift or daily, which put Resident 12 at risk for constipation and impaction. The ADON stated the staff did not inform the doctor about Resident 12's repeated refusals or the lack of BM. The ADON stated Resident 12 was not put on a bowel protocol (a standardized guidelines designed to prevent and manage constipation and promote regular bowel movement). The ADON stated we did not know Resident 12 was constipated. The ADON stated constipation, and impaction could cause serious health problems, like confusion, low BP, and severe infection. The ADON stated these conditions were life-threatening and may lead to death. During a concurrent interview and record review on 4/21/25 at 12:05 p.m. with License Vocational Nurse (LVN) 2, Resident 12's Bowel Continence (BC), dated 2/2025 and 3/2025 was reviewed. The BC indicated: On 2/23/25 at 1:59 p.m. and 9:34 p.m. Resident 12 refused care. LVN 2 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 2/24/25 Resident 12 refused care. LVN 2 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 2/25/25 at 9:59 p.m. and 10:58 p.m. Resident 12 had no BM. LVN 2 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 2/26/25, 2/27/25, 2/28/25, 3/1/2025, 3/2/25 Resident 12 refused care. LVN 2 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 3/3/25 at 5:20 a.m. Resident 12 had no BM, and at 1:52 p.m. and 9:59 p.m. Resident 12 refused care. LVN 2 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 3/4/25 at 3:52 a.m. Resident12 had incontinence [urine and bowel], and at 1:51 p.m. and 9:59 p.m. Resident 12 refused care. LVN 2 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. LVN 2 stated Bowel Continence section was where the Certified Nursing Assistant would document Resident 12's bladder and bowel movement and incontinent care. LVN 2 stated she was the License Nurse assigned to care for Resident 12 on 2/28/24, 3/1/24, and 3/2/25. LVN 2 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. LVN 2 stated Resident 12 was on a stool softener medication that could be given as needed, she did not give it because she could not confirm if Resident 12 had a BM. LVN 2 stated Resident 12 was alert, knew what was going on, and could make her own decisions. LVN 2 stated they respect Resident 12's right to refused care. LVN 2 stated she tried three times to get Resident 12 to accept care, but the Resident 12 kept on refusing. LVN 2 stated she told the Physician, but she did not document that she has done so. LVN 2 stated she should have documented. LVN 2 stated it was important to notify the physician and document to keep Resident 12 safe. LVN 2 stated unfortunately, Resident 12 chose not to receive care and refused to be checked for a BM. LVN 2 stated the physician knew about Resident 12's refusal and did not give any new orders. During an interview on 4/21/25 at 1:50 p.m. with CNA 12, CNA 12 stated she was the CNA assigned to Resident 12 the day she was sent out to the hospital on 3/6/25. CNA 12 stated she checked on Resident 12 every two hours and encouraged her to accept care but Resident 12 still refused. CNA 12 stated it was difficult to know if Resident 12 had a bad BM because Resident 12 did not allow anyone to touch her. CNA 12 stated she told the nurse, and the nurse would talk to Resident 12, but Resident 12 still refused care. CNA 12 stated Resident 12 refused to be checked for toileting, hygiene, and bowel movement. CNA 12 stated no assessment was conducted to check if Resident 12 had bowel movements or is she had abdominal distention. During an interview on 4/21/25 at 2 p.m. with the Physician, the Physician stated Resident 12 was alert, aware, and able to make her own decision. The Physician stated Resident 12 refused care, and the license nurse did inform him and did not give any new orders. The Physician stated if a resident refuses care, there was nothing he could do. The Physician stated Resident 12 refused care and had the right to refuse essential care. The Physician stated forcing care could lead to a lawsuit for assault. The Physician stated there was no meeting held with Resident 12, family, and the facility to talk about Resident 12's goals of care. The Physician stated the facility did not arrange goals of care meeting because no one asked for one, and Resident 12 sometimes accepted care. The Physician stated it was hard to prevent the impaction because Resident 12 kept on refusing care. During a concurrent interview and record review on 4/21/25 at 2:15 p.m. with Certified Nursing Assistant (CNA) 10, Resident 12's Bowel Continence (BC), dated 2/2025 and 3/2025 was reviewed. The BC indicated: On 2/23/25 at 1:59 p.m. and 9:34 p.m. Resident 12 refused care. CNA 10 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 2/24/25 Resident 12 refused care. CNA 10 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 2/25/25 at 9:59 p.m. and 10:58 p.m. Resident 12 had no BM. CNA 10 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 2/26/25, 2/27/25, 2/28/25, 3/1/2025, 3/2/25 Resident 12 refused care. CNA 10 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 3/3/25 at 5:20 a.m. Resident 12 had no BM, and at 1:52 p.m. and 9:59 p.m. Resident 12 refused care. CNA 10 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. On 3/4/25 at 3:52 a.m. Resident12 had incontinence [urine and bowel], and at 1:51 p.m. and 9:59 p.m. Resident 12 refused care. CNA 10 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. CNA 10 stated she had worked at the facility for three years. CNA 10 stated she was assigned to care for Resident 12 on 2/28/25 and 3/1/25. CNA 10 stated on those days, Resident 12 refused to be checked for BM and refused to be changed. CNA 10 stated she told the nurse about Resident 12's refusal. CNA 10 stated the nurse spoke to Resident 12, but Resident 12 still refused. CNA 10 stated she did not know if Resident 12 had a BM on those dates because staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. During an interview on 4/21/25 at 2:30 p.m. with CNA 13, CNA 13 stated she had worked at the facility for [AGE] years. CNA 12 stated she was familiar with Resident 13. CNA 13 stated Resident 13 often refused diaper changes, getting dressed, and taking showers. CNA 13 stated Resident 13 had been like that since she was admitted to the facility. CNA 13 stated Resident 13 was alert and aware of what is going on. CNA 13 stated Resident 13 needed staff help with all her daily activities. CNA 13 stated nurses would talk to Resident 13, but she would still refuse care. CNA 13 stated it was hard to know if Resident 13 had a BM because she refused to be checked. CNA 13 stated it was the first time she heard Resident 13 had a stool impaction. During an interview on 4/23/25 on 3:13 p.m. with the Director of Nursing (DON), the DON stated she started working as the DON in February 2025. The DON stated she was aware of Resident 12's refusal with care. The DON stated Resident 12 was alert and oriented, and the facility respects her right to refuse essential care. The DON stated they tried to contact the family and have a meeting, but the family declined. The DON stated when residents refuse care, staff talk to them and explain the benefits of care. The DON stated they also notify the doctor about the resident's refusal. The DON stated she believes there was an Interdisciplinary Team Meeting (IDT- a group of healthcare professional from different disciplines who work together to plan and coordinate care for resident). The DON stated staff did not check if Resident 12 had bowel movements, abdominal distention and did not check her abdominal girth. During a review of the facility document titled, IDT CONFERENCE NOTES (ICN), dated 6/12/22, the ICN indicated, . Quarterly . List of risk factors . Impaired mobility, B&B [bladder and Bowel] incontinence, . impaired cognition . Activities . Refuses group participation and individual activities . present in today's CC [conference call] via phone DPOA [durable power of Attorney- a person who is legally chosen to make decisions on behalf of someone else, if the person becomes unable to make decisions on their own] [name] and [name]. Topics discuss or residence refusal of care and non-compliance with bathing, and refusals to get out of bed. [Name] stated his mother has always had a great hygiene and does not understand why such a change in behavior. [name] stated he had been estranged from resident for almost [AGE] years. [name] and [name] are new DPOA . SSD visits resident often to encourage her to allow staff to assist her with her ADL's and to bathing regularly . During a review of the facility's Policy and Procedure titled Refusal of Treatment dated, 05/2013, the P&P indicated, Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care . Policy Interpretation and Implementation The resident is not forced to accept any medical treatment and may refuse specific treatment even though is prescribed by a physician . Treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms . If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences .The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan . If the resident's refusal brings about a significant change, a reassessment will be made, and such information will be incorporated into the resident's care plan . Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record .Documentation pertaining to a resident's refusal of treatment shall include at least the following: a. The date and time the staff tried to give a medication or treatment was attempted. b. The medication or treatment refused. c. The resident's response and reason(s) for refusal; d. The name of the person attempting to administer the treatment; e. That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment; f. The resident's condition and any adverse effects due to such refusal; g. The date and time the physician was notified as well as the physician's response; h. All other pertinent observations; and i. The signature and title of the person recording the data . The Attending Physician must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the refusal . During a review of the professional reference titled The Refusing Resident: Risk Management Principles from https://www.caringfortheages.com/article/S1526-4114(17)30261-5/fulltext, dated 7/2017 the Professional reference indicated, The Right to Refuse. Residents in a SNF (Skilled Nursing Facility) have the right to consent to or to refuse any treatment or procedure, even to the detriment of their health. This right to refuse is juxtaposed (placing two or more things side by side, often to compare or contrast them and highlight their differences or similarities) with the facility's duty to help each resident attain or maintain the highest practicable physical, mental, and psychosocial well-being and to ensure that the resident's condition does not decline unless it is medically unavoidable . If the resident refuses specific treatments, the attending physician and facility staff should document all steps that were taken to address the resident's concerns and alternatives that were offered. The facility also needs to assess the resident for decision-making capacity. Once capacity is assessed, the facility is expected to determine and document what the resident is refusing, to assess the reasons for the resident's refusal, to advise the resident about the consequences of refusal, to offer pertinent alternative treatments, and to continue to provide all other appropriate services . It is generally the attending physician's determination as to whether a resident has decision-making capacity. In complex or ambiguous cases, a mental health professional (psychiatrist or psychologist) may be asked to weigh in . In the case of a refusing resident, the facility should not only document every incident of a refusal (or noncompliance/nonadherence), but also take the extra steps to conduct a timely interdisciplinary team (IDT) meeting; communicate with the attending physician and conduct a care conference with the family, documenting all the efforts made by the facility and the care team to try to render care; and encourage compliance and consider alternatives - in addition to explicitly stating the risks of continued refusals . Best Practices . Documentation is key when caring for a resident who is refusing treatment and that refusal leads to a deterioration in condition. The facility should document the following: The resident's capacity to make decisions. What the resident is refusing The reasons for refusal, if known. Advising the resident/responsible party about consequences of refusal. Offering pertinent alternative treatments. Continuing to provide all other appropriate services. Attention to documentation may not prevent a lawsuit, but it will provide the facility with the best defense possible, with the goal of minimizing the risk involved . During a review of the professional reference titled, Fecal Impaction, dated 7/2023, indicated, Fecal impaction occurs because of hardened fecal matter retained in the large bowel which cannot be evacuated by regular peristaltic activity. If this is not recognized and treated early, it can give rise to the formation of fecoliths, or stone-like feces. Fecal impaction is a cause for increased morbidity (the condition of suffering from a disease or medical condition) and a significant cause of a decrease in quality of life among the elderly. This activity reviews the causes, pathophysiology [is the study of how the disease starts] and presentation of fecal impaction and highlights the role of the interprofessional team in its management. Objectives: Review the causes of fecal impaction. Describe the evaluation of a patient with fecal impaction. Summarize the treatment options for fecal impaction. Explain modalities to improve care coordination among interprofessional team members in order to improve outcomes for patients affected by fecal impaction[IL36] . . Fecal impaction commonly occurs among elderly individuals, rarely presenting as an acute emergency to a hospital. Severe constipation is a significant problem that affects almost 70% of elderly people who are under care in nursing homes. Among those affected, about 7% will have the condition detected during a digital rectal examination. Fecal impaction is more common among older women who are in institutional care and have associated neuropsychiatric disorders. It is a cause for increased morbidity among the elderly, and if allowed to progress, this can lead to complications causing mortality (death) in the older age group . Physical examination findings often reveal a distended abdomen. In thinly built or emaciated individuals, hard fecal mass masses may be palpable along the colon. Occasionally, patients may also present with a spurious or overflow diarrhea. The diagnosis of fecal impaction is primarily based on clinical signs. A detailed history of bowel habits and a full physical examination which includes a digital rectal exam is mandatory . Prognosis Fecal impaction is a significant but preventable problem in the elderly population within hospitals and other institutions. The best way to treat it is to prevent it from developing in the first place. The cause of constipation should be identified early and managed appropriately. The patient should be educated about lifestyle measures and dietary habits to prevent fecal impaction. Unfortunately, recurrent fecal impaction is very common in elderly and institutionalized patients. Often these patients present to the emergency department because the presenting symptoms can mimic other sinister intestinal pathology . The key to successful management of fecal impaction is a preventive and active management strategy with early recognition of severe constipation and prompt intervention to prevent the occurrence of fecal impaction. This proactive approach will prevent morbidity as well as increase the quality of life among the elderly and hospitalized patients . During a review of the professional reference titled, Significant morbidity and mortality associated with fecal impaction in patients who present to the emergency department from https://pmc.ncbi.nlm.nih.gov/articles/PMC6499648/#:~:text=A%20systematic%20review%20of%20FI,of%20case%20reports%20(10) titled, dated 12/2018 indicated, .Fecal impaction (FI) is defined by a large mass of stool in the rectum and/or colon that is unable to be evacuated . FIs are most common in the elderly population and become more prevalent with increasing age (3,4). In 2011, there were over 42,000 emergency department (ED) visits for FI, with 85+ and 65-[AGE] year age groups having the highest and second highest visit rates, respectively, relative to all ED visits in each age group (5). FIs are particularly prevalent in the institutionalized [a person living in a structured setting] elderly . A high rate of mortality has been linked with FI, often due to the complications occurring in elderly and chronically ill patients (11). A systematic review of FI reported that death occurred secondary to FI complications in 29% of cases (10) . Treatment for FI includes use of digital disimpaction, enemas, suppositories, and oral laxative regimens (3,11). For at-risk or refractory patients, preventative strategies like use of stool softeners or reduction in use of constipating medications are known to reduce FI incidence (11) . [

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for two of six sampled residents (Residents 1 and 4) when: 1. Nursing staff were aware of Resident 1's cognitive impairment (difficulties with mental processes such as memory, attention, reasoning, and decision making), poor safety awareness, impulsive behaviors of getting up from bed without using the call light, history of falls, and did not implement effective interventions to prevent falls. These failures resulted in Resident 1 suffering avoidable falls on the following dates: 9/30/24, 11/5/24, 12/9/24, 12/16/24, 12/18/24, and 2/1/25. and placed the resident at risk for injury, pain. and suffering. These failures resulted in Resident 1's experiencing five unwitnessed falls prior to the avoidable fall on 2/1/25 with injury, sustaining a (laceration (cut in the skin caused by an injury) above the left eyebrow requiring transportation to the emergency department (ED) for sutures (a row of stitches holding together edges of a wound) and avoidable pain and suffering. Resident 1 had two additional avoidable falls. Resident 1 had a unwitnessed fall in his room on 3/11/25 sustaining a laceration to the forehead which required transportation to the emergency department for evaluation and a additional fall in his room on 3/12/25 opening the same area to his forehead and required transportation back to the emergency department for repair. Resident 1 was diagnosed with a subdural hematoma (pool of blood between the brain and its outermost covering) measuring up to 11 mm (millimeters) (unit of measure) in thickness. Resident 1 passed away on 3/17/25 at ACH from his injuries related to the fall on 3/12/25. 2. Resident 4 was assessed as being a fall risk, had poor safety awareness, impulsive behaviors of standing while unattended and multiple falls and the facility did not implement effective interventions to prevent falls, including adequate supervision consistent with the resident's needs, goals and care. This failure resulted in Resident 4 falling eight times in 30 days, placing him at risk for significant injuries and/or death. Findings: 1. During an observation on 2/13/25 at 8:15 a.m., in Resident 1's room, Resident 1 was lying in bed with eyes closed. Resident 1 had a sutured laceration above his left eye. Resident 1's bed was in low position, fall mat on the floor next to bed on left side, no fall mat on right side. Call light within reach. No staff present in the room. During a review of Resident 1's Admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia[CE2] (a group of symptoms that affect memory, thinking, and social abilities), abnormalities of gait and mobility, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 10 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1's cognition was moderately impaired. During a review of the Acute Care Hospital (ACH) document titled, Emergency Department Report, dated 2/1/25, the note indicated . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after fall. Per skilled nursing facility, patient had an unwitnessed ground level fall in his room between his bed and bathroom door .3-centimeter (unit of measure) (cm) linear (straight line) wound located on the face . Left eyebrow laceration was repaired . follow up for wound check and suture removal . During an interview on 2/13/25 at 9:35 a.m. with Certified Nurse Assistant, (CNA) 1 CNA 1 stated she had provided care for Resident 1 before and was familiar with him. CNA 1 stated Resident 1 was a high fall risk because he would get out of bed and stand without assistance. CNA 1 stated attempts to redirect Resident 1 or remind him to use the call light were not successful because the resident was disoriented and did not remember. CNA 1 stated, Resident 1 does not use his call light when getting out of bed and was not safe to get out of bed by himself. CNA 1 stated, Resident 1 was unsteady on his feet and needed supervision when standing. During an interview on 2/13/25 at 9:50 a.m. with CNA 2, CNA 2 stated she knew Resident 1 and had provided care for him before. CNA 2 stated, Resident 1 would wake up and try to get up out of bed without using the call light to ask for help. CNA 2 stated, Resident 1 was unsteady on his feet and needed supervision when walking. During an interview on 2/13/25 at 10 a.m., with Licensed Vocational Nurse (LVN), LVN stated, Resident 1 was confused and a high risk for falls. LVN stated, Resident 1 does not follow commands and would try to get out of bed without help all the time. LVN stated, Resident 1 would get out of bed without using his call light, stands and tries to walk without supervision or assistance. LVN stated, Resident 1 did not have supervision on 2/1/25 when he got out of bed and fell in his room. LVN stated, Resident 1 needs supervision and continuous monitoring for his safety and was not provided. During an interview on 2/13/25 at 10:20 a.m., with CNA 3, CNA 3 stated, she had provided care to Resident 1 before and was familiar with him. CNA 3 stated, Resident 1 did not use his call light to ask for help. CNA 3 stated, Resident 1 was wobbly and unsteady when standing up. CNA 3 stated Resident 1 was not safe to get out of bed on his own and needed supervision because he was unsteady on his feet. CNA 3 stated, Resident 1 was impulsive and needed one-on-one monitoring (refers to providing residents, focused attention and monitoring, ensuring their safety and wellbeing) to keep him safe and prevent falls. CNA 3 stated one-on one supervision was not provided. During a concurrent interview and record review on 2/13/25 at 10:40 a.m., with Minimum Data Set Coordinator (MDSC), Resident 1's Minimum Data Set (MDS- a standardized assessment tool used for all residents in a skilled in nursing home) dated 2/5/25 was reviewed. The MDS Section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool that identifies cognitive impairment levels (0-7 Severe cognitive impairment, 8-12 Mild cognitive impairment and 13-15 Cognitive intact) score of 10, indicating Resident 1 had moderate cognitive impairment. The MDSC stated, Resident 1 would not remember to use the call light to ask for help. The MDSC stated, Resident 1 needed supervision when getting out of bed and when moving from sitting to standing. The MDSC stated, she knew Resident 1 fell in his room while getting out of bed and walking, and that no supervision was provided at the time of the fall on 2/1/25. The MDSC stated, Resident 1 needed supervision due to his cognitive impairment, impulsive behavior, and mobility issues. Resident 1 MDS Section GG (GG-focuses on residents' functional abilities), was reviewed. The MDS section GG indicated Resident 1 needed supervision for getting out of bed, standing, and walking. The MDSC stated, Resident 1's fall on 2/1/25 which resulted to a wound on his face and left eyebrow laceration which required a sutured could have been prevented had he been supervised when getting out of bed, moving from a sitting position to standing, and walking. The MDSC stated, it was the facility's responsibility to keep residents safe from falls resulting in injuries. The MSDC stated, Resident 1 was known to be impulsive, cognitively impaired, and had poor safety awareness. During an interview on 2/13/25 at 11:15 a.m. with CNA 4, CNA 4 stated, he was the CNA assigned to Resident 1 on 2/1/25. CNA 4 stated, Resident 1 was unsteady on his feet, impulsive, cognitively impaired, and had poor safety awareness. CNA 4 stated, Resident 1 would stand up and starts walking without asking for help. CNA 4 stated Resident 1 was wobbly and unstable when walking and was not safe on his own. CNA 4 stated Resident 1 does not recognize the risk of getting out of bed without help. Resident CNA 4 stated, he would walk by Resident 1's room and see him getting out of bed on his own, so he had to quickly enter the room to stop Resident 1 from falling. CNA 4 stated Resident 1 was a high fall risk and does not use his call light. CNA 4 stated, he had reminded Resident 1 to use his call light, but Resident 1 would still stand up and walk without assistance. During a concurrent interview and record review on 2/13/25 at 11:30 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Medical Records (MR) was reviewed. The MR indicated Resident 1 had a fall on 2/1/25 in his room and suffered a laceration to his left brow with bleeding and bruising. The ADON stated, she knew Resident 1 was impulsive, cognitively impaired, and had poor safety awareness. The ADON stated Resident 1's fall on 2/1/25 could have been prevented if a one-on-one monitoring intervention had been put in place to keep him safe from falls. During an interview on 2/13/25 at 12 p.m. with Administrator (ADM), the ADM stated, we need to have the correct interventions in place to keep residents safe. The ADM stated it was our responsibility to keep residents safe. The ADM stated, we did not do enough fall interventions to keep Resident 1 safe from harm. During a concurrent interview and record review on 3/11/25 at 8:30 a.m. with the ADON, Resident 1's falls since 9/25/24 were reviewed. The falls were as follows: 9/30/24 at 12 a.m. Found on the floor next to bed 11/05/24 at 7:04 p.m. Found on the floor next to bed 12/09/24 at 4:00 p.m. Found on the floor next to bed 12/16/24 at 10:00 p.m. Found on the floor next to bed 12/18/24 at 9:09 a.m. Found on the floor next to bed 2/1/25 at 4:12 p.m. Found on the floor next to bed ADON stated, Resident 1's falls occurred while Resident 1 was in his room. ADON reviewed Resident 1's care plan dated 2/10/25, the care plan indicated, . resident is (high) risk for falls with injury r/t [related to] unsteady gait, poor balance . history of falls, poor safety awareness d/t [due to] DX [diagnosis] Dementia (a group of symptoms characterized by a decline in memory, thinking, and social abilities), hx [history of] multiple falls, non-compliance, impulsive behaviors . Interventions . Toileting scheduled . Anticipate and meet needs . Keep call light within reach . Educate remind resident to call for assistance with all transfers .encourage room change closer to the nurses station . Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility .Falling Star Program [a program in nursing homes uses a visual cue, like a falling star graphic on resident's door, to flag high-risk fall residents] .Keep personal items frequently used within reach .Landing mat to left side of bed . IDT [Interdisciplinary Team- a group of healthcare professionals who collaborate to provide comprehensive, individualized care for residents] Recommends . Non-skid strips to left side of bed .Bowel and Bladder Program (a structured plan designed to help individual manage their bowel and bladder functions) every 2 hours .Room change closer to nurses station .Fall mats to both sides of bed .Falling Star Program .Educate remind resident to call for assistance with all transfers . The ADON stated Resident 1's falls occurred while he was in his room and the interventions of keeping call light within reach, and encouraging to use would not address the cause of the falls, which occurred when he was unsupervised in his room. During a concurrent observation and interview on 3/24/25 at 9:30 a.m. with LVN 2 in the hallway by Resident 1's room, the name tag listing name of residents in the room by the doorway was missing a name for Resident 1. LVN 2 stated, Resident 1 had a fall on 3/11/25 and 3/12/25. LVN stated, Resident 1 was sent to ACH on 3/12/25 and had not returned. During a telephone interview on 3/26/25 at 11:08 a.m. with CNA 5, CNA 5 stated, she was assigned to Resident 1on 3/12/25 at the time of his fall. CNA 5 stated, Resident 1 was confused and would get out of bed by himself to go to the bathroom. CNA 5 stated, we tried to keep an eye on him when passing by his room. CNA 5 stated, she walked by his room and saw Resident 1 lying on the floor at the foot of his bed and partially in the open bathroom door. CNA 5 stated, she did not witness the fall and found him on the floor. CNA 5 stated she ran into his room and saw a small puddle of blood by his head. CNA 5 stated, Resident 1 was groaning while on the floor. CNA 5 stated, Resident 1 was bleeding from his forehead and blood was running down his face when CNA 5 and LVN assisted him to a sitting position on the side of his bed. CNA 5 stated, staff member came into the room to assist her in changing Resident 1's shirt and jacket due to blood on his clothing. CNA 5 stated, she stayed with Resident 1 and assisted him back into bed. CNA 1 stated, Resident 1 vomited and she alerted the LVN. CNA 5 stated, she was not in the room at the time of the fall providing care to other residents in the room. During a telephone interview on 3/27 /25 at 10:27 a.m. with ADON, ADON stated, Resident 1 had an unwitnessed fall on 3/11/25 at 7:24 p.m. in his room. ADON stated, Resident 1 was found on the floor by his bed. ADON stated, Resident 1 was bleeding from his forehead and was sent to ACH. ADON stated, Resident 1 returned from ACH on 3/12/25 at 1:22 a.m. During a telephone interview on 3/27/25 at 1:00 p.m. with ADON, ADON stated, Resident 1 had a fall in his room on 3/12/25 at 7:03 p.m. ADON stated, Resident 1 was found lying on the floor and assisted back to bed by staff. ADON stated, Resident 1 was sent to ACH on 3/12/25 and has not returned. ADON stated, Resident 1 was taking [name of medication] to thin his blood which could cause excessive bleeding with any injuries from a fall. ADON stated, Resident 1 was a high fall risk due to the history of his falls and had the potential for life threatening outcomes. During a record review of the Resident 1's falls since 9/25/24 were reviewed. The falls were as follows: 9/30/24 at 12 a.m. Found on the floor next to bed 11/05/24 at 7:04 p.m. Found on the floor next to bed 12/09/24 at 4:00 p.m. Found on the floor next to bed 12/16/24 at 10:00 p.m. Found on the floor next to bed 12/18/24 at 9:09 a.m. Found on the floor next to bed 2/1/25 at 4:12 p.m. Found on the floor next to bed 3/11/25 at 7:24 p.m. Found on floor next to bed 3/12/25 at 7:03 p.m. Found on floor next to bed During a review of the Acute Care Hospital (ACH) document titled, ED Physicians Notes, dated 3/11/25, at 9:08 p.m. the note indicated ( . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after a fall out of bed and hit his forehead .2 cm (centimeter) (unit of measure) mid forehead superficial (occurring on the skin or immediately beneath it) abrasion (a area damaged by scrapping) .Diagnosis, Mechanical Fall, forehead abrasion, severe dementia . During a review of the Acute Care Hospital (ACH) document titled, ED Physicians Notes, dated 3/12/25, at 8:10 p.m. the note indicated ( . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after a fall out of bed and hit his forehead .CT scan of head was performed indicating Intracranial hemorrhage (life threatening medical emergency when blood leaks inside or between the brain and skull) of left frontal , subdural hematoma ( pool of blood between the brain and its outermost covering) measuring up to 11 mm (millimeters) (unit of measure) in thickness and small volume left parietal subarachnoid hemorrhage (a type of stroke where bleeding occurs in the space between the brain and the tissues covering it) . Patient presents after a fall with head trauma while on blood thinner medication placing him at high risk for intracranial hemorrhage .Intensive Care Unit (ICU) physician was consulted, who requested to transfer the patient to neuro [neurological] ICU .[Name of ACH] [Name of Neurosurgeon] was consulted who then spoke to family in regards to potential management for this patient .Eventually family decided that they do not want to pursue any neurological intervention and did not want him transferred to another facility .Prefer that the patient stays here at this hospital .Resident 1 passed away on 3/17/25 . During a record review of the Death Certificate for Resident 1, indicated . Cause of Death as Cardiopulmonary Arrest (Cardiac arrest-sudden loss of heart function) and Subdural Hematoma w/loc (loss of consciousness-unresponsive to stimuli) status . During a review of the facility's Policy and Procedure titled Falls and Fall Risk Managing, dated 3/2018, the P&P indicated, .Based on previous evaluations and current data, staff may identify interventions related to the resident's specific risks and causes in the attempt to reduce falls and minimize complications from falling .Resident centered fall prevention plans should be reviewed and revised as appropriate .If the resident continues to fall, the situation should be reevaluated to determine whether it would be appropriate to continue or change current interventions. During a review of the facility's P&P titled Safety and Supervision of Residents, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible . Safety risks and environmental hazards are identified on an ongoing basis . When accident hazards are identified, the QAPI [Quality Assurance and Performance Improvement- is a data driven, proactive approach to improve the quality of care in nursing homes]/safety committee shall evaluate and analyze the cause(s) . Employees shall be trained on potential accident hazards and demonstrate competency . and try to prevent avoidable accidents . Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . ` During a review of the facility's P&P titled Fall Prevention Program/Falling Star, updated 2/3/25, the P & P indicated .Staff to assist resident to the bathroom before meals, after meals, at bedtime and as needed .Resident not to be left alone in room while out of bed . During a review of a professional reference located at https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess2.html titled Module 3: Falls Prevention and Management, dated 10/2014, the reference indicated, . An important job for licensed nurses is to assess residents' risk of falling. This is best done using a protocol or instrument that asks the licensed nurse to look at or test several features about the residents . Implement an individualized care plan . nursing should add an individualized approach for falls to the resident's care plan . An individualized care plan for falls is not a one-time solution. Licensed nurses and other staff must revisit the plan to make sure it is effective in preventing additional falls and injuries from falls . 42123 2. During a review of Resident 4's Admission Record, undated, the admission record indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses which included fracture (break in bone) of the skull, muscle weakness, abnormalities of gait (pattern of walking) and mobility (ability to move freely), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), cognitive (relating to the mental process involved in knowing, learning, and understanding) communication deficit (communication difficulty caused by cognitive impairment), cerebral infarction (condition where blood flow to the brain is blocked, causing brain tissue damage), nontraumatic intracerebral hemorrhage (bleeding occurs within the brain tissue), traumatic subdural hemorrhage (collection of blood between the brain and inner layer of skull) and traumatic subarachnoid hemorrhage (type of stroke) with loss of consciousness (state of being awake). During a review of Residents 4's MDS assessment dated [DATE], indicated Resident 4's BIMS scored 09 of 15. The BIMS assessment indicated Resident 4's cognition was moderately impaired. During an interview on 4/3/25 at 2:56 p.m. with CNA 6, CNA 6 stated she was familiar with Resident 4 and had taken care of him prior to his discharge. CNA 6 stated Resident 4 was very confused, difficult to communicate with and impulsive. CNA 6 stated Resident 4 was very weak and unable to stand safely by himself but had behaviors of standing up suddenly and falling. CNA 6 stated Resident 4 was very confused and did not realize how weak he was and that it was not safe for him to stand on his own. CNA 6 stated at Resident 4 was on every 15-minute checks but still had falls. CNA 6 stated Resident 4 would have required one on one (1:1) supervision (constant staff supervision) to prevent him from falling. During a concurrent interview and record review on 4/3/25 at 3:29 p.m. with LVN 2 Resident 4's falls were reviewed. The falls were as follows: 1/19/25-Resident fell trying to get off bed 1/23/25-Resident fell getting out of wheelchair 1/28/25-8:45 a.m. Resident found on floor 1/28/25-3:17 p.m. Resident found on floor 2/2/25-Resident on floor, dragging self out of room asking staff to put him into wheelchair 2/4/25-Resident fell getting up from wheelchair across from nurses' station 2/10/25-Resident fell in dining room 2/14/25-Resident fell across from nurses' station LVN 2 stated Resident 4 was at high risk for falls because he had non-compliant behaviors, was constantly trying to get up unsupervised, had weak legs and poor balance. LVN 2 stated Resident 4's primary language was not English which caused some communication issues. LVN 2 stated she thought he could understand the reminders to call for help but could not retain it due to cognition. LVN 2 stated Resident 4 was stubborn and would continue to do what he wanted to do even if it was not safe. LVN 2 stated Resident 4 was never placed on 1:1 supervision, and the only way to prevent falls would have been for staff to always stay with the resident. LVN 2 stated she would keep the resident close to the nurse's station when she was sitting there, and he did not fall when she had him under constant supervision because she could redirect him quickly. Resident 4's fall risk scores (0-8 low risk, 9-15 moderate risk, 16-42 high risk) were reviewed. Resident 4's fall risk scores were reviewed as follows: 1/17/25 score 10, moderate risk for falls 1/23/25 score 14, moderate risk for falls 1/28/25 score 22, high risk for falls 1/28/25 score 20, high risk for falls 2/4/25 score 20, high risk for falls 2/10/25 score 20, high risk for falls 2/14/25 score 22, high risk for falls LVN 2 stated Resident 4 was a moderate risk for falls when he was admitted but his fall risk increased as he continued to have falls. Resident 4's care plans were reviewed, LVN 2 stated she was unable to locate any fall risk care plan interventions before his first fall on 1/19/25. LVN 2 stated there were no fall prevention interventions in the care plan until his fall on 2/4/25. LVN 2 stated Resident 4 was on hourly checks, but it was not documented on the care plan and should have been. LVN 2 stated care plans were important because they direct the resident's care. LVN 2 stated care plans were used to involve the residents in their care, indicate what interventions are needed to meet their needs, included details about the resident's life including the treatments provided and physician ordered interventions. During a telephone interview on 4/4/25 at 7:50 a.m., with Family Member (FM) 2, FM 2 stated he was Resident 4's responsible party. FM 2 stated Resident 4 had frequent falls while at the facility and he did not feel like the facility did enough to prevent the resident's falls. FM 2 stated Resident 4 was agitated which caused him to stand up frequently and then he would fall, but he did not feel like the facility addressed the issue and the resident kept falling. During a review of Resident 4's Nurse's Note, dated 1/19/25, the note indicated, . At around 0120 [1:20 a.m.], writer was sitting at nurses station charting . notified by resident roommate, that roommate had fell trying to get off bed . Upon entering the room, the resident was found on the floor on right side of his bed, facedown with head facility the head of the bed . resident stated was trying to go to the restroom. Resident stated to have a headache . During a review of Resident 4's Interdisciplinary Team (IDT-Interdisciplinary Team- involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident) note dated 1/29/25 at 10:21 a.m., the IDT note indicated, . IDT met on 01/20/25 to discuss resident's fall on 01/19/25 . IDT intervention: Resident added to B&B program X4 hours . During a review of Resident 4's SBAR, dated 1/23/25, the SBAR indicated, . change in condition, symptoms, or signs observed and evaluated is/are: Falls . 01/23/25 . During a review of Resident 4's Alert Charting, dated 1/23/25 at 9:10 p.m., the note indicated, . Approximately 2110 [9:10 p.m.] . notified by staff member, resident fell trying to get out of wheelchair . resident was found on the floor on left side, face down . resident stated was trying to get to bed . During a review of Resident 4's IDT Note, dated 1/24/25, the note indicated, . IDT met to discuss resident's fall on 01/23/25 . IDT intervention: Non-skid material to wheelchair & Resident will be added to falling star program. Resident's last fall was 01/19/2025 . During a review of Resident 4's SBAR, dated 1/28/25 at 8:50 a.m., the SBAR indicated, . writer was called into resident room by residents roommate. Upon entering room, resident found on the floor on his bottom, his head against roommates' foot board . During a review of Resident 4's Nurses Notes, dated 1/28/25 at 3:25 p.m., the note indicated, . called into resident room by CNA and activity director stating that resident was on floor kneeling with back to bed and him facing the table. Writer went to go observe and noted resident was on floor on both knees with back to bed and him facing the table. Resident wheelchair was next to him . During a review of Resident 4's Nurse's Note, dated 2/4/25 at 2:00 p.m., the note indicated, . resident sitting across from nurses station, resident [resident] stood up and was very unsteady and week [weak] . This writer attempted to reach resident to sit him back in wheelchair and resident fell on to floor, fall witnessed and resident assisted back onto his feet and placed back in wheelchair . During a review of Resident 4's IDT Note, dated 2/5/25 at 9:54 a.m., the note indicated, . IDT met to discuss resident's fall on 02/04/2025 . IDT intervention: Resident placed on 1 hour checks. SSD [Social Services Director] scheduled a care conference for 02/14/2025 to discuss POC [plan of care] with family . During a review of Resident 4's Nurse's Note, dated 2/10/25 at 7:50 a.m., the note indicated, . On 2/10/25 at approx. [approximately] 0655 [6:55 a.m.] CNA called writer to dining room due to resident having unwitnessed fall. Upon entering dining room resident noted to be laying on floor on his bottom his wheelchair behind him . Resident was noted with no socks . During a review of Resident 4's IDT Note, dated 2/11/25 at 9:36 a.m., the note indicated, . IDT met to discuss [discuss] resident's fall on 02/10/2025 . IDT recommendations: Sensory pad to bed & wheel chair. Nursing to obtain consent . During a review of Resident 4's SBAR, dated 2/14/25, the SBAR indicated, . change in condition . Falls . 02/14/2025 . Writer approaching nurses station and CNA states resident had fallen. Resident noted to be sitting in wheelchair. CNA x2 had assisted resident back to chair without waiting for writer to asses resident . Resident continued to stand up being non compliant . Resident unable to give description . During a review of Resident 4's IDT note, dated 2/17/25 at 4:47 p.m., the IDT note indicated, . IDT met to discuss resident's fall on 02/14/2025 . Resident is currently out at acute care hospital. Upon his readmission resident will be placed on Q2 [every two] hour checks . During a concurrent interview and record review on 4/4/25 at 9:12 a.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 4 was a resident at the facility for one month. The ADON stated, he had a few falls. I'm not sure how many. Resident 4's fall risk care plan was reviewed. The care plan indicated, . Resident is at risk for falls with or without injury . unwitnessed fall on 1-19-25 . witnessed fall on 1-23-25 . witnessed fall 2/4/25 . Unwitnessed fall 2/10/25 . Unwitnessed fall 2/14/25 . Date initiated 1/17/2025 . Will minimize risk for falls to extent possible . Date initiated: 2/4/25 . Add sensor pad [a device used to monitor patients to ensure they do not rise from the bed or chair on their own to reduce falls] to bed and wheelchair . Date initiated: 2/04/25 . Add to B&B [bowel and bladder program-scheduled toileting] Q [every] 2 hours . Anticipate and meet needs . falling star program . Keep bed in low position with brakes locked . Keep call light within reach . Keep personal items frequently used within reach . Non skid material [flexible material used to prevent slipping] to w/c [wheelchair] . The ADON stated she was unable to find a fall risk care plan with interventions before 2/4/25. The ADON stated care plans were used to provide person-centered care for each resident and should have measurable objectives and the interventions reflecting the residents abilities to perform ADLs and transfers. The ADON stated the cause of Resident 4's falls was his need to get up. The ADON stated the facility did not place Resident 4 on 1:1 supervision, but he was placed on every hour checks. The ADON stated Resident 4 did continue to have falls while on every hour supervision. The ADON stated Resident 4 should not have stood up without staff assistance because he needed supervision for safety. Resident 4's Nurse's Note, dated 2/2/25 at 7:57 p.m. was reviewed. The note indicated, . Upon shift change, resident on the floor on his bottom dragging himself out of room asking staff to put him in his wheelchair . staff transferred resident from floor to w/c. Resident noncompliant with use of call light, and wheelchair . The ADON stated the note did not specify the resident fell and she was unsure what dragging himself out of room referred to. Resident 4's SBAR, dated 2/2/25 was reviewed and indicated, . lump to left forehead, No changes observed . This started on 2/2/25 . during staff PM report, staff member came to writer and notified resident noted to have lump to his forehead . Resident was asked what happened and resident denies falling or hitting self . The ADON stated she was unable to clarify the note and whether Resident 4 fell on [DATE], because the nurse no longer worked at the facility. The facility's P&P titled Falls and Fall Risk, [NAME] [TRUNCATED]

Based on interview and record review the facility failed to ensure residents who were hospitalized were permitted to return to the skilled nursing facility (SNF-a healthcare facility that provides a higher level of care that what is typically offered in assisted living or residential care) for one of seven residents (Resident 5) when the facility refused to take Resident 5 back after Resident 5 was medically cleared (when a patient no longer needs to receive inpatient care) to return to the facility from the acute care hospital (ACH-is a healthcare facility that provides short-term, intensive treatment for patients with serious medical conditions). This failure placed Resident 5 at risk for psychosocial harm by not allowing the resident to return to the SNF and caused her to be transferred to a different SNF. This caused her emotional stress and repeated request to come back to the facility. Findings: During a review of Resident 5's admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 5 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing food and or liquids) Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing) Major Depressive disorder, (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormalities of gait and mobility, During a review of Residents 5's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 5's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 5 was cognitively intact. During a telephone interview on 3/10/25 at 1:45 p.m. with the family member (FM), the FM stated, she was involved in Resident 5's care. The FM stated Resident 5 had been at a Skilled Nursing Facility (SNF) since 5/13/24. The FM stated, Resident 5 returned home and was admitted to SNF again on 10/23/24. The FM stated, Resident 5 was transferred to ACH on 1/30/25 from the SNF. The FM stated, she received a phone call from an ACH staff, who informed her the SNF said there were no female beds available for Resident 5 to return. The FM stated, Resident 5 was alert and oriented and able to express her needs. The FM stated, Resident 5 was very upset and crying because she wanted to return to the facility. FM stated, on 2/28/25 Resident 5 was discharged from acute care to a SNF in another city. During an interview on 3/11/25 at 9:50 a.m., with Admissions Director (AD), the AD stated, she was responsible for all documents related to new admissions and readmission. The AD stated, Resident 5 was admitted to the facility on [DATE] from ACH. The AD stated Resident 5 was sent to ACH on 1/30/25, and a bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) was put in place from 1/30/25 -2/6/25. The AD stated, she received a call from ACH on 2/18/25, informing her Resident 5 was ready to return back to SNF with orders for radiation treatments. The AD stated, the facility does not accept residents with radiation or chemotherapy (cancer treatment that uses drugs to kill or slow growth of cancer cells) treatment orders because the facility would be responsible to pay for the treatment. During an interview on 3/11/25 at 11:45 a.m., with the AD, the AD stated on 2/20 /25 at 9:35 a.m. she received notification from ACH Resident 5 was ready to be discharge back to the facility. The AD stated, she spoke with a Licensed Nurse (LN) about the admission and the resident care needs. The LN told her the facility would not be able to provide the care Resident 5 needed. During a concurrent interview and record review on 3/11/25 at 12:10 p.m., with Business Office Manager (BOM) the document titled Name of Facility dated 2/20/25 was reviewed. The BOM stated, the documents were the daily census, which show the availability of open beds in the facility. The BOM provided documents for 2/20/25-2/27/25 which indicated the following: 02/20/25- three female bed available 02/21/25- three female bed available 02/22/25 -three female beds available 02/23/25-two female beds available 02/24/25- two female beds available 02/25/25-no female beds available 02/26/25- one female bed available 02/27/25-no female beds available During an interview on 3/11/25 at 12:30 p.m. with Administrator (ADM), the ADM stated, he was contacted by staff at ACH on 2/20/25 at 5:21, to inform him Resident 5 was ready to return back to the facility. The ADM stated, the facility had female beds available on 2/20/25. The ADM stated, he was not aware of the regulations that gives a long-term care resident the right to return to the facility when a bed is available. The ADM stated, the daily census document showed three female beds available on 2/20/25. The ADM refused to continue the interview or answer questions. During a review of the facility's Policy and Procedure titled Bed-Holds and Return, dated 10/2022, the P&P indicated, .Residents and /or representatives are informed (in writing) of the facility and state (if applicable bed-hold policies) All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave) The requirements that residents be permitted to return to the facility applies to all residents regardless of payer source .Residents who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to their previous room .Residents who seek to return to the facility after the state bed-hold period has expired ( or when state law does not provide for bed holds) are allowed to return to their previous room if available or immediately to the first available bed . Based on interview and record review the facility failed to ensure residents who were hospitalized were permitted to return to the skilled nursing facility (SNF-a healthcare facility that provides a higher level of care that what is typically offered in assisted living or residential care) for one of seven residents (Resident 5) when the facility refused to take Resident 5 back after Resident 5 was medically cleared (when a patient no longer needs to receive inpatient care) to return to the facility from the acute care hospital (ACH-is a healthcare facility that provides short-term, intensive treatment for patients with serious medical conditions). This failure placed Resident 5 at risk for psychosocial harm by not allowing the resident to return to the SNF and caused her to be transferred to a different SNF. This caused her emotional stress and repeated request to come back to the facility. Findings: During a review of Resident 5's admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 5 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing food and or liquids) Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing) Major Depressive disorder, (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormalities of gait and mobility, During a review of Residents 5's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 5's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 5 was cognitively intact. During a telephone interview on 3/10/25 at 1:45 p.m. with the family member (FM), the FM stated, she was involved in Resident 5's care. The FM stated Resident 5 had been at a Skilled Nursing Facility (SNF) since 5/13/24. The FM stated, Resident 5 returned home and was admitted to SNF again on 10/23/24. The FM stated, Resident 5 was transferred to ACH on 1/30/25 from the SNF. The FM stated, she received a phone call from an ACH staff, who informed her the SNF said there were no female beds available for Resident 5 to return. The FM stated, Resident 5 was alert and oriented and able to express her needs. The FM stated, Resident 5 was very upset and crying because she wanted to return to the facility. FM stated, on 2/28/25 Resident 5 was discharged from acute care to a SNF in another city. During an interview on 3/11/25 at 9:50 a.m., with Admissions Director (AD), the AD stated, she was responsible for all documents related to new admissions and readmission. The AD stated, Resident 5 was admitted to the facility on [DATE] from ACH. The AD stated Resident 5 was sent to ACH on 1/30/25, and a bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) was put in place from 1/30/25 -2/6/25. The AD stated, she received a call from ACH on 2/18/25, informing her Resident 5 was ready to return back to SNF with orders for radiation treatments. The AD stated, the facility does not accept residents with radiation or chemotherapy (cancer treatment that uses drugs to kill or slow growth of cancer cells) treatment orders because the facility would be responsible to pay for the treatment. During an interview on 3/11/25 at 11:45 a.m., with the AD, the AD stated on 2/20 /25 at 9:35 a.m. she received notification from ACH Resident 5 was ready to be discharge back to the facility. The AD stated, she spoke with a Licensed Nurse (LN) about the admission and the resident care needs. The LN told her the facility would not be able to provide the care Resident 5 needed. During a concurrent interview and record review on 3/11/25 at 12:10 p.m., with Business Office Manager (BOM) the document titled Name of Facility dated 2/20/25 was reviewed. The BOM stated, the documents were the daily census, which show the availability of open beds in the facility. The BOM provided documents for 2/20/25-2/27/25 which indicated the following: 02/20/25- three female bed available 02/21/25- three female bed available 02/22/25 -three female beds available 02/23/25-two female beds available 02/24/25- two female beds available 02/25/25-no female beds available 02/26/25- one female bed available 02/27/25-no female beds available During an interview on 3/11/25 at 12:30 p.m. with Administrator (ADM), the ADM stated, he was contacted by staff at ACH on 2/20/25 at 5:21, to inform him Resident 5 was ready to return back to the facility. The ADM stated, the facility had female beds available on 2/20/25. The ADM stated, he was not aware of the regulations that gives a long-term care resident the right to return to the facility when a bed is available. The ADM stated, the daily census document showed three female beds available on 2/20/25. The ADM refused to continue the interview or answer questions. During a review of the facility's Policy and Procedure titled Bed-Holds and Return, dated 10/2022, the P&P indicated, .Residents and /or representatives are informed (in writing) of the facility and state (if applicable bed-hold policies) All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave) The requirements that residents be permitted to return to the facility applies to all residents regardless of payer source .Residents who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to their previous room .Residents who seek to return to the facility after the state bed-hold period has expired ( or when state law does not provide for bed holds) are allowed to return to their previous room if available or immediately to the first available bed .

Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to meet the identified needs for one of six sampled residents (Resident 4) when Resident 4 was assessed as being a fall risk, had known behaviors of standing up without staff supervision and the facility did not put a fall risk care plan with effective interventions into place to prevent falls. This failure resulted in Resident 4 falling eight times, on 1/19/25, 1/23/25, 1/28/25 at 8:45 a.m., 1/28/25 at 3:17 p.m., 2/2/25, 2/4/25, 2/10/25 and 2/14/25 placing the resident at risk for significant injuries. (Cross reference F689) Findings: During a review of Resident 4 ' s Admission Record, undated, the admission record indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses which included fracture (break in bone) of the skull, muscle weakness, abnormalities of gait (pattern of walking) and mobility (ability to move freely), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), cognitive (relating to the mental process involved in knowing, learning, and understanding) communication deficit (communication difficulty caused by cognitive impairment), cerebral infarction (condition where blood flow to the brain is blocked, causing brain tissue damage), nontraumatic intracerebral hemorrhage (bleeding occurs within the brain tissue), traumatic subdural hemorrhage (collection of blood between the brain and inner layer of skull) and traumatic subarachnoid hemorrhage (type of stroke) with loss of consciousness (state of being awake). During a review of Residents 4 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 4 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 09 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 4 ' s cognition was moderately impaired. During an interview on 4/3/25 at 2:56 p.m. with CNA 6, CNA 6 stated she was familiar with Resident 4 and had taken care of him prior to his discharge. CNA 6 stated Resident 4 was very confused, difficult to communicate with and impulsive. CNA 6 stated Resident 4 was very weak and unable to stand safely by himself but had behaviors of standing up suddenly and falling. CNA 6 stated Resident 4 was very confused and did not realize how weak he was and that it was not safe for him to stand on his own. CNA 6 stated at Resident 4 was on every 15-minute checks but still had falls. CNA 6 stated Resident 4 would have required one on one (1:1) supervision (constant staff supervision) to prevent him from falling. During a concurrent interview and record review on 4/3/25 at 3:29 p.m. with LVN 2 Resident 4 ' s falls were reviewed. The falls were as follows: 1/19/25-Resident fell trying to get off bed 1/23/25-Resident fell getting out of wheelchair 1/28/25-8:45 a.m. Resident found on floor 1/28/25-3:17 p.m. Resident found on floor 2/2/25-Resident on floor, dragging self out of room asking staff to put him into wheelchair 2/4/25-Resident fell getting up from wheelchair across from nurses ' station 2/10/25-Resident fell in dining room 2/14/25-Resident fell across from nurses ' station LVN 2 stated Resident 4 was at high risk for falls because he had non-compliant behaviors, was constantly trying to get up unsupervised, had weak legs and poor balance. LVN 2 stated Resident 4 ' s primary language was not English which caused some communication issues. LVN 2 stated she thought he could understand the reminders to call for help but could not retain it due to cognition. LVN 2 stated Resident 4 was stubborn and would continue to do what he wanted to do even if it was not safe. LVN 2 stated Resident 4 was never placed on 1:1 supervision, and the only way to prevent falls would have been for staff to always stay with the resident. LVN 2 stated she would keep the resident close to the nurse ' s station when she was sitting there, and he did not fall when she had him under constant supervision because she could redirect him quickly. Resident 4 ' s fall risk scores (0-8 low risk, 9-15 moderate risk, 16-42 high risk) were reviewed. Resident 4 ' s fall risk scores were reviewed as follows: 1/17/25 score 10, moderate risk for falls 1/23/25 score 14, moderate risk for falls 1/28/25 score 22, high risk for falls 1/28/25 score 20, high risk for falls 2/4/25 score 20, high risk for falls 2/10/25 score 20, high risk for falls 2/14/25 score 22, high risk for falls LVN 2 stated Resident 4 was a moderate risk for falls when he was admitted but his fall risk increased as he continued to have falls. Resident 4 ' s care plans were reviewed, LVN 2 stated she was unable to locate any fall risk care plan interventions before his first fall on 1/19/25. LVN 2 stated there were no fall prevention interventions in the care plan until his fall on 2/4/25. LVN 2 stated Resident 4 was on hourly checks, but it was not documented on the care plan and should have been. LVN 2 stated care plans were important because they direct the resident ' s care. LVN 2 stated care plans were used to involve the residents in their care, indicate what interventions are needed to meet their needs, included details about the resident ' s life including the treatments provided and physician ordered interventions. During a telephone interview on 4/4/25 at 7:50 a.m., with Family Member (FM) 2, FM 2 stated he was Resident 4 ' s responsible party. FM 2 stated Resident 4 had frequent falls while at the facility and he did not feel like the facility did enough to prevent the resident ' s falls. FM 2 stated Resident 4 was agitated which caused him to stand up frequently and then he would fall, but he did not feel like the facility addressed the issue and the resident kept falling. During a concurrent interview and record review on 4/4/25 at 9:12 a.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 4 was a resident at the facility for one month. The ADON stated, he had a few falls. I ' m not sure how many. Resident 4 ' s fall risk care plan was reviewed. The care plan indicated, . Resident is at risk for falls with or without injury . unwitnessed fall on 1-19-25 . witnessed fall on 1-23-25 . witnessed fall 2/4/25 . Unwitnessed fall 2/10/25 . Unwitnessed fall 2/14/25 . Date initiated 1/17/2025 . Will minimize risk for falls to extent possible . Date initiated: 2/4/25 . Add sensor pad [a device used to monitor patients to ensure they do not rise from the bed or chair on their own to reduce falls] to bed and wheelchair . Date initiated: 2/04/25 . Add to B&B [bowel and bladder program-scheduled toileting] Q [every] 2 hours . Anticipate and meet needs . falling star program . Keep bed in low position with brakes locked . Keep call light within reach . Keep personal items frequently used within reach . Non skid material [flexible material used to prevent slipping] to w/c [wheelchair] . The ADON stated she was unable to find a fall risk care plan with interventions before 2/4/25. The ADON stated Resident 4 did not have a fall risk care plan started on admission. The ADON stated it was her expectation for a fall risk care plan to be implemented on admission to prevent resident falls. The ADON stated care plans were used to provide person-centered care for each resident and should have measurable objectives and the interventions reflecting the residents ' abilities to perform ADLs and transfers. The ADON stated the cause of Resident 4 ' s falls was his need to get up. The ADON stated Resident 4 ' s need for supervision was not addressed on the fall risk care plan. The ADON stated Resident 4 was not safe to stand up without assistance. During a review of the facility ' s policy and procedure (P&P) titled Care plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, . A comprehensive, person-centered care plan should include measurable objectives and timetables to meet a resident ' s physical, psychosocial and functional needs . A comprehensive, person-centered care plan should be developed within the seven (7) days of the completion of the required MDS assessment . Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing . When possible, interventions should address the underlying source(s) of the problem . The interdisciplinary team should review and updates the care plan . The facility ' s policy and procedure (P&P) titled Falls and Fall Risk, Managing, dated 2/2018 was reviewed. The P&P indicated, . the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling . Environmental factors that contribute to the risk of falls . footwear that is unsafe or absent . Resident conditions that may contribute to the risk of falls . cognitive impairment . lower extremity weakness . functional impairments . Medical factors that contribute to the risk of falls . neurological disorders . balance and gait disorders . implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling . or until the reason for the continuation of the falling is identified as unavoidable . staff will monitor and document each resident ' s response to interventions intended to reduce falling . If the resident continues to fall, staff will re-evaluate the situation . The facility ' s P&P titled Care Planning-Interdisciplinary Team, dated 3/2022, the P&P indicated, . interdisciplinary team is responsible for the development of resident care plans . Resident care plans are developed according to the timeframes and criteria established . Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team . The facility ' s P&P titled Falls and Fall Risk, Managing, dated 2/2018 was reviewed. The P&P indicated, . the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling . Environmental factors that contribute to the risk of falls . footwear that is unsafe or absent . Resident conditions that may contribute to the risk of falls . cognitive impairment . lower extremity weakness . functional impairments . Medical factors that contribute to the risk of falls . neurological disorders . balance and gait disorders . implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling . or until the reason for the continuation of the falling is identified as unavoidable . staff will monitor and document each resident ' s response to interventions intended to reduce falling . If the resident continues to fall, staff will re-evaluate the situation .

Based on interview and record review, the Administrator (ADM) failed to provide consistent administrative oversight and resources to ensure residents received adequate supervision and care planning when the administrator was aware of multiple falls for one of six sampled residents (Resident 1) and did not ensure the Interdisciplinary Team implemented effective fall prevention interventions. These failures resulted in Resident 1 suffering avoidable falls on the following dates: 9/30/24, 11/5/24, 12/9/24, 12/16/24, 12/18/24, and 2/1/25. and placed the resident at risk for injury, pain. and suffering. These failures resulted in Resident 1 ' s experiencing five unwitnessed falls prior to the avoidable fall on 2/1/25 with injury, sustaining a (laceration (cut in the skin caused by an injury) above the left eyebrow requiring transportation to the emergency department (ED) for sutures (a row of stitches holding together edges of a wound) and avoidable pain and suffering. Resident 1 had two additional avoidable falls. Resident 1 had a unwitnessed fall in his room on 3/11/25 sustaining a laceration to the forehead which required transportation to the emergency department for evaluation and a additional fall in his room on 3/12/25 opening the same area to his forehead and required transportation back to the emergency department for repair. Resident 1 was diagnosed with a subdural hematoma (pool of blood between the brain and its outermost covering) measuring up to 11 mm (millimeters) (unit of measure) in thickness. Resident 1 passed away on 3/17/25 at ACH from his injuries related to the fall on 3/12/25. (Cross reference F689 and F865) Findings: During an observation on 2/13/25 at 8:15 a.m., in Resident 1 ' s room, Resident 1 was lying in bed with eyes closed. Resident 1 had a sutured laceration above his left eye. Resident 1 ' s bed was in low position, fall mat on the floor next to bed on left side, no fall mat on right side. Call light within reach. No staff present in the room. During a review of Resident 1 ' s Admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a group of symptoms that affect memory, thinking, and social abilities), abnormalities of gait and mobility, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 10 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 ' s cognition was moderately impaired. During a review of the Acute Care Hospital (ACH) document titled, Emergency Department Report, dated 2/1/25, the note indicated . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after fall. Per skilled nursing facility, patient had an unwitnessed ground level fall in his room between his bed and bathroom door .3-centimeter (unit of measure) (cm) linear (straight line) wound located on the face . Left eyebrow laceration was repaired . follow up for wound check and suture removal . During an interview on 2/13/25 at 10 a.m., with Licensed Vocational Nurse (LVN), LVN stated, Resident 1 was confused and a high risk for falls. LVN stated, Resident 1 does not follow commands and would try to get out of bed without help all the time. LVN stated, Resident 1 would get out of bed without using his call light, stands and tries to walk without supervision or assistance. LVN stated, Resident 1 did not have supervision on 2/1/25 when he got out of bed and fell in his room. LVN stated, Resident 1 needs supervision and continuous monitoring for his safety and was not provided During an interview on 2/13/25 at 10:20 a.m., with CNA 3, CNA 3 stated, she had provided care to Resident 1 before and was familiar with him. CNA 3 stated, Resident 1 did not use his call light to ask for help. CNA 3 stated, Resident 1 was wobbly and unsteady when standing up. CNA 3 stated Resident 1 was not safe to get out of bed on his own and needed supervision because he was unsteady on his feet. CNA 3 stated, Resident 1 was impulsive and needed one-on-one monitoring (refers to providing residents, focused attention and monitoring, ensuring their safety and wellbeing) to keep him safe and prevent falls. CNA 3 stated one-on one supervision was not provided. During an interview on 2/13/25 at 12 p.m. with Administrator (ADM), the ADM stated, we need to have the correct interventions in place to keep residents safe. The ADM stated it was our responsibility to keep residents safe. The ADM stated, we did not do enough fall interventions to keep Resident 1 safe from harm. During a concurrent interview and record review on 3/11/25 at 8:30 a.m. with the ADON, Resident 1 ' s falls since 9/25/24 were reviewed. The falls were as follows: 9/30/24 at 12 a.m. Found on the floor next to bed 11/05/24 at 7:04 p.m. Found on the floor next to bed 12/09/24 at 4:00 p.m. Found on the floor next to bed 12/16/24 at 10:00 p.m. Found on the floor next to bed 12/18/24 at 9:09 a.m. Found on the floor next to bed 2/1/25 at 4:12 p.m. Found on the floor next to bed The ADON stated Resident 1 ' s falls occurred while he was in his room and the interventions of keeping call light within reach, and encouraging to use would not address the cause of the falls, which occurred when he was unsupervised in his room. During a concurrent observation and interview on 3/24/25 at 9:30 a.m. with LVN 2 in the hallway by Resident 1 ' s room, the name tag listing name of residents in the room by the doorway was missing a name for Resident 1. LVN 2 stated, Resident 1 had a fall on 3/11/25 and 3/12/25. LVN stated, Resident 1 was sent to ACH on 3/12/25 and had not returned. During a telephone interview on 3/27/25 at 10:27 a.m. with ADON, ADON stated, Resident 1 had an unwitnessed fall on 3/11/25 at 7:24 p.m. in his room. ADON stated, Resident 1 was found on the floor by his bed. ADON stated, Resident 1 was bleeding from his forehead and was sent to ACH. ADON stated, Resident 1 returned from ACH on 3/12/25 at 1:22 a.m. During a telephone interview on 3/27/25 at 1:00 p.m. with ADON, ADON stated, Resident 1 had a fall in his room on 3/12/25 at 7:03 p.m. ADON stated, Resident 1 was found lying on the floor and assisted back to bed by staff. ADON stated, Resident 1 was sent to ACH on 3/12/25 and has not returned. ADON stated, Resident 1 was taking [name of medication] to thin his blood which could cause excessive bleeding with any injuries from a fall. ADON stated, Resident 1 was a high fall risk due to the history of his falls and had the potential for life threatening outcomes. During a review of the Acute Care Hospital (ACH) document titled, ED Physicians Notes, dated 3/11/25, at 9:08 p.m. the note indicated ( . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after a fall out of bed and hit his forehead .2 cm (centimeter) (unit of measure) mid forehead superficial (occurring on the skin or immediately beneath it) abrasion (an area damaged by scrapping) .Diagnosis, Mechanical Fall, forehead abrasion, severe dementia . During a review of the Acute Care Hospital (ACH) document titled, ED Physicians Notes, dated 3/12/25, at 8:10 p.m. the note indicated ( . patient is a 93 y.o. [year old] male . presents to the ED [emergency department] after a fall out of bed and hit his forehead .CT scan of head was performed indicating Intracranial hemorrhage (life threatening medical emergency when blood leaks inside or between the brain and skull) of left frontal , subdural hematoma ( pool of blood between the brain and its outermost covering) measuring up to 11 mm (millimeters) (unit of measure) in thickness and small volume left parietal subarachnoid hemorrhage (a type of stroke where bleeding occurs in the space between the brain and the tissues covering it) . Patient presents after a fall with head trauma while on blood thinner medication placing him at high risk for intracranial hemorrhage .Intensive Care Unit (ICU) physician was consulted, who requested to transfer the patient to neuro [neurological] ICU .[Name of ACH] [Name of Neurosurgeon] was consulted who then spoke to family in regards to potential management for this patient .Eventually family decided that they do not want to pursue any neurological intervention and did not want him transferred to another facility .Prefer that the patient stays here at this hospital .Resident 1 passed away on 3/17/25 . During a record review of the Death Certificate for Resident 1, indicated . Cause of Death as Cardiopulmonary Arrest (Cardiac arrest-sudden loss of heart function) and Subdural Hematoma w/loc (loss of consciousness-unresponsive to stimuli) status . During a review of the facility ' s Policy and Procedure titled Falls and Fall Risk Managing, dated 3/2018, the P&P indicated, .Based on previous evaluations and current data, staff may identify interventions related to the resident ' s specific risks and causes in the attempt to reduce falls and minimize complications from falling .Resident centered fall prevention plans should be reviewed and revised as appropriate .If the resident continues to fall, the situation should be reevaluated to determine whether it would be appropriate to continue or change current interventions. During a review of the facility ' s job description titled Job Description: Administrator, undated, . Position Title . Administrator . primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . Oversees Quality care and analyzes the entire operation of the nursing facility . Plan, develop, organize, implement, evaluate, and direct the facility ' s programs and activities in accordance with guidelines issued by the governing board . Supports Clinical efforts by understanding QA measures . Understand and reviews Quality Measures on a regular basis .

Based on interview and record review the facility failed to identify and develop an effective QAPI (Quality Assurance and Performance Improvement-a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program when the facility ' s QAPI failed to utilize resident fall data to establish an effective safety plan for fall prevention for one of six sampled residents (Residents 1). These failures resulted in Resident 1 suffering avoidable falls on the following dates: 9/30/24, 11/5/24, 12/9/24, 12/16/24, 12/18/24, and 2/1/25. and placed the resident at risk for injury, pain. and suffering. These failures resulted in Resident 1 ' s experiencing five unwitnessed falls prior to the avoidable fall on 2/1/25 with injury, sustaining a (laceration (cut in the skin caused by an injury) above the left eyebrow requiring transportation to the emergency department (ED) for sutures (a row of stitches holding together edges of a wound) and avoidable pain and suffering. Resident 1 had two additional avoidable falls. Resident 1 had a unwitnessed fall in his room on 3/11/25 sustaining a laceration to the forehead which required transportation to the emergency department for evaluation and a additional fall in his room on 3/12/25 opening the same area to his forehead and required transportation back to the emergency department for repair. Resident 1 was diagnosed with a subdural hematoma (pool of blood between the brain and its outermost covering) measuring up to 11 mm (millimeters) (unit of measure) in thickness. Resident 1 passed away on 3/17/25 at ACH from his injuries related to the fall on 3/12/25. (Cross reference F689 and F835) Findings: During an interview on 4/4/25 at 1:28 p.m. with the Administrator (ADM) and Administrator Consultant (ADMC), the ADM stated the facility held their last QAPI meeting on 3/25/25. The ADM stated the facility utilized the fall data to give the staff incentives to prevent falls. The ADM stated, We started doing a pizza party for staff if they go 7 days without resident falls. We have seen success [at decreasing falls]. The ADM stated the QAPI tracks the number of falls, and he used the information to present at the QAPI meeting but was unable to verbalize how the data was used to ensure the facility had an effective fall prevention program in place. During a review of the facility ' s job description titled Job Description: Administrator, undated, . Position Title . Administrator . primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . Oversees Quality care and analyzes the entire operation of the nursing facility . Plan, develop, organize, implement, evaluate, and direct the facility ' s programs and activities in accordance with guidelines issued by the governing board . Supports Clinical efforts by understanding QA measures . Understand and reviews Quality Measures on a regular basis . During a review of the facility ' s policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Plan, dated 4/2014, The P&P indicated, . facility shall develop, implement and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care . objectives of the QAPI Plan are to . Provide a means to identify and resolve present and potential negative outcomes related to resident care and services . Provide structure and processes to correct identified quality and/or safety deficiencies . Establish and implement plans to correct deficiencies . committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities .

Based on observation, interview, and record review, the facility failed to follow their facility intravenous (IV: in the vein - medications or fluids flowing directly into a vein) therapy policy and procedure and pharmacy standards of practice for IV fluid administration, procurement (obtaining), preparation and infection control standard of practice for 23 of 23 sampled residents (Residents 10, 12, 13, 17, 18, 19, 20, 27, 28, 30, 32, 33, 35, 37, 45, 46, 47, 48, 49, 50, 51, 52, and 53) when: 1. The facility permitted the contracted Physician Assistant (PA) to provide compounded (is the act of combining or altering ingredients to create medicines to meet the unique medical needs of individual patients) IV therapy prepared from a non-pharmacy offsite location without the oversight of the licensed pharmacist employed by the facility to ensure infection control, safe preparation, and labeling pharmacy standards of practice. 2. The Director of Nursing (DON) did not administer the IV compounded therapy within the required one hour of IV compounded therapy. 3. The DON administered potentially unsterile and unsafe compounded IV Immune Boost (vitamin C and B-complex and minerals [MEDICATION(S)] and Magnesium mixed in IV fluid) therapy in [MEDICATION(S)] (IV solution - a mixture of sterile solution composed of water, [MEDICATION(S)] [salt], sodium [MEDICATION(S)] [salt], potassium chloride, calcium chloride) that was prepared in a non-pharmacy offsite location, without having documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. The DON administered IV therapy without documenting resident assessments on the need for IV therapy, did not document date or time of IV cannulation (cannulation- is a technique in which the IV cannula is placed inside a vein to provide access for the administration of fluids or medications) insertions, did not document number of IV sticks (a procedure in which a needle is inserted into a vein to provide a continuous supply of Immune Boost directly to the bloodstream), did not document IV site assessment, did not document residents response to IV therapy or procedures, did not document action taken when IV catheter was removed due to infiltration or other complications, did not document resident teaching, condition of IV site and cannula upon on removal. These failures resulted in the administration of potentially unsterile and unsafe IV therapy to Residents 10, 12, 13, 17, 18, 19, 20, 27, 28, 30, 32, 33, 35, 37, 45, 46, 47, 48, 49, 50, 51, 52, and 53 and placed residents that received IV therapy at risk for [CONDITION(S)] (bloodstream [life threatening] infection), [CONDITION(S)] (skin infection that happens when bacteria spread through the skin to deeper tissues), and Fluid overload ([also known as hypervolemia] is a condition where the liquid portion of the blood is too high, resulting in weight gain, swelling, and shortness of breath), placing residents at risk of injury and/or death. Because of the serious potential harm to all residents that received Immune Boost IV therapy and facility not following IV infection control standards of practice, Licensed Nurses administering potentially unsterile and unsafe IV therapy, facility not having qualified and competent Licensed Nurse (LN) staff to administer and monitor residents on IV therapy, Registered Nurses (RN's) not conducting resident assessments that identified the need for IV fluids, not assessing residents during the IV fluid bolus administration by qualified and competent LN staff, facility not following IV compounding pharmacy standard of practice, facility not collaborating with the contracted pharmacist for pharmacy oversight of IV compounded fluids. The DON delegated to unqualified and untraining LN to sign the Medication Administration Record (MAR) for IV therapy that was administered by DON and DON did not sign the MAR as the nurse who administered IV therapy for (Residents 10, 12, 13, 17, 18, 19, 20, 27, 28, 30, 32, 33, 35, 37, 45, 46, 47, 48, 49, 50, 51, 52, and 53), an Immediate Jeopardy (IJ) situation was called on 3/23/21 at 9:24 p.m., under Code of Federal Regulations (CFR) 483.25 (F694) with the facility Administrator (ADM) and Regional Director of Operations (RDO), on 3/23/21 at 9:37 p.m., the IJ Template was provided to the ADM. The facility submitted a plan of removal on 3/29/21 at 3:01 p.m., to address the IJ situation. The IJ plan of removal included to immediately stop the procurement and compounding of IV fluids from the PA, conduct in service/competency training for PA, licensed nurse and DON on IV pharmacy standards of practice, safe IV administration, Resident assessments and monitoring of IV therapies. Immediately provide License Nurses in-service education regarding license nurse requirement to have IV certifications and competencies prior to being assign the care of residents receiving IV therapy. Immediately educate Licensed Nurses and DON on MAR documentation, the nurse administering the IV therapy would be the nurse signing the MAR. The Medical Director (MD) would educate the ADM and complete IV competencies for the DON on medications and IV fluids standards of practice, medications and IV fluids coming only from licensed pharmacist, safe IV administration, ensuring the facility had IV competent licensed staff, and safe IV infection control practices, conducting and documenting resident assessments for IV therapy and DON signing the MAR for the IV therapy she administered and not delegate to other unqualified/trained licensed nurses to sign for her. The IJ Plan of Removal was accepted on 3/29/21 at 3:09 p.m. While onsite, the survey team verified by observations, interview and record reviews and confirmed the interventions to address the IJ situation on the Plan of Removal were fully implemented. The IJ was removed on 3/29/21 at 4:57 p.m., with the ADM and DON. Findings: During a review of Resident 32's Admission record, Resident information (document with resident demographic and medical diagnosis) undated, indicated Resident 32 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .stage 4) kidney disease (severe kidney damage), Chronic Obstructive Pulmonary Disease ([CONDITION(S)]- chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs), and Mild Intermittent Asthma (condition in which the airways (the tubes that carry air in and out of the lungs) narrow and swell causing reversible obstruction). During a review of Resident 32's Laboratory (lab) results for COVID-19 virus test dated 1/11/21, lab result indicated Resident 32 was tested on [DATE] with positive COVID-19 test results received on 1/11/21. During a review of Resident 32's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical functional level) assessment dated [DATE] indicated Resident 32's Brief Interview for Mental Status (BIMS) assessment score of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 32 had no cognitive deficits, and had intact memory and judgement. During a concurrent interview and review of Resident 32's clinical record on 2/12/21, at 2:38 p.m. through 3:20 p.m., with the DON, the DON stated the facility began experiencing COVID-19 virus outbreak (a sudden rise in the number of cases of a disease) on the first week of January 2021. The DON stated the outbreak began with facility staff testing COVID-19 positive on the week of 1/6/21 and the facility began to test all resident and staff. The DON reviewed Resident 32's clinical record and stated Resident 32 had been tested for COVID -19 on 1/8/21 and results received on 1/11/21 indicated Resident 32 tested positive. The DON reviewed progress note dated 1/11/21 at 3:49 p.m., indicating Resident 32 was to receive IV infusion medication over 1 hour. The progress note indicated, Monitor [Resident 32] for 1 hour after infusion. The DON stated Resident 32 did not receive the IV medication because the medication was not available. The progress note dated 1/11/21 at 4:21 p.m., indicated Resident 32, .showing signs of weakness and fatigue .exhibiting signs of lethargy (condition causing drowsiness and an unusual lack of energy and mental alertness) . Licensed Vocational Nurse (LVN) notified medical provider via (by way of) phone. New orders were given for, IV bolus (is a large dose, rapid infusion of medication or fluid into the bloodstream) NS [normal saline - medicine used for fluid and electrolyte (fluid in the body that conducts electrical energy to facilitate important bodily functions)] at 125 ml(milliliters)/hr(hour) related to lethargy (drowsy, slow to respond) .IV in place to left hand by DON .No s/s [signs and symptoms] of fluid overload .will continue to monitor . The DON reviewed Resident 32's MAR dated 1/2021 for IV NS fluids and stated the initials on the MAR were Staff 9's not hers. The DON reviewed Resident 32's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the LVN (Staff 9-Licensed Vocational Nurse) was monitoring Resident 32 and was the nurse that would document fluid overload status. The DON stated she was the only nurse that was inserting IV's and administering IV fluids during the outbreak but had not ensured Resident 32 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she and had not documented on the MAR as the nurse administering the IV fluids. The DON reviewed Resident 32's progress note dated 1/12/21 at 11:15 a.m., indicated, During vitals [measurement of heart, blood pressure, temperature and respiration rate] check at 10:00 a.m., resident respirations were increased and seemed labored .Resident 02 [oxygen] sat [saturation- oxygen measurement in the blood] between 89%-91% (percent) on room air (According to Resident 32's baseline (normal level) vital signs dated 1/1/21- 1/10 /21, blood oxygen saturation levels were are 96-98 percent). Notified MD [Medical Doctor] . Order .2L [liters] 02 via nasal cannula [nose- oxygen tubing] for difficulty breathing . The DON reviewed Resident 32's clinical record and was unable to find Registered Nurse assessment of decline in oxygen level. The DON reviewed progress note dated 1/12/21 at 8:30 p.m. which indicated, Resident [32] is on alert charting, new order for 1000 ml (milliliter- unit of measurement) of [MEDICATION(S)] [a mixture of [MEDICATION(S)] [salt water], sodium [MEDICATION(S)] [salt from sugar source], potassium chloride, and calcium chloride in water] w/ [with] Vitamin C 3000 mg, B-complex 2 mls (milliliters), [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr .[completed by LVN] The progress noted dated 9:30 p.m., indicated Resident 32, Completed IV fluids last night. No s/s of fluid overload [LVN] had cough and was started on [MEDICATION(S)] (medication to treat infection). The progress note dated 1/18/21, at 12:57 a.m., indicated, Resident observed to have altered mental status. Resident [32] clenching chest, screaming out. Resident in acute distress. Resident . yelling 'send me to the hospital I am going to die' . [Resident] Sent to Emergency Department [ED] for further evaluation . The DON stated by the time Resident 32 arrived at the ED she was having a heart attack. The DON reviewed Resident 32 progress notes and stated LVNs were monitoring Resident 32's IV therapy. The DON reviewed Resident 32 clinical record and was unable to find Registered Nurse (RN) documentation of date and time of IV catheter (tubing) insertion, number of IV venipuncture attempts (sticks), condition of IV catheter on insertion and removal, IV site assessment, resident response to IV therapy, assessment indicating reason for IV therapy and procedure, complication and resident teaching. The DON stated she had delegated to LVN's to monitor Resident 32 so why would an RN need to conduct the monitoring, documentation, or assessments. The DON stated Intake and Output (I&O) were not taken for residents on IV immune boost or hydration IV therapies and I&O's should have been done. During a concurrent interview and review of Resident 32's clinical record on 2/23/21, at 3:22 p.m., with the DON, the MAR dated 1/2021 indicated, 1,000ml of [MEDICATION(S)] mixed with Vitamin C 3000 mg,/ B complex 2 ml, [MEDICATION(S)] 20 mg, Magnesium 200 via IV at 200 ml/ Hr .for COVID-19 start on 1/12/21 at 1300 [1:00 p.m.]. The MAR indicated [Staff 9] signed as the nurse who administered the IV therapy at 3:57 p.m. (1 hour and 57 minutes later than 1 hour following the start of the preparation of the CSP). The DON stated the Physician Assistant (PA) had ordered the administration of the IV therapy for residents who tested COVID-19 positive. The DON stated the medical need for the IV therapy was for weakness, fatigue or when the resident looked tired. The DON stated she administered all the IV therapies during the facility COVID-19 virus outbreak, approximately 20 to 25 IV therapies were administered to residents who tested positive with COVID-19. The DON stated it took her all day long to administered IV therapies to residents. The DON reviewed the MAR and was unable to find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 32's clinical record did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation, interview, and review of Resident 32's clinical record on 2/23/21, at 4:48 p.m., with Staff 9, Staff 9 stated she was not aware if the facility had IV therapy protocols or policy and procedures. Staff 9 looked for policies at the nurse's stations and stated, We don't have policies and procedures or protocols for IV therapy. Staff 9 stated LVN's would monitor resident receiving IV therapy by checking oxygen levels and listen for lung sounds. Staff 9 reviewed Resident 32's MAR on 1/10/21 and 1/12/21, IV therapy and stated the initials on the MAR were hers and not the DON's. Staff 9 stated her initials on the MAR indicated she administered the IV therapy. Staff 9 reviewed Resident 32's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and review of Resident 32's clinical record on 2/25/21, at 5:56 p.m., with the DON, the DON stated the facility did not have IV therapy protocols or policies and procedures to guide nurses on IV standards of practice and monitoring. The DON stated the facility may have an IV policy, but she would look for it. The DON stated Resident 32 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the PA had prepared the IV Immune Boost therapy in her private office and deliver the IV fluid bags to the facility labeled with resident name and a date. The DON stated she did not know how the PA prepared the IV Immune boost therapy she did not ask. The DON stated some of the IV bags were delivered spiked (inserting IV tubing into the sterile IV solution) and ready for administration. The DON stated she had a difficult time accessing a vein for Resident 32 and had attempted three (IV sticks- inserting IV needle) times but was unable to find a vein. The DON stated the PA also attempted to insert the IV and was able to find a vein. The DON stated she did not document the number of IV sticks performed on Resident 32 and she should have. The DON reviewed Resident 32's MAR dated 1/10/21 and 1/12/21 and stated she administered the IV NS fluids on 1/10/21 and administered the IV Immune boost therapy on 1/12/21. The DON stated the initials of the person who administered the IV therapies on the MAR were not hers, the initials were staff 9 (LN). The DON stated she did not know how to access and document on the MAR and progress notes for Resident 32, that was the reason her initials were not on the MAR. The DON stated Resident 32's respiratory medical conditions required increase monitoring and that did not occur. During a review of Resident 35's Admission Record, Resident information undated, the Admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 35's lab results for COVID-19 virus test dated 1/11/21, lab indicated Resident 35 was tested on [DATE] and results indicated positive for COVID-19. During a review of Resident 35's MDS assessment dated [DATE] indicated Resident BIMS assessment score of 15, with 15 indicating Resident 35 had no cognitive deficits and had intact memory and judgement. During a concurrent interview and review of Resident 35's clinical record on 2/12/21, at 4:40 p.m., with the DON, the clinical record was reviewed with the DON. The Progress Note dated 1/14/21, at 3:05 p.m., indicated Resident 35 was experiencing spells of confusion, intermittent shortness of breath and cough. Resident 35, . receiving [bolus] IV therapy. The DON stated the progress note did not contain an assessment indicate the reason for the IV therapy infusion and did not include fluid overload RN assessment. The progress note dated 1/14/21, at 9:00 p.m., indicated Resident 35 was receiving, IV medication . experiencing cough, breath sounds adventitious- wheezing [abnormal lung sounds] LVN had resident with cooling measures. The DON stated Resident 35's clinical record did not contain RN assessments for resident change in condition and IV therapy. During a concurrent interview and review of Resident 35's clinical record on 2/23/21 at 4:55 p.m., with Staff 9, Staff 9 reviewed Resident 35's clinical record and stated the DON was aware of Resident 35's increase acuity (the measurement of the intensity of nursing care required by a patient) need because the DON was administering IV therapy to residents. Staff 9 reviewed Resident 35's MAR dated 1/13/21 and stated the initials on the MAR were hers and not the DON's. Staff 9 stated her initials on the MAR indicated she administered the IV therapy. Staff 9 reviewed Resident 35's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and review of Resident 35's clinical record on 2/25/21, at 3:21 p.m., with the DON, Resident 35's MAR dated 1/2021 indicated, 1,000ml of [MEDICATION(S)] mixed with Vitamin C 3000 mg,/ B complex 2 ml, [MEDICATION(S)] 20 mg, Magnesium 200mg via IV at 200 ml/ Hr [bolus] to be ran for 5 hours by gravity .for dehydration start on 1/13/21 at 1700 [5:00 p.m.]. The MAR indicated [Staff 9] signed as the nurse who administered the IV therapy at 6:56 p.m. The DON stated she administered all the IV therapies during the facility COVID-19 virus outbreak but did not sign as the nurses who administered the IV therapy because she did not know how to access the MAR and did not know how to document on the MAR. The DON reviewed the MAR and was unable to find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reviewed the clinical record and was unable to find documentation of date and time of IV insertion, condition of IV catheter on insertion and removal, IV site assessment, resident response to IV therapy and procedure, complications, and resident teaching. The DON stated, we do not have that. The DON stated Resident 35 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 35's medical conditions required increase monitoring and that did occur. During a review of the facility's policy and procedure titled, Peripheral (near the skin surface) IV Catheter Insertion dated 4/2016, indicated, .The purpose of this procedure is to provide guidelines for the safe and aseptic insertion of a peripheral intravenous catheter for the administration fluids and/or medications .Steps in the procedure .(1) Verify with the state Nurse Practice Act for LPN[Licensed Practice Nurse]/ RN function and competency requirements (2) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .(2) The number of venipuncture attempts (maximum of two) . (3) The type, length and gauge of catheter, and type of cleansing agent used .Date and time [of procedure] .Type, location, gauge and length of device used . Reason for restart, if applicable . Resident teaching . (10) residents' response to procedure (11) the signature and title of the person [performing the procedure] . During a concurrent interview and record review on 2/25/21, at 5:56 p.m., with the DON, the DON stated during the facility COVID-19 outbreak in January 2021 multiple residents that tested positive for COVID -19 were administered IV Immune Boost therapy. The DON stated the contracted PA informed the facility (Administrator and DON) that she was administering IV immune Boost therapy to her patients in her private office and would like to do the same for facility residents. The PA informed the DON that she was purchasing IV therapy supplies from a pharmacy located in Florida. The PA informed the facility the Florida pharmacy would mail her the IV therapy supplies to her office. The DON stated the PA would compound IV Immune Boost therapy and had IV supplies for IV therapy administration. The DON stated the facility (Administrator and DON) agreed with PA's plan to have the PA procure, prepare, label, and deliver IV therapy bags without licensed pharmacist oversight for resident IV therapy administration. The DON stated the PA would bill for the IV pharmacy services. The DON stated the facility had a contract with a licensed pharmacy that was able to provide compounded IV therapy for residents and made the decision not to use the contracted licensed pharmacist for the compounded IV therapy. The DON stated the facility did not inform or request guidance from the facility contracted licensed pharmacist prior to permitting the PA to begin compounding and delivering IV therapy for resident administration. The DON was asked regarding the decision not to use their licensed pharmacy and stated, Because this (PA compounding and delivering the IV therapy supplies was) was easier. The DON stated the PA began prescribing IV Immune Boost therapy for resident that had confirmed laboratory positive COVID-19 results. The DON stated the PA prepared IV Immune Boost infusion (injection of a substance into a vein or tissue) therapy bags in her private office, label the IV bags with resident name, contents vitamins and minerals and delivered the IV solution bags in a carboard or plastic box to the facility. Medication Administration records for Residents 10, 12, 13, 17,18, 19, 20, 27, 28, 30, 32, 33, 37, 35, 45, 46, 47, 48, 49, 50, 51, 52, and 53 were reviewed and indicated the 23 residents had received IV Immune Boost therapy. The DON stated she had administered all the IV Immune Boost therapy to residents. The DON stated she would begin administering IV therapy to 10 to 12 residents on the same day. The DON stated some of the residents had IV that infiltrated (IV fluid or medications leak into the surrounding tissue, caused by improper placement or dislodgment of the IV catheter [tubing]) but did not remember which residents IV infiltrated and had not document the IV infiltration on the resident clinical record. The DON stated she did not know how to access and document on the electronic clinical record. The DON reviewed residents' clinical records and was unable to find IV insertion RN documentation and RN assessment documentation for medical reason for the IV therapies. The DON stated, I need to improve on that [documentation]. The DON stated she had administered IV fluids that were delivered to the facility spiked (IV tubing penetrating the IV bag port) by the PA, IV fluids that had not been not procured, compounded, and labeled by a licensed pharmacist. The DON stated, What is the difference from the PA [compounding IV fluids] and a licensed Pharmacist [compounding IV fluids]. I don't know if the pharmacist added something, he shouldn't add to the IV bag .I don't see a problem . The DON stated she was not knowledgeable about pharmacy standards of practice for IV medications and or fluid therapy procurement, compounding or labeling requirements. The DON stated, I don't know if it [IV therapy] was done right .I was not worried about that . we were in the middle of a COVID outbreak . During an interview on 2/25/21, at 7:20 p.m., with the PA, the PA stated she began compounding IV Immune Boost therapy for residents that tested COVID-19 positive in January 2021. The PA stated she had a pamphlet that was provided to her from the Florida pharmacy on how to compound the Immune Boost IV therapy. The PA stated and she would deliver the compounded IV Immune [NAME] therapy to the facility for the nurses to administered to resident that were experiencing weakness. The PA stated she had a contract with (pharmacy name) in Florida which supplied her with IV supplies and instructions on how to compound Immune Boost IV therapy. The PA stated the IV compounding supplies were mailed from the Florida pharmacy to her office. The PA stated she prepares the Immune Boost [vitamins and minerals] in IV solution bags in batches of 10 to 12 and would deliver the prepared IV bags to the facility in batches. During an interview on 2/26/21, at 9:30 a.m., with the DON, the DON stated the IV compounded therapy was provided by the PA because it was easy access and because the PA preferred to provide the Immune Boost and billed for it by her (PA). The DON stated she administered all the IV Immune Boost therapy and stated it took her from morning and went to the hours of the night to administer the prepared IV infusions to batches of 10 to 12 residents on different days during the COVID-19 outbreak in January 202. The DON stated some of the residents IV's infiltrated and she would have to re-start a new IV for those residents. The DON stated that IV Immune Boost bags were stored at the nursing station waiting to be administered for hours. During a review of the professional reference titled, 797 PARMACEUTICAL COMPOUNDING- STERILE PREPARATIONS dated 2008, indicated The immediate-use provision is intended only for those situations where there is a need for emergency or immediate patient administration of a CSP [compounded sterile preparations] Immediate-use CSPs are not intended for storage for anticipated needs or batch compounding .Administration begins not later than 1 hour following the start of the preparation of the CSP . During an interview on 2/26/21, at 11:11 a.m., with the DON, the DON stated she administered the IV therapy to multiple residents during the January 2021 COVID-19 outbreak and did not think the IV immune Boost delivered by the PA had an infection control risk. The DON stated she did not document Resident IV insertion, interventions, or assessments prior or after IV therapy. The DON stated she would need to refer to the RN professional standards to see whether she needed to document her IV insertion, administration, interventions, and assessments. During a concurrent interview and record review on 2/26/21, at 11:35 a.m., with the DON, the updated, (pharmacy name) IV therapy pamphlet with instruction for .Immune boost formulas was provided by the DON and reviewed with DON. The DON stated the IV therapy formula ordered by the PA was not one of the IV therapy formulas on the pharmacy IV therapy pamphlet and did not know which formula the PA used. The DON was asked for a copy of the pharmacy manufacturer instruction on compounding used by the PA to mix the two vitamins and two minerals in the IV fluid and manufacturer instruction on how long the prepared IV therapy could sit out prior to administering the IV therapy to the residents. The DON stated she had contacted the PA and the PA would not return her calls. The DON stated the facility did not have a copy of the pharmacy immune boost IV therapy the PA used but would provide the information if she received it from the PA. The Pharmacy instructions for IV immune boost were requested multiple times and no additional information was provided by the PA and the facility. During a review of Resident 10's MAR dated 1/2020, the MAR indicated, .1000ml of [MEDICATION(S)] w/Vitamin C 3000 mg, B-Complex 2 mls, [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr [hour] to be ran for 5 hours by gravity one time only related to dehydration .[no start or end date indicated] . signed as administered by DON on 1/16/21. During a review of Resident 12's MAR dated 1/2020, the MAR indicated, .1000ml of [MEDICATION(S)] w/Vitamin C 3000 mg, B-Complex 2 mls, [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr [hour] to be ran for 5 hours by gravity one time a day related to COVID-19 .start date 1/17/21 [signed as administered on 1/17/21 and 1/21/21 by staff 9 signed by staff 7 on 1/18/21 and 1/19/21, signed by Staff 15 as administered on MAR on 1/20/21 and signed as by Staff 16 on 1/22/21 -total of 6 days of IV therapy] . The MAR did not have DON signature as the nurse administering the IV therapy. During a review of Resident 13's MAR dated 1/2020, the MAR indicated, .1000ml of [MEDICATION(S)] w/Vitamin C 3000 mg, B-Complex 2 mls, [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr [hour] to be ran for 5 hours by gravity one time only related to dehydration .start date 1/19/21 at 1800 [6pm] . signed as administered by staff 14 on 1/19/21 at 11 pm., [five hours late]. The MAR did not have DON signature as the nurse administering the IV therapy. During a review of Resident 17's MAR dated 1/2020, the MAR indicated, .1000ml of [MEDICATION(S)] w/Vitamin C 3000 mg, B-Complex 2 mls, [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr [hour] to be ran for 5 hours by gravity one time only related to dehydration .start date 1/19/21 at [5:45pm] . signed as administered by staff 17 on 1/19/21 at 9:04 pm. [2 hours and 19 minutes late]. [The MAR did not have DON signature as the nurse administering the IV therapy. During a review of Resident 18's MAR dated 1/2020, the MAR indicated, .1000ml of [MEDICATION(S)] w/Vitamin C 3000 mg, B-Complex 2 mls, [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr [hour] to be ran for 5 hours by gravity one time only related to dehydration .start date 1/19/21 at [2:30pm] . signed as administered by staff 17 on 1/19/21 at 7:06 pm [4 hours and 36 minutes late]. The MAR did not have DON signature as the nurse administering the IV therapy. During a review of Resident 19's MAR dated 1/2020, the MAR indicated, .1000ml of [MEDICATION(S)] w/Vitamin C 3000 mg, B-Complex 2 mls, [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr [hour] to be ran for 5 hours by gravity one time only related to dehydration . Signed as administered by the DON, administration time not indicated. During a review of Resident 20's MAR dated 1/2020, the MAR indicated, .1000ml of [MEDICATION(S)] w/Vitamin C 3000 mg, B-Complex 2 mls, [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr

Based on observation, interview, and record review, the facility failed to have sufficient number of qualified licensed nurses (LN) with appropriate IV (Intravenous- In a vein) competencies, training and skill sets to safely administer Intravenous (IV-medications or fluids flowing directly into a vein) fluid therapy to 23 of 23 sampled residents (Residents 10, 12, 13, 17, 18, 19, 20, 27, 28, 30, 32, 33, 35, 37, 45, 46, 47, 48, 49, 50, 51, 52, and 53) who received IV therapy during a COVID-19 outbreak in [DATE] when Licensed Nurses (LN) administered potentially unsterile and unsafe physician assistant (PA) ordered [MEDICATION(S)] ((IV solution - a mixture of sterile solution composed of water, [MEDICATION(S)] [salt], sodium [MEDICATION(S)] [salt], potassium chloride [potassium salt], calcium chloride) bolus (a large volume of fluid or dose of a drug given intravenously and rapidly) of 1-liter bags mixed with vitamins and minerals [Immune Boost] IV therapy to the 23 residents and did not conduct assessment or document the medical need for the IV therapy. Licensed nurses administered the IV therapy without first being IV certified and competent to perform IV skill set, did not follow the facility policy and procedure for IV therapy safe administration. The Director of Nurses (DON) relegated IV therapy administration, monitoring and order transcription to LN that did not possess IV certification or competencies to administer, and monitor IV therapy. The DON did not possess competencies and skills sets required for assessment, order transcription, and documentation of IV therapy she administered. DON asked LN to sign for IV therapy DON administered and DON was not knowledgeable of and did not follow the IV policy and procedure on safely administering and documenting IV therapy for the 23 residents. These failures resulted in the administration of potentially unsterile, unsafe, and unnecessary IV therapy to the Residents 10, 12, 13, 17, 18, 19, 20, 27, 28, 30, 32, 33, 35, 37, 45, 46, 47, 48, 49, 50, 51, 52, and 53. The administration of potentially unsterile and medically unneeded IV therapy had the potential for residents to develop [CONDITION(S)] infection (a life-threatening infection-medical emergency), could lead to fluid overload (too much fluid flowing around the circulatory system [system that moves blood throughout the body] which can overwork the heart and lead to heart failure) and could result in resident harm, injury or death. Because of the serious potential harm to 23 of 23 residents (Residents 10, 12, 13, 17, 18, 19, 20, 27, 28, 30, 32, 33, 35, 37, 45, 46, 47, 48, 49, 50, 51, 52, and 53) on the facility not having sufficient, IV qualified licensed nurses (LN) with appropriate IV competencies, training and skill sets to safely assess, administer and monitor residents on IV therapy. Licensed Nursing staff not following standard of practice for safe administration of IV therapy, and DON not signing resident Medication Administration Records (MAR) for IV therapy she administered. DON delegated Licensed Vocation Nurses (LVN's) not IV certified, qualified, and trained to sign MAR for IV therapy DON administered. The DON and LVN's administered compounded IV therapy after the one-hour IV therapy compounded requirement. The DON did not obtain IV insertion orders prior o IV insertion. The DON did not document resident assessment need for IV therapy, did not document resident assessment prior, during or after IV therapy. DON did not document IV infiltration experienced by resident and/or interventions to monitor infiltrated site for medical complication. The DON/Registered nurse (RN) delegated to LVN's assessments and monitoring of residents experiencing declining respiratory complications and IV therapy monitoring. The DON and Licensed nurses did not collaborate with the contacted licensed pharmacy for safe IV therapy administration and monitoring of resident at high risk for fluid overload. Licensed Nurses did not follow IV therapy Policies and procedures on safe IV therapy administration, monitoring and documentation. LVN's signed for IV therapy administered by DON an Immediate Jeopardy (IJ) situation was called on [DATE] at 9:19 p.m. under Code of Federal Regulations (CFR) 483.25 (F694) with the facility Administrator (ADM) and Director of Operations (RDO). The IJ Template was provided to the ADM. The facility submitted a plan of removal on [DATE] at 6:26 p.m., to address the IJ situation, which included to immediately stop the acquiring and administration of IV fluids from the Physician Assistant (PA), conduct in service, competency training for IV certified licensed nurse and DON on safe administration of IV therapies, in-service on IV certified LN on scope of practice, Medical Director (MD) to conduct in service and competency training for the ADM and DON on safe administration of medications and IV fluids that should be procured from a contracted licensed pharmacist. MD to conduct competency training for DON on RN to Licensed Vocational Nurse (LVN) delegation scope of practice. LN to receive in-service and competencies on administration of timely, and save IV administration, following safe IV infection control practices, IV administration procedures, IV documentation policies and procedures, resident assessments on IV therapy medical need, acquiring and requiring IV insertion Physician prescription. DON and LN to complete competencies on standard of practice with the Nurse administering IV therapies will be the nurses signing as the administering individual, completed competencies on Licensed staff not signing for other nurses on the Medication Administration Record (MAR) for IV therapies. The Plan of Removal was accepted on [DATE] at 5:40 p.m. While onsite, the surveyor verified by observations, interview and record reviews and confirmed the interventions to address the IJ situation on the Plan of Removal were fully implemented. The IJ was removed on [DATE] at 1:27 p.m., with the ADM and DON. Findings: During a review of Resident 32's Admission record, Resident information (document with resident demographic and medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 32's Laboratory (lab) results for COVID-19 virus test dated [DATE], lab indicated Resident 32 was tested on [DATE] with positive COVID-19 results received on [DATE]. During a review of Resident 32's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical functional level) assessment dated [DATE] indicated Resident 32's Brief Interview for Mental Status (BIMS) assessment score of 15 (,d+[DATE] scale [,d+[DATE] severe cognitive deficit, ,d+[DATE] moderate cognitive deficit, ,d+[DATE] no cognitive deficit]) with 15 indicating no cognitive deficits, intact memory and judgement. During a concurrent interview and review of Resident 32's clinical record on [DATE], at 2:38 p.m. through 3:20 p.m., with the Director of Nurses (DON), the DON stated the facility began experiencing COVID-19 virus outbreak (a sudden rise in the number of cases of a disease) on the first week of [DATE]. The DON stated the outbreak began with facility staff testing COVID-19 positive on the week of [DATE] and the facility began to test all residents and staff. The DON stated over 50 out of 68 residents became infected with COVID-19 virus during this time. The DON reviewed Resident 32's clinical record and stated Resident 32 was tested for COVID -19 on [DATE] and results received on [DATE] indicating Resident 32 tested positive. The DON stated Resident 32 began showing COVID symptoms on [DATE]. The DON reviewed progress note dated [DATE], at 4:21 p.m., which indicated Resident 32 was exhibiting signs of lethargy (condition causing drowsiness, slow to respond and an unusual lack of energy and mental alertness). Licensed Vocational Nurse (LVN) notified medical provider via (by way of) phone. New orders were given for .IV NS [normal saline - fluid and electrolyte [fluid in the body that conducts electrical energy to facilitate important bodily functions) at 125 ml(milliliters)/hr(hour) related to lethargy .IV in place .No s/s [signs and symptoms] of fluid overload (signed by Staff 9 who did not have documented IV certification/training). The DON stated the LVN documented fluid overload status because the LVN was monitoring Resident 32 receiving the IV Immune therapy. The COVID-19 daily skilled documentation dated [DATE] at 6:02 p.m. indicated Resident 32 was experiencing muscle aches, complaint of body aches, generalized weakness, worsening malaise (ill) and to monitor for Emergency warning signs .trouble breathing .confusion .inability to arouse .every shift. The DON stated the clinical record did not contain a resident assessment for monitoring emergency warning signs on every shift. The progress note dated [DATE] at 11:15 a.m., indicated, During vital [measurement of heart, blood pressure, temperature and respiration rate] check at 10:00 a.m., resident respirations were increased and seemed labored .Resident 02 [oxygen] sat [saturation- oxygen measurement in the blood] between 89%-91% on room air (According to Resident 32's baseline vital signs, her blood oxygen saturation levels are ranging from ,d+[DATE] percent).2L [liters-unit of measurement] 02 [oxygen] via nasal cannula [nose- oxygen tubing] for difficulty breathing . Progress note dated [DATE] at 8:30 p.m. indicated, Resident [32] is on . 