Every finding on record at Healthbridge Children's Hospital - Orange D/P SNF

Based on observation, interview, medical record review, document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the risk and development of pressure injuries for two of three final sampled residents (Residents 19 and 23) reviewed for pressure injuries. * The facility failed to ensure Resident 19's low air loss mattress setting was accurate and on alternate mode setting. * The facility failed to ensure Resident 23's low air loss mattress settings were accurate and failed to obtain a physician's order specifying the low air loss mattress setting. These failures placed Residents 19 and 23 at risk for the development or worsening of pressure injuries and to not benefit from the therapy provided by the LAL mattress.Findings: Review of the facility's P&P titled Use of Low Air Loss Mattresses revised 11/2022 showed to provide guidelines for the safe and appropriate use of low air loss mattresses to prevent and treat pressure injuries, promote skin integrity, and enhance patient comfort in the acute care setting. These devices shall be used in accordance with physician orders, manufacturer guidelines, and clinical assessment to ensure patient safety and optimal therapeutic outcomes. A physician's order is required for the initiation of the low air loss mattress use. The order must specify the type of mattress/support surface, clinical indication and duration of use. Nursing staff should verify the physician order, inspect the mattress for proper function, ensure correct installation per manufacturer guidelines and set appropriate pressure settings based on patient weight and condition. Review of the Adapt Pro Elite Low Air Loss Alternating Pressure Mattress Manual (undated) showed the Adapt Pro Elite mattress was intended to help and reduce pressure sores while optimizing patient's comfort. The Adapt Pro Elite may be used in a variety of settings including but not limited to individual home care setting as prescribed by the physician. In addition, under the operation instructions, it was recommended the air mattress's pump settings were adjusted to the patient's weight and comfort. 1. On 4/27/2026 at 1011 hours, Resident 23 was observed in bed on a low air loss mattress. The low air loss mattress machine pump setting was set at a 400 lbs – firm. Medical record review for Resident 23 was initiated on 4/27/26. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Order Summary Report dated 4/28/26, showed a physician's order dated 4/20/26, to use a low air loss mattress every shift for skin breakdown prevention. However, further review of the Order Summary Report failed to show a physician's order specifying the setting for the low air loss mattress. On 4/28/26 at 0838 hours, an observation, interview and concurrent medical record review for Resident 23 was conducted with RN 2. RN 2 verified Resident 23's use of the low air loss mattress. When asked about the low air loss mattress setting on the machine, RN 2 verified the low air loss machine setting was set at firm (firmest level) based on the light indicator on the machine. RN 2 was asked if there was a physician's order for the setting of the low air loss mattress to be set at the firm setting, RN 2 stated she was unsure and would review resident's medical record. RN 2 verified the physician's order addressed only the use of the low air loss mattress and did not include specific instructions for the mattress settings. On 4/29/26 at 1204 hours, an interview and concurrent medical record review for Resident 23 was conducted with RN 1. RN 1 verified Resident 23's use of the low air loss mattress and the physician's order. RN 1 stated the licensed nurses adjusted the low air loss mattress setting based on the resident's weight. RN 1 verified there was no physician's order specifying the setting for the mattress. On 4/30/26 at 1416 hours, an interview and concurrent medical record review for Resident 23 was conducted with the ADON. The ADON was informed and verified the above findings. Cross Reference to F0657, example # 3. 2. On 4/27/26 at 1136 hours, during the initial tour of the facility, Resident 19 was observed lying on his back on a LAL mattress (Adapt Pro Elite) set to alternate mode with a weight setting of 110 pounds. Medical record review for Resident 19 was initiated on 4/27/26. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 12/16/25, showed Resident 19 had a diagnosis of anoxic brain injury and no decision-making capacity. Review of Resident 19's Quarterly MDS assessment dated [DATE], showed Resident 19 required total assistance from staff for all ADL care. Review of Resident 19's plan of care showed a care plan problem dated 12/26/25, addressing the resident's potential for pressure ulcer development related to immobility. The interventions included the resident to have LAL mattress. Review of Resident 19's Order Summary Report for 4/2026, showed the following physician's orders: - dated 12/16/25, for air mattress. - dated 4/29/26, for low air loss mattress every shift for skin breakdown prevention. Set pressure settings according to weight. Adjust pressure settings to Static while providing care and set back to Alternating setting when done. On 4/28/26 at 1210 hours, an observation and concurrent interview was conducted with RN 6 for Resident 19. Resident 19 was observed lying on a LAL mattress (Adapt Pro Elite) set to static mode with a weight setting of 110 pounds. RN 6 verified the above findings, and stated she was not familiar of different the setting types for the LAL mattress. On 4/29/26 at 1613 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 was informed of the findings and stated the LAL mattress should have been on alternate mode setting when care was not being provided and switched to static mode setting only when care was provided. In addition, RN 5 stated the LAL mattress prevented the development of pressure injuries and the wrong setting could compromised the resident's skin integrity. On 4/30/26 at 1409 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the antibiotic stewardship program was monitored, and addressed the use of the antibiotics for two of 12 final sampled residents (Residents 3 and 19) and one nonsampled resident (Resident 9). * The facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria. This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled 2026 Infection Prevention Program Plan and Policy dated 1/2026 showed the infection surveillance will follow the standardized McGeers's Criteria in the subacute unit. The Infection Prevention Program will assure appropriate use of antibiotics through active participation in the antibiotic stewardship committee. Review of the facility's P&P titled Antibiotic Stewardship Program revised 1/2022 showed the facility will established an antibiotic stewardship program team accountable for stewardship activities. The Infection Preventionist will review infections and monitor antibiotic usage patterns on a regular basis. The IP will include a separate report on the number of residents on antibiotics that did not meet the criteria for active infection. An antibiotic review process, also known as antibiotic time-out (ATO) for all antibiotics prescribed in the facility. ATO's prompt clinicians to reassess the ongoing need for a choice of antibiotic when the clinical picture is clearer and more information available. The ATO can be considered a stop order of an antibiotic when diagnostic test results or symptoms of the resident do not support the diagnosis of infection. Review of the facility's Subacute Surveillance Line Listing for March 2026 showed the following:- Resident 3 was prescribed levofloxacin (antibiotic medication) 250 mg. However, the McGeer's Criteria for true infection was not met;- Resident 19 was prescribed Augmentin (antibiotic medication) 500 mg. However, McGeer's Criteria for true infection was not met; and - Resident 9 was prescribed ciprofloxacin (antibiotic medication) 500 mg. However, the McGeer's Criteria for true infection was not met. Review of the Revised McGeer Criteria for Surveillance Checklist for Residents 3, 9, and 19 (undated) showed each resident exhibited signs and symptoms of infection; however, the residents did not meet the criteria for true infection based on the checklist. On 4/30/26 at 1107 hours, an interview, facility document review and concurrent facility P&P review was conducted with the IP. The IP stated the facility used McGeer's Criteria as part of its antibiotic stewardship program. The IP stated for the residents who DNMC and were prescribed antibiotic medications, the facility completed the ATO, which was documented in the resident's medical record. The IP stated the physician reviewed the resident's signs and symptoms with the RN supervisor to determine if continuation of antibiotic therapy was appropriate. The IP was able to show the documentation of the ATO for Residents 3, 9, and 19, showing the physician was made aware of the residents' signs and symptoms and opted to continue the course of the antibiotic therapy. However, the IP was asked if the prescribing physician documented the clinical rationale for continuing the antibiotic medication despite not meeting the criteria, the IP verified there was no physician's progress note documented to show the rational for the continuation use of the antibiotic medication for the