Every finding on record at Hayward Post Acute

Based on observation, interview and record review, the facility failed to protect one of two sampled residents (Resident 1) from sexual abuse when Certified Nursing Assistant (CNA) 1 introduced Resident 1 to Resident 2 as sexy. This failure resulted in Resident 1 feeling sexually harassed.During an interview on 8/19/26 at 12:16 p.m., with Resident 1, Resident 1 stated that on 8/5/26, CNA 1 inappropriately introduced her to Resident 2 by calling Resident 1 sexy. The resident reported feeling sexually harassed by this comment. Resident 1 also noted that CNA 1 asked Resident 2 if they had a boyfriend. A review of Resident 1's Face Sheet (information containing contact details, brief medical history at-a-glance) dated 8/19/26, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included personal history of adult physical and sexual abuse. During a review of Resident 1's Minimum Data Sheet (MDS, an assessment tool) dated 8/3/26, it indicated a Brief Interview for Mental Status (BIMS) of 15 (BIMS score of 13 to 15 indicates cognition is intact). During an interview on 8/19/26 at 1:00 p.m. with Resident 2, Resident 2 stated that on 8/5/26, CNA 1 asked the resident the question, Do you have a boyfriend or a girlfriend? CNA 1 then introduced Resident 1 as being sexy. Resident 2 stated that CNA 1 was very inappropriate in asking those questions and calling Resident 1 as sexy. During a review of Resident 2's MDS dated [DATE], it indicated a BIMS of 13 (indicates cognition is intact). During a review of facility's Interdisciplinary Team (IDT, a group of individuals representing different departments of the facility) notes dated 8/10/26, the IDT notes indicated that Resident 1 stated the resident was introduced to her roommate (Resident 2) by CNA 1 as sexy. During an interview on 8/19/26 at 3:10 p.m. with the Director of Staff Development (DSD), DSD stated that calling Resident 1 as sexy was considered sexual abuse and asking Resident 2 if the resident had a boyfriend or girlfriend was very inappropriate. During an interview on 8/19/26 at 4:19 p.m. with the Director of Nursing (DON), DON stated that CNA 1 should not have called Resident 1 sexy. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition, revised 10/25/24, the P&P indicated, .Health Care Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of all residents. Sexual abuse is non-consensual sexual contact of any type with a resident. It includes but it is not limited to sexual harassment, sexual coercion or sexual assault.

Based on interview and record review, the facility failed to report allegations of sexual abuse involving one of two sampled residents (Resident 1) to the California Department of Public Health (CDPH) within the required timeframe.This failure to report allegations of abuse placed Resident 1 at risk of further abuse.During an interview on 8/19/26 at 12:16 p.m., Resident 1 stated that on 8/5/26, Resident 1 reported to Certified Nursing Assistant (CNA) 2 that CNA 1 inserted her fingers into the Resident 1's vagina while changing her diaper. Resident 1 also stated that CNA 1 changed her diaper again on 8/5/26, after she reported the incident to CNA 2. During a review of Resident 1's Face Sheet (information containing contact details, brief medical history at-a-glance) dated 8/19/26, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included personal history of adult physical and sexual abuse. During an interview on 8/19/26 at 1:02 p.m., CNA 2 admitted that Resident 1 reported to her that CNA 1 inserted her fingers into Resident 1's vagina while changing her diaper. CNA 2 stated she reported the alleged sexual abuse incident to Licensed Vocational Nurse (LVN) 1. During an interview on 8/19/26 at 2:49 p.m., with LVN 1, LVN 1 stated CNA 2 did not report the alleged abuse incident to her on 8/5/26. During an interview on 8/19/26 at 3:10 p.m. with the Director of Staff Development (DSD), DSD stated when there is an allegation of abuse, staff should report the incident to the Administrator, the facility's abuse coordinator. DSD further stated that CNA 2 should have reported the alleged sexual abuse incident to the Administrator immediately after Resident 1 reported it. Also stated reporting this promptly would have ensured a proper investigation was initiated on 8/5/26 for Resident 1's protection from further abuse. During an interview on 8/19/26 at 4:19 p.m., with the Director of Nursing (DON),DON stated the timeline of events:8/5/26: Resident 1 reported the incident to CNA 2.8/6/26: Resident 1 informed the DON about the incident.8/6/26: DON launched the investigation and reported the incident to the department.DON stated that CNA 2 should have reported the alleged sexual abuse incident to the Administrator on 8/5/26 as soon as Resident 1 reported it. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition, revised 10/25/24, the P&P indicated, 6. a. Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. i. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 1.If the patient/resident sustains serious bodily injury, the employee who forms the suspicion or witnesses the incident must report no later than two (2) hours after forming the suspicion. ii. The employee alleged to have committed the act of abuse will be immediately removed from duty pending investigation. According to Code of Federal Regulation 42 CFR S483.12(c)(1):(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on interview and record review, the facility failed to provide immediate access to the residents' census list to the Long-Term Care (LTC) Ombudsman (a trained advocate who protects the rights, health, and quality of life for residents living in nursing homes).This failure had the potential to impede the LTC Ombudsman's role to protect residents' rights, improve care quality, and promote systemic change. According to the LTC Ombudsman, on 6/25/26, she requested the current resident census list from the facility via email, but the facility did not provide the census by 7/8/26, which was nine business days after the initial request (a census is list of all residents living in the facility). During an interview on 8/20/26 at 11:45 a.m., the Social Services Director (SSD) acknowledged she was the one who received the Ombudsman emails in the facility and confirmed that she communicated with the Ombudsman via email. A review of email correspondence between the Ombudsman and the SSD indicated that the Ombudsman requested the census list on 6/25/26, and the SSD provided it on 7/8/26, after a follow-up reminder from the Ombudsman. During an interview on 8/20/26 at 4:20 p.m., the Administrator (ADM) stated that making the Ombudsman wait nine business days for the census list was unacceptable and that the information should have been provided promptly so the Ombudsman could perform their duties. The facility was unable to produce a policy and procedure outlining the timeline for document delivery to the Ombudsman. Under Code of Federal Regulations S483.10(f)(4)(i) The facility must provide immediate access to any resident by:(C) Any representative of the Office of the State long term care ombudsman.

Based on interview and record review, the facility failed to develop and revise a comprehensive person-centered care plan for Resident 1 when their nasogastric tube (NGT is a soft tube inserted through the nose, throat and into the stomach to provide nutrition, hydration, and medications when a person can't eat by mouth ) dislodged three times within a 17-day period. This failure placed Resident 1 at risk for aspiration, interruption of nutrition and hydration, missing medication doses, and repeated exposures to X-rays.During a record review of Resident 1's admission Record (AR) printed on 5/13/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke (brain suddenly stops getting enough blood) and dysphagia (have trouble swallowing).A review of Resident 1's Minimum Data Set (MDS, an assessment tool to direct residents' care) dated 12/30/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a scoring system to identify memory, orientation, and judgment status of residents) score of 15 out of 15. A BIMS score of 15 indicated that the resident is cognitively intact.A review of Resident 1's care plan initiated on 12/27/25 indicated Resident 1 had an NGT in place to meet nutritional needs, however, no interventions were identified to prevent the NGT from becoming dislodged. During a review of the Change in Condition Evaluation (CICE) dated 12/28/25, the CICE indicated when the licensed nurse went to the room to check the resident, nurse found the NGT was pulled out. The CICE indicated Resident 1 was alert and oriented times two (a person is awake, knows their own name, and knows where they are) and able to obey simple commands. The CICE also indicated that the physician ordered to reinsert the NGT and an X-ray to confirm proper tube placement.A review of the care plan initiated on 12/28/25 indicated an intervention to closely monitor and secure placement of NGT every shift. however, there is no evidence for monitoring parameters or an assessment of the factors contributing to the NGT dislodgement. During a review of CICE dated 12/30/25 indicated Resident 1 had pulled out his NGT. The CICE indicated the physician ordered NGT reinsertion and a follow-up X-ray for verifying placement. However, the care plan was not revised to identify the cause of the repeated NGT dislodgements or to implement person-centered interventions to prevent further NGT dislodgement. During a review of CICE dated 1/11/26, the CICE indicated Resident 1's NGT was pulled out for the third time. The CICE indicated that Resident 1 was confused at the time of the event.A review of Resident 1's care plan dated 1/11/26 showed no evidence that nursing staff reassessed Resident 1's behavior, evaluated the cause of repeated NGT dislodgements, or implemented a person-centered intervention(s) to prevent further episodes. During an interview on 5/14/26 at 9:24 a.m., RN 1stated that the resident-centered comprehensive care plan should be developed within seven days of admission and revised after each incident to reflect residents' current situation.During an interview on 5/14/26 at 10:00 A.M., the Director of Nursing (DON) stated that the care plan should be measurable and resident centered.A review of the facility's Policy and Procedures (P&P) titled Care Plan Comprehensive, effective date 8/25/21, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.