1000 ml (milliliter- unit of measurement) of [MEDICATION(S)] w/ [with] Vitamin C 3000 mg [milligrams- unit of measurement], B-complex 2 mls (milliliters), [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr [bolus] within 5 hours for COVID . The COVID-19 daily skilled documentation dated [DATE] at 2:54 p.m. indicated Resident 32 had the presence of shortness of breath, change in cough and was receiving oxygen at 2L by nasal cannula. The COVID-19 daily skilled documentation dated [DATE] at 9:02 p.m., indicated Resident 32 was complaining of pain level 7 [out of ,d+[DATE]- moderate pain level], shortness of breath . The COVID-19 daily skilled documentation dated [DATE] at 9:02 p.m. indicated resident was experiencing shortness of breath . The COVID-19 daily skilled documentation dated [DATE] at 6:20 p.m., indicated Resident 32 was experiencing shortness of breath . The progress note dated [DATE] at 12:57 a.m., indicated, Resident observed to have altered mental status. Resident [32] clenching chest, screaming out. Resident in acute distress. Resident . yelling 'send me to the hospital I am going to die' . [Resident] Sent to Emergency department for further evaluation . The DON reviewed nurse progress notes and stated the clinical record indicated Resident 32 was experiencing shortness of breath and cognition fluctuations since [DATE]. The DON stated by the time Resident 32 arrived at the emergency room she was experiencing a heart attack. The DON stated LVNs were monitoring Resident 32 COVID-19 virus shortness of breath and IV therapy status once every 24 hours and on some days LVNs monitored residents more than once in 24 hours. The DON reviewed Resident 32's clinical record and was unable to find a Registered Nurse (RN) assessment for Resident 32's ongoing complaint of shortness of breath and assessment on medical condition requiring IV therapy. The DON stated she did not think an RN assessment was required to conduct assessment, monitor of document if the LVN monitored Resident 32 shortness of breath and IV therapy at least once in 24 hours, but she would have to look at the RN scope of practice to be sure. The DON stated she was the RN that administered the IV therapy on [DATE] and [DATE] and did not document as the RN who administered the IV therapy. The DON stated she did not document an assessment indicating Resident 32's medical condition requiring IV therapy, IV insertion orders, or IV therapy monitoring because she did not think she was required to do that. The DON reviewed the progress notes and Medication Administration Record (MAR) for IV therapy and indicated an LVN [Staff 9- not IV certified/ trained] signed as the nurse that administered IV therapy and not the DON. The DON stated she administered the IV therapy but did not sign for the IV therapy. The DON stated when the facility experienced COVID-19 virus outbreak over 50 out of 68 residents tested positive for COVID-19 virus. The DON stated during the outbreak she felt the facility had sufficient nursing staff to meet residents increase level of care, initiation of IV therapy for over 20 residents and did not think the facility needed additional staff for residents increase acuity (measurement of the intensity of nursing care required by a patient) level of care requiring IV therapy. The DON stated she and a weekend RN were the two RN's she deemed needed for the facility. The DON stated she and the Administrator did not feel there was a need to hire additional RNs because she felt she and the weekend RN would be sufficient to meet residents' acuity needs with COVID-19 virus, respiratory change of condition, and IV therapy during the COVID-19 outbreak. The DON stated she did not think an RN would need to conduct and document assessments if LVN's were monitoring residents during respiratory change of condition. The DON stated she realized, in retrospect, Resident 32 had experienced worsening respiratory status and required a higher level of care than an LVN could provide. The DON stated she as the RN should have conducted change of condition assessments for Resident 32 when the respiratory status was worsening. DON stated that did not occur because she was busy administering IV therapy to many residents. The DON stated after Resident 32 requested to be sent out to the hospital, Resident 32 was hospitalized from [DATE] through [DATE] and was transferred back to the facility after the hospital informed the facility Resident 32s medical condition did not improve and there was nothing else the hospital could do for Resident 32. The DON stated Resident 32 was readmitted to the facility and died approximately a week after she was readmitted . During a concurrent interview and review of Resident 32's clinical record on [DATE], at 3:20 p.m. with the DON, the MAR dated ,d+[DATE] indicated, 1,000ml of [MEDICATION(S)] mixed with Vitamin C 3000 mg,/ B complex 2 ml, [MEDICATION(S)] 20 mg, Magnesium 200mg via IV at 200 ml/ Hr .for COVID-19 start on [DATE] at 1300 [1:00 p.m.]. The MAR indicated [Staff 9- not IV certified/ trained] signed as the nurse who administered the IV therapy at 3:57 p.m. (1 hour and 57 minutes late). The DON stated the Physician Assistant (PA) had ordered the administration of the IV therapy for resident after tested COVID-19 positive. The DON stated the medical need for the IV therapy was for weakness, fatigue or when the resident looked tired. The DON stated she administered all the IV therapies during the facility COVID-19 virus outbreak, approximately 20 to 25 IV therapies were administered to residents who tested positive with COVID-19. The DON reviewed the clinical record and was unable to find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] &O -monitoring of fluid balance required for resident with kidney failure) and resident procedure tolerance documentation. The DON stated Resident 32's clinical record did not contain the information. During a concurrent interview and record review with staff 10 on [DATE], at 3:45 p.m., Staff 10 (Licensed Nurse-LN) reviewed Resident 32's clinical record and stated she worked with Resident 32 when she had tested positive for COVID-19 virus. Staff 10 reviewed Resident 32's progress noted dated [DATE] at 12:37 a.m. and stated prior to Resident 32 testing positive for COVID-19 she was alert, a cheerful, very active and social lady with staff and roommates. Staff 10 stated Resident 32 enjoyed her independence as much as she could. Staff 10 stated Resident 32 became really sick after she was infected with COVID-19. Staff 10 stated she was assigned 25 to 28 residents that were really sick and she was doing the best she could to care for all residents under her care. Staff 10 stated she was trying to monitor all resident that were COVID-19 positive and had IV therapy but she was unable to keep up with all the work. Staff 10 stated she was not be able to keep up with the workload. Staff 10 reviewed progress note dated [DATE] which indicated Resident 32 was really sick. Staff 10 stated, This is really bad documentation of a resident [32] that was really sick. Staff 10 stated She [Resident 32] needed to go to the emergency room , sooner. Staff 10 stated LVNs were not able to meet resident's high acuity medical needs and the Administrator and DON did not agree the facility needed additional Licensed Nurses. Staff 10 stated the acuity of resident experiencing COVID-19 symptoms, IV therapy and having so many residents assigned to a nurse made it impossible to attend or respond to resident that were experiencing respiratory issue. Staff 10 stated the Administrator and DON knew staff were struggling but nothing was done to help. Staff 10 stated, We did the best we could. Staff 10 stated she had worked at the facility for a little over one year and had not received IV competencies skills check. Staff 10 stated she would feel more comfortable caring for resident with IV's if the facility had offered and provided IV competencies skills. During a concurrent interview and record review on [DATE] at 3:59 p.m., with Staff 13 (LN), Resident 20 and 45's MAR dated ,d+[DATE] was reviewed with Staff 13. The MAR indicated on [DATE] Staff 13 signed as the nurse who administered the IV therapy. Staff 13 stated she was not sure why she signed the MAR. Staff 13 stated she had not administered any IV therapy for Residents 20 and Resident 45, she was monitoring residents on IV therapy but had not administered the IV. Staff 13 stated signing the MAR for a medication she did not give would be considered false documentation. Staff 13 stated she did not administer the IV therapy and should not have signed the MAR for another nurse [DON]. Staff 13 stated she had been assigned 25 to 28 residents during the COVID outbreak and IV therapy administration. Staff 13 stated the facility did not have sufficient nurses to meet the needs of the residents and the ADM and DON were aware but did not add additional nurses. During a concurrent observation, interview, and review of Resident 32's clinical record on [DATE] at 4:48 p.m., with Staff 9 [LN], at the nurse station, Staff 9 stated she was not aware if the facility had IV therapy protocols or policy and procedures. Staff 9 was observed looking for policies at the nurse's stations and stated, We don't have policies and procedures or protocols for IV therapy. Staff 9 stated LVN's would monitor resident receiving IV therapy by checking oxygen levels and listen for lung sounds. Staff 9 stated, Things were crazy busy almost all residents were covid [positive during [DATE] COVID-19 outbreak]. Staff 9 stated she had been on duty for most of the COVID-19 virus outbreak helping with IV's in the facility on the month of January. Staff 9 stated LVN's documented a brief assessment on the COVID-19 daily skilled documentation form. Staff 9 reviewed Resident 32's COVID-19 daily skilled documentation dated [DATE] and stated she had documented Resident 32 was experiencing shortness of breath, cough and body aches and she documented no COVID symptoms on the same documentation which was wrong. Staff 9 stated Resident 32 was experiencing shortness of breath, and a bad cough. Staff 9 stated Resident 32 experienced shortness of breath from the beginning of COVID-19 infection [DATE] and became worst as time progressed. Staff 9 stated, She was really weak, we literally had to physically hold her to sit up. She was unable to hold herself up on her own. She was really sick . Staff 9 stated Resident 32 would receive oxygen therapy at 2 liters for her shortness of breath. Staff 9 stated LVN's were assigned 25 to 30 residents and when residents began to experience COVID -19 symptoms and had IV therapy. Staff 9 stated, It was impossible to conduct a full resident assessment. Staff 9 stated, We did the best we could. Staff 9 stated the Administrator and DON were aware of residents' increase acuity level and that LVN's were having difficulty keeping up with the workload, but nothing was done to help licensed nursing staff. Staff 9 stated the DON was aware of residents increased level of acuity when the DON administered IV therapy to all residents with COVID-19 infection. Staff 9 reviewed Resident 32's MAR on [DATE] and stated the initials on the MAR were hers and not the DON's. Staff 9 reviewed Resident 32's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 9 stated Resident 32 was monitored once every 24 hours for [DATE], [DATE] and [DATE] and resident was complaining of shortness of breath on those days. Staff 9 stated based on residents' respiratory condition she should have been monitored every 30 minutes. Staff 9 stated Resident 32 should have been sent to the hospital before her condition became critical and that was not done. During an interview on [DATE] at 4:56 p.m., with the DON, the DON stated during the COVID-19 outbreak in [DATE], she agreed with the plan to allow the PA to prepare and deliver IV Immune Boost therapy from her office because the PA could deliver the IV therapy faster than the facility contracted licensed pharmacy. The DON stated she acknowledges that any resident sick enough to need urgent IV fluids and not wait for the IV fluids to come through the pharmacy should have been sent to the hospital. The DON stated the facility was unaware of where the PA obtained the IV fluid from. The DON stated the risk taken by the facility to allow the PA to use IV fluids from an unknown source and mixing IV fluids in her private office without contracted licensed pharmacist oversight placed residents receiving the potentially unsterile, and unsafe IV Immune Boost therapy at risk for serious infection and possible [CONDITION(S)]. The DON stated the facility only had her (DON) and the weekend RN to oversee residents experiencing respiratory decline and needing IV therapy. The DON stated she received the IV Immune Boost therapy orders either on the telephone or in person from the PA. The DON stated she did not know how to enter orders into the clinical record or how to sign the MAR so she relayed the orders given to her by the PA to Staff 9 [LN- not IV certified/trained] and Staff 9 would enter the IV Immune Boost prescription into the resident clinical records. The DON stated she did not know Staff 9 was not IV certified and the facility did not have additional RN's to help her. The DON stated the standard of practice would require IV certified licensed nurses to speak with provider directly, readback orders to the provider for accuracy and enter the orders themselves. The DON stated the nurses have not received training or competency skills check for IV's since she started to work as the DON of the facility in early late [DATE]. During an interview on [DATE] at 4:58 p.m., with the ADM, the ADM stated he thought the facility had enough licensed nursing staff to resident ratio at the time of the COVID-19 outbreak and IV therapy ,d+[DATE]. The ADM stated now he realized the residents that received IV therapy were at a higher skill level and the facility should have brought in RNs to care for the residents who received IV therapy. The ADM stated additional RN's were not brought in to care for residents experiencing higher medical needs and IV therapy. During a concurrent interview and record review on [DATE] at 7:25 p.m., with Staff 14 (LN), Resident 13 and Resident 53's MAR dated ,d+[DATE] was reviewed with Staff 14. The MAR indicated, on [DATE] Staff 14 signed as the nurse who administered the IV therapy. Staff 14 stated she came to work on the night shift on [DATE] and the IV therapy was already running for Resident 13 and Resident 53. Staff 14 stated she did not administer the IV therapy to the two residents. Staff 14 stated she signed the MAR as the nurse who administered the IV therapy. Staff 14 stated she was assigned 25 to 30 residents during the COVID-19 virus outbreak and the facility did not have sufficient Licensed Nurses to care for the resident that were experiencing respiratory difficulty and were on IV therapy. Staff 14 stated residents experiencing breathing difficulties and on IV therapy were not assessed because the facility did not have sufficient staff that were competent to conduct those assessment. Staff 14 stated the ADM and DON were aware the facility did not have sufficient Licensed Nurses because the DON was the RN administering all the IV therapy to COVID-19 positive residents. Staff 14 stated additional nurses were not added to meet residents increased level of care, COVID-19 and IV therapy needs. During a concurrent interview and record review on [DATE] at 7:25 p.m., with Staff 14, Resident 28's Medication Administration Record (MAR), dated ,d+[DATE] was reviewed. The MAR indicated, on [DATE] Staff 14 signed as the nurse who administered the IV therapy. Staff 14 stated when she came to work the IV therapy was already running and she was not sure who started it. Staff 14 stated she did not administer the IV therapy to Resident 28. Staff 14 stated the MAR was signed by the person who administered the medication and she did not administer the IV therapy and should not have signed it. Staff 14 stated the facility had not performed education or competency checks for IV therapy since she started in ,d+[DATE]. During a review of Resident 35's Admission Record, Resident information (document with resident demographic and medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 35's lab results for COVID-19 virus test dated [DATE], lab indicated Resident 35 was tested on [DATE] and results indicated positive for COVID-19. During a review of Resident 35's MDS assessment dated [DATE] indicated Resident BIMS assessment score of 15 (,d+[DATE] scale with 15 indicating no cognitive deficits with intact memory and judgement). During a concurrent interview and review of Resident 35's clinical record on [DATE], at 4:40 p.m., with the DON, the Progress note dated [DATE], at 10:15 a.m., indicated Resident 35 was experiencing cough with slightly elevated temperature. Progress note dated [DATE], at 2:17 a.m. indicated, While providing care . resident [35 complained] shortness of breath, [oxygen level] 88% on room air .has cough . LVN notified MD .Progress note dated [DATE], at 3:05 p.m., indicated Resident 35 was experiencing bouts of confusion, intermittent shortness of breath and cough. Resident 35 had an IV. The DON stated the progress note did not indicate the reason for the IV therapy. Progress note dated [DATE], at 8:00 p.m. indicated, Resident [35 had] temperature 101.2 at [7 pm] cooling measures initiated .: The DON stated the progress note did not contain a documented assessment. Progress noted dated [DATE], at 9:00 p.m., indicated Resident 35 was receiving IV medication . experiencing cough, breath sounds adventitious- wheezing [abnormal lung sounds] LVN had resident with cooling measures. The DON stated the progress note did not contain a body temperature reading or oxygen level. Progress note dated [DATE], at 8:11 p.m., indicated Resident 35 was experiencing intermittent shortness of breath .oxygen level at 94% with 2 liters of oxygen. Progress note dated [DATE], at 8:17 p.m., indicated Resident 35 was experiencing intermittent shortness of breath, and cough with oxygen level at 90% with 2 liters of oxygen therapy. Progress note dated [DATE], at 1:37 a.m., indicated Resident 35 was experiencing altered level of consciousness, shortness of breath with oxygen level of 88% on room air . LVN notified Physician who gave order to send resident to the emergency room . Progress note dated [DATE] at 2:04 a.m. indicated Resident 35 was experiencing labored [struggle] breathing, . oxygen level 89% and was given 2 liters of oxygen. LVN informed Resident 35's son on the phone and son was requesting for his mother to be sent out to the hospital. Ambulance was called and Resident 35 was sent to the hospital. The DON stated Resident 35 died in the hospital on [DATE]. The DON stated the progress notes did not contain an RN assessment of Resident 35 ongoing oxygen decline related to her COVID -19 virus infection and IV therapy. The DON stated LVN's were monitoring Resident 35 once every 24 hours. The DON stated the progress noted did not contain a full assessment of Resident 35's respiratory decline and it should have. The DON stated, If we sent her out to the hospital sooner, what could the hospital do, just sent her back to us. She had COVID [19]. We did the best we could do . During a concurrent interview and review of Resident 35's clinical record on [DATE] at 3:21 pm. with the DON, Resident 35's Mar was reviewed with the DON. Resident 35's MAR dated ,d+[DATE] indicated, 1,000ml of [MEDICATION(S)] mixed with Vitamin C 3000 mg,/ B complex 2 ml, [MEDICATION(S)] 20 mg, Magnesium 200 via IV at 200 ml/ Hr to be ran for 5 hours by gravity .for dehydration start on [DATE] at 1700 [5:00 p.m.]. The MAR indicated [Staff 9] signed as the nurse who administered the IV therapy at 6:56 p.m. The DON stated she administered all the IV therapies during the facility COVID-19 virus outbreak. The DON stated it took her all day long to administer 10 to 12 IV bolus therapies to residents with COVID-19 infections because the facility did not have additional RN's. The DON stated she did not initial as the nurse who administered the IV therapy because she did not know how to access the electronic MAR and did not know how to document in the electronic clinical record. The DON reviewed Resident 35's MAR and was unable to find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 35's clinical record did not contain a prescription for IV insertion and an order should have been obtained. The DON reviewed the clinical record and was unable to find RN assessments indicating resident clinical condition requiring the IV therapy, or hydration assessment. The DON stated, We do not have that. During a review of Resident 36's COVID-19 virus test dated [DATE], indicated Resident 36 tested positive for COVID-19 on [DATE]. During a review of Resident 36's MDS assessment dated [DATE] indicated Resident 36's BIMS assessment score of 12 (,d+[DATE] scale with 12 indicating moderate cognitive deficits with memory and judgement). During a concurrent interview and review of Resident 36's clinical record on [DATE], at 4:55 p.m., with the DON, the COVID-19 daily Skilled Documentation dated [DATE] at 3:45 indicated Resident 36 complain of shortness of breath and to monitor for Emergency warning signs .trouble breathing .confusion .inability to arouse .every shift. The DON stated the clinical record did not contain a nursing note for [DATE] for monitoring of Resident 36's emergency warning signs. Progress note d [TRUNCATED]

Based on interview and record review, the facility failed to provide care in accordance with professional standards of practice and conduct Respiratory decline, IV therapy need and wound assessment of residents for 24 of 24 (Residents 10, 12, 13, 17,18, 19, 20, 27, 28, 30, 32, 33, 37, 35, 36, 45, 46, 47, 48, 49, 50, 51, 52, and 53) residents when: 1. Residents 32, 35 and 36 were diagnosed with [CONDITION(S)] CoV2 (COVID-19- a serious contagious respiratory [Lung] infection transmitted from person to person) on [DATE] and [DATE] and nursing staff did not conduct respiratory (oxygen) decline Registered Nurse (RN) assessments, oxygen status monitoring and did not identify and promptly act on signs and symptoms of deteriorating respiratory status. These failures resulted in residents 32, 35 and 36 not providing the respiratory support needed for complaints of shortness of breath, resulted in residents experiencing pain, suffering, and hospitalization and in the case of Resident 32 and Resident 35 death and resulted in the administration of potentially unsterile and unsafe IV therapy and had the potential for harm of fluid overload and the potential to result in injury and/or death of residents receiving IV therapy for 24 of 24 residents. 2. Nursing staff failed to accurately assess skin integrity and utilize factors that could increase the risk of pressure ulcers for Residents 50 and 31 and did not implement appropriate interventions. Nursing staff failed to communicate accurate skin assessments to the Wound Doctor in order to provide necessary treatment to promote healing for Residents 50 and 31. These failures resulted in Resident 31 and Resident 50 developing and worsening pressure related wounds on heels, worsening to an open wound with dark tissue, and Resident 31 developed an additional wound which placed him at additional risk for wound infection. Findings: 1. During a review of Resident 32's Admission record, Resident information (document with resident demographic and medical diagnosis) undated, indicated Resident 32 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .stage 4) kidney disease (severe kidney damage), Chronic Obstructive Pulmonary Disease ([CONDITION(S)]- chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs), and Mild Intermittent Asthma (condition in which the airways (the tubes that carry air in and out of the lungs) narrow and swell causing reversible obstruction). During a review of Resident 32's Laboratory (lab) results for COVID-19 virus test dated [DATE], lab result indicated Resident 32 was tested on [DATE] with positive COVID-19 test results received on [DATE]. During a review of Resident 32's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical functional level) assessment dated [DATE] indicated Resident 32's Brief Interview for Mental Status (BIMS) assessment score of 15 (,d+[DATE] scale [,d+[DATE] severe cognitive deficit, ,d+[DATE] moderate cognitive deficit, ,d+[DATE] no cognitive deficit]) indicating Resident 32 had no cognitive deficits, and had intact memory and judgement. During a concurrent interview and review of Resident 32's clinical record on [DATE], at 2:38 p.m. through 3:20 p.m., with the DON, the DON stated the facility began experiencing COVID-19 virus outbreak (a sudden rise in the number of cases of a disease) on the first week of [DATE]. The DON stated the outbreak began with facility staff testing COVID-19 positive on the week of [DATE] and the facility began to test all resident and staff. The DON reviewed Resident 32's clinical record and stated Resident 32 had been tested for COVID -19 on [DATE] and results received on [DATE] indicated Resident 32 tested positive. The DON reviewed progress note dated [DATE] at 3:49 p.m., indicating Resident 32 was to receive IV infusion medication over 1 hour. The progress note indicated, Monitor [Resident 32] for 1 hour after infusion. The DON stated Resident 32 did not receive the IV medication because the medication was not available. The progress note dated [DATE] at 4:21 p.m., indicated Resident 32, .showing signs of weakness and fatigue .exhibiting signs of lethargy (condition causing drowsiness and an unusual lack of energy and mental alertness) . Licensed Vocational Nurse (LVN) notified medical provider via (by way of) phone. New orders were given for, IV bolus (is a large dose, rapid infusion of medication or fluid into the bloodstream) NS [normal saline - medicine used for fluid and electrolyte (fluid in the body that conducts electrical energy to facilitate important bodily functions)] at 125 ml(milliliters)/hr(hour) related to lethargy (drowsy, slow to respond) .IV in place to left hand by DON .No s/s [signs and symptoms] of fluid overload .will continue to monitor . The DON reviewed Resident 32's MAR dated ,d+[DATE] for IV NS fluids and stated the initials on the MAR were Staff 9's not hers. The DON reviewed Resident 32's physician orders and nursing notes and was unable to find an order or documentation for the IV insertion. The DON stated the LVN (Staff 9-Licensed Vocational Nurse) was monitoring Resident 32 and was the nurse that would document fluid overload status. The DON stated she was the only nurse that was inserting IV's and administering IV fluids during the outbreak but had not ensured Resident 32 had physician orders for IV insertion and an assessment indicating Resident 32's condition requiring IV fluids prior to beginning treatment. The DON stated she and had not documented on the MAR as the nurse administering the IV fluids. The DON reviewed Resident 32's progress note dated [DATE] at 11:15 a.m., indicated, During vitals [measurement of heart, blood pressure, temperature and respiration rate] check at 10:00 a.m., resident respirations were increased and seemed labored .Resident 02 [oxygen] sat [saturation- oxygen measurement in the blood] between 89%-91% (percent) on room air (According to Resident 32's baseline (normal level) vital signs dated [DATE]- ,d+[DATE] /21, blood oxygen saturation levels were are ,d+[DATE] percent). Notified MD [Medical Doctor] . Order .2L [liters] 02 via nasal cannula [nose- oxygen tubing] for difficulty breathing . The DON reviewed Resident 32's clinical record and was unable to find Registered Nurse assessment of decline in oxygen level. The DON reviewed progress note dated [DATE] at 8:30 p.m. which indicated, Resident [32] is on alert charting, new order for 1000 ml (milliliter- unit of measurement) of [MEDICATION(S)] [a mixture of [MEDICATION(S)] [salt water], sodium [MEDICATION(S)] [salt from sugar source], potassium chloride, and calcium chloride in water] w/ [with] Vitamin C 3000 mg, B-complex 2 mls (milliliters), [MEDICATION(S)] 20 mg, Magnesium 200 mg via IV at 200ml/hr .