residents. On 4/30/26 at 1416 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment for four of nine residents (Residents 1, 17, 18, and 22) observed during medication administration observation. * During the medication administration observation for Resident 1, LVN 3 failed to don PPE gown for EBP precautions. In addition, LVN 3 failed to perform hand hygiene in between the glove changes. * During the medication administration observation for Residents 17 and 22, LVN 3 failed to don PPE gown for EBP precautions. * The facility failed to ensure RN 6 donned PPE, including gloves, prior to taking Resident 18's vital signs in an EBP room. These failures posed the risk for transmission of infection to residents, staff, and visitors.Findings: Review of the facility's P&P titled Hand Hygiene revised 2/2023 showed hand hygiene was the single most effective measure to reduce the spread of infection and all staff should comply with the hand hygiene policy. In addition, hands should always be decontaminated before donning and after removing gloves. Review of the facility's P&P titled Enhanced Barrier Precautions revised 8/2024 showed enhanced barrier precautions (EBP) was implemented to reduce the risk of transmission of Multidrug-Resistant Organisms (MDRO) within the facility. Enhanced barrier precautions utilized the use of gowns and gloves for when high-contact patient care activities were indicated; examples of high-contact patient activities included device care (central line, urinary catheter, feeding tube, and tracheostomy/ventilator). 1. Medical record review for Resident 1 was initiated on 4/27/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a feeding tube. Review of Resident 1's Order Summary Report showed a physician's orders dated 6/20/23, to provide enhanced standard precautions every shift for infection prevention. On 4/28/26 at 0523 hours, a medication administration observation was conducted with LVN 3 for Resident 1. LVN 3 was observed preparing the following medications:- three tablets of baclofen (muscle relaxant) 10 mg,- one chewable tablet of simethicone (medication to relieve excess gas and bloating) 80 mg, and- one tube of Aquaphor (protects and soothes dry skin) ointment. On 4/28/26 at 0531 hours, an enhanced barrier sign was posted outside of Resident 1's room. The sign indicated providers and staff must wear gloves and gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, assisting with toileting, device care or use for central lines, urinary catheter, feeding tube, and tracheostomy, and wound care. LVN 3 was observed performing hand hygiene and donning gloves when he entered Resident 1's room to administer the medications. However, LVN 3 was not observed wearing a gown. After administering Resident 1's medications via GT, LVN 3 was observed removing his gloves and donning a new pair of gloves without performing hand hygiene. LVN 3 then administered Resident 1's topical medication. 2. Medical record review for Resident 17 was initiated on 4/27/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's H&P examination dated 9/26/25, showed Resident 17 had a GT. Review of Resident 17's Order Summary Report showed a physician's orders dated 1/13/26, to provide enhanced barrier precautions every shift for infection prevention. On 4/28/26 at 0543 hours, a medication administration observation was conducted with LVN 3 for Resident 17. LVN 3 was observed preparing 0.3 ml of simethicone medication. On 4/28/26 at 0544 hours, an enhanced barrier sign was posted outside of Resident 17's room. LVN 3 was observed performing hand hygiene and donning gloves when he entered Resident 17's room to administer the resident's medication via GT. However, LVN 3 was not observed wearing a gown. 3. Medical record review for Resident 22 was initiated on 4/27/26. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's MDS assessment dated [DATE], showed Resident 22 used a feeding tube. Review of Resident 22's Order Summary Report showed a physician's orders dated 1/13/26, to provide enhanced barrier precautions every shift for infection prevention. On 4/28/26 at 0605 hours, a medication administration observation was conducted with LVN 3 for Resident 22. LVN 3 was observed preparing the following medications:- one tablet of baclofen 20 mg,- one bottle of dextran ophthalmic solution (a medication to relieve dry eyes),- one bottle of artificial saliva moisturizing gel (a medication to relieve dry mouth symptoms),- four ml of glycopyrrolate (a medication to reduce severe drooling) liquid solution, and- one bottle of nighttime relief lubricant eye ointment. On 4/28/26 at 0612 hours, an enhanced barrier sign was posted outside of Resident 22's room. LVN 3 was observed performing hand hygiene and donning gloves when he entered Resident 22's room to administer the medications. However, LVN 3 was not observed wearing a gown. On 4/28/26 at 0630 hours, an interview was conducted with LVN 3. LVN 3 stated when providing care for the residents with EBP, the staff members should wear a mask, gown, and gloves. LVN 3 verified he did not wear a gown when he administered Resident 1,17, and 22's GT medication and he did not perform hand hygiene between the glove use during the medication administration observation for Resident 1. On 4/30/26 at 1409 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings. 4. On 4/28/26 at 0838 hours, during the medication administration observation with RN 6 for Resident 18. RN 6 was observed taking Resident 18's vital signs inside the room (with EBP precautions) prior to medication administration, however, RN 6 was not wearing PPE, such as gloves. Review of Resident 18's medical record was initiated on 4/28/26. Resident 18 was admitted to the facility on [DATE]. Review of the Physician H&P examination dated 9/6/25, showed Resident 18 had global developmental delay and GT dependent. Review of Resident 18's Order Summary Report for 4/2026 showed a physician's order dated 1/13/26, for enhanced barrier precautions during high contact care for infection prevention protocol. On 4/28/26 at 0916 hours, an interview was conducted with RN 6. RN 6 acknowledged the above findings and stated there was no need to wear the gloves when taking vital signs or turning off feeding pumps, since she was not actually rendering care or touching any other lines. On 4/29/26 at 1557 hours, an interview was conducted with RN 5. RN 5 was informed of the above findings and stated the PPE required for EBP included gown, gloves, and mask for high contact care, however, gloves should be worn when touching the resident. On 4/30/26 at 0951 hours, an interview was conducted with the IP. The IP was informed of the above findings and stated the PPE required for EBP included gloves and gown for high contact care such as dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, device care and wound care. When asked if the vital signs check was considered contact care, the IP stated, RN 6 should have at least worn gloves when touching the resident. On 4/30/26 at 1416 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in three of three garbage dumpsters. * The facility failed to ensure the two garbage dumpster lids had fully closed lids and one dumpster had a lid in place. This failure had the potential to attract pest/rodents that carried diseases.Findings: Review of the facility's P&P titled Non-Medical Waste Management revised date 1/2026 showed non-biomedical waste (general trash) must be disposed of in the designated hospital dumpsters. Staff must ensure that trash bags are securely tied before disposal and dumpster lids remain closed to prevent pests and odors. According to the 2022 FDA (Food and Drug Administration) Food Code, the outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 4/27/26 at 0929 hours, an observation with the CDM was conducted of the facility's three outside garbage dumpsters. Two of the garbage dumpsters had lids partially propped open due to garbage bags and cardboard boxes, preventing full closure. The third dumpster was observed without a lid and was fully open with garbage bags exposed. On 4/27/26 at 0938 hours, an interview was conducted with the Maintenance Director/Plant Operations Director. The Maintenance Director/Plant Operations Director was shown a photograph taken on 4/27/26 at 0929 hours, showing the above observations for the three dumpsters. The Maintenance Director/Plant Operations Director verified the above findings and stated the dumpster lids should be fully closed to prevent trash from coming out of the containers. On 4/29/26 at 1505 hours, a follow-up interview was conducted with the CDM. The CDM verified the above findings and stated the garbage dumpsters should have lids and the lids should be closed to prevent items from entering or exiting of the trash containers and to maintain infection control. On 4/30/26 at 1416 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary conditions were maintained in the kitchen. * The facility failed to ensure the hood over the stove was maintained in a sanitary condition. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were kept in good repair. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were maintained in a sanitary condition and had smooth, cleanable surfaces. These failures had the potential for cross contamination and foodborne illnesses to the two residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Diet Type Report dated 4/28/26, showed two of 21 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Kitchen Ansul Hood Fire Suppression System date revised 3/2022 showed the kitchen's Ansul hood system must remain in safe working condition, be regularly inspected, and be free of grease accumulation. Dietary staff must ensure hood, filters, and surrounding surfaces are free of visible grease. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 4/27/26 at 0842 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the CDM. The kitchen hood over the stove had yellowish, greasy residue. The CDM acknowledged the observation and stated the dietary staff cleaned the hood once a week and the hood was also serviced by an outside company. The sticker on the hood showed it was last serviced on 2/11/26. 2. Review of the facility's P&P titled Cleaning and Sanitizing Utensils and Cutting boards date revised 4/2025 showed to ensure all utensils, cutting boards, and food contact surfaces are properly cleaned and sanitized to prevent foodborne illness and maintain compliance with California health regulations and infection control standards. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/27/26 at 0842 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the CDM. The following was observed and verified by the CDM: - One red peeler with black handle, discolored and worn out.- One light blue rubber basting brush was discolored with yellowish stains at the base.- One stainless steel can opener with orange discoloration, consistent with rust.- Three white rubber spatulas with red handles, partially melted; one had peeling rubber edges and discoloration. 3. Review of the facility's P&P titled Cleaning and Sanitizing Utensils and Cutting boards date revised 4/2025 showed to ensure all utensils, cutting boards, and food contact surfaces are properly cleaned and sanitized to prevent foodborne illness and maintain compliance with California health regulations and infection control standards. All utensils and cutting boards must be cleaned and sanitized after each use and between preparation of different food types to prevent cross-contamination, in accordance with the California Retail Food Code (CalCode) and applicable public health standards. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Nonfood- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 4/27/26 at 0842 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the CDM. The following was observed and verified by the CDM: - One stainless steel slotted scoop with green handle had fuzzy film and watermarks.- One stainless steel scoop with gray handle, dirty, with fuzzy film and watermarks.- One stainless steel scoop with black handle had fuzzy film and watermarks. - Two stainless steel scoops with green handles had fuzzy film and watermarks. - One stainless steel scoop with blue handle with watermarks and dry crusted residue. - One stainless steel spatula with wooden handle, dirty with orange residue, fuzzy film and watermarks. - One stainless steel scissor with black handle, dirty with dry crusted residue. 4. Review of the facility's P&P titled Cleaning and Sanitizing Utensils and Cutting boards date revised 4/2025 showed to use color-coded cutting boards to prevent cross-contamination. Clean and sanitize cutting boards after each use and between different food types. Inspect cutting boards regularly. Discard or resurface if deeply scratched, cracked, or worn. According to the USDA Food Code 2022 Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 4/27/26 at 0842 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the CDM. The green, red and yellow cutting boards were observed fuzzy, heavily marred and had deep groves. The CDM verified the findings and stated the thin cutting boards were replaced every six months. On 4/29/26 at 1505 hours, a follow-up interview was conducted with the CDM. The CDM acknowledged all the above findings and stated the following: - The hood over the stove should not have any grease residue due to fire hazard and infection control purposes. - All dirty and worn-out utensils and kitchenware should have been washed, discarded and replaced for infection control purposes.- The cutting boards should have been replaced because the deep grooves could not be cleaned thoroughly. On 4/30/26 at 1416 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure three of four licensed nurses observed for medication administration demonstrated competency verifying GT placement prior to administering medications (LVNs 3 and 4 and RN 3). * LVN 3 failed to verify the GT placement prior to administering the medications for Residents 1, 17, and 22. * RN 3 failed to verify the GT placement prior to administering the medications for Resident 6. * LVN 4 failed to verify the GT placement prior to administering the medications for Resident 10. These failures had the potential to place the residents at risk for unsafe and improper care, including aspiration and complications related to incorrect tube placement. Findings: Review of the facility's P&P titled Medication Administration; oral; IM; SQ; ID; Metered Dose; NGT; GT; JT; Vaginal, Urethral; Suppository; Eye & Ear Drops revised 4/2022 showed the procedure for administering medications via NGT and GT included to elevate the head of the bed, confirm placement of the tube by aspiration contents and/or injecting 20 ml of air; aspiration would result if tube was not in the stomach. Review of the facility's document titled Medication Administration dated 2/28/25, showed a lesson plan that contained instructions for the use of NGT/GT. The instructions included checking the placement of the tube and checking the gastric residuals immediately before administering medications. 1. Medical record review for Resident 22 was initiated on 4/27/26. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's MDS assessment dated [DATE], showed Resident 22 used a feeding tube. Review of Resident 22's Care Plan Report showed a care plan problem revised 8/18/23, addressing Resident 22's alteration in gastrointestinal status related to her NPO status and enteral feeding dependency. The interventions included elevating the head of bed during and thirty minutes after tube feeding and checking for tube placement and gastric contents/residual volume per facility protocol. On 4/28/26 at 0605 hours, a medication administration observation was conducted with LVN 3 for Resident 22. LVN 3 was observed preparing the following medications:- one tablet of baclofen (muscle relaxant) 20 mg,- one bottle of dextran ophthalmic solution (eye lubricant),- one bottle of artificial saliva moisturizing gel (oral moisturizer),- four ml of glycopyrrolate liquid solution (used to reduce chronic severe drooling), and- one bottle of nighttime relief lubricant eye ointment. On 4/28/26 at 0612 hours, during the medication administration observation with LVN 3, LVN 3 was observed connecting the enteral syringe to Resident 22's GT. LVN 3 was observed administering multiple medications and water through the resident's GT but did not verify the GT placement by aspirating gastric contents or injecting 20 ml of air prior to administering the medications and water. Cross Reference to F693, example #1. 2. Medical record review for Resident 1 was initiated on 4/27/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a feeding tube. Review of Resident 1's Care Plan Report showed a plan of care revised 8/3/23, addressing Resident 1's risk for malnutrition, dehydration, weight loss, and altered fluid balance related to NPO status with enteral feeding dependency. The interventions included checking the GT placement and gastric contents/residual volume per facility protocol, and holding the enteral feeding if residuals were greater than 75 ml. On 4/28/26 at 0523 hours, a medication administration observation was conducted with LVN 3 for Resident 1. LVN 3 was observed preparing the following medications:- three tablets of baclofen 10 mg,- one chewable tablet of simethicone (medication to relieve excess gas and bloating) 80 mg, and- one tube of Aquaphor (protects and soothes dry skin) ointment. On 4/28/26 at 0531 hours, during the medication administration observation with LVN 3, LVN 3 was observed connecting the enteral syringe to Resident 1's GT. LVN 3 was observed checking Resident 1's gastric residuals by pulling back on the enteral syringe. LVN 3 then administered 30 ml of water to Resident 1's GT, followed by the simethicone medication and an additional 30 ml of water. LVN 3 then administered the baclofen medication, followed by 30 ml of water. LVN 3 was not observed injecting 20 ml of air into Resident 1's GT prior to the medication administration. Cross Reference to F693, example #3. 