Based on interviews and record reviews, the facility failed to ensure that one of seven sampled residents (Resident 2) received the necessary care and services according to their clinical needs related to diabetes (a chronic disease in which the body has elevated blood sugar, also call blood glucose) monitoring, ileostomy (surgical procedure that creates an opening in the abdominal wall, bring the end of the small intestines to the surface to allow waste to exit the body directly into external pouch call ileostomy bag, bypassing the colon and rectum.) care, medication management, and indwelling urinary catheter (also called Foley catheter, a thin, flexible tube inserted into the bladder and left in place to continuously drain urine) care when1. Resident 2 was receiving insulin (a medication that lowers blood glucose), yet the facility did not document their blood glucose levels.2. Resident 2 received laxative (medication or substance to lose stools and increase bowel movements) while having large, watery stools, and at the same time continued to receive medication for diarrhea.3. Resident 2 had an indwelling Foley catheter (F/C),but the facility failed to provide catheter care, monitoring, and documenting urine output and urine characteristics.This failure resulted in inadequate clinical oversight and placed Resident 2 at risk for unrecognized changes in condition, complications related to diabetes, dehydration, and infection.Based on interviews and record reviews, the facility failed to ensure that one of seven sampled residents (Resident 2) received the necessary care and services according to their clinical needs related to diabetes (a chronic disease in which the body has elevated blood sugar, also call blood glucose) monitoring, ileostomy (surgical procedure that creates an opening in the abdominal wall, bring the end of the small intestines to the surface to allow waste to exit the body directly into external pouch call ileostomy bag, bypassing the colon and rectum.) care, medication management, and indwelling urinary catheter (also call Foley catheter, a thin, flexible tube inserted into the bladder and left in place to continuously drain urine) care when1. Resident 2 was receiving insulin (a medication that lowers blood glucose), yet the facility did not document their blood glucose levels.2. Resident 2 received laxative (medication or substance to lose stools and increase bowel movements) while having large, watery stools, and at the same time continued to receive medication for diarrhea.3. Resident 2 had an indwelling Foley catheter (F/C), the facility failed to provide catheter care, monitoring, and documenting urine output and urine characteristics.This failure resulted in inadequate clinical oversight and placed Resident 2 at risk for unrecognized changes in condition, complications related to diabetes, dehydration, and infection.Findings:During an interview on 5/14/26 at 8:08 a.m., the complainant stated that Resident 2's Responsible Party (RP) reported Resident 2's ileostomy bag was consistently full and leaked onto Resident 2's clothing during their stay in the facility. During a review of Resident 2's admission Record (AR) date 5/14/26, the AR indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, long-term use of insulin, urine retention, and ileostomy status.During a review of Resident 2's Minimum Date Set (MDS, an assessment tool to direct resident care) dated 1/26/26, the MDS indicated that Resident 2 had an indwelling catheter, an ileostomy, and was receiving insulin injections as well as oral medication to decrease blood glucose levels.During a review of Resident 2's January 2026 Medication Administration Record (MAR), the MAR indicated that Resident 2 received insulin twice a day on 1/23, 1/24, 1/25, and once on 1/26. The MAR also indicated that blood glucose was monitored before meals and at bedtime; however, the blood glucose results were not documented for the care team to review trends or identify abnormal values. (blood glucose was documented once on 1/25/25 at 5:55 am).During a review of Resident 2's January 2026 MAR, the MAR indicated that Resident 2 was receiving MiraLax (an over-the-counter laxative used to treat constipation) powder, 17 grams by mouth daily on 1/23, 1/24, 1/25 and 1/26. The instructions for MiraLax indicated hold for loose stool. The MAR also indicated Resident 2 was receiving Loperamide (a medication used to treat diarrhea) 2 milligram (mg), one tablet by mouth, on 1/22, 1/23, 1/24, 1/25, and 1/26 for diarrhea.A review of Resident 2's Documentation Survey Report (DSR) of January 2026, the DSR indicated Resident 2 had large, watery stools on 1/23 at 5:33 a.m., 2:59 p.m., and 8:43 p.m., and 1/25 at 6:59 a.m.A review of Resident 2's Change in Condition Evaluation (CICE) dated 1/26/26 at 8:52 p.m. indicated Resident 2 experienced a change in mental status, a drop in blood pressure to 60/45, and was ultimately transferred to the emergency room for evaluation.During a record review and interview on 5/14/26 at 10:21 a.m. with Director of Nursing (DON), there was no evidence that F/C care or monitoring had been provided, and no care plan was in place for the F/C or ileostomy. DON stated that these are basic nursing measures that should be implemented and care-planned upon admission. During an interview on 5/18/26 at 10:07a.m., Licensed Vocational Nurse (LVN) 1 stated nursing staff should check and document blood glucose levels for residents with diabetics to monitor for hyperglycemic (there is too much glucose in the blood) and hypoglycemic (glucose level in the blood drops too low). LVN 1 further stated that nursing staff should monitor bowel movement (BM)s for residents with ileostomy to identify signs and symptoms of constipation, diarrhea, or bowel obstruction, and that urinary output should be monitored and documented to detect early signs and symptoms of catheter blockage or urinary tract infection.During an interview on 5/18/26 at 10:28 am, DON stated Certified Nursing Assistance (CNA)s are expected to report to the charge nurse when residents have diarrhea. DON stated charge nurse should monitor the characteristics of residents' urine and BMs especially for those with a F/C or an ileostomy. DON further stated that it is standard nursing practice to monitor and document BG levels, urine output, and BM output. DON stated the nurses are expected to contact the physician to clarify whether Resident 2 should receive medication for both diarrhea and constipation at the same time. During a review of facility's Policy and Procedures (P&P) titled Nursing Care of the Older Adult with Diabetes Mellitus, revision date 4/2026, subtitled Blood Glucose Monitoring, No. 3. For the residents receiving insulin whose BG is well controlled: a. monitor glucose levels twice a day if on insulin.A review of the facility's P&P titled Providing Catheter Care, no revision date, indicated during catheter care, the urine characteristics, color, clarity, odor and volume should be documented.

Based on interview and record review, the facility failed to ensure adequate monitoring and implement appropriate interventions for Resident 1 when Resident 1's nasogastric tube (NGT is a soft tube inserted through the nose, throat and into the stomach to provide nutrition, hydration, and medications when a person can't eat by mouth) dislodged three times within a 17-day period. This failure placed Resident 1 at risk for aspiration, interruption of nutrition and hydration, missing medication doses, and repeated exposures to X-rays.During a record review of Resident 1's admission Record (AR) printed on 5/13/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke (brain suddenly stops getting enough blood) and dysphagia (difficulty swallowing).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool to direct residents' care) dated 12/30/26 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a scoring system to identify memory, orientation, and judgment status of residents) score of 15 out of 15. A BIMS score of 15 indicated that the resident is cognitively intact.A review of Resident 1's care plan initiated on 12/27/25 indicated Resident 1 had an NGT in place to meet nutritional needs, however, no interventions were identified to prevent the NGT from becoming dislodged. During a review of the Change in Condition Evaluation (CICE) dated 12/28/25, the CICE indicated when the licensed nurse went to the room to check the resident and found the NGT was pulled out. However, the document does not specify who removed the tube, or how it happened. The CICE indicated Resident 1 was alert, oriented times two (a person is awake, knows their own name, and knows where they are) and able to obey simple commands. The CICE also indicated that the physician ordered to reinsert the NGT and an X-ray to confirm proper tube placement.A review of the care plan initiated on 12/28/26 indicated an intervention to closely monitor and secure placement of NGT every shift. however, there is no evidence for monitoring parameters or an assessment of the factors contributing to the NGT dislodgement.During a review of CICE dated 12/30/25 indicated Resident 1 had pulled out his NGT. The CICE indicated the physician ordered NGT reinsertion and a follow-up X-ray for verifying placement. However, the care plan was not revised to identify the cause of the repeated NGT dislodgements. There was also no evidence that the interdisciplinary team (IDT) implemented any intervention or increased supervision to prevent further NGT dislodgment.During a review of CICE dated 1/11/26, the CICE indicated Resident 1's NGT was pulled out for the third time. The CICE indicated that Resident 1 was confused at the time of the event.A review of Resident 1's care plan initiated on 1/11/26 showed no evidence that nursing staff or ITD reassessed Resident 1's behavior, evaluated the cause of repeated NGT dislodgements, or implemented a person-centered intervention(s) to prevent further episodes. A review of Resident 1's CICE dated1/28/26 indicated Resident 1 developed a productive cough and experienced a decrease in oxygen saturation (O2 sat, a measurement of how much oxygen the blood is carrying as a percentage, normal level is 95-100 percent, below 95 indicates a person is not getting enough O2) to 89 percent, resulting in transfer to the hospital.During an interview on 5/14/26 at 10:00 A.M., the Director of Nursing (DON) stated that residents with NGTs are at high risk for dislodging and aspiration and should be monitored closely to prevent dislodgement. DON stated that staff had been checking Resident 1 hourly, however, the DON was unable to provide document supporting that hourly monitoring occurred.During a review of the facility's Policy and Procedures (P&P) titled NG tube/tube feeding/ re insertion, effective date 6/27/22, the P&P did not include guidance on monitoring NGT.