[completed by LVN] The progress noted dated 9:30 p.m., indicated Resident 32, Completed IV fluids last night. No s/s of fluid overload [LVN] had cough and was started on [MEDICATION(S)] (medication to treat infection). The progress note dated [DATE], at 12:57 a.m., indicated, Resident observed to have altered mental status. Resident [32] clenching chest, screaming out. Resident in acute distress. Resident . yelling 'send me to the hospital I am going to die' . [Resident] Sent to Emergency Department [ED] for further evaluation . The DON stated by the time Resident 32 arrived at the ED she was having a heart attack. The DON reviewed Resident 32 progress notes and stated LVNs were monitoring Resident 32's IV therapy. The DON reviewed Resident 32 clinical record and was unable to find Registered Nurse (RN) documentation of date and time of IV catheter (tubing) insertion, number of IV venipuncture attempts (sticks), condition of IV catheter on insertion and removal, IV site assessment, resident response to IV therapy, assessment indicating reason for IV therapy and procedure, complication and resident teaching. The DON stated she had delegated to LVN's to monitor Resident 32 so why would an RN need to conduct the monitoring, documentation, or assessments. The DON stated Intake and Output (I&O) were not taken for residents on IV immune boost or hydration IV therapies and I&O's should have been done. During a review of professional reference from the Centers for Disease control and Prevention (CDC), retrieved from https://www.cdc.gov/coronavirus/2019-nCoV/index.html, dated 2019 indicated, What are some of the warning signs of low oxygen levels in people with COVID-19 . An oxygen saturation of 95 to 100 percent is normal for healthy adults. Warning signs of a low oxygen level include trouble breathing, confusion, difficulty waking up, and bluish lips or face . During a review of Centers for Disease Control and Prevention (CDC) People at Increased Risk for Severe Illness .Older adults dated [DATE], indicated, .Precautions for Nursing Homes . Regularly check . residents for fevers and symptoms . If you or someone you know has COVID-19 emergency warning signs (e.g., trouble breathing, persistent chest pain, new confusion, inability to wake or stay awake, or pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone or face), seek emergency care immediately. Call 911 . A care plan can have benefits beyond the current pandemic .update your care plan . any time you have a change in your health or medicines. Care plans can help reduce emergency room visits and hospitalization s and improve overall medical management for people with a chronic medical condition, resulting in better quality of life . a care plan is an important part of emergency preparedness . During a concurrent interview and review of Resident 32's clinical record on [DATE], at 3:22 p.m., with the DON, the MAR dated ,d+[DATE] indicated, 1,000ml of [MEDICATION(S)] mixed with Vitamin C 3000 mg,/ B complex 2 ml, [MEDICATION(S)] 20 mg, Magnesium 200 via IV at 200 ml/ Hr .for COVID-19 start on [DATE] at 1300 [1:00 p.m.]. The MAR indicated [Staff 9] signed as the nurse who administered the IV therapy at 3:57 p.m. (1 hour and 57 minutes later than 1 hour following the start of the preparation of the IV compounded therapy). The DON stated the Physician Assistant (PA) had ordered the administration of the IV therapy for residents who tested COVID-19 positive. The DON stated the medical need for the IV therapy was for weakness, fatigue or when the resident looked tired. The DON stated she administered all the IV therapies during the facility COVID-19 virus outbreak, approximately 20 to 25 IV therapies were administered to residents who tested positive with COVID-19. The DON stated it took her all day long to administered IV therapies to residents. The DON reviewed the MAR and was unable to find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 32's clinical record did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reviewed the clinical record and was unable find to care plans or assessments for complaints of shortness of breath, IV therapy, or antibiotic [MEDICATION(S)] to treat COVID-19 virus. The DON stated, we do not have that. The DON reviewed Resident 32's COVID-19 positive care plan dated [DATE] which indicated, Resident tested COVID-19 positive after possible exposure from staff .interventions monitor vital signs q 4 [hours] and PRN [as needed] report abnormalities to MD [Medical Doctor] . Monitor for emergency Warning signs: trouble breathing, persistent pian .Pressure in the chest .confusion .q [every shift . The DON stated the facility did not follow the care plan intervention of monitored Resident 32 every shift for emergency warning signs. The DON stated, At least LVN's monitored once every 24 hours. The DON stated the facility did not begin monitoring Resident 32 vital signs on [DATE] as indicated on the care plan intervention and began monitoring of the vital signs every 4 hour on [DATE] (4 days later). The DON stated the facility did not implement COVID-19 care plan intervention for Resident 32 vital signs and monitoring and responding to emergency warning signs on every shift and they should have. During a concurrent interview and record review with Staff 10 on [DATE], at 3:45 p.m., Staff 10 (Licensed Nurse-LN) reviewed Resident 32's clinical record and stated she worked with Resident 32 when she had tested positive for COVID-19 virus. Staff 10 reviewed Resident 32's progress noted dated [DATE] at 12:37 a.m. and stated prior to Resident 32 testing positive for COVID-19 she was alert, a cheerful, very active and social lady with staff and roommates. Staff 10 stated Resident 32 enjoyed her independence as much as she could. Staff 10 stated Resident 32 became really sick after she was infected with COVID-19. Staff 10 stated she was assigned 25 to 28 residents that were really sick and she was doing the best she could to care for all residents under her care. Staff 10 stated she was trying to monitor all resident that were COVID-19 positive and had IV therapy but she was unable to keep up with all the work. Staff 10 stated she was not be able to keep up with the workload. Staff 10 reviewed progress note dated [DATE] which indicated Resident 32 was really sick. Staff 10 stated, This is really bad documentation of a resident [32] that was really sick. Staff 10 stated She [Resident 32] needed to go to the emergency room , sooner. Staff 10 stated LVNs were not able to meet resident's high acuity medical needs and the Administrator and DON did not agree the facility needed additional Licensed Nurses. Staff 10 stated the acuity of resident experiencing COVID-19 symptoms, IV therapy and having so many residents assigned to a nurse made it impossible to attend or respond to resident that were experiencing respiratory issue. Staff 10 stated the Administrator and DON knew staff were struggling but nothing was done to help. Staff 10 stated, We did the best we could. Staff 10 stated she had worked at the facility for a little over one year and had not received IV competencies skills check. Staff 10 stated she would feel more comfortable caring for resident with IV's if the facility had offered and provided IV competencies skills. During a concurrent observation, interview, and review of Resident 32's clinical record on [DATE] at 4:48 p.m., with Staff 9, at nurses' station, Staff 9 stated she was not aware if the facility had IV therapy protocols or policy and procedures. Staff 9 looked for policies at the nurse's stations and stated, We don't have policies and procedures or protocols for IV therapy. Staff 9 stated LVN's would monitor resident receiving IV therapy by checking oxygen levels and listen for lung sounds. Staff 9 stated, Things were crazy busy almost all resident were COVID [positive]. Staff 9 reviewed Resident 32's clinical record and was unable to find documented assessments and monitoring nurses notes for [DATE], [DATE], and [DATE]. Staff 9 stated she had been on duty for most of the COVID-19 virus outbreak in the facility on the month of January. Staff 9 stated LVN's documented a brief assessment on the COVID-19 daily skilled documentation form. Staff 9 reviewed Resident 32's COVID-19 daily skilled documentation dated [DATE] and stated Resident 32 was experiencing shortness of breath, cough, and body aches. Staff 9 stated she had documented no COVID symptoms on the same COVID-19 daily skilled documentation form which was not an accurate assessment. Staff 9 stated Resident 32 had been experiencing shortness of breath, and a bad cough. Staff 9 stated Resident 32 had been experiencing oxygen decline from the beginning of her infection [DATE] and became worst as time progressed. Staff 9 stated, She was really weak, we literally had to physically hold her up to sit up. She was unable to hold herself up on her own. She was really sick . Staff 9 stated Resident 32 would receive oxygen therapy at 2 liters for her breathing difficulty. Staff 9 LVN's were assigned 20 to 30 resident and when resident began to experience COVID -19 symptoms it was impossible to conduct a full assessment. Staff 9 stated, We did the best we could. Staff 9 stated the Administrator and DON were aware of residents increase acuity level and that LVN's were having difficulty keeping up with workload, but nothing was done to help. Staff 9 stated the DON aware of the resident increase acuity she was administering IV therapy to residents. Staff 9 reviewed Resident 32's MAR on [DATE] and stated the initiated on the MAR were hers and not the DON's. Staff 9 reviewed Resident 32's Physician orders and stated that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 9 stated Resident 32 was only monitored once within a 24-hour period on [DATE], [DATE] and [DATE] when resident was having breathing difficulties. Staff 9 stated based on residents' respiratory decline she should have been monitored every 30 minutes and send her to the hospital before her condition became critical and that was not done. During a concurrent interview and review of Resident 32's clinical record review on [DATE], at 5:56 p.m., with the DON, the DON reviewed Resident 32 care plans and was unable to find a care plan for the administration of IV therapy, and [MEDICATION(S)] for COVID-19 virus. The DON stated care plan were not developed and the facility did not have IV therapy protocols to guide nurse on IV standards of practice and monitoring. The DON stated the facility may have an IV policy, but she would look for it. The DON stated Resident 32 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 32's medical conditions required increase monitoring and prompt response when emergency warning signs of shortness of breath and trouble breathing occurred. The DON reviewed COVID-19 daily skilled documentation indicating Residents should be monitored .every shift the DON stated that did not occur. The DON stated the hospital record for Resident 32 indicated that by the time Resident 32 arrived at the emergency room she was experiencing a heart attack. The DON stated the facility did not conduct resident acuity assessments which resulted in resident not receiving the level of care and monitoring required for the emergency symptoms Resident 32 was experiencing. 1b.During a review of Resident 35's Admission Record, Resident information (document with resident demographic and medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 35's lab results for COVID-19 virus test dated [DATE], lab indicated Resident 35 was tested on [DATE] and results indicated positive for COVID-19. During a review of Resident 35's MDS assessment dated [DATE] indicated Resident BIMS assessment score of 15 (,d+[DATE] scale with 15 indicating no cognitive deficits with intact memory and judgement). During a concurrent interview and review of Resident 35's clinical record on [DATE], at 4:40 p.m., with the DON, the Progress Note dated [DATE], at 6:38 p.m. indicated Resident 35 was experiencing mild confusion. Progress note dated [DATE], at 11:09 p.m. indicated resident was complaining of pain. Progress note dated [DATE], at 1:56 a.m. indicates Resident 35's oxygen level was 93% on room air, LVNs will continue to monitor. Progress note [DATE], at 10:15 a.m., Resident 35 was experiencing cough with slightly elevated temperature. Progress note dated [DATE], at 9:40 p.m. indicated Resident 35 was experiencing cough with oxygen level 93% on room air. Progress note dated [DATE], at 2:17 a.m. indicated, While providing care . resident [35 complained] shortness of breath, [oxygen level] 88% on room air .has cough . LVN notified MD and new order was received for oxygen at 2 liters as needed to maintain oxygen level greater than 90 %. Progress note dated [DATE], at 3:05 p.m., indicated Resident 35 was experiencing bouts of confusion, intermittent shortness of breath and cough. Resident 35 receiving [MEDICATION(S)] and had an IV. The DON stated the progress note did not indicate the reason for the IV Immune Boost therapy. Progress note dated [DATE], at 8:00 p.m. indicated, Resident [35] temperature 101.2 at [7 pm] cooling measures initiated .[MD] notified .new orders . Tylenol [medication to treat temperature] [MEDICATION(S)] [medication to treat inflammation] .[oxygen level] 93% on 02 L . Progress note dated [DATE], at 9:00 p.m., indicated Resident 35 was receiving IV medication . experiencing cough, breath sounds adventitious- wheezing [abnormal lung sounds] LVN had Resident 35 with cooling measures. The DON stated the progress note did not contain Resident 35's body temperature reading or oxygen level. Progress note dated [DATE], at 8:11 p.m., indicated Resident 35 was experiencing intermittent shortness of breath and cough. Progress note dated [DATE], at 8:17 p.m., indicated Resident 35 was experiencing intermittent shortness of breath, and cough with oxygen level at 90% with 2 liters of oxygen therapy. Progress note dated [DATE], at 1:37 a.m., indicated Resident 35 was experiencing altered level of consciousness, shortness of breath with oxygen level of 88% on room air, temperature 99.6. LVN notified Physician who gave order to send resident to the emergency room . Progress note dated [DATE] at 2:04 a.m. indicated Resident 35 was experiencing labored breathing, adventitious lung sounds-wheezing, oxygen level 89% and was given 2 liters of oxygen. LVN informed Resident 35's son on the phone and son was requesting for his mother to be sent out to the hospital. Ambulance was called and Resident 35 was sent to the hospital. The DON stated Resident 35 died in the hospital on [DATE] from COVID-19 complications. The DON stated none of the progress note contained an RN assessment of Resident 35 ongoing medical decline related to her COVID -19 virus infection. The DON stated LVN's were monitoring Resident 35 at least once within 24 hours. The DON stated the progress note did not contain a full assessment of Resident 35's respiratory decline. The DON stated, If we sent her out to the hospital sooner, what could the hospital do, just sent her back to us. She had COVID [19]. We did the best we could do . During a review of professional reference mayoclinic.org 2021, retrieved from https://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 normal blood oxygen saturation levels in humans are ,d+[DATE] percent. During a concurrent interview and review of Resident 35's clinical record on [DATE] at 4:55 p.m., with Staff 9, Staff 9 reviewed Resident 35's clinical record and stated LVN's documented a brief assessment on the COVID-19 daily skilled documentation form. Staff 9 reviewed Resident 35's clinical record dated [DATE] and stated Resident 35 was experiencing shortness of breath, cough, and confusion. Staff 9 stated Resident 35 had been experiencing shortness of breath, and confusion and related her confusion to Liver failure not COVID-19 symptoms. Staff 9 stated Resident 35 would receive oxygen therapy at 2 liters for her breathing difficulty. Staff 9 stated LVN's were assigned 20 to 30 residents and when resident began to experience COVID -19 symptoms it was impossible to conduct a full assessment. Staff 9 stated, we did the best we could. Staff 9 stated the Administrator and DON were aware of Residents increase acuity level and that LVN's were having difficulty, but nothing was done to help. Staff 9 stated the DON was aware of the residents increase acuity she was administering IV therapy to residents. Staff 9 reviewed Resident 35's MAR on [DATE] and stated the initiated on the MAR were hers and not the DON's. Staff 9 reviewed Resident 35's Physician orders and stated that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 9 stated most resident were being monitored only once within a 24-hour period because residents acuity level was too much for one nurse to do. Staff 9 stated when Resident 35 began experiencing increase respiratory difficulty, they should have been monitored every 30 minutes and send resident to the hospital before the condition became critical. During a concurrent interview and review of Resident 35's clinical record on [DATE] at 3:21 pm. with the DON, Resident 35's MAR dated ,d+[DATE] indicated, 1,000 ml of [MEDICATION(S)] mixed with Vitamin C 3000 mg,/ B complex 2 ml, [MEDICATION(S)] 20 mg, Magnesium 200 via IV at 200 ml/ hr to be ran for 5 hours by gravity .for dehydration start on [DATE] at 1700 [5:00 p.m.]. The MAR indicated [Staff 9] signed as the nurse who administered the IV therapy at 6:56 p.m. (56 minutes late). The DON stated she administered all the IV therapies during the facility COVID-19 virus outbreak. The DON stated it took all day long to administered batches of 10 to 12 IV therapies to residents. The DON reviewed the MAR and was unable to find documentation indicating she administered the IV therapy and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated an order should have been obtained. The DON reviewed the clinical record and was unable to find care plans for the IV therapy, and dehydration. The DON stated, we do not have that. During a concurrent interview and clinical record review for Resident 32, on [DATE], at 6:48 p.m., with the DON, the DON stated the facility did not have IV therapy standard of practice protocols. The DON stated Resident 35 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 35's medical conditions required increase monitoring and prompt response when emergency warning signs like shortness of breath and trouble breathing occurred. The DON reviewed the daily skilled documentation indicating Resident 35 should have been monitored for Emergency signs .every shift DON stated, monitoring on every shift did not occur. DON stated the hospital informed the facility that Resident 35 died at the hospital the day she arrived. The DON stated the facility did not conduct resident acuity assessments which resulted in resident not receiving the increase level of care required for the symptoms Resident 35 was experiencing. 1c.During a review of Resident 36's Admission Record, Resident Information undated, the Admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 36's COVID-19 virus test dated [DATE], indicated Resident 36 tested positive for COVID-19 on [DATE]. During a review of Resident 36's MDS assessment dated [DATE] indicated Resident 36's Brief Interview for Mental Status (BIMS) assessment score of 12 (,d+[DATE] scale with 12 indicating moderate cognitive deficits with memory and judgement). During a concurrent interview and review of Resident 36's clinical record on [DATE], at 4:55 p.m., with the DON, the COVID-19 daily Skilled Documentation dated [DATE] at 3:45 indicated Resident 36 was complaining of shortness of breath and to monitor for Emergency warning signs .trouble breathing .confusion .inability to arouse .every shift. The DON stated the clinical record did not contain a nursing noted for [DATE] for monitoring of Resident 36's emergency warning signs. Progress note dated [DATE] at 6:36 p.m., indicated, Resident [36] is more lethargic and sleepier. Shortness of breath . [has] altered level of consciousness . [oxygen level at] 72% [with oxygen at 2 liters]. Progress note dated [DATE] at 7:12 p.m., indicated, Resident appears lethargic. O2 sats [oxygen saturation rate] 72% [with] 2 [liters of oxygen] .sent to ER [emergency room ]. The DON stated the benefit of the LVN administering oxygen at 2 liters when resident was experiencing an oxygen level of 72 % was like Someone peeing in the ocean no effect. The DON stated oxygen at 2 liters would have no benefit because the oxygen level was too low. The DON stated at least resident was sent to the emergency room . The DON stated Resident 36's clinical record did not contain RN assessment when Resident 36 was experiencing emergency warning respiratory symptoms. The DON stated Resident 36 was hospitalized and returned the facility where she recovered During a concurrent interview and review of Resident 36 clinical record on [DATE], at 6:42 p.m., with the DON, the DON reviewed Resident 36 clinical record and stated Resident 36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated Resident 36's medical conditions required increase monitoring and prompt response when emergency warning signs like shortness of breath and trouble breathing occurred. The DON reviewed the daily skilled documentation indicating Residents should be monitored for Emergency signs .every shift the DON stated that did not occur. The DON stated the facility did not conduct resident acuity assessments which resulted in Resident 36 not receiving the level of care required for the symptoms Resident 36 was experiencing. During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated ,d+[DATE], the P&P indicated, .A comprehensive person centered care plan that includes measurable objectives and interventions [will be developed] to meet the residents physical .needs .The person centered care plan will .describe services that are furnished .include .goals . and desired outcomes .incorporate identified problem areas .Incorporate risk factors, associated with identified problems .Aid in preventing or reducing decline in the residents' functional status and or functional levels .The Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of resident's problem areas and their causes .Assessments of resident should be ongoing and care plans revised as information about the resident and the resident condition change . During a review of the facility's policy and procedure titled, Peripheral (near the skin surface) IV Catheter Insertion dated ,d+[DATE], indicated, .The purpose of this procedure is to provide guidelines for the safe and aseptic insertion of a peripheral intravenous catheter for the administration fluids and/or medications .Steps in the procedure .(1) Verify with the state Nurse Practice Act for LPN[Licensed Practice Nurse]/ RN function and competency requirements (2) A physician's order is necessary for this procedure .Documentation: The following information should be recorded in the resident's medical record: .(2) The number of venipuncture attempts (maximum of two) (3) The type, length and gauge of catheter, and type of cleansing agent used .(10) residents' response to procedure (11) the signature and title of the person [performing the procedure] . During a review of document titled, VOCATIONAL NURSING PRACTICE ACT WITH RULES AND REGULATIONS dated, [DATE], indicated, .Start and superimpose intravenous fluids if all of the following additional conditions exist: (1) The nurse has satisfactorily completed a prescribed course of instruction approved by the board or has demonstrated c [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide supervision and assistance during meals on [DATE] for one of three sampled residents (Resident 50). When Resident 50 was diagnosed with dysphagia (difficulty in swallowing), and contractures (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity which results in pain and loss of movement in the joint) of his hands and assessed to need one-person physical assist during meals and was not provided the assistance on [DATE] for the noon time meal. This failure resulted in Resident 50 being unsupervised and unassisted during lunch and Resident 50 poured his soup into a cup in order to drink the meal, choked on the meal, could not breathe, turned blue and required transport to the Emergency Department (ED) for higher level of care. This failure resulted in the potential harm of injury and/or death. Findings: During a review of Resident 50's face sheet (a document containing resident profile information) indicated Resident 50 was [AGE] year-old, admitted to the facility on [DATE] with diagnoses which included dysphagia, Contracture of Muscles, Muscle spasms (is an involuntary contraction of a muscle that can cause a great deal of pain), lack of coordination, muscle weakness and complete loss of teeth. During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated [DATE] indicated Resident 50's Brief Interview for Mental Status (BIMS- assessment of cognitive status for memory and judgement) score of 6 of 15 points (6 = severe cognitive impairment). Functional status assessment indicated Resident 50 required supervision (oversight, encouragement, or cueing) and one staff members physical assistance with meals. Resident 50's Functional Limitation in Range of Motion assessment indicated Resident 50 had impairment and limitations on both shoulders, elbow, wrist, and hands that interfered with his daily functions and placed resident at risk of injury. Swallowing assessment indicated Resident 50 had problems and difficulty with swallowing. During an observation on [DATE], at 12:20 p.m., through 1:09 p.m., in hallway, Certified Nursing Assistance (CNA) 1 stepped out of Resident 50's room and walked quickly down the hallway towards the nurse's station and reported to Staff 9, [Resident 20] is choking. Staff 9 stood up from her chair at the nurses' station and waked down the hallway into Resident 50's room approximately 100 feet away from nurse's station. Out in hallway in front of Resident 50's room approximately 20 feet way, Resident 50 could be heard moaning and gurgling (gurgle - throat noise with an accompanying wet bubbling sound) loudly. Staff 9 began slapping Resident 50's upper back and asking Resident 50 to, open your mouth, I need to get my finger in your mouth to get [object] out of your mouth. I can't see it. Open your mouth . Resident was heard forcefully coughing and gurgling. CNA 1 stated, The resident is choking! with licensed nurses Staff 9 in room stated, 'Let me put my finger in your mouth and check. Staff 9 stated, Open up so I can stick my finger in there. Staff 8 put her finger in Resident 50's mouth. Staff 9 was making resident gag (a feeling and noises of throwing up). Staff 9 stated, [Resident 50] you're doing good, open mouth. Resident began yelling. CNA 2 entered room at 12:37 p.m., Holding resident up Staff 9 asked Resident 50, big cough for me, resident coughing. Staff 9 asked Resident 50 how are you feeling? Resident 50 stated in gurgling voice, like hell. At 12:39p.m., CNA 2 brought a stethoscope (a medical instrument for listening to the action of someone's heart or breathing) into Resident 50's room. Staff 9 began listening to Resident 50's lung sounds. At 12:41 Staff 9 asked CNA 2 stated, bring 02 sat (Pulse oximetry (ox) medical devise to measure oxygen level). Staff 9 stated, We will get x-ray. [asked resident 50] how long have you been coughing? Resident 50 stated, Can't catch my breath while moaning and gurgling loudly. Staff 9 and CNA 1 prompted resident up in sitting position. Resident 50's meal tray was by his bed side. The meal tray had uncut carrots, and hot dog. At 12:46 p.m., Resident 50's gurgling and coughing. CNA 2 enters the room with pulse Ox. At 12:47 p.m., [27 minutes after the choking episode began] the Director of Staff Development (DSD- the second Licensed nurse arrived) entered Resident 50's room. Staff 9 stated, I can hear something in [Resident 50's] upper lungs. Resident 50 was observed with continued forced cough, moaning, and gurgling loudly. They [CNA 1] told me he was choking. O2 sat 93 percent, room air [According to Resident 50's Medication Administration Record (MAR) his normal oxygen baseline levels from [DATE] through [DATE] were 96 to 98 percent on room air]. The DSD asked Staff 9, See if we can get chest x-ray either that or send him out [to the hospital]. I will call and see if we can send him out [to hospital] or keep him here. Call Physician Assistant [PA] tell her his oxygen [level] is 94% Resident 50 continues gurgling and moaning loudly. At 12:51p.m. Staff 9 asked the DSD, Stay with him [Resident 9], I will go find out if we are sending him [Resident 50] out. At 12:53 p.m., Staff 9 returns to Resident 50's room and states, Send him out. I got an order from PA for dysphagia, coughing . At 12:55 p.m., Resident 50 continues gurgling and moaning loudly. CNA 1 and Staff 9 begin to dress Resident 50 to get him ready to go to the emergency room . Staff 9 told Resident 50, We will get you some cough medication. At 12:58 p.m., CNA 2 brought a thermometer and Blood Pressure equipment into resident 50's room. CNA 2 stated Resident 50's body temperature was 98.4 (degree Fahrenheit (F), Heart Rate (HR) 88, oxygen level 95 % on room air. Resident 50 continues moaning and gurgling loudly. Staff 9 was observed listening to Resident 50's lung sound and stated, Lower lung clear upper lung sound like rattle. At 1:00 p.m., staff 9 was taking Resident 50's blood pressure and stated, It is ,d+[DATE]. At 1:01 p.m., the Director of Nursing (DON) entered Resident 50's room (41 minutes after choking incident began) stated I am going to listen to his lungs . take deep breaths Resident 50 starting coughing, gurgling, and moaning loudly. At 1:02 p.m., the ambulance staff arrived at Resident 50's room. Staff 9 gave report to the emergency medical services (EMTs four) Staff 9 stated Resident 50 had a choking episode and was coughing with soup. Staff 9 stated, I did sweep, he progressively has been coughing since yesterday on and off. When CNA was feeding him his soup, that's when he coughed. At 1:09 p.m., Resident was transferred onto the ambulance gurney, Resident 50 was pale in color, gurgling, and moaning loudly. Resident 50 was taken by ambulance [49 minutes after choking episode began] to the Hospital emergency room (ER). During a concurrent observation and interview on [DATE], at 12:41 p.m., with CNA 1, CNA 1 stated she was helping Resident 50 's roommate in bed A and had the privacy curtains pulled closed between A bed and Resident 50's B bed. CNA stated she was not able to see Resident 50 but heard