3. Medical record review for Resident 17 was initiated on 4/27/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's H&P examination dated 9/26/25, showed Resident 17 had a GT. Review of Resident 17's Care Plan Report showed a plan of care revised 10/23/25, addressing Resident 17's GT use related to his swallowing problem. The interventions included checking the GT placement and gastric contents/residual volume per facility protocol. On 4/28/26 at 0543 hours, a medication administration observation was conducted with LVN 3 for Resident 17. LVN 3 was observed preparing 0.3 ml of simethicone medication. On 4/28/26 at 0544 hours, during the medication administration observation for Resident 17 with LVN 3, Resident 17 was observed in bed receiving enteral feeding via the enteral pump. LVN 3 stopped the pump, connected the enteral syringe, and administered 10 ml of water to Resident 17's GT. LVN 3 then administered the simethicone medication and an additional 5 ml of water. LVN 3 then restarted the feeding pump. LVN 3 was not observed aspirating gastric contents or injecting 20 ml of air to Resident 17's GT prior to medication administration. On 4/28/26 at 0630 hours, an interview was conducted with LVN 3. LVN 3 stated he did not check Residents 17 and 22's residuals or GT placement because the licensed staff members checked the tube every shift, and he had completed this at the beginning of his shift. On 4/28/26 at 0854 hours, an interview was conducted with LVN 2. LVN 2 stated the tube placement should be checked every time medications were administered through the enteral tube to ensure the tube was functioning properly. On 4/30/26 at 0954 hours, an interview was conducted with the IP. The IP stated prior to medication administration via GT, the licensed nurse should verify placement and patency of the GT by checking the resident's gastric residuals and by auscultating with a stethoscope while injecting air through the GT to ensure the medications were administered to the correct location. On 4/30/26 at 1409 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings. Cross Reference to F693, example #4. 4. On 4/28/26 at 0634 hours, a medication administration observation for Resident 6 and concurrent interview was conducted with RN 3. RN 3 was observed preparing and administering 4 ml of sucralfate suspension medication via GT without verifying the GT placement. When RN 3 was asked how to check for GT placement, RN 3 stated GT placement was checked using a stethoscope and injecting air. RN 3 acknowledged she did not check GT placement using a stethoscope prior to medication administration. Medical record review for Resident 6 was initiated on 4/27/26. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's H&P examination dated 3/17/26, showed Resident 6 was GT dependent. Review of Resident 6's care plan showed a plan of care dated 8/6/23, addressing Resident 6's feeding tube use related to her swallowing problem. The interventions included checking the GT placement and gastric contents/residual volume per facility protocol. On 4/29/26 at 1607 hours, an interview was conducted with RN 5. RN 5 was informed of the above findings and stated GT placement should have been checked prior to medication administration to ensure GT was not dislodged. Cross Reference to F693, example #5. 5. On 4/28/26 at 0536 hours a medication administration observation for Resident 10 and concurrent interview was conducted with LVN 4. LVN 4 was observed preparing and administering the following medications without verifying the GT placement: - erythromycin (antibiotic) 500 mg oral solution 1.13 ml; - sodium chloride 23.4% oral solution 3.75 ml; and - tizanidine (muscle relaxer) 2 mg tablet half tablet (1 mg). When LVN 4 was asked about the facility's GT medication administration protocol, LVN 4 stated she would have to check the facility's protocol but acknowledged she did not check GT placement using a stethoscope prior to medication administration. Medical record review for Resident 10 was initiated on 4/28/26. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE]. On 4/28/26 at 0555 hours, an interview was conducted with RN 4. RN 4 was informed of the above findings and stated GT placement should have been checked prior to medication administration to ensure GT patency. On 4/30/26 at 1416 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings for Residents 6 and 10. Cross Reference to F693, example #6.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services were provided for six of 19 residents (Residents 1, 6,10, 11, 17, and 22) receiving enteral feeding. * LVN 3 failed to verify GT placement prior to administering medications for Residents 1 and 17. * RN 3 failed to verify GT placement prior to administering medications for Resident 6. * LVN 4 failed to verify GT placement prior to administering medications for Resident 10. * The facility failed to ensure Resident 11's HOB (head of bed) was elevated to a minimum of 30 degrees during NGT feeding. * The facility failed to ensure Resident 22's HOB was elevated to a minimum of 30 degrees during the GT feeding. In addition, LVN 3 did not verify the GT placement prior to administering medications through the tube. These failures posed the risk for aspiration due to the improper feeding tube care.Findings: Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump dated 3/2022 showed steps in the procedure included to position the head of the bed at 30 to 45 degrees for feeding, unless medically contraindicated and to verify placement of the tube. Review of the facility's P&P titled Medication Administration; oral; IM; SQ; ID; Metered Dose; NGT; GT; JT; Vaginal, Urethral; Suppository; Eye & Ear Drops revised 4/2022 showed the procedure for administering medications via NGT and GT included to elevate the head of the bed, confirm placement of the tube by aspiration contents and/or injecting 20 ml of air; aspiration would result if tube was not in the stomach. 1. Medical record review for Resident 22 was initiated on 4/27/26. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's MDS assessment dated [DATE], showed Resident 22 used a feeding tube. Review of Resident 22's Care Plan Report showed the following plan of care: - revised 9/23/22, a care plan problem addressing Resident 22's risk for aspiration. The interventions included to monitor signs and symptoms of aspiration, to keep the head of the bed elevated during feeds, and follow orders for feeds and flushes. - revised 8/18/23, a care plan problem addressing Resident 22's alteration in gastrointestinal status related to her NPO status and enteral feeding dependency. The interventions included elevating the head of bed during and thirty minutes after tube feeding and checking for tube placement and gastric contents / residual volume per facility protocol. Review of Resident 22's Order Summary Report showed the following physician's orders: - dated 7/14/23, to elevate the head of bed to 30 degrees during feeds and for 30 minutes following every day shift for aspiration precautions; and - dated 7/27/25, to administer IsoSource 1.5 (enteral feeding formula) at 195 ml via GT for one hour followed by 300 ml of water to run over one hour three times a day. a. On 4/27/26 at 1004 hours, Resident 22 was observed in bed receiving Isosource 1.5 formula (enteral feeding) at 195 ml an hour. Resident 22's HOB was elevated to 15 degrees. On 4/27/26 at 1018 hours, an observation and concurrent interview for Resident 22 was conducted with LVN 1. LVN 1 verified Resident 22's HOB was not elevated to 30 degrees while receiving enteral nutrition. On 4/29/26 at 1538 hours, an interview was conducted with RN 1. RN 1 stated when the residents were receiving enteral feedings, the HOB should be elevated at least 30 degrees to prevent aspiration. b. On 4/28/26 at 0612 hours, during the medication administration observation with LVN 3, LVN 3 was observed connecting the enteral syringe to Resident 22's GT. LVN 3 was observed administering multiple medications and water through the resident's GT but did not verify the GT placement by aspirating gastric contents or injecting 20 ml of air prior to administering the medications and water. 2. On 4/27/26 at 0946 and 1557 hours, and on 4/29/26 at 0914 hours, Resident 11 was observed in a crib bed and receiving Compleat 1.0 (enteral formula) at 38 ml an hour via NGT. Resident 11's HOB was observed flat. Medical record review for Resident 11 was initiated on 4/27/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's MDS assessment dated [DATE], showed Resident 11 used a feeding tube. Review of Resident 11's Order Summary Report showed the following physician's orders: - dated 3/31/22, a nothing by mouth (NPO) diet, and - dated 3/26/26, to administer Compleat 1.0 at 38 ml an hour via NGT continuously. Review of Resident 11's Care Plan Report showed a plan of care revised 1/22/24, addressing Resident 11's tube feeding use and altered nutritional status related to dysphagia. The interventions included elevating the HOB to 45 degrees due to Resident 11's continuous feeding. On 4/27/26 at 0955 hours, an interview and concurrent observation of Resident 11 was conducted with LVN 1. LVN 1 verified Resident 11's HOB was flat while Resident 11 was receiving the enteral feeding. LVN 1 stated Resident 11 frequently slid down in bed when the HOB was elevated. LVN 1 stated the facility staff members were aware of Resident 11's positioning during enteral feeding and stated keeping Resident 11's HOB at a flat position was the best they could do. On 4/29/26 at 0929 hours, an interview and concurrent observation for Resident 11 was conducted with LVN 2. LVN 2 verified Resident 11's HOB was flat while Resident 11 was receiving the enteral feeding. LVN 2 stated Resident 11's HOB should be elevated when she received the enteral feeding. On 4/29/26 at 1538 hours, an interview was conducted with RN 1. RN 1 stated when the residents were receiving enteral feedings, the HOB should be elevated at least 30 degrees to prevent aspiration. 