Based on interview and record review, the facility failed to follow up on Resident 1's grievance.This failure led to Resident 1 feeling angry and sad. Findings:During a review of Resident 1's admission Record, dated 9/10/25, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder.During an interview on 9/10/25 at 11:50 a.m., with Resident 1, the resident stated Resident 2 resided in the room across Resident 1's room and he could hear him yelling and screaming at the staff. Also stated Resident 2 had a behavior of pounding on and off on overbed table. Further stated that Resident 2's behavior made him angry and sad. Stated he had brought his concern to the staff on multiple occasions, but nothing was done about it.During a review of Resident 1's Minimum Data Set (an assessment tool) dated 6/25/25, it indicated he had a brief interview for mental status or BIMS of 15 (score of 15 indicates a cognitively intact status, meaning the resident shows no significant or minimal cognitive impairment). During an interview on 9/10/25 at 2:31p.m., with Certified Nursing Assistant (CNA) 1, CNA1 stated Resident 2 had a behavior of screaming, banging on bedside tables, throwing whatever he could get a hold of from his bedside to the staff. Further stated Resident 1 was complaining he could not sleep because of the noise.During an interview on 9/10/25 at 1:23 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 1 had been complaining of Resident 2's behavior of screaming and banging whatever items he could grab on his table for the past year.During an interview on 9/10/25 at 2:20 p.m., with Registered nurse (RN) 1, RN 1 stated Resident 2 had a behavior of banging on his bedside table and Resident 1 complained about Resident 2's behavior. RN 1 stated the management was aware of Resident 1's complaints.During an interview on 9/10/25 at 2:44 p.m., with the Assistant Director of Nursing (ADON), ADON stated she was not aware of Resident 1's grievance and the nursing staff should tell the management if residents have grievances.During an interview on 9/10/25 at 3:11 p.m., with the Director of Nursing (DON), DON stated she was not aware of Resident 1's grievance and the nursing staff should tell the management if residents have concerns or grievances. Stated she should be informed of the grievances, so interventions were done to resolve Resident 1's concerns. During a review of the facility's undated policy and procedure (P&P) titled, Resident Grievance/Complaint Procedures, the P&P indicated, Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members.

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. The kitchen refrigerator had packages of uncooked meat stored directly above fruit.2. Diet Aide (DA) 1 had uncovered facial hair while they prepared resident food. These failures had the potential for contamination of food resulting in food borne illness for the 88 residents who lived at the facility.During an observation on 12/8/25 at 9:30 a.m., in the kitchen, the refrigerator had uncooked turkey and beef stored directly over cantaloupes. During an observation on 12/8/25 at 12:53 p.m., in the kitchen, DA 1 had uncovered facial hair while DA 1 prepared resident sandwiches. During an interview on 12/11/25 at 2:21 p.m., with Registered Dietician (RD), RD stated uncooked meat should not have been stored over fruit and it was important to avoid cross contamination. RD stated DA 1 should have covered their facial hair when they prepared resident food and it was important to avoid food contamination. According to the 2022 Federal Food Code, food is to be protected from cross contamination by separating raw animal foods during storage from fruits and vegetables before they are washed. During a review of the facility's policy and procedure (P&P) titled, Staff Attire, revised January 2025, the P&P indicated, All staff will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on observation, interview, and record review, the facility failed to allow one out of 22 Residents (Resident 11) to exercise their right to self-determination when they were not provided nutrition in accordance with their preferences. This failure had the potential to result in Resident 11 feeling upset and disrespected. During a review of Resident 11's admission Record, printed 12/9/25, the record indicated Resident 11 was admitted to the facility in January 2025 with a diagnosis of moderate protein-calorie malnutrition. During a review of Resident 11's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.), dated 2/3/25, the record indicated Resident 11's BIMS score was 14. During a concurrent observation and interview on 12/8/25, at 12:43 p.m., with Resident 11, Resident 11's lunch tray was observed with mixed vegetables that included cauliflower. Resident 11 stated it made them upset, and they would not eat it. During a review of Resident 11's Lunch Meal Ticket, dated 12/8/25, the Meal Ticket indicated, Resident 11's Dislikes: . Cauliflower. During an interview on 12/8/25, at 12:54 p.m., with [NAME] (CK) 1, CK 1 stated Resident 11 should not have received mixed vegetables that had cauliflower, and it was a mistake. During an interview on 12/11/25, at 2:49 p.m., with Director of Nursing (DON), DON stated it was important to honor resident food choices so they could have eaten more, prevent weight loss and for resident happiness. During a review of Resident 11's Care Plan, Resident is at nutritional risk., printed 12/11/25, the Care Plan indicated, Honor food preferences within meal plan.

Based on interview, and record review, the facility failed to develop new interventions to address the prevention of displacement and clogging of one of one sampled resident's (Resident 1) nasogastric tube (NGT, a tube that is inserted through the nose going down into the stomach) when Resident 1's NGT was displaced or clogged five times between January to July 2024. This deficient practice resulted in five transfers to the acute care hospital emergency department for NGT reinsertion for Resident 1. This also had the potential of making Resident 1 feel discomfort and develop infections. Findings: Review of the Admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (an interruption in the flow of blood to cells in the brain), dysphagia (difficulty swallowing) and hemiplegia (paralysis that affects only one side of your body). Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/19/24 under Section C, indicated Resident 1's short- and long-term memory was impaired, and had moderately impaired decision-making capacity (decisions poor, cues/supervision required). Review of Resident 1's Physician's Orders (PO), dated 8/9/24, the PO indicated an active diet order of NPO (nothing by mouth) dated 11/25/22 and an order of Glucerna (liquid food/nutrition) at a rate of 70 milliliters (ml., a form of measurement) per hour for 16 hours a day thru NGT. Review of Resident 1's Physical Therapy Evaluation and Treatment, dated 7/23/24, indicated the Resident 1 was able to move her left upper extremity (the region of the body that includes the left arm, forearm, left wrist, and left hand). Review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, is a structured communication framework that can help teams share information about a change in the condition of a resident) notes dated 1/15/24, 1/27/24, 3/9/24 and 7/31/24, the SBAR indicated Resident 1 ' s NGT was dislodged or was pulled out. The SBAR indicated Resident 1 was sent to the hospital ' s emergency department on 1/15/24, 1/27/24, 3/9/24, and 7/31/24 for NGT reinsertion. Review of Resident 1's SBARs dated 4/18/24 and 4/22/24 indicated Resident 1 ' s NGT was clogged. SBAR indicated Resident 1 was sent to the emergency department on 4/18/24. Review of Resident 1's PO dated 8/9/24, the PO indicated an order to transfer Resident 1 to the emergency department for the replacement of NGT on 1/15/24, 1/27/24, 3/9/24, 4/18/24 and 7/31/24 for NGT reinsertion. During an interview with the Licensed Vocational Nurse (LVN) 1, on 8/16/24 at 1:18 p.m. , acknowledged updating and revising the care plan to add new interventions to prevent dislodgement and clogging of NGT and could have prevented some of Resident 1 ' s transfer to the emergency department for NGT reinsertion. LVN further stated staff monitored Resident 1's NGT every 2 hours but was unable to provide documentation. During a concurrent interview and review of Resident 1's nutritional care plan dated with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 8/8/24 at 2:17 p.m., DON and ADON were not able to find a care plan revision and new interventions to address how to prevent the clogging and dislodgement of NGT after 1/15/24. DON stated the purpose of revising the care plan was to change the interventions because the previous intervention did not work. Review of facility's policy and procedure, titled care plan comprehensive, dated August 2021 indicated, . the interdisciplinary team is responsible for evaluation and updating of care plans: a. When there has been a significant change in the residence condition . c. When the resident has been readmitted to the facility from a hospital stay and d. At least quarterly .

Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Corn was rinsed in the handwashing sink, during food preparation, 2. Meat was thawed in still water, 3. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for the 3-part compartment sink, 4. Hand Hygiene protocol was not followed during food preparation, and 5. Hand Hygiene protocol was not followed during tray line. These failures had the potential to cause food borne illnesses for 81 residents who received food from the kitchen for a facility census of 88. Findings: 1. During an observation in the kitchen, on 6/25/24, at 9:15 a.m., [NAME] 1 washed corn in the sink labeled and used for handwashing. During an interview, on 6/26/24, at 2:22 p.m., with Registered Dietician (RD) 2, RD 2 stated food should not be rinsed in the handwashing sink because it can cause bacterial or chemical cross contamination. During an interview on 6/27/24, at 9:10 a.m., with [NAME] 1, [NAME] 1 stated she should not have washed corn in the sink for handwashing sink. 2. During a concurrent observation and interview, in the kitchen, on 6/25/24, at 9:05 a.m., with Dietary Manager (DM), two meat bags thawed in still water in the sink. DM stated meat should be thawed under cold running water. During an interview, on 6/25/24, at 10:00 a.m., with RD 2, RD 2 stated if meat was thawed in water, it should be under running water to flush away any loose particles. 3. During a concurrent observation and interview, in the kitchen, on 6/27/24, at 9:10 a.m., with Maintenance Director (MD), the drainpipe from the 2-part compartment sinks currently used as food preparation sink connected directly into the floor and there was no air gap (a gap of air between the floor and a drainpipe) for the 2- part compartment sink. MD confirmed the sink water is pumped directly into the wastewater system/sewer. MD stated air gap is needed so there is no back flow into the sink. According to the 2017 Federal Food Code, 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. 4. During a concurrent observation and interview, in the kitchen, on 6/25/24, at 10:05 a.m., [NAME] 1 cut meat with gloved hands. [NAME] 1 without changing gloves, retrieved aluminum foil from the counter past the cooking stove. [NAME] 1 then touched the food processor, opened the processor, and transferred the meat into the cooking vessel. [NAME] 1 used the same gloved hand and covered the food with aluminum foil. [NAME] 1 then opened the oven without changing gloves and placed the cooking vessel inside the oven. [NAME] 1 then continued working on the meat. RD 2 stated is was not acceptable to use the same gloves used to cut meat to get other items and touch other kitchen surfaces and equipment. RD 2 stated it can cause cross contamination. RD 2 stated when something was on the gloves, it can be transferred to other items. 5. During an observation in the kitchen, on 6/25/24, at 12:15 p.m., [NAME] 1 served food in tray line. [NAME] 1 wore gloves and retrieved the soup ladle from above the food prep table. [NAME] 1 did not change gloves or performing hand hygiene. [NAME] 1 used the same gloved hands to break dinner rolls transferred one dinner roll each to Resident 239's and Resident 238's plates. During an observation in the kitchen, on 6/25/24, at 12:40 p.m., the lunch tray was served to Resident 239 and Resident 238 with the same dinner rolls in the dining room. During an interview on 6/26/24, at 12:24 p.m., with RD 2, RD 2 stated dinner rolls should be handled with tongs. RD 2 stated if food was handled improperly, it should be discarded. RD 2 also stated there was a risk of cross contamination and cross contact with bacteria and allergens. According to the 2022 Federal Food Code, food except when washing fruits and vegetables as, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable Utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipments. During a review of the facility's undated Policy and Procedure (P&P) titled, Food Preparation and Service, the P&P indicated, .3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness .Thawing Frozen Food: 1. Foods are not thawed at room temperature .Appropriate thawing procedures include: .completely submerging the item in cold running water (70 degrees F or below) that is running fast enough to agitate and remove loose ice particles .

Based on observation, interview and record review, the facility failed to ensure two of four sample selected residents (Resident 193 and Resident 43) received the necessary services to maintain good grooming, and personal hygiene, when Resident 193 and 43's shower schedules were not followed as scheduled. This deficient practice resulted in Resident 193 and 43 not receiving showers and were unhappy about their hygiene. Findings: A review of Resident 43's Admission Record indicated Resident 43 was admitted to the facility with multiple diagnoses including Hemiplegia (paralysis of one side of the body). A review of Resident 193's Admission Record indicated Resident 193 was admitted to the facility with multiple diagnoses including C-Diff (a bacterium that can infect the bowel and cause diarrhea) and Osteomyelitis (bone infection). A review of Resident Shower and CNA lunch schedule, dated 3/5/24, indicated Resident 193 and 43 were supposed to have showers during the P.M. shift, Resident 43 every Monday and Thursday, and Resident 193 every Tuesday and Friday. A review of Resident 193 and 43's follow up question report indicated Resident 43 did not have a shower on 6/10/24, and Resident 193 did not have any showers since admission to the facility. A review of Resident 43's ADL's care plan indicated, . Bathing: Avoid scrubbing and pat dry sensitive skin . A review of Resident 193's ADL's care plan indicated, . provide shower as scheduled and as needed . During an interview, on 6/24/24, at 12:30 p.m., with Resident 43, Resident 43 stated he took a shower once a week and preferred to take more showers but staff refused to give him more showers. During an interview, on 6/24/24, at 11:22 p.m., with Resident 193, Resident 193 stated he had been in the facility for the last three weeks and has not had a shower. Resident 193 stated he was unhappy and had only one sponge bath. During an interview, on 6/25/24, at 10:10 a.m., in Resident 193's room, with the Certified Nurse Assistant (CNA) 1, CNA 1 confirmed and stated she did not give Resident 193 the sponge bath as scheduled on 6/23/24, and documented on the Activities of Daily Living (ADL) sheet by mistake. CNA 1 stated she did not give Resident 193 a shower because he was on isolation and contact precaution. CNA 1 further stated giving sponge baths every day is important for the residents because they need to assess the resident's skin, and ensure the residents are clean for infection prevention. During an interview, on 6/27/24, at 12:10 p.m., with the Director of Nursing (DON), the DON stated she was unable to find any shower sheets that indicated if Resident 43 refused showers or had a shower on 6/10/24. The DON stated they did not have any documents that indicated why Resident 43 missed a shower on 6/10/24. A review of the facility's policy and procedure (P&P) titled, Bath, Bed, revised March 2021, indicated, .The purposes of this procedure are to promote cleanliness, provide comfort and to observe the condition of the resident's skin . Notify the supervisor if the resident refuses the bed bath . A review of the facility's P&P titled, Activities of Daily Living (ADL's) Supporting revised March 2018, indicated, .1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADL's) do not diminish .

Based on interview and record review, for one of one sampled resident (Resident 70) investigated for resident assessment, the facility failed to electronically transmit Minimum Data Set (MDS, an assessment tool used to direct resident care) Discharge assessment within the required 14 days. This failure had the potential to result in the lack of specific information for quality measure purposes. Findings: During a review of Resident 70's Admission Record, the Admission Record indicated Resident 70 was admitted to the facility for idiopathic aseptic necrosis (A condition in which there is a loss of blood flow to bone tissue, which causes the bone to die) of right femur. During a concurrent joint interview and record review on 6/26/24 at 12:15 p.m. with Minimum Data Set Coordinator (MDSC) and Licensed Vocational Nurse (LVN) 1, MDSC stated Resident 70's discharge assessment, dated 2/6/24, was completed on 2/16/24 but was transmitted late on 6/24/24, well beyond the required 14 days after completion date. MDSC stated there was an error in their computer system where some MDS assessments were missed.

Based on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) assessment for one (1) of two (2) sampled residents (Resident 35) when Resident 35's PASRR assessment did not indicate diagnoses of Schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), and Depression (mental condition where the affected feels negative emotions more strongly than ever). This failure placed Resident 35 at risk to not receive care and services appropriate to his needs. Findings: During a review of Resident 35's Admission Record, printed on 6/25/24, the Admission Record indicated Resident 35 had medical diagnoses of Schizophrenia and Depression. During a concurrent interview and record review, on 6/26/24, at 11:30 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 35's Preadmission Screening and Resident Review (PASRR) Level I Screening, submitted on 2/27/24 was reviewed. LVN 1 confirmed Resident 35's PASRR Question 10. Does the individual have serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizoaffective Disorder, or symptoms of psychosis, and /or mood Disturbance? was answered No. During a concurrent interview and record review, on 6/26/24, at 11:32 a.m., with LVN 1, Resident 35's Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 4/3/24 was reviewed. The MDS indicated Resident 35 had medical diagnoses of Schizophrenia and Depression. The LVN 1 stated the facility was expected to code Yes to Question 10 on the PASRR Level I Assessment submitted on 2/27/24. LVN 1 also stated the documentation in the PASRR Level 1 assessment coding was incorrect and completing the PASRR Level I assessment accurately was important to identify if residents with mental disorder required Level II evaluation or not. LVN 1 stated if coded correctly, a Level II evaluation would be completed. LVN 1 also stated a Level 2 evaluation would help with providing any special accommodations or recommended services needed for Resident 35's care and well-being.