Resident 50 start to gurgle and when she pulled the privacy curtain Resident 50's face was blue in color and his lips were blue. CNA 1 stated she left the room walked to the nurses' station and informed staff 9 Resident 50 was choking. CNA 1 stated Resident 50 was left alone eating his lunch meal on his own while lying in bed, in his room. CNA 1 stated no one was helping him. CNA 1 stated she had walked into the room to help the resident in bed A get up out of bed. CNA 1 stated she was not assigned to provide care for residents in that room she was just helping the resident in bed A. During a concurrent observation and interview on [DATE], at 12:50 p.m., with CNA 2 and CNA 1, at the doorway of Resident 50's room, Resident 50's lunch tray was observed with CNA 1 and 2. CNA 1 was holding Resident 50's lunch tray with both hands. CNA 2 was at CNA 1's right side. During a review of Resident 50's diet card on the meal tray, the diet card indicated Resident 50's diet was prescribed as a Regular Mechanical Soft Diet (diet designed for people who have trouble chewing and swallowing, Chopped, ground and pureed foods are included in this diet, as well as foods that break apart without the use of a knife) with ground meat. The meal tray was observation to have a half full clear transparent eight-ounce glass with yellow fluid and yellow noodles, a divided plate contained ground white meat and orange baby sized whole carrots and a brown bread roll wrapped in a plastic bag. CNA 2 took a spoon and cut into one of the chunky baby carrots that was approximately one and one-half inch in diameter while CNA 1 held the meal tray. CNA 1 had to use pressure to cut into the carrot, causing the tray to push downward onto CNA 1's hands. CNA 1 stated, That was hard. CNA 1 stated she was previously a dietary assistant in the facility and stated the carrot was too hard for Resident 50 on a mechanical soft diet. CNA 1 stated the carrots should have been soft and either chopped or easily cut into, like melted butter. During an interview on [DATE], at 1:15 p.m., with Staff 9, Staff 9 stated she didn't know what was in Resident 50's mouth but when she did the finger sweep Resident 50 coughed up orange and white pieces of some substance. Staff 9 stated she knew she had to do a finger sweep but could not remember where she learned it from. Staff 9 stated she did not know if the facility had emergency codes to call out in case of emergency like choking to get other nurses to come help and to get emergency crash cart equipment (a cart that contains lifesaving equipment) to the Resident 50's bed side. During a concurrent interview and record review on [DATE], at 6:53 p.m., with DA 1, DA 1 stated mechanical soft diet food must have a soft texture and be under a half inch in diameter including meat and vegetables. DA 1 reviewed the diet for Resident 50 on the dietary diet spreadsheet and stated the kitchen staff used the spreadsheet when food for the residents was prepared and plated. DA 1 stated Resident 50 was on a Regular Mechanical soft with ground meat. DA 1 stated ground meat was a very fine texture and carrots would be cooked until very soft. The DA stated residents on a mechanical soft diet should receive carrots that have are soft enough to cut like butter with no resistance when cutting through them. DA 1 stated the cook was responsible to ensure the texture and softness of the food was served as prescribed for resident safety. During a concurrent interview and record review on [DATE], at 10:05 a.m., with Cook 1, the dietary spreadsheet was reviewed with Cook 1. Cook 1 stated the spreadsheet was used to make different type of diets. Cook 1 stated Resident 50's diet was Regular Mechanical Soft with ground Meats. Cook 1 stated mechanical soft diet vegetables were cooked until soft and were tested by squishing with a spoon or pinching with his fingers. Cook 1 stated carrots should be cooked so a spoon could easily cut through them with no resistance. Cook stated mechanical diets are served to patients at risk for choking. Cook 1 stated he did not remember if he tested for softness of the chunky baby carrots on [DATE]. During a concurrent interview and record review on [DATE], at 10:18 a.m., with the Certified Dietary Manager (CDM), the dietary menu spreadsheet was reviewed CDM. The CDM stated Resident 50's prescribed diet on [DATE] was Regular Mechanical Soft with ground meat. The CDM stated the carrots should have been soft enough for a spoon to cut through it without any resistance. The CDM stated if a resident was not given the correct diet, a resident could choke and die which was the biggest fears for the dietary department. During an interview on [DATE], at 10:45 a.m., with CNA 1, CNA 1 stated Resident 50 requires feeding assistance to eat. CNA 1 stated she did not know why Resident 50 was left alone with his tray in front of him. CNA 1 stated she saw Resident 50 was choking on [DATE]. On that day she saw Resident 50's meal tray with the spoon with carrots. CNA 1 stated any resident that required feeding assistance with eating should not have their trays in front of them without a staff member in the room helping resident eat. CNA 1 stated the carrot was not soft when CNA 2 tried to cut into it, and she was holding the meal tray. CNA 1 stated Mechanical soft diets are served to residents that have chewing and swallowing difficulties. CNA 1 stated if a resident was carrots that were hard and that was the wrong diet texture and consistency that could cause a resident to choke. CNA 1 stated Resident 50 did not have teeth, was not wearing his dentures, did not have good use of hand and fingers to eat. CNA 1 stated Resident 50's fingers were contacted sideways and inward. CNA 1 stated Resident 50's lower dentures were in his room, but his upper dentures were missing. During an interview on [DATE], at 11:38 a.m., with CNA 2, CNA 2 stated Resident 50 was able to eat on his own. CNA 2 stated she set his lunch tray in front of him on [DATE] because he was on a mechanical soft diet, did not need his food to be cut up for him and could eat on his own. CNA 2 stated Resident 50 did not require staff supervision while eating. CNA 2 stated she would set his meal up in front of him and leave Resident 50 to eat on his own. CNA 2 stated when she cut through the orange carrots on [DATE] after Resident 50's choking episode the carrots were not mushy. CNA 2 stated she was not sure if the resident needed or wears his dentures. CNA 2 stated Resident 50 did not have his own teeth. During an interview on [DATE], at 3:55 p.m., with CNA 4, CNA 4 stated she had previously been assigned to care for Resident 50 and when she cared for him, Resident 50 did not have teeth or dentures to eat. CNA 4 stated Resident 50 requires feeding assistance from staff for eating. CNA 4 stated Resident 50 had difficulty swallowing while eating. During an interview on [DATE], at 9:31 a.m., with Speech Pathology Therapist (ST), ST stated she had been providing ST services to Resident 50 five times a week for the past three months because of his Dysphagia diagnosis. ST stated she had not looked to see if Resident 50 wore dentures because he was good at chewing his mechanical diet with his gums. ST stated she would provide verbal cues to Resident 50 on when to chew food and when to take a drink of fluids. ST stated Resident 50's level of feeding would fluctuate, and on some days, he would be able to help feed himself and on other days he would not. ST stated she would normally assess a resident dentation (teeth) but for Resident 50 she did not do that. ST stated dentation was a very important part of safe mastication. ST stated she had not made safety recommendations for Resident 50 while eating because she has seen that staff deliver his tray, leave Resident 50 and, He eats on his own . During a concurrent observation and interview on [DATE], at 10:04 a.m., in Resident 50's room. Resident 50 was in bed lying down flat. Resident 50 was greeted and stated he was doing good. Resident was thin, frail, and talkative. Resident stated he needed dentures, that he had some and someone stole them. Resident 50 stated look in my drawer for them. when I first came here, I had dentures which went missing and some of the nurses helped me get [new] dentures . they [new dentures] have been lost for long time. Resident 50 stated he had been in the facility for a long time, about one year. Resident 50 stated he was admitted to the facility since [DATE] because he was unable to walk and had lost weight. Resident 50 stated he need to gain weight so that he could go home to his family. Resident 50 stated his goal was to walk again. Resident 50 stated, on [DATE] the day of the choking episode a lady gave me a wafer, the day I choked . I choked on the soup . I put it [soup] in a cup. I had a carrot in my mouth and the stuff in the cup, the broth went down the wrong pipe. I started coughing . Resident 50 stated he was sent to the hospital and now, they [staff] are giving me everything smashed. Resident 50 stated, I try to eat by myself, I need my teeth and my hands don't work. Resident 50 lifted his hands that were shaking, fingers contacted inward and bend at the knuckles, wrist on both hands were stiff and had a hard time moving wrist forward and backward. Resident 50 was unable to close his hand to make a fist. Resident 50 stated, I am getting old. Resident 50's lower denture plate was in a blue cup in his nightstand. Resident 50 stated, I want the top [denture] too. I can't use the bottoms only. During an interview and record review on [DATE], at 10:26 a.m., with Minimum Data Set Coordinator (MDSC), Resident 50's clinical record titled MDS and ADL [activities of daily Living] Care plan was reviewed with MDSC. MDSC reviewed MDS functional status assessment dated [DATE] and stated Resident 50 required one staff member physical assistance while eating. MDSC stated the functional assessment indicated Resident 50 was at risk for swallowing difficulties and that was why he was on a modified (mechanically alter) diet and required one staff members physical assistance when eating. MDSC review Resident 50 ADL care plan dated [DATE], which indicated, Eating: resident [50] required on staff participation to eat. MDSC stated the facility knew Resident 50 was at risk for choking because the facility had him on a mechanically altered diet. MDSC reviewed Resident 50's cognitive assessment and stated Resident 50 was assessed as having severe cognitive deficit but residents had days where he was not confused and would remember everything clearly. During a concurrent interview and review of the clinical record on [DATE] at 10:33 a.m., MDSC reviewed Resident 50's person item inventory sheet and stated she did not know if Resident 50 had Dentures that he was able to use when eating. During a concurrent interview and record review on [DATE], at 11:35 a.m., with MDSC and CNA 2, Resident 50s clinical record was reviewed. CNA 2 checked Resident 50's clinical record on the wall mounted computer and stated she would set Resident 50 up to eat and does not stay in the room with him. CNA 2 stated she had never looked at Resident 50's ADL care plan to review the level of supervision and assistance Resident 50 required with meals. CNA 2 stated, We just ask the nurse. CNA 2 stated, I have never been shown how to look at the care plan [to review the level of care each resident would need]. MDSC demonstrated how to access Resident 50's ADL care plan and CNA 2 stated, I have not been doing that. I set him up for lunch and left the room on the day of choking incident [DATE]. CNA stated no one had educated her on how to review Resident 50's care plans to be knowledge on the level of care Resident 50 required. During a concurrent interview and record review on [DATE], at 4:44 p.m., with the DON and ADON, Resident 50's clinical record was reviewed with the DON and ADON. The DON reviewed Resident 50's care plan for meal assistance assessment and interventions and stated the care plan indicated Resident 50 needed one-person supervision and assistance. The DON stated Resident 50 required more help than others depending on what kind of day he was having. The DON stated CNA's were able to make the determination on how much help Resident 50 needed based on how Resident 50 was doing on that specific day. The DON stated the facility did not provide one-person physical assistance with meals to Resident 50 because care plan did not specify that Resident 50 needed constant supervision. The DON stated the care plan interventions could change from day to day depending on Resident 50's status. The DON stated facility CNAs could make determinations if Resident 50 required feeding assistance or not. The DON stated she did not see a problem with CNAs not following the assessed feeding need of Resident 50 based on the CNA's determination and not just the risk of choking. During a review of Resident 50's hospital clinical record titled, Emergency Department Reports dated [DATE] at 2:12 p.m., indicated, Patient presents with choking episode Risk factors consist of Dysphagia, Gerd (gastroesophageal reflux disease- occurs when stomach acid frequently flows back into the tube connecting the mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of the esophagus] .Diagnosis choking episode, aspiration (breathing in a foreign object [sucking food into the airway]). During an interview on [DATE] at 9:21 a.m. with the DON, the DON stated Resident 50 had decreased mental status and had dysphagia which placed him at risk for choking or aspiration. The DON stated, It can place him at higher risk. Edentulous [without teeth] also places him at risk if he was not tolerating diet. The DON stated prior to the chocking incident with Resident 50 she and the nursing Licensed Nursing staff were not aware the facility had emergency code they could call in case of an emergency. The DON stated she called facility regional staff and asked if the facility had emergency code policy and procedure. The DON stated the facility had a policy and procedure for emergency codes and a code red should have been called by the first person on site when Resident 50 was choking, and no one did that because staff were not aware the facility had this policy. Resident 50 was in his bed and the crash cart (equipped with medical equipment and supplies for various emergencies) was not accessed. The DON stated the emergency equipment was not available in Resident [50's] room for use, like oxygen a CPR (cardiopulmonary resuscitation- rescue breathing and chest compressions) board, a suction machine (medical device used to suction excess oral secretions), other nurses were not aware resident was choking and she was not aware Resident 50 was choking. The DON stated a code Blue should have been called to ensure resident received emergency care immediately and no one called the code to mobilize licensed staff to respond to the site of the emergency. The DON stated not calling the code Blue delayed emergency response from licensed nurses and could have resulted in Resident 50 dying. During a review of professional reference titled, Choking Victim- How to help retrieved from https://www.aedcpr.com/articles/choking-victim-how-to-help/ dated ,d+[DATE], indicated, Choking occurs when a person's airway becomes blocked by food or another foreign object. When this happens, the choking victim will be unable to breath normally and is at risk of suffocating. When treating a choking victim, the first goal is to remove the obstruction to restore normal breathing function .Thousands of choking deaths occur each year. While choking can happen to anyone, . the elderly are at increased risk Signs of Choking: Choking can be a serious emergency. Because of this, it is important to quickly recognize the signs of choking and take appropriate action . Difficulty speaking. If someone is choking .Coughing or wheezing . Sometimes, a choking victim will cough of wheeze excessively. This happens when the airway is only partially obstructed. Pay attention to the victim's breathing; if coughing or wheezing suddenly stop, it may mean that their airway is now fully obstructed .Changes in skin color. For instance, the skin, lips, and nails may change to a pale or bluish color, indicating a lack of oxygen in the blood . Performing First Aid on a Choking Victim . The [MEDICATION(S)] Maneuver (Abdominal thrusts) is the .first aid technique for choking. However, it is important to note that this technique is used on conscious victims only . it is important to know when to call for an ambulance. If you are the only rescuer on the scene, try to use ,d+[DATE] abdominal thrusts before calling 911. But if you're not alone, have someone else call for an ambulance while you perform first aid . back blows [delivering forceful slaps with the heel of the hand on the victim's back, between the shoulder blades] . It's important to note, if done incorrectly, back blows can cause the obstruction to worsen. To perform back blows correctly: Stand to the side of and slightly behind the choking victim. Keep one arm around their waist for support and have them bend over at the waist at a 90-degree angle (important). Firmly deliver several blows to the center of the victim's back. You should aim for the area in between their shoulder blades using the palm of your hand . If the obstruction is visible in their mouth, you may try to use your finger to remove it. However, be careful to not push the object further into the airway. If the object is not visible, do not try to reach for it . During a review of the facility policy and procedure titled Emergency procedure- Choking dated ,d+[DATE] indicated, .Trained staff will assist the resident who is attempting to expel the foreign body from the airway .[Steps to perform on] CONSCIOUS RESIDENT .if the able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object .Call for help, but stay with the resident .[steps to perform on] UNCONSCIOUS RESIDENT - lying down .Preform the finger Sweep (a technique for clearing a mechanical obstruction from the upper airway. The rescuer opens the victim's mouth by grasping the lower jaw and tongue between the thumb and fingers. The rescuer then attempts to sweep the foreign object out of the victim's mouth with a finger) maneuver to check for a foreign body as follows .Avoid pushing foreign object deeper into the throat . During a concurrent interview and review of facility policy and procedure (P&P) titled, Emergency Management Codes and Procedures undated ,d+[DATE] with the DON, the P&P was reviewed with the DON. The P&P indicated, Emergency management codes are used to notify employees of a crisis .Codes are used to inform employees and begin mobilization . (1.) The following codes are utilized to notify the employees of the various crises or disaster situations that may impact the facility [Residents] .(c.) Medical Emergency/Someone Stopped breathing ([call a] CODE BLUE) . The DON stated she and the licensed Nursing staff were not aware the facility had an emergency code policy and procedure. The DON stated when Resident 50 began experiencing his choking episode the nurse could have called a CODE BLUE to mobilize other nurses to Resident 50's room with the emergency cart that contained, oxygen, a CPR board, and other emergency equipment to help stabilize resident while another nurse was calling and activating [DATE] to respond to the facility. The DON stated she was not aware Resident 50 was choking until another staff member asked her if she knew that Resident 50 was choking. The DON stated Staff 9 could have called a CODE BLUE, but Staff 9 and DON did not know the facility had an emergency code policy and procedure and that placed facility residents at increased risk not to receive the help they needed during an emergency. The DON stated all staff should have been trained on emergency codes policies and procedures and that did not occur.

Based on observation, interview, and record review, the facility failed to ensure one of three residents, Resident 1, was free from accidents and injury when Certified Nursing Assistant (CNA) 1 and CNA 2 failed to check the sling (a hammock like device to hold the resident during transfer) of a mechanical lift was securely attached to the lift before transfer. Resident 1 was suspended in the sling three and one half feet above the ground when the sling came unhooked from the mechanical lift causing Resident 1, who had osteopenia (thin, fragile bones) and was unable to bear weight on her legs, to slide out of the sling and contact the floor with her feet. As a result of this failure Resident 1 sustained a left femur (thigh) bone fracture (break), and fractures of the right tibia and fibula (two lower leg bones) in both the proximal (upper) and distal (lower) areas of both bones. Resident 1 experienced pain and was transported to the general acute care hospital (GACH) for evaluation and treatment of [REDACTED]. Findings: Resident 1's Admission Record indicated Resident 1 was a [AGE] year-old female, originally admitted to the SNF facility on 7/11/11 with [DIAGNOSES REDACTED]. underlying bone involving 5 or more joints simultaneously), Pain in the right hip, and other abnormalities of gait and mobility. Review of facility investigative report, fax dated 2/28/18, and signed by the facility Administrator (Admin) indicated Resident 1's accident and injury occurred on 2/23/18. The report indicated, . (Resident 1) had a two person assist while being transferred and the lift and sling were in good working order. As she was sitting in her chair with the sling attached to the lift, her front left loop (of the sling) had some slack in it and when the lift began to rise it slipped from its slotted position. This caused the resident to begin to slide to where she was held in a standing position and then lowered to the floor both for her safety and for the two (Certified Nursing Attendants) CNA's that were helping her . On 3/6/18 at 1:30 p.m., during an interview, the Director of Nursing (DON) stated, .She's (Resident 1) brittle. We knew she had history of multiple fractures . The DON stated Resident 1 did not return to the SNF after evaluation and treatment of [REDACTED]. The DON stated Resident 1 was placed elsewhere per family request. On 3/6/18 at 1:35 p.m., during an interview, CNA 1 stated on 2/23/18 CNA 2 asked for help to get Resident 1 back into bed. CNA 1 stated they used a mechanical lift to transfer Resident 1 back to bed. CNA 1 stated the sling was in place under Resident 1 from an earlier transfer when staff had gotten her up into the chair. CNA 1 stated, We pushed the lift into position, connected the straps (inserted the loop of the strap over the hook on the lift), lifted, pulled the chair out and while suspended in the air the resident began to slide to her left (began to slide out of the sling). CNA 1 stated she and CNA 2 supported Resident 1's upper body which was still partially supported by the lift, to an upright standing position. CNA 1 stated Resident 1's feet touched the ground and then they lowered Resident 1 to the ground. CNA 1 stated, She (Resident 1) was moaning, Oh, my legs hurt. CNA 1 stated Resident 1 did not indicate where her legs hurt. CNA 1 stated if they had tugged on the straps and ensured they were well seated on the lift hooks before lifting and moving the chair out from underneath Resident 1, the accident could have been avoided. CNA 1 stated if they had tugged on the straps, and lifted without moving the chair, they could have lowered Resident 1 back down on the chair and adjusted the strap to remove the slack. CNA 1 stated, Keeping the chair in place longer, would be what I would do differently. On 5/10/18 at 1:05 p.m., during an interview and concurrent observation, CNA 1 demonstrated use of the mechanical lift. CNA 1 demonstrated step-by-step how she used the lift on 2/23/18, the day of Resident 1's accident with injury. CNA 1 stated, The step of checking that the strap (loop) was securely hooked on the hook (of the mechanical lift) before lifting and moving the chair got missed. On 5/10/18 at 1:41 p.m., during an interview, CNA 2 stated on 2/23/18 she used the mechanical lift to transfer Resident 1 from a chair back to bed. CNA 2 stated, When we (CNA 1 and CNA 2) lifted (Resident 1) everything was fine. Then when we moved the wheelchair under her she started sliding. We realized one of the hooks had come undone and she was sliding to the side where the hook had come off. CNA 2 stated Resident 1 was suspended in the sling approximately three and a half feet in the air when she started leaning to the left and sliding down, legs first. CNA 2 stated she and CNA 1 lowered Resident 1 to the ground. CNA 2 stated, We should have double checked the straps after the resident was elevated above the chair, before moving the chair. Tugging on the strap to ensure that the strap loop was seated and taunt (without slack) on the hook would have prevented the accident. Review of Resident 1's GACH X-Ray Final Report, dated 2/23/18 at 10:51 p.m., indicated, There is severe osteopenia. Acute (new) displaced (end of the broken bone is separated) femoral fracture .Acute fractures of the proximal and distal tib-fib (tibia and fibula). Review of Resident 1's GACH History and Physical (H&P) Report, dated 2/24/18, page one of five indicated, .Patient is a [AGE] year-old (y/o) white female with a history of osteopenia, multiple fractures, who has been essentially bedridden and wheelchair bound for the past 4-1/2 years . Patient has chronic (persisting for a long time or constantly recurring) pain. Patient was brought into the emergency room . for evaluation s/p (status [REDACTED]. X-ray of leg shows a [MEDICAL CONDITION] fibula and tibia. Patient also has a rod (hardware used in the repair of a [MEDICAL CONDITION]) in her right mid femur and an artificial right hip. Because of this new fracture, patient is being referred for acute admission, orthopedic evaluation . H&P page three of five indicated, PAST MEDICAL HISTORY .her bones fracture easily. She had a left humerus (upper arm bone) fracture just by them moving her in a nursing home in the past . page five of five of the H&P indicated, .x-rays: multiple old fracture and osteopenia, new fracture prox (proximal) right tibia and fibular. Impression and Plan 92 y/o woman who non-ambulating (not walking) came from nursing home with history of fall from (mechanical lift) lift and sustained new fractures . Resident 1's GACH Discharge Summary Report, dated 2/28/18, indicated .In the hospital, ortho (branch of medicine specializing the musculoskeletal system) consulted and felt surgery was not the best option for her. She ended up getting bilateral leg braces and is now stable for transport . Review of the facility copy of the manufacturer's user manual for the Manual/Electric Mobile Patient Lift dated 2013, indicated on page three, DEALER: This manual MUST be given to the user of the product. USER: BEFORE using this product, read this manual and save for future reference . Page five of the manual indicated, .Warnings: Signal words are used in this manual and apply to hazards or unsafe practices which could result in personal injury or property damage. See information below for definitions of the signal words. (The symbol of a triangle with an exclamation point inside it indicated Danger, Warning and Caution) DANGER: Danger indicates an imminently hazardous situation which, if not avoided, will result in death or serious injury. WARNING: Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. CAUTION: Caution indicates a potentially hazardous situation which, if not avoided, may result in property damage or minor injury or both. On page seven, the following was indicated beside the symbol of a triangle with an exclamation point inside it: 2. Safety: The Safety section contains important information for the safe operation and use of this product. 2.1 General Guidelines: WARNING DO NOT use this product or any available optional equipment without first completely reading and understanding these instructions . otherwise, injury or damage may occur . On page nine, the following was indicated beside the symbol of a triangle with an exclamation point inside it: Using the sling: WARNING .Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode) . Lifting the Patient (another symbol of a triangle with an exclamation point inside it) WARNING .When elevated a few inches of the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem . The warning verbiage for lifting the patient, as quoted above on page nine, was repeated on page 10, beside the symbol of a triangle with an exclamation point inside it, for transferring the patient as follows: Transferring the Patient WARNING .When elevated a few inches of the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object (wheelchair, commode, or bed) and correct this problem . On page 30, the following was indicated beside the symbol of a triangle with an exclamation point inside it: Lifting/Moving the Patient . WARNING: When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure the sling is properly connected to the hooks of the hanger bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem - otherwise, injury or damage may occur . This warning was repeated beside the symbol of a triangle with an exclamation point inside it for Transferring the Patient on page 32, repeated again on page 35, and again on page 36. On 5/10/18, at 2:15 p.m., during an interview and concurrent record review with the Director of Staff Development (DSD), the facility's lift and sling manufacturer's user manual and the facility's undated Competency Evaluation Worksheet titled, Transferring with a Mechanical Lift (2 person Assist) were reviewed. The repeated warnings in the user manual were reviewed with the DSD. The DSD stated, I taught the double checks after the incident (Resident 1's accident with injury on 2/23/18) . Double checking the loop (on the sling) is seated on the hook (of the lift) is necessary for safe operation of the lift. The DSD stated the double checking to make sure the sling is properly connected to the hooks on the lift should have been inserted after item 22 of the facility Competency Evaluation Worksheet, which speaks to raising the resident in the sling. The DSD stated, It (the double checking the loop placement) is missing. It was omitted. It should be there.