3. On 4/28/26 at 0531 hours, during the medication administration observation with LVN 3, LVN 3 was observed connecting the enteral syringe to Resident 1's GT. LVN 3 was observed checking Resident 1's gastric residuals by pulling back on the enteral syringe. LVN 3 then administered 30 ml of water to Resident 1's GT, followed by the simethicone medication and an additional 30 ml of water. LVN 3 then administered the baclofen medication, followed by 30 ml of water. LVN 3 was not observed injecting 20 ml of air into Resident 1's GT prior to the medication administration. On 4/28/26 at 0630 hours, an interview was conducted with LVN 3. LVN 3 stated he did not check Resident 1's GT placement because the licensed staff members checked the tube every shift, and he had completed this at the beginning of his shift. Medical record review for Resident 1 was initiated on 4/27/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Care Plan Report showed a plan of care revised 8/3/23, addressing Resident 1's risk for malnutrition, dehydration, weight loss, and altered fluid balance related to NPO status with enteral feeding dependency. The interventions included checking the GT placement and gastric contents/residual volume per facility protocol, and holding the enteral feeding if residuals were greater than 75 ml. 4. On 4/28/26 at 0544 hours, during the medication administration observation for Resident 17 with LVN 3, Resident 17 was observed in bed receiving enteral feeding via the enteral pump. LVN 3 stopped the pump, connected the enteral syringe, and administered 10 ml of water to Resident 17's GT. LVN 3 then administered the simethicone medication and an additional 5 ml of water. LVN 3 then restarted the feeding pump. LVN 3 was not observed aspirating gastric contents or injecting 20 ml of air to Resident 17's GT prior to medication administration. Medical record review for Resident 17 was initiated on 4/27/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's H&P examination dated 9/26/25, showed Resident 17 had a GT. Review of Resident 17's Care Plan Report showed a plan of care revised 10/23/25, addressing Resident 17's GT use related to his swallowing problem. The interventions included checking the GT placement and gastric contents/residual volume per facility protocol. On 4/28/26 at 0630 hours, an interview was conducted with LVN 3. LVN 3 stated he did not check Residents 17 and 22's residuals or GT placement because the licensed staff members checked the tube every shift, and he had completed this at the beginning of his shift. On 4/28/26 at 0854 hours, an interview was conducted with LVN 2. LVN 2 stated the tube placement should be checked every time medications were administered through the enteral tube to ensure the tube was functioning properly. On 4/30/26 at 0954 hours, an interview was conducted with the IP. The IP stated prior to medication administration via GT, the licensed nurse should verify placement and patency of the GT by checking the resident's gastric residuals and by auscultating with a stethoscope while injecting air through the GT to ensure the medications were administered to the correct location. On 4/30/26 at 1409 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings. 5. On 4/28/26 at 0634 hours, a medication administration observation for Resident 6 and concurrent interview was conducted with RN 3. RN 3 was observed preparing and administering 4 ml of sucralfate suspension medication via GT without verifying the GT placement. When RN 3 was asked how to check for GT placement, RN 3 stated GT placement was checked using a stethoscope and injecting air. RN 3 acknowledged she did not check GT placement using a stethoscope prior to medication administration. Medical record review for Resident 6 was initiated on 4/27/26. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's H&P examination dated 3/17/26, showed Resident 6 was GT dependent. Review of Resident 6's care plan showed a plan of care dated 8/6/23, addressing Resident 6's feeding tube use related to her swallowing problem. The interventions included checking the GT placement and gastric contents/residual volume per facility protocol. On 4/29/26 at 1607 hours, an interview was conducted with RN 5. RN 5 was informed of the above findings and stated GT placement should have been checked prior to medication administration to ensure GT was not dislodged. Cross Reference to F726, example #4. 6. On 4/28/26 at 0536 hours a medication administration observation for Resident 10 and concurrent interview was conducted with LVN 4. LVN 4 was observed preparing and administering the following medications without verifying the GT placement: - erythromycin (antibiotic) 500 mg oral solution 1.13 ml; - sodium chloride 23.4% oral solution 3.75 ml; and - tizanidine (muscle relaxer) 2 mg tablet half tablet (1 mg). When LVN 4 was asked about the facility's GT medication administration protocol, LVN 4 stated she would have to check the facility's protocol but acknowledged she did not check GT placement using a stethoscope prior to medication administration. Medical record review for Resident 10 was initiated on 4/28/26. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. On 4/28/26 at 0555 hours, an interview was conducted with RN 4. RN 4 was informed of the above findings and stated GT placement should have been checked prior to medication administration to ensure GT patency. On 4/30/26 at 1416 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings for Residents 6 and 10. Cross Reference to F726, example #5

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one nonsampled resident (Resident 17) was free from accident hazards. * The facility failed to provide padded side rails for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions per the physician's order for Resident 17. This failure placed Resident 17 at risk for serious injury.Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised 6/2022 showed that consideration was given to the resident's safety, medical condition, comfort, and freedom of movement, as well as input from the resident and family. On 4/27/26 at 0938 and 1535 hours, 4/28/26 at 1015 hours, and at 4/29/26 at 0914 hours, Resident 17 was observed in bed with side rails in use. The side rails were not padded. Medical record review for Resident 17 was initiated on 4/27/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's H&P examination dated 9/26/25, showed Resident 17 had a diagnosis of seizure. Review of Resident 17's Side Rail Assessment Form dated 9/26/25, showed Resident 17's family member had requested the use of the side rails while the resident was in bed for safety and/or comfort, and noted seizure precautions as the reason for the use. Review of Resident 17's Order Summary Report showed a physician's order dated 4/24/26, to provide a padded side rails for seizure precautions. On 4/29/26 at 0929 hours, an interview and concurrent observation of Resident 17 was conducted with LVN 2. LVN 2 verified Resident 17's side rails were not padded. LVN 2 stated Resident 17's family had declined the use of the padded side rails for Resident 17's seizure precautions. LVN 2 also stated the refusal of the physician's order for the padded side rails should be documented in Resident 17's medical record. On 4/29/26 at 1046 hours, a follow-up interview and concurrent observation of Resident 17 was conducted with LVN 2. Resident 17 was observed in bed with padded siderails in place. LVN 2 stated she was unable to locate documentation in the resident's medical record to show the family had declined the use of the padded side rails. LVN 2 also stated she did not see an order for the padded side rails on Resident 17's MAR and acknowledged the physician's order had been missed. On 4/30/26 at 1409 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for two of 12 final sampled residents (Residents 4 and 10) reviewed for respiratory care. * The facility failed to ensure Resident 4 and 10's oxygen tubing were stored in a sanitary condition when not in use. These failures had the potential to negatively affect the respiratory health and well-being of the residents in the facility.Findings: Review of the facility's P&P titled Changing Respiratory Equipment revised 1/2025 showed the oxygen masks and cannulas will be changed weekly and as needed. All respiratory disposable treatment equipment will be dated when changed weekly. 1. On 4/27/26 at 0918 hours and 4/28/26 at 0852 hours, Resident 4 was observed in bed. Resident 4's oxygen tubing was observed hanging on the wall hook. The tubing was unlabeled, undated, and not stored inside the clear plastic bag setup bag. Medical record review for Resident 4 was initiated on 4/27/26. Resident 4 was admitted to the facility on [DATE], with a diagnosis of chronic respiratory failure. Review of Resident 4's Order Summary Report dated 4/28/26, showed a physician's order dated 3/20/24, to provide cool aerosol during nights with FLO2 to keep oxygen saturation above 92%. 