Based on observation, interview and record review, for one of three (Resident 33) sampled residents investigated for limited range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point), the facility failed to ensure the comprehensive care plan that addressed Resident 33's limited range of motion was revised. This failure had the potential to result in the lack of coordination of care for Resident 33. Findings: During a review of Resident 33's Admission Record, the Admission Record indicated Resident 33 had diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) affecting the right dominant side, weakness, and cognitive communication deficit (person has difficulty communicating both verbal and non-verbal). During an observation on 6/24/24, at 10:36 a.m., Resident 33 was sitting at the edge of the bed, wearing a hospital gown that was coming off both shoulders. Resident 33, unable to move right hand, attempted to swing entire right arm to put the hospital gown back on both shoulders. Resident 33 did not have a splint or a rolled towel on the right hand. During another observation on 6/25/24, at 1:02 p.m., Resident 33 was up in a wheelchair sitting in front of the nurses' station. Resident 33 did not wear a splint or rolled hand towel. During a review of Resident 33's Minimum Data Assessment (MDS, an assessment tool used to direct resident care), dated 2/23/24, the MDS indicated Resident 33 had functional limitation in range of motion on one side of the upper and lower extremity. Resident 33's MDS, dated [DATE], also indicated functional limitation in range of motion on one side of upper and lower extremity. During a review of Resident 33's Order Summary Report, the Order Summary Report indicated a physician order, dated 9/13/23, for staff to Use rolled hand towels for right hand splint refusals, check placement every shift. During an observation and concurrent interview, on 6/26/24, at 9:45 a.m., with Registered Nurse (RN) 3, Resident 33 was observed in bed watching TV and did not wear rolled hand towel on the right hand. RN 3 stated not knowing how often and for how long the splint was placed by the Restorative Nursing Assistant (RNA). RN 3 also stated not knowing if Resident 33 was on an RNA program. During an interview on 6/26/24, at 10 a.m., with RNA, RNA stated Resident 33 refused any hand splint on the right hand. RNA also stated having tried using the rolled hand towels but Resident 33 only held the towel for a few seconds before quickly refusing to hold it. RNA stated Resident 33's refusals to use the rolled hand towels were documented manually in the clinical record. During an interview and concurrent record review, on 6/26/24, at 10:22 a.m., with Assistant Director of Nursing (ADON), ADON stated not being aware of Resident 33's refusal of the hand splint/rolled hand towels until this morning. ADON stated Resident 33's limited range of motion care plan will now be revised. Resident 33's clinical record did not indicate any limited range of motion/RNA care plan. During a review of Resident 33's limited range of motion/RNA care plan created on 9/13/23, the care plan indicated a revision date of 6/26/24. The care plan indicated interventions; monitor resident pain and discomfort and administer pain medications as needed, and notify responsible party and physician of any changes. During a review of the facility's policy and procedure (P&P), titled Care Plan Goals and Objectives, last revised November 2012, the P&P indicated goals and/or objectives are reviewed and revised at least quarterly.

Based on observation, interview and record review, for one of four (Resident 33) sampled residents reviewed for activities of daily living care (ADL care), the facility failed to ensure Resident 33 received proper treatment and care to maintain good foot health when podiatry (branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot, ankle and lower limb) services were not provided. This failure had the potential to result in foot pain and loss of toenails for Resident 33. Findings: During a review of Resident 33's Admission Record, the Admission Record indicated Resident 33 had diagnoses of type 2 diabetes mellitus (long-term [chronic] disease in which the body cannot regulate the amount of sugar in the blood) and cognitive communication deficit (person has difficulty communicating both verbal and non-verbal). During an observation, on 6/24/24, at 10:36 a.m., Resident 33 had thickened, curly and yellowish gray toenails on both feet. During a review of Resident 33's Order Summary Report, dated 6/25/24, the Order Summary Report indicated a physician's order dated 3/20/23 for the podiatry service for treatment of hypertrophic (also called onychauxis, a nail disorder that causes toenails to grow abnormally thick, over time, the nails become curled and turn white or yellow, increasing the risk for developing a fungal infection. This thickening of the nail may force the nail plate [the part you paint with nail polish] to separate from the nail bed) toenails and other foot problems every 61 days as needed. During an observation and concurrent joint interview, on 6/25/24, at 10:16 a.m., with Licensed Vocational Nurse (LVN) 2, with Registered Nurse (RN) 1 present, LVN 2 stated body/skin assessments were done weekly and it indicated the status of the skin including the toenails. LVN 2 stated Resident 33's toenails were very thick and discolored (yellowish gray), with the left pinky toenails (little toe or baby toe, the outermost toe in our foot) absent, and right pinky toenail only covered one fourth of the nailbed (layer of cells under the toenail). LVN 2 stated Resident 33 needed podiatry service. Resident 33's skin on both feet very dry and scaly. During an observation and concurrent interview, on 6/25/24, at 10:25 a.m., with Assistant Director of Nursing (DON), ADON stated Resident 33's toenails were too thick for the staff to clip and needed podiatry services. During an interview, on 6/25/24, at 10:34 a.m., with Social Services Director (SSD), SSD stated residents have not had podiatry services since October 2023. SSD stated the podiatrist (foot doctor) re-scheduled visits multiple times until finally cutting down hours. SSD stated not knowing how to go about the shortage in podiatrists to provide the services. During a review of the facility's policy and procedure (P&P) titled, Foot Care, last revised October 2022, the P&P indicated, Residents are assisted in making appointments and with transportation to and from specialists (podiatrist, endocrinologist, etc) as needed .Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals. Foot disorder that require treatment include .nail disorders.

Based on observation, interview, and record review, the facility failed to ensure effective storage of non-controlled medications when medications for disposal were not securely stored and rendered irretrievable. This failure had the potential for misuse of the medications. Findings: During an observation on 6/26/24, at 9:30 a.m., Licensed Vocational Nurse (LVN) 2 dispensed, crushed and placed four medications in separate 30 milliliters (ml) transparent plastic cup for a resident. However, LVN 2 was unable to administer and held these medications. During a concurrent observation and interview, on 6/26/24, at 9:40 a.m., with LVN 2, in room [ROOM NUMBER], LVN 2 discarded held medications in the trash bin attached to the right external side of the medication cart. Medication cart trash bin was left open. LVN 2 stated, non-controlled medications can be discarded in a regular trash bin or flushed in the toilet. During a concurrent observation and interview, on 6/26/24, at 10:45 a.m., with Director of Nursing (DON), in Station 2B hallway, DON showed stacks of 30 ml transparent plastic cups with wet and crushed white particles. DON stated, she retrieved the medications that was discarded by LVN 2 from the medication cart trash bin. DON further stated these medications should not be in that trash bin. During an interview, on 6/26/24, at 3:10 p.m., with DON, DON stated when the nurses were unable to administer and held medications, the nurse was to cover, label and give the medications to the DON or the Assistant Director of Nursing (ADON). The DON stated the DON/ADON disposed the medications in the medication collection receptacles located in their office. DON further stated medications not properly disposed can be easily accessed by anybody and could lead to an accidental ingestion of the medication. During a review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated November 2022, Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste .non-controlled substances may be disposed of in the collection receptacle.

Based on interview and record review, the facility failed to ensure one of three sample selected residents (Resident 1) stays free from accidents, when Resident 1 fell from the bed while Certified Nurse Assistance (CNA) 1 provided Activities of Daily Living (ADL, those activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). This failure in practice resulted in Resident 1 sustaining a skin laceration and transported to the emergency department. Findings: During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Patient 1 was admitted to the facility in 2019 with multiple diagnoses including stroke (a loss of blood flow to part of the brain, which damages brain tissue) and paralytic syndrome (a medical condition characterized by neuromuscular weakness that can progress to paralysis in severe cases) due to stroke. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) Section G, dated in 2023, the MDS indicated Resident 1 had total dependence on staff for bed mobility (moving from side to side or changing position in bed) with a two person physical assist. During a review of Interdisciplinary Fall, dated 6/4/24, the document indicated .as per CNA resident was given ADL care at the time and resident slipped next to resident's right side of the head . During a review of Resident 1's Body Check, dated 6/5/24, (after Resident 1 was back from hospital), the Body Check indicated Forehead laceration S/P (Status Post) fall. During an interview on 6/17/24 at 4:30 p.m. with CNA 1, CNA 1 stated she was giving Resident 1 ADL care when Resident 1 fell from the bed. CAN 1 stated she had provided ADLs for Resident 1 for many years and none of the nurses told her that two people were needed for Resident 1's ADL. CNA stated usually nurses inform the CNAs about any residents who needed two CNAs to provide ADL, CNA 1 also stated the last few years she was always giving ADL to Resident 1 by herself and never two CNAs involved in Resident 1's care at the same time. During an interview on 6/18/24 at 1:45 p.m. with the Director of Nursing Assistant ([NAME]), [NAME] stated Resident 1 always had one CNA for providing ADLs because Resident 1 was immobile. During an interview on 6/18/24 at 1:45 with [NAME], [NAME] stated that the facility does not have any policy and procedure for accidents. During a review of the facility's policy and procedure Resident Rights, revised December 2021, the policy indicated, .resident right to be free from abuse, neglect, misappropriation of property .

Based on observation, interview, and record review, the facility failed to maintain resident's privacy for one of three residents (Resident 1) when the privacy curtain was not fully drawn, exposing resident's body, brief (diaper), and legs during provision of care for activities of daily living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). This deficient practice had the potential to result in public exposure of Resident 1's body during provision of care and cause emotional distress. Findings: A review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/21/24, indicated Resident 1 was totally dependent on the assistance of two staff for ADLs. During an observation on 6/6/24 at 11:15 am, Resident 1 was in an occupied 2-bed room with Resident 1's bed on the side of the room near the window. Certified Nursing Assistant (CAN) 1 was assisting Resident 1 with a bed bath and incontinent care. The curtain on the foot of the bed was not pulled and the curtain at the window was not fully drawn for complete enclosure. Resident 1 laid flat in bed with no clothing on while CNA 1 assisted Resident 1 with ADL care. On two occasions, a staff person was observed walking past the window rolling the laundry hamper. During an interview on 6/6/24 at around 12:25 pm with CNA 1, CNA 1 acknowledged the privacy curtains were not fully drawn when she was performing ADL care for Resident 1. CNA 1 stated they have in their policy to always maintain resident's visual privacy during ADL care. During an interview on 6/6/24 at 4 pm with Director of Nursing (DON), DON stated staff should always have the privacy curtains drawn and can close the door when they are changing residents or doing ADL care. A review of the facility's policy and procedure (P&P) titled SNFCLINIC Resident Rights, revised December 2021, indicated Policy .Employees shall treat all residents with .respect, and dignity .Federal and state laws .basic rights to all residents .include the resident's right to a dignified existence . A review of the facility's P&P titled, SNFCLINIC Resident Rights Guidelines for all Nursing Procedures, revised October 2010, indicated, . Close the room entrance door and provide for the resident's privacy .