Based on observation, interview, and clinical record and document review, the facility failed to provide the necessary care and services to ensure the highest practicable level of physical well-being related to dementia care and implement person-centered interventions in accordance with the comprehensive assessments and plans of care for three of seven sampled residents (Residents 1, 3, and 4) as evidenced by: 1. For Resident 3 who received [MEDICAL CONDITION] medications, the clinical record failed to show the justification for the continued use of the [MEDICAL CONDITION] medications since the resident's behaviors had decreased and the resident had manifested some possible adverse effects from these medications, such as decreased appetite, weight loss (22 pounds since admission), involuntary movement of the hand/arm, and constipation. 2. For Resident 1 who was at risk for falls and sustained an injurious fall, the facility failed to perform an IDT assessment within 24 hours as per the facility's P&P. 3. For Resident 4, the clinical record did not show an accurate pain assessment and documented evidence the resident had a [DIAGNOSES REDACTED]. These failures had adversely affected the residents with dementia causing further decline and psychological distress. Findings: 1. On [DATE] at 1350 hours, Resident 3 was observed trying to get out of bed that caused the bed alarm to sound. One-half (,[DATE]) siderails on both sides of the bed were raised. No floor pad was observed next to the resident's bed. CNA 1 was observed entering the resident's room and asked the resident what he needed. The CNA offered the resident a drink of water and the resident stated, "That is a good idea." Resident 3 remained in bed in a lying position. The resident's right hand was observed with shaking movements. On [DATE] at 1655 hours, the resident was observed sitting in a wheelchair in the dining room. The resident was observed attempting to stand, but staff intervened by redirecting the resident. On [DATE] at 1750 hours, Resident 3 was observed in bed with eyes closed. ,[DATE] siderails on both sides of the bed were raised. No floor pad was observed next to the resident's bed. On [DATE] at 1910 hours, Resident 3 was observed lying in bed and both legs were out of the covers. When asked if he needed to go to the bathroom, the resident stated, "I think so." Staff was notified by the surveyor that Resident 3 needed assistance. On [DATE] at 0621 hours, Resident 3 was observed in bed and ,[DATE] siderails on both sides of the bed were raised. No floor pad was observed next to the resident's bed. Interview with the night shift nurse, LVN 1 was conducted at 0645 hours. When asked if Resident 3 had any behaviors during the night, LVN 1 stated the resident talked, tried to get out of bed, pulled on his indwelling catheter (...), and moaned; however, the resident had no aggressive behavior. LVN 1 also stated the resident had fallen when he was in the room which was located in the other side of the building. The resident had had no falls since he was transferred to his new room which was located in front of the nursing station. LVN 1 stated staff could hear the resident when he tried to move the siderails. The bed had a TAB alarm (used to alert the staff when a resident is leaving a bed, chair, or wheelchair). On [DATE] at 0717 hours, 0735 hours and 0752 hours, the resident was observed in bed with eyes closed and appeared sleeping. No floor pad was observed next to the resident's bed. On [DATE] at 0754 hours, Resident 3's breakfast tray arrived. A CNA was observed placing the breakfast tray on Resident 3's overbed table and announcing that it was breakfast time. The CNA had set up the resident's food by adding condiments on the food items. The fork was given to the resident and the resident tried to feed himself using his right hand. At 0810 hours, the morning shift nurse, LVN 2, was observed preparing Resident 3's medications. LVN 2 entered the resident's room and administered the prepared medications with applesauce followed by water to the resident. Observation showed the resident's breakfast was barely eaten. LVN 2 encouraged the resident to eat his breakfast ,but the resident stated he did not want anymore. LVN 2 asked the resident if he wanted the vanilla shake on the breakfast tray, the resident stated it looked good. The LVN poured the vanilla shake in a glass and handed it to the resident. On [DATE] at 0914 hours, Resident 3 was observed in bed with ,[DATE] siderails raised on both sides of the bed. The resident was observed trying to remove his bed covers. On [DATE] at 1300 hours, Resident 3 was observed in a wheelchair that was being pushed by a female visitor who introduced herself as Resident 3's wife. The resident's wife stated she brought the resident some pizza since it was his birthday; however, he only took two bites. The resident's wife stated she was concerned with the resident's weight loss and staff were giving her a run around regarding the resident's current weight. The resident's wife stated she had brought in chocolate shake for supplemental nourishment and informed the staff that the resident did not like vanilla shake. The resident was observed trying to stand up and walk one to two steps away from the wheelchair; and the wife had to redirect him. PTA 1 came to assist and asked the resident if he would like to walk instead of being pushed in the wheelchair. The resident stated he did not like to walk; however, the resident kept on standing up from his wheelchair and tried to walk away from his wheelchair. The resident was wheeled back to his room next to his bed. At this time, the residents' right hand/arm was observed shaking repeatedly. When the resident's wife was asked if the shaking of the resident's hand/arm was usual, the wife stated she had not noticed the hand/arm shaking until the resident came to the facility. The resident's wife stated, "I do not know if it is from his medication or from [MEDICAL CONDITION]. I have a relative who died of [MEDICAL CONDITION]." On [DATE] at 1430 hours, an interview with the AD was conducted. When asked what room activities were provided to Resident 3, the AD stated they had not offered the resident any room activities. The AD stated the resident's wife informed her that the resident liked to watch television. When asked if the resident manifested any aggressive behaviors while in the activity room, the AD stated no aggressive behaviors were observed, but the resident had tried to stand up from his wheelchair often. Observations showed the resident did not have a television in his room. His roommate had a television and the back of the television was facing Resident 3. On [DATE] at 0800 hours, Resident 3 was observed eating breakfast in bed. ,[DATE] siderails were raised on both sides of the bed. No hand movement was observed at this time. At 1010 hours, Resident 3 was observed in bed with eyes closed and appeared sleeping. ,[DATE] siderails were raised on both sides of the bed. No floor mat was observed by the resident's bed. On [DATE] at 1410 hours, during the care conference attended by the IDT and the resident's wife, the resident's wife stated the resident loved chocolate and did not like vanilla shake. On [DATE], review of Resident 3's clinical record was initiated. The resident was admitted to the facility on [DATE], with diagnoses, including head injury, depressive type [MEDICAL CONDITION], unspecified [MEDICAL CONDITIONS], unspecified retention of urine, and unspecified constipation. The resident's diet included regular no added salt diet. Review of the admission orders [REDACTED]. On [DATE], the physician ordered [MEDICATION NAME] (antianxiety, brand name is [MEDICATION NAME]) 0.5 mg one tablet three times per day for anxiety manifested by repetitive anxious movements. On [DATE], the order for [MEDICATION NAME] was changed to 0.25 mg every six hours as needed and the [MEDICATION NAME] was increased to 1 mg one tablet two times per day. On [DATE], an order was written for [MEDICATION NAME] 0.5 mg every morning and 1 mg every evening. The order also included to discontinue [MEDICATION NAME] when current supply was finished due to not being covered by the insurance and to give [MEDICATION NAME] (antianxiety) 0.25 mg one tablet every 6 hours as needed for anxiety manifested by repetitive anxious movements. On [DATE], the order for [MEDICATION NAME] was changed to 1 mg in the morning and 1 mg in the evening. On [DATE], the order for [MEDICATION NAME] was clarified per the pharmacist's recommendation to give 0.25 mg every 6 hours as needed, not to exceed 0.75 mg in 24 hours. On [DATE], the order for [MEDICATION NAME] was changed to 0.25 mg every 12 hours. Review of the monthly physician's orders [REDACTED]. Some of the listed adverse reactions were as follows: - For [MEDICATION NAME] and [MEDICATION NAME], observe and report akathisia (a condition marked by motor restlessness, ranging from anxiety to inability to lie, sit quietly, or sleep, a common extrapyramidal side effect of neuroleptic drugs), parkinsonism (any condition that causes a combination of the movement abnormalities seen in [MEDICAL CONDITION], such as tremor, slow movement, impaired speech, or muscle stiffness), tardive dyskinesia (a disorder that involves involuntary movements), dysphagia (the medical term for the symptom of difficulty in swallowing), [MEDICAL CONDITION] (elevated blood sugar), and constipation. Review of the Resident Care Plan addressing anxiety showed approach plans that included observing the resident for the side effects that included sedation, drowsiness, blurred vision, headache, skin rash, dizziness, nausea, vomiting and ataxia (drunk walk). Review of the Resident Care Plan addressing [MEDICAL CONDITION] showed approach plans that included observing the resident for the side effects of [MEDICATION NAME] and [MEDICATION NAME] that included sedation, drowsiness, dry mouth, blurred vision, [MEDICAL CONDITION], muscle tremor, agitation, headache, weight gain or loss, [MEDICAL CONDITION], constipation, extrapyramidal reaction (symptoms can include things such as repetitive, involuntary muscle movements (such as lip smacking), or an undeniable urge to be moving constantly). Further review of the clinical record and the electronic health record showed the following: a. The resident's weight on admission ([DATE]) was 199 pounds. Review of the Dietary Progress Notes dated [DATE], showed the resident's weight was 197 pounds, a 2 pound weight loss since admission and the goal was to maintain the resident's weight. The dietary progress notes dated [DATE], showed the resident's current weight as 195 pounds, a 4 pound weight loss since admission. It was also documented the meal intake was 48% with 355 cc average per meal. The dietary progress notes dated [DATE], showed the IDT met to review the resident's plan of care and the resident's weight on [DATE] was down to 191 pounds, a 5 pound weight loss in one week. It was also documented the weight fluctuation due to recent medication changes. The dietary progress notes dated [DATE], showed the the IDT met, and the weight on [DATE] was 186 pounds, a 5 pound weight loss in one week and a 13 pound weight loss since admission on [DATE] (less than 2 months). It was documented an IDT recommendation for nutritional shake with lunch. On [DATE], a physician's orders [REDACTED]. Review of the Weights and Vitals Summary form showed the resident's weight on ,[DATE] and [DATE] was 179 pounds, a 20 pound weight loss since admission on [DATE] (less than 3 months). On [DATE], a physician's orders [REDACTED]. Documentation on the Weights and Vitals Summary form showed the resident weighed 181 pounds on [DATE]. Review of the Progress Notes for the period from [DATE] through [DATE] showed the following: - On [DATE] at 2213 hours, the licensed nurse documented the resident consumed less than 50% of his meals. The licensed nurse also documented snacks were offered and accepted. - On [DATE] at 0208 hours, the licensed nurse documented the resident consumed less than 50% of his meals. The licensed nurse also documented snacks were offered and accepted. - On [DATE] at 1420 hours, the licensed nurse documented the resident consumed less than 50% of his meals. The licensed nurse also documented the CNAs offered alternate meal but refused as well. - On [DATE] at 1431 hours, the licensed nurse documented the resident consumed less than 50% of his meals. The licensed nurse also documented CNAs offered alternate meals and offered snacks throughout the day. - On [DATE] at 0324 hours, the licensed nurse documented the resident consumed less than 50% of his meals. The licensed nurse also documented snacks were offered and declined. - On [DATE] at 0256 hours, the licensed nurse documented the resident consumed less than 50% of meal. The licensed nurse also documented snacks were offered and refused. - On [DATE] at 1458 hours, the licensed nurse documented the resident consumed less than 50% of his meals. - On [DATE] at 1822 hours, the licensed nurse documented the resident consumed less than 50% of his breakfast and lunch. The licensed nurse also documented alternate meals were offered but refused. - On [DATE] at hours, the CNA documented the resident ate less than 50 % of his breaks and consumed snacks offered. There was no documentation in the clinical record to show how much the resident consumed the offered snacks on the dates the resident consumed less than 50% of meals. In addition, there was no documentation in the clinical record to address the resident's preference of chocolate than vanilla shake. As of [DATE], the resident's weight was documented as 177 pounds, a total weight loss of 22 pounds since admission on [DATE] (about 3 months). b. Review of the physician's progress record, dated [DATE], showed the following comments: "Sleepy Responds 2? (secondary) to [MEDICATION NAME]. Keeps getting up. but He is not safe according to report from PT. was not falling befor (sic) Took [MEDICATION NAME]. but now too sleepy to ambulate safly (sic). will (decrease) [MEDICATION NAME] & (increase)Resperidol (sic) & see if he does better 2? Alzheimers." Review of an electronic health record showed a "focus" indicating the resident had actual falls on [DATE], [DATE], and [DATE], with no serious injury. Review of the Rehabilitation Screen form, completed by the PTA dated [DATE], indicated the resident falls happened after the resident attempted to transfer/get out of bed without assistance. The PTA also documented to consider room change to allow for increased supervision and landing mat by the resident's bed to decrease the risk of injury. However, multiple observations during the survey days from [DATE]-[DATE], showed no landing mat or floor mat was observed by the resident's bed during visit to Resident 3's room by the surveyor. c. Review of the physician's orders [REDACTED]. - [MEDICATION NAME] 10 mg suppository to be administered rectally at bedtime. - [MEDICATION NAME] 100 mg one capsule two times per day. - [MEDICATION NAME] suppository one suppository as needed at night 3rd day with no bowel movement. - Fleets enema as needed to be given in the morning if still no BM by the 4th day. - High fiber juice 4 ounces as needed if no bowel movement after 2 days. - Milk of Magnesia 30 ml as needed at noon if no results from high fiber juice. Review of the progress notes for the period [DATE] through [DATE], showed the following: - On [DATE] at 0301 hours, the licensed nurse documented the resident had no BM in 48 hours and a suppository was administered at 2100 hours. - On [DATE] at 0346 hours, the licensed nurse documented the resident had no BM in 48 hours and a suppository was administered. - On [DATE] at 1021 hours, the licensed nurse documented the resident had no BM in 48 hours and a suppository was administered. - On [DATE] at 0240 hours, the licensed nurse documented the resident had no BM and a suppository was given. - On [DATE], at 1430 hours, the licensed nurse documented the resident had no BM since ,[DATE] /14, and high fiber juice and milk of magnesia were given. - On [DATE] at 1345 hours, the licensed nurse documented the resident's last BM was on [DATE], and a bowel protocol was initiated. d. Review of the Chemical Restraints form to document data of behaviors and side effects showed the following: - For the behavior of delusion requiring use of [MEDICATION NAME], the resident manifested the behavior 5 times in June, one time in July, 11 times in August, and zero times in [DATE]. These totals to 17 times in more than three months. The form also showed no adverse reactions were noted in June, July, August, and [DATE]. - For the [MEDICAL CONDITION] manifested by verbalization of visual or auditory hallucinations requiring the use of [MEDICATION NAME], the resident manifested the behavior six times in June, three times in July, nine times in August, and zero times in [DATE]. These totals to 18 times in more than three months. The form also showed no adverse reactions were noted in June, July, August, and [DATE]. - For the repetitive anxious movements requiring the use of [MEDICATION NAME], the resident manifested the behavior 52 times in July and 72 times in [DATE]. The form also showed no adverse reaction were noted in July and three in [DATE]; however, the specific adverse reactions were not documented. On [DATE] at 0824 hours, an interview was conducted with the DON. When asked what anxious behaviors were manifested by the resident that required the [MEDICATION NAME], the DON stated the resident constantly tried to stand up from the wheelchair and get out of the bed. When asked about the involuntary right hand movement, the DON stated she was not aware of this. The DON was informed about the concerns regarding the possible adverse effects from the [MEDICAL CONDITION] medications like decreased appetite, weight loss, constipation, falls, and the involuntary hand movement. The DON stated the resident's physician liked to prescribe [MEDICATION NAME] to his residents. When asked if we could call the resident's physician, she stated the physician was on vacation. On [DATE], the DON was requested for documentation of drug regimen review conducted by the Consultant Pharmacist since Resident 3 was admitted to the facility. Review of the Consultant Pharmacist's Medication Regiment Review form showed during the review between [DATE] and [DATE], the Consultant Pharmacist addressed the resident receiving [MEDICATION NAME], and [MEDICATION NAME] had not had any hallucinations, had delusions one of 23 days, and was anxious 7 of 10 days. The Consultant Pharmacist documented maximizing the dose of the two antipsychotics was not recommended due to its increased side effects. The Consultant Pharmacist recommended discontinuing the [MEDICATION NAME] since the [MEDICATION NAME] had recently been increased; considering routine [MEDICATION NAME] 0.25 mg two times per day for 14 days since the resident had appeared to be regularly anxious to allow increased [MEDICATION NAME] to become effective; and reducing the [MEDICATION NAME] to 0.25 mg every 8 hours as needed for anxiety, not to exceed 0.75 mg in 24 hours. Review of the Consultant Pharmacist's Recommendation to Inter-Disciplinary Team (IDT) form, created between [DATE] and [DATE], showed handwritten notes to indicate staff had spoken to the resident's wife who would like to have the doctor increase the [MEDICATION NAME] a little at a time, then slowly titrate off the [MEDICATION NAME]. The date on the form for the IDT's signatures was [DATE]. There was no documentation of any follow-up with the physician regarding the Consultant Pharmacist's recommendations. As of [DATE], Resident 3 continued to receive the following [MEDICAL CONDITION] medications: [REDACTED] - [MEDICATION NAME] 0.25 mg every 12 hours for anxiety manifested by repetitive anxious movements. - [MEDICATION NAME] 50 mg at bedtime for depressive type [MEDICAL CONDITION] manifested by delusions. - [MEDICATION NAME] 0.5 mg every morning and 1 mg at night for unspecified [MEDICAL CONDITION] manifested by auditory hallucinations. 2. Clinical record review indicated Resident 1 was an [AGE] year-old admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's multi-disciplinary quarterly electronic MDS 3.0 (a standardized assessment tool for nursing home residents) dated [DATE], indicated Resident 1 had moderately impaired vision, fluctuating disorganized thinking, and impaired safety awareness. Resident 1's cognitive assessment (BIMS) indicated a score of 10, meaning Resident 1 was moderately cognitively impaired. The assessment further indicated Resident 1 used a walker and required limited assistance to use the toilet. During the initial tour on [DATE] at approximately 1120 hours, Resident 1, who was lying in bed and clad in ankle socks (without a non-skid sole), was observed to slowly stand up from her bed and, after prompting by her son, use her front-wheeled walker to ambulate (on linoleum flooring) to the bathroom. Review of Resident 1's current physician's orders [REDACTED]. On [DATE] at 1715 hours, Resident 1 was observed sitting up in bed eating dinner; her dinner tray had been placed on a wheeled overbed table. Review of Resident 1's nurses notes dated [DATE] at 1925 hours, indicated: "Resident was found on floor crying near bed at dinner time. Resident had abrasion to mid lower back approx. 0.7 cm x 0.3 cm. Resident Doctor contacted..." A subsequent note at 1956 hours indicated: "Resident R/P (responsible party) notified of fall on floor..." On [DATE] at 1815 hours, Resident 1, who was clad in ankle socks (without a non-skid sole) was observed ambulating with her walker in the back hallway of the facility (on linoleum flooring); no staff were nearby for several minutes. Further review of Resident 1's clinical record indicated care plan problem for Falls dated [DATE] and [DATE], which identified approaches to prevent falls, including evaluating reason for falls, resident's ability to safely transfer and ambulate, referral to therapy, and use of non-skid foot wear. Review of the facility's P&P titled Fall Prevention Program revised [DATE], indicated under 2. Post Falls: "e. Following an Elder's fall, the IDT will complete a post fall assessment within 24 hours or as soon as practicable. The assessment will include review of possible causal factors." During an interview on [DATE] at 1020 hours, the Director of Rehab Services, who stated she had attended the morning leadership meeting at the facility and confirmed she was a member of the IDT, indicated she usually received a referral from licensed nursing staff after a resident's fall. The Director of Rehab Services confirmed she had not received an assessment referral after Resident 1's fall on [DATE]. Review of Resident 1's electronic health record on [DATE] at 0905 hours, indicated no documentation related to the IDT's post fall assessment had been conducted after the resident's fall at dinner time on [DATE]. During a concurrent interview, the DON confirmed no post fall assessment had yet been performed (approximately 40 hours after Resident 1's fall). 3.a. According to www.biomedcentral.com, a web based internet site, pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is ,[DATE]%, showing they are at great risk of experiencing pain. There is evidence that pain assessment is currently inadequate and elderly people with dementia are being undertreated. This undertreatment could lead to various additional problems like cognitive (e.g. concentration problems) and behavioral symptoms (e.g. aggression or depression) at patient level. According to www.alz.org, a web based internet site, a person with dementia will be a poor reporter and may not be able to acknowledge discomfort or request a pain pill. Review of the facility's P&P titled Care and Services for a Resident with Dementia (not dated) showed the care plan should reflect baseline and ongoing details of common behavioral expressions and expected responses to interventions and specific goals for monitoring of all interventions for effectiveness. Review of the facility's P&P titled Psychotherapeutic Drug Management with a revised date of [DATE], showed if a resident has dementia with associated agitated behaviors, the resident shall be reviewed for preventable reasons (pain). Clinical record review for Resident 4 was initiated on [DATE]. Resident 4 was admitted to the facility on ,[DATE], with [DIAGNOSES REDACTED]. Review of Resident 4's MDS dated [DATE], showed the resident had severe cognitive impairment and disorganized thinking. In addition, her MDS showed she had no complaints of pain. Review of Resident 4's Geriatric Depression Scale (GDS) dated [DATE], showed the resident was nonverbal and unable to answer questions. The GDS form was blank. Review of Resident 4's physician order [REDACTED]. an order written [REDACTED]. Review of Resident 4's MARs showed she received [MEDICATION NAME] (narcotic) ,[DATE] mg two tablets on [DATE], [DATE] and [DATE], and received ,[DATE] mg one tablet on [DATE], [DATE], and [DATE]. Review of Resident 4's PRN (as needed) Pain Assessment Flow Sheet showed on [DATE], [DATE], and [DATE], Resident 4 was given [MEDICATION NAME] ,[DATE] mg one tablet for signs and symptoms of pain. On [DATE], [DATE] and [DATE], [MEDICATION NAME] ,[DATE] mg two tablets were given for generalized pain. All licensed nurses documented the pain medication was effective. Review of Resident 4's physician monthly orders for [DATE], showed no routine pain medications were ordered. Review of Resident 4's Social Service assessment dated [DATE], showed Resident 4 required extensive assistance from staff for her care. Resident 4 was unable to verbalize and communicate with the staff and the staff continued to anticipate the needs of Resident 4. Under the behavior problems, the SSD documented Resident 4 continued to make loud verbal sounds that stopped when the resident was laid down in bed. Review of Resident 4's Weekly Summary dated [DATE], showed Resident 4 had memory problems, was rarely/never understood, and had a sad, worried facial expression. In addition, the summary showed Resident 4 had no pain symptoms. Review of Resident 4's Pain Evaluation dated [DATE], showed she was at risk for pain and had experienced pain in the past. The section to measure pain in residents with dementia who could not verbalize (such as whimpering or groaning) had a zero (0=absent). Review of Resident 4's care plans to address her communication impairment and depression (revised dates [DATE]) showed Resident 4 had verbal noises and inconsolable crying. During an interview on [DATE] at 0640 hours, LVN 1 stated Resident 4 was disoriented and unable to make her needs known. She stated Resident 4 moaned intermittently. LVN 1 stated she had tried to give Resident 4 pain medications, but it was ineffective. During an interview on [DATE] at 0655 hours, LVN 2 stated Resident 4 was disoriented and nonverbal (could not speak). When LVN 2 was asked if Resident 4 had any behaviors, she stated Resident 4 occasionally moaned, but she would not say that was a behavior symptom. LVN 2 stated Resident 4 only moaned when she was sitting in the wheelchair; as soon as Resident 4 was put back in bed, the moaning would stop. During an interview on [DATE] at 0820 hours, the SSD stated Resident 4 was nonverbal and would make verbal sounds. She stated once Resident 4 would lay down, the resident was fine and go to sleep. The SSD stated a long time ago, Resident 4 was able to walk independently and talk. On [DATE] at 0910 hours, an interview was conducted with RNAs 1 and 2. They stated Resident 4 was nonverbal and had no other behavior issues except moaning. RNAs 1 and 2 stated Resident 4 was able to ambulate 150 feet with hand-held assistance, three times a week, but sometimes Resident 4 needed assistance to stand up. During an interview on [DATE] at 1050 hours, the DON confirmed she was aware of Resident 4's moaning and had not been assessed for routine pain medication. During an interview on [DATE] at 1340 hours, the AD stated Resident 4 would "holler out" and had constant verbal grunts, at least once a day. She stated when Resident 4 was put back to bed, the hollering would stop. b. According to www.lexi.com, a web based internet site, [MEDICATION NAME] Patch is used for the treatment of [REDACTED]. A warning included: may cause CNS depression, which may impair physical or mental abilities and may exacerbate or induce extrapyramidal symptoms; worsening of symptoms (e.g., tremors). [MEDICATION NAME] is used for the treatment of [REDACTED]. Review of Resident 4's physician's monthly orders for [DATE], showed orders dated [DATE], to apply an [MEDICATION NAME] Patch 9.5 mg/24 hr every day and administer [MEDICATION NAME] XR 28 mg by mouth every day for the treatment of [REDACTED]. No documentation was available to show how Resident 4's dementia was diagnosed . No neurologist, psychiatrist, or psychologist's evaluations were available. No scans or x-ray reports were available related to the [DIAGNOSES REDACTED]. During an interview on [DATE] at 0820 hours, the SSD stated Resident 4's [DIAGNOSES REDACTED]. The SSD was unaware if Resident 4 had a mini-mental examination or was seen by a psychiatrist. During an interview on [DATE] at 1050 hours, the DON stated Resident 4's [DIAGNOSES REDACTED]. She stated the [DIAGNOSES REDACTED]. The DON stated Resident 4 had no neurologist consultation or x-ray reports available to [DIAGNOSES REDACTED]. During a telephone interview on [DATE] at 0925 hours, MD 1 stated Resident 4's [DIAGNOSES REDACTED]. He stated Resident 4 did not have a psychiatrist or psychologist's evaluation. MD 1 stated Resident 4 did not have any scans or x-rays done because the scans/x-rays do not determine "dementia." He stated no specific testing was done to confirm the dementia diagnosis.