2. On 4/27/26 at 0955 hours and 4/28/25 at 0852 hours, Resident 10 was observed in bed. Resident 10's oxygen tubing was observed coiled around the oxygen regulator at the wall. The tubing was unlabeled, undated, and not stored inside the clear plastic setup bag. Medical record review for Resident 10 was initiated om 4/27/26. Resident 10 was admitted to the facility on [DATE], with a diagnosis of chronic respiratory failure. Review of Resident 10's Order Summary Report dated 4/28/26, showed a physician's order dated 11/17/24, to titrate FLO2 to keep oxygen saturation above 92%. On 4/28/26 at 0852 hours, an observation and concurrent interview for Residents 4 and 10 was conducted at bedside with RT 1. RT 1 stated the respiratory staff changed the setup bag weekly the oxygen administrator supplies, nebulizer supplies and ventilator tubing. RT 1 stated the setup bags should be labeled with the resident's name and date. When asked where the oxygen tubing should be stored when not in use, RT 1 stated it should be placed inside the labeled setup bag. When asked about the oxygen tubing observed hanging on the wall hook for Resident 4 and coiled on the oxygen regulator for Resident 10, RT 1 verified the tubing should have been labeled and stored inside the setup bag. On 4/29/26 at 1136 hours, an interview and concurrent medical record review for Residents 4 and 10 was conducted with RN 1. RN 1 stated the respiratory therapists were responsible for the respiratory care and the supplies used for oxygen administration. RN 1 stated the respiratory supplies were changed weekly and labeled with the resident's name and date. RN 1 was informed of the observations regarding unlabeled and undated tubing not stored inside the setup bag. RN 1 verified the findings. On 4/30/26 at 1416, an interview and concurrent medical record review for Residents 4 and 10 was conducted with the ADON. The ADON was informed and verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the accuracy of the medical record for one nonsampled resident (Resident 18) was accurate. * Resident 18's medical record contained behavior and side-effect monitoring for the use of the quetiapine (antipsychotic) medication; however, there was no physician's order for the quetiapine medication. This failure had the potential for the resident's care team having inaccurate information.Findings: Review of the facility's P&P titled Charting and Documentation date revised 3/2022 showed all the services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Medical record review for Resident 18 was initiated on 4/28/26. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's Order Summary Report for 4/2026 showed the following physician's orders:- dated 10/5/25, for side-effects monitoring for the quetiapine medication; and- dated 10/14/25, for behavior monitoring for the quetiapine medication.However, the Order Summary Report failed to show a physician's order for the quetiapine medication. Review of Resident 18's eMAR for 4/2026 failed to show a physician's order for the quetiapine medication. On 4/29/26 at 1557 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 acknowledged the above findings and stated the quetiapine medication order had been discontinued in January 2026, and behavior and side-effect monitoring should have been discontinued as well. On 4/30/26 at 1416 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on interview, observation, medical record review, and facility P&P review, the facility failed to provide pharmaceutical services to meet the resident's need for one of nine residents observed during the medication administration observation. * LVN 3 failed to ensure Resident 22's eye medications were administered per the physician's order. This failure had the potential to negatively affect Resident 22's well-being.Findings: Review of the facility's P&P titled Medication Administration; Oral; IM; SQ; ID; Metered Dose; NGT; GT; JT; Vaginal; Urethral; Suppository; Eye & Ear Drops revised 4/2022 showed the procedure for administering eye drops included to wash hands prior to administration, to place the resident in a comfortable position, to place the medication in the conjunctival sac or if an ointment to place along the inside of the lower lid from the inner to outer canthus, and if the patient was to receive two or more medication, to wait five minutes in between drops. Medical record review for Resident 22 was initiated on 4/27/26. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Order Summary Report showed the following physician's orders:- dated 11/26/23, to administer dextran 70-hypromellose ophthalmic solution (lubricating eye drop) 0.1-0.3% to bilateral eyes every two hours for dry eyes while awake and to wait five to ten minutes between eye drop medications;- dated 5/1/25, to administer Refresh P.M. (lubricating eye drop) ophthalmic ointment to bilateral eyes every six hours for eye dryness, [NAME] 4/28/26 at 0605 hours, a medication administration observation was conducted with LVN 3 for Resident 22. LVN 3 was observed preparing the following medications:- one tablet of baclofen (muscle relaxant) 20 mg,- one bottle of dextran ophthalmic solution,- one bottle of artificial saliva moisturizing gel,- four ml of glycopyrrolate liquid solution, and- one bottle of nighttime relief lubricant eye ointment. On 4/28/26 at 0620 hours, LVN 3 was observed administering the dextran ophthalmic solution to Resident 22's bilateral eyes. At 0622 hours, LVN 3 was then observed administering the nighttime relief lubricant eye ointment to Resident 22's right eye and at 0624 hours, to the resident's left eye. On 4/28/26 at 0630 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 22's physician's order required waiting five to ten minutes between administering eye drops. LVN 3 verified the above findings. On 4/30/26 at 1409 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to ensure the resident's dignity was maintained for two of 12 final sampled residents (Residents 3 and 23). * The facility failed to ensure Resident 3 and 23's indwelling urinary catheter drainage bag were covered. These failures had the potential to negatively affect the residents' sense of dignity and well-being. Findings: Review of the facility's P&P titled Management of Urinary Catheter Drainage Bags date revised 4/2022 showed all the urinary catheter drainage systems shall be maintained as a closed system and handled using aseptic technique to reduce the risk of catheter-associated urinary tract infections (CAUTIs). Staff will follow evidence-based practices for drainage bag positioning, emptying, and replacement. 1. On 4/27/26 at 0825 hours and 4/28/26 at 0838 hours, Resident 23 was observed in bed with the indwelling urinary catheter drainage bag placed at the side of the bed and uncovered. Medical record review for Resident 23 was initiated on 4/27/26. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's MDS assessment dated [DATE], showed Resident 23 had an indwelling urinary catheter and required total assistance from the staff for all the ADL care. On 4/28/26 at 0838 hours, an observation and concurrent interview for Resident 23 was conducted with RN 2. RN 2 verified the resident had a suprapubic urinary catheter with a drainage bag. When asked about the drainage bag being placed at the side of the bed, RN 2 stated it must be kept below the level of the bladder to ensure proper drainage. RN 2 was asked about the facility's process for ensuring privacy for the urinary catheter drainage bags, RN 2 stated the facility staff would place the drainage bag at the side of the bed without any covering. RN 2 denied the facility practice of using a privacy or dignity covers for the urinary catheter drainage bags. On 4/29/26 at 1204 hours, an interview and concurrent medical record review for Resident 23 was conducted with RN 1. When asked about the facility's expectations for the indwelling urianry catheter drainage bags, RN 1 stated the drainage bag should be placed in a dignity cover or privacy bag to protect the resident's privacy. RN 1 was informed of the observations and verified the findings. On 4/30/26 at 1416 hour, an interview and concurrent medical record review for Resident 23 was conducted with the ADON. The ADON was informed and verified the above findings. 2. On 4/28/26 at 0800 and 0829 hours, Resident 3 was observed in bed with the indwelling urinary catheter drainage bag placed at the side of the bed by near the room entrance and uncovered. Medical record review for Resident 3 was initiated on 4/27/26. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's Quarterly MDS assessment dated [DATE], showed Resident 3 had an indwelling urinary catheter with intermittent catheterization and was dependent on staff for her activities of daily living. Review of Resident 3's care plan addressing the resident's intermittent catheterization dated 1/21/26, showed an intervention dated 1/30/26, to position the catheter bag and tubing below the level of the bladder and away from the room entrance door. On 4/30/26 at 1222 hours, an interview and concurrent medical record review for Resident 3 was conducted with the ADON. The ADON was shown a photograph taken on 4/28/26 at 0836 hours, showing the uncovered urinary catheter drainage bag. The ADON verified the observation and stated the urinary catheter drainage bag should have been placed inside a dignity bag to protect the resident's dignity. On 4/30/26 at 1416 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their abuse P&P for one of 12 final sampled residents (Resident 19). * The facility failed to assess Resident 19 when the resident reported an allegation of abuse against a staff member. In addition, the facility failed to monitor Resident 19 after Resident 19 reported an allegation of abuse. These failures posed the risk for the delay of identifying the negative outcomes to the resident and implementation of the necessary interventions after a report of an allegation of abuse. Findings: Review of the facility's P&P titled Abuse revised date 1/2026 showed the following: - It is the policy of this facility to establish an environment for all residents that is free from abuse, neglect, misappropriation of personal property, corporal punishment and involuntary seclusion. The facility will follow a seven step process to prevent, detect and report any mistreatment, neglect, or abuse of the resident; - Under Reporting/Response showed, the staff will monitor residents who have been abused and document findings at least once per shift for a minimum of 72 hours or until their medical condition, mood and function have stabilized (whichever is greater), and periodically thereafter. Staff will ensure that basic, medical, functional and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately; and - Under Investigation showed, the licensed nurse will assess the individual and document related findings. Assessment date will include: injury assessment (bleeding, bruising, deformity, swelling, etc). Documentation in the medical record will include objective data and a care plan is initiated to reflect the resident's condition and measures to be taken to prevent recurrence. Review of the facility's SOC-341 dated 4/21/26, showed Resident 19 verbalized to the facility staff a CNA touched his private parts while in the shower on an unknown date. Medical record review for Resident 19 was initiated on 4/27/26. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 12/16/25, showed Resident 19 had a diagnosis of anoxic brain injury and had no decision-making capacity. Review of Resident 19's Quarterly MDS assessment dated [DATE], showed Resident 19 required total assistance from staff for all ADL care. Review of Resident 19's medical records failed to show any documentation if Resident 19 was assessed after an allegation of abuse was reported. In addition, review of Resident 19's medical records failed to show documentation if Resident 19 was monitored after the abuse allegation was reported. On 4/29/26 at 1613 hours, an interview and concurrent medical record review for Resident 19 was conducted with RN 5. RN 5 stated an allegation of abuse was considered a change of condition. However, RN 5 verified there were no change of condition assessment documentation initiated and no skin assessment was documented after Resident 19 reported an allegation of abuse. RN 5 stated it should have been done. On 4/30/26 at 1222 hours, an interview and concurrent record review for Resident 19 was conducted with the ADON. The ADON verified the change of condition assessment, skin assessment and resident monitoring were not completed for Resident 19 when the abuse allegation was reported. On 4/30/26 at 1409 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a care plan for two of 12 final sampled residents (Residents 5 and 19). * The facility failed to develop a care plan to address Resident 5's use of anticoagulant medication. * The facility failed to develop a care plan to address Resident 19's use of bilateral side rails. These failures had the potential for the resident needs not being communicated to the IDT, placing the residents at risk of not being provided with appropriate, consistent, and individualized care.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 5/2024 showed the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 1. Medical record review for Resident 5 was initiated on 4/27/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's H&P examination dated 11/22/25, showed Resident 5 had no decision-making capacity. Review of Resident 5's MDS assessment dated [DATE], showed Resident was receiving anticoagulant medication. Review of Resident 5's Order Summary Report dated 4/28/26, showed a physician's order dated 2/9/26, to administer enoxaparin sodium injection (anticoagulant medication) 30 mg/0.3 ml subcutaneously in the evening for DVT prophylaxis. Further review of the Order Summary Report failed to show a physician's order for monitoring for side effects or adverse reactions related to anticoagulant therapy. Review of Resident 5's plan of care failed to show a care plan problem was developed to address the resident's use of an anticoagulant medication. Additionally, there was no care plan problem or intervention indicating the need to monitor for signs and symptoms of bleeding or other complications associated with anticoagulant therapy. On 4/29/26 at 1136 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 verified Resident 5's use of anticoagulant medication for DVT prophylaxis. When asked to provide the care plan addressing the resident's anticoagulant use, RN 1 was unable to show any care plan problem or interventions related to anticoagulant therapy. RN 1 verified and acknowledged a care plan should have been developed for the resident's anticoagulant use. On 4/30/26 at 1416 hours, an interview and concurrent medical record review for Resident 5 was conducted with the ADON. The ADON was informed and verified the above findings. 2. Medical record review for Resident 19 was initiated on 4/27/26. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 12/16/25, showed Resident 19 had a diagnosis of anoxic brain injury and had no decision-making capacity. Review of Resident 19's Quarterly MDS assessment dated [DATE], showed Resident 19 required total assistance from staff for all ADL care. Review of Resident 19's Order Summary Report for 4/2026 showed a physician's order dated 1/28/26, for bilateral side rails up for safety. Review of Resident 19's plan of care failed to show a care plan problem was developed to address the resident's use of bilateral side rails. On 4/29/26 at 1613 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified Resident 19's use of bilateral side rails and acknowledged a care plan should have been developed for the resident's use of bilateral side rails to ensure the staff were on the same page regarding resident's care. On 4/30/26 at 1409 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above findings.

Based on interview, observation, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect current care needs and interventions for three of 12 final sampled residents (Residents 3, 11, and 23) and one nonsampled resident (Resident 17). * The facility failed to revise Resident 11's care plan to address Resident 11's hospitalization on 3/9/26. * The facility failed to revise Resident 17's care plan for seizure precautions to include padded side rails. * The facility failed to ensure Resident 23's care plan for wound care management was revised to include the use of the low air loss mattress. * The facility failed to ensure Resident 3's care plan for bilateral side rails was revised to remove the intervention of padded side rails. These failures posed the risk of not providing the residents with individualized and person-centered care.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 5/2024 showed a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, which included the services provided by the facility. In addition, care plans were revised as information about the residents and the residents' condition changes. 1. Medical record review for Resident 11 was initiated on 4/27/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's eINTERACT Transfer Form V6 dated 3/10/26, showed Resident 11 was transferred to an acute care hospital on 3/9/26, due to an uncontrolled nosebleed. Review of Resident 11's Order Summary Report showed the following completed physician's orders:- dated 3/9/26, to transfer Resident 11 to an acute care hospital due to uncontrolled bleeding and a seven-day bed hold.- dated 3/10/26, to not place an NGT to Resident 11's nostril for two weeks due to a deviated septum. However, review of Resident 11's Care Plan Report did not include the resident's hospitalization on 3/9/26. On 4/30/26 at 1040 hours, an interview and concurrent medical record review for Resident 11 was conducted with the ADON. The ADON stated a transfer to an acute care hospital was considered a change in condition to a resident's status and should be reflected in the resident's care plan. The ADON reviewed Resident 11's care plan and verified the resident's care plan did not include the resident's hospitalization on 3/9/26. 2. Medical record review for Resident 17 was initiated on 4/27/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's H&P examination dated 9/26/25, showed Resident 17 had a diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). Review of Resident 17's Care Plan Report showed a care plan problem initiated on 10/23/25, addressing his seizure precautions. The care plan interventions did not include the use of padded side rails. Review of Resident 17's Order Summary Report showed a physician's order dated 4/24/26, to provide padded side rails for seizure precautions. On 4/29/26 at 1046 hours, an observation and concurrent interview was conducted for Resident 17 with LVN 2. Resident 17 was observed in bed with padded side rails. LVN 2 stated Resident 17 should have padded side rails for his seizure precautions. On 4/29/26 at 1558 hours, an interview and concurrent medical record review for Resident 17 was conducted with RN 1. RN 1 stated the purpose of a care plan was to be used as a guide for the resident's care. RN 1 reviewed Resident 17's Care Plan Report and verified Resident 17's use of padded side rails were not included in the resident's care plan. On 4/30/26 at 1409 hours, an interview was conducted with the DON and ADON. The DON and ADON were informed and acknowledged the above finding for Residents 11 and 17. 