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain bathing, personal hygiene, turning & repositioning for one of three resident samples (Resident 1), when one staff instead of two staff provided care for activities of daily living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) for Resident 1. This failure caused undue pain and distress for Resident 1. Findings: A review of Resident1's Admission record indicated Resident 1 was admitted with diagnoses that included diabetes, generalized muscle weakness, lack of coordination, hypertensin, and depression. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/21/24, the MDS indicated Resident 1 was totally dependent on the assistance of two staff for ADLs, Helper does ALL the effort. Resident does none of the effort to complete the activities. Or the assistance of 2 or more helpers is required for the resident to complete the activity for performances such as toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, ., personal hygiene; roll left and right, . During an interview on 6/6/24 at 10:45 am with Resident 1, Resident 1 stated he was blind and only able to see slightly with the right eye. Resident 1 stated he could not move and can only move his legs a little. Resident stated it was always uncomfortable and painful when staff move and turn him in bed. Resident 1 stated it has always been one staff assisting him with turning. During an observation on 6/6/24 at 11:30 am in Resident 1's room, Certified Nursing Assistant (CNA) 1 assisted Resident 1 with a bed bath and incontinent care. CNA 1 urged Resident 1 to help with turning during the ADL care. Resident 1 informed CNA1 that he was unable to and never did help turn. CNA 1 attempted to place her hands on Resident 1 ' s left arm and shoulder to turn him, Resident 1 cried out in pain and asked CNA 1 to use the drawsheet under him instead. Then CNA 1 turned Resident 1 with the drawsheet, but Resident 1 still cried out in pain. The skin on Resident 1's buttocks area was red and had abrasions (scrapes). Resident 1 had wounds on his right leg and left foot, with dressings on them. Resident 1 was moved and turned by CNA 1 three times during the ADL care for Resident 1. After changing the bed sheet, placing a clean brief, and putting on a clean gown for Resident 1, CNA 1 then moved Resident 1 up in the bed with the draw sheet which was also uncomfortable and painful for Resident 1. During an interview on 6/6/24 at 12:15 pm with CNA 1, CNA 1 acknowledged Resident 1 is dependent and needed two people to change and turn him to ensure resident was comfortable and for safety. During a concurrent interview and record review on 6/6/24 at 12:40 pm with Licensed Vocation Nurse (LVN) 1, Resident1's MDS, dated [DATE], was reviewed. LVN 1 stated two people were needed to change Resident and it was indicated in the MDS that Resident 1 is dependent and requires two or more helpers to complete the activity for turning/repositioning. During a concurrent interview and record review on 6/6/24 at 12:58 pm with LVN 1, Resident 1's Physician Orders, dated June 2024, were reviewed. The Physician Orders indicated Gabapentin (medication to treat nerve pain) for Resident 1. LVN 1 stated Resident 1 did not have PRN (as needed) pain medication ordered. During an interview on 6/6/24 at 3:30 pm with Director of Nursing (DON) and assistant DON (ADON), DON stated that they are supposed to have two staff to change and reposition dependent residents such as Resident 1. DON and ADON stated they gave all staff in-service yesterday. During a review of the weekly summaries dated 5/12, 5/19, 5/26, and 6/5/24, the weekly summaries indicated one person performed ADLs for Resident 1. During a review of the facility's policy and procedure (P&P) titled, SNFCLINIC Activities of Daily Living (ADLs) Supporting Personal Care, revised March 2018, indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with: Hygiene (bathing, dressing .). A resident's ability to perform ADLs will be measured using clinical tools, including the MDS . During a review of the P&P titled, SNFCLINIC Repositioning, Positioning and Moving, revised May 2013, the P&P indicated, Check the care plan, assignment sheet or the communication system to determine resident's specific positioning needs .resident level of participation and the number of staff required to complete the procedure .Use two people and a draw sheet to avoid shearing while turning or moving the resident up in bed.

Based on observation, interview and record review, the facility failed to prevent an avoidable accident by not following the resident's plan of care to have two or more persons assisting the resident with transfers from the wheel chair to the bed. This failure resulted in one (Resident 1) of three sampled residents falling and sustaining a hip fracture. Findings: During a review of the clinical record for Resident 1, the admission record indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan, last revised on 10/14/15, for Resident 1 showed she was at risk for falls due to use of cardiovascular medication, visual impairment, poor safety awareness, poor balance and severely impaired mental abilities. Review of the Minimum Data Set (MDS, an assessment tool used to direct resident's care) dated 10/9/15 for Resident 1 showed she was not able to walk but was able to sit up in a wheelchair. The MDS indicated Resident 1 required two or more staff members to transfer to and from the bed and the wheelchair. The MDS showed Resident 1's activity preferences included to do things with groups of people, to go outside, and to participate in religious services. The clinical record included an Interdisciplinary Team progress note dated 12/4/15 for Resident 1 that indicated the resident had an assisted fall on 12/1/15 while transferring from the wheelchair to the bed. A review of the nurse's progress notes showed Resident 1 had pain in her left hip on 12/3/15. Her physician was notified and an x-ray of her left hip was done. The x-ray showed a left hip fracture. After an investigation the facility concluded that Resident 1 sustained the hip fracture during her fall on 12/1/15. Resident 1 was transferred to a local hospital. A review of the discharge summary from the hospital showed Resident 1's son declined surgery to repair the hip fracture. Resident 1 was placed on bedrest and hospice services (care provided at the end of life) and returned to the facility. During an observation on 12/17/15 at 1:35 p.m., Resident 1 was observed in her bed. Certified Nursing Assistant 2 (CNA 2) was providing care to Resident 1. Resident 1 frowned, cried out Oh and rubbed her left upper leg and hip area when turned in the bed. Old bruising (green discoloration) of her left knee was observed. During an interview on 12/17/15 at 1:37 p.m., CNA 2 stated she had cared for Resident 1 prior to her fall on 12/1/15. CNA 2 stated Resident 1 always required the assistance of two staff members to transfer to and from the wheelchair and the bed. CNA 2 also stated Resident 1 enjoyed being up in the wheelchair and attending activities prior to her fall. Resident 1 was on bedrest and required frequent turning and repositioning to prevent skin breakdown since her fall. During an interview on 12/17/15 at 2:10 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she had been caring for Resident 1 since October 2015. LVN 1 stated Resident 1 was on bedrest since her fall and she has pain when moved and turned in the bed. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 12/17/15 at 3:10 p.m., she stated she was caring for Resident 1 on 12/1/15 at the time of her fall. She stated that Certified Nursing Assistant 1 (CNA 1) reported that Resident 1 had a fall while being transferred from the wheelchair to the bed. CNA 1 placed Resident 1 back in the bed prior to notifying LVN 2. LVN 2 stated CNA 1 was not the usual aide assigned to care for Resident 1. During a telephone interview with Certified Nursing Assistant 1 (CNA 1) on 12/22/15 at 2:15 p.m., she stated she was assigned to care for Resident 1 on 12/1/15. CNA 1 stated on 12/1/15 at about 7 p.m. she attempted to transfer Resident 1 from the wheelchair to the bed without assistance. Resident 1 grabbed CNA 1 under her arm. CNA 1 released Resident 1's left side and Resident 1 slipped to the floor landing on her left side. CNA 1 stated she lifted Resident 1 off the floor and placed her in her bed. CNA 1 stated 12/1/15 was the second time she had cared for Resident 1. She stated she was not aware that Resident 1 required two or more people to transfer her from the wheelchair to the bed. CNA 1 stated the facility's Director of Nursing told her after the fall that Resident 1 required two or more people to transfer. CNA 1 stated the information on care needs for the residents was available in the facility's computer system (Point Click Care) but she did not check the computer prior to attempting to transfer the resident. During a telephone interview with Certified Nursing Assistant 3 (CNA 3) on 1/4/16 at 3:15 p.m., she stated she was assigned to care for Resident 1 on the 7 a.m. to 3 p.m. shift on 12/1/15. CNA 3 stated she was aware that Resident 1 required assistance of at least 2 people to transfer but she did not inform CNA 1. She stated Resident 1 was up in the wheelchair attending activities when she left the facility at 3:30 p.m. CNA 3 stated Resident 1 had always required assistance of two people for transfers and that the information was available to staff in the computer. During a telephone interview with the facility's Assistant Director of Nursing (ADON) on 1/8/16 at 1:34 p.m., she confirmed Resident 1 required two staff members for transfers to and from the wheelchair prior to her fall on 12/1/15.

Based on observation, interview and record review, the facility failed to adequately assess the pain levels and provide the prescribed pain medications for two of 22 sampled residents (15, 17) resulting in the residents experiencing pain without relief and failed to ensure arm splints were ordered for one additionally sampled resident (24) resulting in a delay of treatment for [REDACTED]. 1. For Resident 17's chronic pain, the facility failed to ensure that they had the pain medication ([MEDICATION NAME] ER 100 milligrams(mg.) orally) as ordered for Resident 17's pain and failed to notify the resident's physician when [MEDICATION NAME] was not available resulting in Resident 17 experiencing unrelieved pain. 2. For Resident 15, the facility failed to provide scheduled pain medication ([MEDICATION NAME] , a narcotic pain reliever) on eleven occasions, that resulted in inadequate pain control and discomfort from symptoms due to not getting the medication. 3. For Resident 24, the facility failed to ensure that arm splints were ordered to provide pain relief for the resident's bilaleral carpal tunnel syndrome (numbness, pain, weakness in hands because of pressure on the median nerve of the wrist). Findings: 1. On 3/24/15 at 8:30 a.m. review of the clinical record showed Resident 17 was admitted on [DATE], after a left hip replacement. The resident had a history of [REDACTED]. (Spinal stenosis is the narrowing of spaces in the spine (backbone) which causes pressure on the spinal cord and nerves.) physician's orders [REDACTED]. a. Pain monitoring scale: Monitor level of pain every shift: 0 = None ( no pain) 1-3 = Mild pain 4-6 = Moderate pain 7-10 = Severe pain every shift, start date 3/18/15 , 3:00 p.m. b. [MEDICATION NAME] ER (Extended Release) (narcotic pain reliever)100 milligram tablet. Give 1 tablet by mouth every 8 hours for pain management. Start date 3/18/ 2015 at 22 (10 pm) . Facility's every eight hour medication schedule was 6 a.m.; 2 p.m.; 10 p.m. c. [MEDICATION NAME] (pain reliever) tablet one tablet every 6 hours, as needed, for moderate pain. d. [MEDICATION NAME] to give 2 tablets every 6 hours for severe pain. On 3/26/15 at 8:00 a.m., during an interview, RN 3 (Registered Nurse 3) said he assisted RN 4 with the admission of Resident 17 between 5:00 p.m. and 6:00 p.m. on 3/18/15. On 3/26/15 at 9:16 a.m., during a telephone interview, RN 4 said she went to check Resident 17 after 9 p.m. (on 3/18/15). Resident 17 was in pain and requested pain medication. RN 4 did not remember what Resident 17's pain level was. RN 4 said she told the medication nurse to give the resident two tablets of "[MEDICATION NAME] ( pain reliever) or [MEDICATION NAME] ( pain reliever)." RN 4 was not sure which pain reliever was ordered but was sure it was not [MEDICATION NAME] because there was no [MEDICATION NAME] tablets available at that time. During the interview, RN 4 was asked if the physician was notified that [MEDICATION NAME] was unavailable, RN 4 stated that she did not notify the physician. Review of Resident 17's admission record indicated that pain assessment was done on 3/18/15 at 11:38 p.m., several hours after admission. The assessment indicated that Resident 17 verbally described his pain intensity and was assessed at level 7. Resident 17 was in severe pain. On 3/26/15 at 9:26 a.m. during an interview, LVN 6 (Licensed Vocational Nurse 6), who was assigned to take care of Resident 17 on 3/19/15 night shift, stated that the report and instructions given to her by the afternoon shift (3/18/15) licensed nurse was that Resident 17's [MEDICATION NAME] tablets were unavailable and not delivered by the pharmacy. Resident 17 missed his 10:00 p.m. dose of [MEDICATION NAME]. LVN 6 gave Resident 17 two [MEDICATION NAME] tablets for his pain at 1:30 a.m. on 3/19/15 . At that time according to LVN 6, Resident 17's pain level was 8 (severe pain) . The documentation did not show that Resident 17's pain level was assessed after [MEDICATION NAME] tablets were administered. Review of Resident 17's MAR ( Medication Administration Record [REDACTED]. [MEDICATION NAME] was not administered until 3/19/15 at 5:00 a.m. eleven hours after admission. On 3/26/15 at 9:35 a.m. during an interview, Resident 17 described how "miserable" he was and in "so much pain and discomfort" on evening of 3/18 and the following night. He stated that he begged and requested the nurses to call his doctor and "do something, they seem to not understand how bad these pains are". The only answer he got was that "they(pharmacy)" did not "deliver" his [MEDICATION NAME]. Instead he was given [MEDICATION NAME] tablets . Resident 17 said that he was on "chronic pain" (persistent pain refers to a pain state that continues for a prolonged period of time or recurs more than intermittently for months or years) management at home and prior to his surgery. He explained that when he misses a dose of [MEDICATION NAME] he cannot manage his pain and the [MEDICATION NAME] medication is only for breakthrough pain in between his doses of [MEDICATION NAME]. During the interview, Resident 17 said the nurses told him [MEDICATION NAME] was delivered at around 2 a.m., (3/19/15) the morning after he was admitted but they did not give it to him because it is not time yet. The nurse did not give him [MEDICATION NAME] until 5 a.m. On 4/8/15 at 11:05 a.m., during an interview, two of the facility pharmacy consultants (PC1 and PC2), confirmed that Resident 17's [MEDICATION NAME] ER was delivered on 3/19/15 at 2:57 a.m. as confirmed by review of the shipping manifest On 3/26/15 at 2:45 p.m. during a telephone interview, Physician 1 stated Resident 17 was on high intravenous dose of [MEDICATION NAME] (opiod narcotic pain reliever ) after Resident 17's hip surgery, therefore it is "very important" for the resident's chronic pain management to administer the prescribed [MEDICATION NAME] on time. Physician 1 stated that when the facility failed to administer the [MEDICATION NAME] for any reason, the nurses should have notified the attending physician or the on call physician so that they can give the nurses appropriate instructions on what to do. Physician 1 stated the facility did not notify him or the on-call physician about the [MEDICATION NAME] not being available. 2. A review of the clinical record for Resident 15 indicated he was admitted to the facility 7/8/14, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 7/18/14, indicated Resident 15 understood was what said to him, and was able to be understood, with a Brief Interview for Mental Status score of 10. (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero the most impaired. A score of 10 is an indication of moderate impairment.) Resident 15 required extensive assistance to get out of the bed or use a wheelchair. The MDS further indicated Resident 15 was on scheduled pain medication, but still had occasional pain at a level of eight on a scale of one to ten (with ten the worst pain). A review of the physician orders [REDACTED]. Nursing staff was to monitor and record Resident 15's level of pain every shift on the "Medication Administration Record [REDACTED]=none; 1-3=mild pain; 4-6=moderate pain; 7-9=severe pain; 10=worst pain." A review of the care plan for Resident 15, created 7/24/14 and revised 3/4/15, with the focus of, "The resident is on Pain Medication Therapy," indicated the first intervention as, "Administer medication as ordered ie [MEDICATION NAME] every 6 hrs (hours), [MEDICATION NAME], [MEDICATION NAME] sulfate prn (as needed)." During review of the clinical record for Resident 15, the MAR, dated 1/1/15 through 1/3/15, indicated 8 doses of [MEDICATION NAME] were not given as ordered: 1/1/15 at 6 a.m., noon, and 6 p.m.; 1/2/15 at midnight, 6 a.m., and noon; 1/3/15 at noon, and 6 p.m. The six consecutive doses missed on 1/1/15 and 1/2/15 resulted in a 42 hour gap without [MEDICATION NAME] administration, followed by administration of three doses as ordered (1/2/15 at 6 p.m., 1/3/15 at midnight, and 1/3/15 at 6 a.m.), followed by another 18 hour gap from two missed doses (1/3/15 at noon, and 6 p.m.). The MAR further indicated that during this same time period, Resident 15 received the "as needed for pain" medication, [MEDICATION NAME] sulfate, eleven times: two doses on 1/1/15, six doses on 1/2/15, and three doses on 1/3/15. During the remaining 28 days of January, Resident 15 received a total of ten doses of [MEDICATION NAME], with no more than 2 doses on any single day. The MAR indicated [REDACTED] During an interview on 4/7/15, at 1:15 p.m., Registered Nurse 1 (RN 1) stated there was no [MEDICATION NAME] available on 1/2/15, and 1/3/15 for Resident 15, and the pharmacy would not release the e-kit [MEDICATION NAME] for use; she left a message with the physician to inform him of the need to provide authorization to the pharmacy for [MEDICATION NAME]. RN 1 stated that Resident 15 had the capacity to tell his level of pain, and would ask for [MEDICATION NAME] when he had pain. During review of the January 2015 MAR for Resident 15, the "Pain Monitoring Scale," indicated presence of pain across all seven nursing shifts from 3 p.m. on 1/1/15, to 3 p.m. on 1/3/15. Five of the seven shifts recorded pain at level 5 (moderate pain). During a review of the Nursing Progress Notes dated 1/2/15 at midnight, 4:03 a.m., and 8 a.m., nurses noted pain at level six out of ten. A review of the March 2015 MAR for Resident 15, indicated three consecutive doses of [MEDICATION NAME] were not given: 3/18/15 at noon and 6 p.m., and 3/19/15 at midnight. The [MEDICATION NAME] schedule was resumed with the 6 a.m. dose on 3/19/15, with 24 hours lapsed time between [MEDICATION NAME] doses. The March 2015 MAR indicated [REDACTED]. At no other time during the month (from 3/7/15 through 3/24/15) were more than two doses of [MEDICATION NAME] given in a single day. During an interview on 3/26/15, at 8:05 a.m., Licensed Vocational Nurse 1 (LVN 1) stated she was aware of Resident 15's missed doses on 3/18/15. She stated she had asked the physician to write a continuation letter for the [MEDICATION NAME] the previous week, but he had not done so. She also sent a refill request to the pharmacy for the [MEDICATION NAME] on 3/13/15. On 3/18/15, the 6 a.m. dose was the last [MEDICATION NAME] given. LVN 1 documented the missed noon dose, and called the pharmacy for the current status of the [MEDICATION NAME]. She was informed that the pharmacy was still waiting for the doctor to complete the continuation letter. LVN 1 stated she then called the doctor, who said he had completed the continuation letter, and the pharmacy should be delivering the medication; he didn't authorize use of the emergency kit (e-kit) for the missed [MEDICATION NAME]. LVN 1 stated she had medicated Resident 15 with [MEDICATION NAME] at 10 a.m., and he appeared comfortable before she left at 3 p.m. A review of an e-mail to the Regional Clinical Director (RCD) from the Back End Manager (BEM) of the pharmacy, dated 3/26/15, at 1:04 p.m. (received by the RCD on 3/26/15, at 3:30 p.m.), indicated the pharmacy had received the continuation authorization letter for the [MEDICATION NAME] for Resident 15 on 3/17/15, at 5:20 p.m., and delivery of the [MEDICATION NAME] was arranged for 3/19/15. A review of the March 2015 MAR for Resident 15, "Pain Monitoring Scale," indicated presence of pain at level six and five during the two nursing shifts from 3/18/15 at 11 p.m., to 3/19/15 at 3 p.m. A review of the Nursing Progress Notes dated 3/19/15 at 4:12 a.m., indicated pain at level seven. During a review of the clinical records for Resident 15, "Progress Notes," dated 3/18/15, at 7:04 p.m., indicated, "Med not available, and 3/19/15 at 12:47 a.m., indicated, "Waiting for medication delivery." During a review of the clinical record for Resident 15, the March 2015 MAR indicated [REDACTED]. The MAR further indicated a documented pain score of 6 (moderate pain) for the shift beginning at 11 p.m. on 3/18/15, and ending 7:30 a.m. on 3/19/15. During a review of the clinical record of Resident 15, the "Progress Notes," dated 3/19/15, at 4:12 a.m., indicated a pain score of seven (severe pain). During an observation and concurrent interview on 3/26/15, at 9:25 a.m., Resident 15 was lying in bed, with the head of the bed elevated, watching television. Resident 15 verbally responded to questions, and although his speech was slightly garbled, he was understandable. He said it was painful when he missed doses of [MEDICATION NAME] the previous week (week of March 15-22). Resident 15 said both his legs hurt, and he "felt bad." He stated he was given doses of [MEDICATION NAME] during the time of the missed [MEDICATION NAME] doses, but that they didn't really take away the pain. He said he had felt "that bad" one other time, sometime after Christmas, when he also didn't receive several doses of [MEDICATION NAME]. Resident 15 said it was hard to speak and took so much energy that he preferred for his Responsible Party (RP 1) to speak for him during extended conversations. During an interview on 3/26/15, at 9:05 a.m., the RP 1 stated she visited daily and assisted with daily care needs (e.g., eating, repositioning, grooming). She stated that Resident 15 had missed doses of the [MEDICATION NAME] on March 18 and 19. When RP 1 visited on the morning of 3/19/15, Resident 15 said he didn't feel right overnight, and thought he might have been going through withdrawal. RP 1 said she had told staff he was in active withdrawal a couple months earlier, when doses of the [MEDICATION NAME] had been missed. She stated that on the earlier occasion of missed [MEDICATION NAME] he was very distressed. She said he had constant jitters, and kept grabbing the bed, saying, "Something's not right." She said he didn't look or act right, and she gave the example that he refused his favorite snack (a lollipop). A review of Lexi-Comp (an on-line drug reference for the healthcare industry), "[MEDICATION NAME]," (accessed 4/6/15) indicated that [MEDICATION NAME] and [MEDICATION NAME] were classified as opiate agonists (a class of drugs that stimulate opiate receptors and effectively relieve pain without producing loss of consciousness), which are known to have the risk of physical dependence with continued administration. Lexi-Comp also indicated, "Individuals who are physically dependent on opiate agonists may remain relatively asymptomatic as long as they are able to maintain their daily opiate agonist requirement ... Physical dependence results in withdrawal symptoms in patients who abruptly discontinue the drug ...The abstinence syndrome varies in severity according to the specific drug and the amount of drug the patient has been taking ...In general, the shorter the onset and duration of action of the drug, the greater the intensity and rapidity of onset of withdrawal symptoms." According to Lexi-Comp, for [MEDICATION NAME], "the [MEDICATION NAME] effect occurs within 10-15 minutes, reaches its maximum in 30-60 minutes, and persists for 3-6 hours." (http://online.lexi.com/lco/action/doc/retrieve/docid/250/ 5#mono-ref-nested) A review of DailyMed (an online resource from the National Library of Medicine, that is the official provider of FDA label information), "[MEDICATION NAME]/[MEDICATION NAME] tablet," (accessed 4/6/15) indicated, "Patients considered opioid tolerant are those who are taking at least ... 30 mg oral [MEDICATION NAME]/day ...for one week or longer." A review of the 2015 January MAR for Resident 15, indicated that the orders for the [MEDICATION NAME] and [MEDICATION NAME] had been in effect since 7/17/14, with no change in dosage. A review of Resident 15's physician orders [REDACTED]. A review of Lexi-Comp, "[MEDICATION NAME]," accessed 4/6/15, indicated a 15 milligram dose of oral [MEDICATION NAME] sulfate would be needed to provide the equivalent pain relief provided by a ten milligram dose of [MEDICATION NAME]. A review of MedlinePlus (the National Institute of Health website for information on health, medications, and diseases), "[MEDICATION NAME]," (accessed 4/6/15) indicated: "Do not stop taking [MEDICATION NAME] without talking to your doctor. If you stop taking this medication suddenly, you may experience withdrawal symptoms such as restlessness, watery eyes, runny nose, sneezing, yawning, sweating, chills, muscle or joint aches or pains, weakness, irritability, anxiety, depression, difficulty falling asleep or staying asleep, cramps, nausea, vomiting, diarrhea, loss of appetite, fast heartbeat, and fast breathing. Your doctor will probably decrease your dose gradually." 3. Review of clinical record showed Resident 24 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. During observation and concurrent interview on 3/23/15 at 9:10 a.m., Resident 24 moved around the facility in an electric wheelchair with a joystick controlled by Resident 24's right hand. Resident 24 stated that the nurse practitioner ordered wrist splints last week and as of 3/23/15, no one had supplied them or discussed obtaining them with him. Review of Resident 24's clinical record on 3/23/15, showed a physician's orders [REDACTED]. Licensed Vocational Nurse (LVN 4) noted this order on 3/16/15. During an interview on 3/25/15 at 9:50 a.m., LVN 4 stated she noted the order on 3/16/15 then entered it into the computer for rehab services to fit resident with wrist splints. LVN 4 further stated she spoke to the Director of Rehab (DR) and notified her of the order. During an interview on 3/25/15 at 3:55 p.m. the Director of Rehab (DR) stated she was not notified of the order for wrist splints until 3/23/15. She stated physical therapy and occupational therapy orders are verbally communicated to the department by the physician or the nursing staff. She stated no one in the therapy department was notified of these orders on 3/16/15. During an interview on 3/24/15 at 3:30 p.m., the Occupational Therapist (OT) stated his evaluation of Resident 24 on 3/23/15 showed Resident 24 had 3 plus of 5 weakness (5 of 5 would indicate normal strength) to wrists and hands and had pain level of four of ten (moderate pain) which "gets worse" (increased to 7 of ten, severe pain) with wrist flexion. During an observation and concurrent interview on 3/26/15 at 11:30 a.m., Resident 24 was in bed. He reported he had not received the splints. He stated the facility had to order a larger size because they did not have splints that fit him available in the facility. He stated he is "taking it easy" and not using his electric wheelchair because the pain and numbness in his hands and wrist increased with movement of his hands operating his wheelchair. The National Institute of Health's Carpal Tunnel Syndrome Fact Sheet showed, "Early [DIAGNOSES REDACTED]. Immobilizing the wrist in a splint avoids further damage from twisting and bending."