3. On 4/27/2026 at 1011 hours, Resident 23 was observed in bed on a low air loss mattress. The low air loss mattress machine pump setting was set at a 400 lbs – firm. Medical record review for Resident 23 was initiated on 4/27/26. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Order Summary Report dated 4/28/26, showed a physician's order dated 4/20/26, for the resident use of a low air loss mattress every shift for skin breakdown prevention. Review of Resident 23's plan of care showed the care plan problem dated 4/17/26, to address the resident's pressure ulcer. However, the care plan interventions failed to include the use of a low air loss mattress. On 4/29/26 at 1204 hours, an interview and concurrent medical record review for Resident 23 was conducted with RN 1. RN 1 reviewed the resident's care plan and verified the use of the low air loss mattress was not included and should have been added. On 4/30/26 at 1416 hours, an interview and concurrent medical record review for Resident 23 was conducted with the ADON. The ADON was informed and verified the above findings. Cross Reference to F0686, example # 1. 4. On 4/27/26 at 1110 hours, an observation was conducted for Resident 3. Resident 3 was observed lying in bed with bilateral side rails elevated. Medical record review for Resident 3 was initiated on 4/27/26. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's H&P examination dated 2/24/22, showed Resident 3's diagnosis included cerebral edema and seizure. Review of Resident 3's Quarterly MDS assessment dated [DATE], showed Resident 3 was dependent on staff for her ADL care. Review of Resident 3's Order Summary Report for 4/2026 showed a physician's order dated 5/4/23, for bilateral side rails up at all times for safety per the resident's mother's preference. Review of Resident 3's plan of care showed a care plan dated 3/21/23, addressing the resident's high risk for falls. The interventions showed the resident needed a safe environment with padded side rails up per physician's order dated 5/21/24. However, the resident's medical record did not include a physician's order for padded side rails. On 4/30/26 at 1222 hour, an interview and concurrent medical record review for Resident 3 was conducted with the ADON. The ADON was informed and verified the above findings. The ADON stated the care plan should have matched the physician's order because the care plan reflected the care rendered to the resident. On 4/30/26 at 1416 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and the facility P&P review, the facility failed to implement their abuse P&P related to the investigation of sexual abuse for one nonsampled resident (Resident 12). This failure had the potential for not taking all the necessary corrective actions to protect Resident 12 and other residents from abuse. Findings: Review of the facility's P&P titled Abuse revised 11/2024 showed the facility is to: * document all allegations of abuse; * the licensed nurse is to assess the individual and document injury assessment; * interview family members, visitors, and other residents as applicable; and * interview staff from different shifts. On 2/20/25 at 1400 hours, an interview was conducted with Family Member 1. Family Member 1 stated the facility was trying to discharge Resident 12 too soon. Family Member 1 stated the facility was doing this in response to Family Member 1 reporting Resident 12 was sexually abused by CNA 2. Family Member 1 stated she observed Resident 12 scream and agitated when Resident 12 heard CNA 2's voice. Family Member 1 stated Resident 12 had communicated to her that CNA 2 touched her breasts and vaginal area. Family Member 1 stated she reported Resident 12 was afraid of CNA 2 to the CEO in April 2024. Medical record review for Resident 12 was initiated on 2/21/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 12/6/23, showed Resident 12's diagnoses included severe brain injury, multiple back fractures, and rib fractures post status fall. Review of Resident 12's medical record failed to show a body assessment was completed in reference to the alleged sexual abuse. Review of Resident 12's progress notes dated 4/24/24, showed Family Member 1 reported Resident 12 was afraid of CNA 2. On 2/21/25 at 0830 hours, an interview and concurrent medical record review was conducted with the CEO. When asked about a sexual abuse allegation regarding Resident 12, the CEO verified she was aware of Resident 12's alleged sexual abuse allegation. The CEO stated she received information about the sexual abuse allegation in May 2024 from the local police department. When asked about the investigation of this allegation, the CEO stated she interviewed all night shift staff. The CEO stated she did not have documented evidence to show the facility staff statements or a list of the facility staff she had interviewed. In addition, the CEO stated she did not interview Resident 12's family members or visitors about the sexual abuse allegation. The CEO stated the allegation was unsubstantiated; however, she did not kept the copy of the investigation she did. The facility failed to provide any documented evidence to show the sexual abuse allegation was thoroughly investigated.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 1) received the appropriate treatment and services to prevent the occurrences of complications from the GT feeding. * The facility failed to ensure Resident 1's head of bed was positioned safely at 30 to 45 degrees during the GT feeding to reduce the risk of aspiration. In addition, the facility failed to ensure Resident 1's tube feeding formula was properly labeled. These failures posed the risk for developing complications related to GT feedings, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 1 was initiated on 2/20/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/6/21, showed Resident 1 had no capacity to understand and make decisions. a. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump dated 3/2022 showed to position the head of the bed at 30 - 45 (semi-Fowler's position) for feeding unless medically contraindicated. On 2/19/24 at 0830 hours, an initial observation was conducted for Resident 1. Resident 1 was observed to have the tracheostomy, ventilator, and a GT feeding setup. On 2/20/25 at 0832 hours, an interview was conducted with RT 1. RT 1 verified the HOB for the residents who had a tracheostomy, on ventilators or tube feedings should be at least 30 to reduce the risk of aspiration and [NAME]. RT 1 stated it was the responsibility of all the staff to ensure the HOB was at the correct elevation. On 2/20/25 at 0844 hours, an observation of Resident 1 and concurrent interview with RN 2 was conducted. The HOB for Resident 1 was confirmed to be only 20 with an angle measurement tool. RN 2 stated she thought the HOB for the residents on GT feedings should be above 45 , but it was ultimately the responsibility of the resident's nurse. RN 2 verified 20 was the incorrect setting for Resident 1 as she had a tracheostomy, ventilator, and was on periodic tube feedings. On 2/20/25 at 0956 hours, an interview was conducted with LVN 1. LVN 1 verified the HOB for Resident 1 should be at least 30 to keep the secretions away so she would not aspirate. On 2/20/25 at 1013 hours, an interview was conducted with CNA 2. CNA 2 verified the HOB should be 30 . CNA 2 stated she knew of the need for the resident to be positioned to 30 degrees from in-service trainings at the facility. On 2/20/25 at 1028 hours, an interview was conducted with LVN 4. LVN 4 verified the HOB for Resident 1 should be at 30 - 45 as per the facility P&P. On 2/2025 at 1332 hours, an observation was conducted of Resident 1. Resident 1 was observed in bed. The HOB for Resident 1 was confirmed to be only 20 with an angle measurement tool. Resident 1 was observed with an ongoing enteral GT feeding. RN 2 entered the resident's room and verified the HOB was too low. The measurement of 20 was verified by RN 2 and she adjusted the HOB to the correct height. b. Review of the facility's P&P titled Enteral Tube Feeding via Continuous Pump issued on 3/2022 showed for the enteral feeding formula label, to document the initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Review of Resident 1's Medication Administration Record showed an enteral feeding physician's order dated 10/19/24, for Boost Kids Essentials with fiber 1.5 three times a day at 195 ml to run over one hour at 0900, 1300, and 1700 hours; and give 75 ml of water flush before and after the feeding. On 2/19/25 at 0830 hours, an initial observation was conducted for Resident 1. Resident 1 was observed to have the tracheostomy, ventilator, and GT feeding setup. The feeding formula and water flush bags were observed with the label showing the date of 2/19/25, and time of 0600 hours. On 2/20/25 at 1028 hours, an interview was conducted with LVN 4. LVN 4 stated the night shift was in charge of changing the water flush and GT feeding bags every 24 hours so the date and time on the empty bags was the date and time when the bags were changed. LVN 4 stated there was no way to know when the GT feeding formula was added to the GT feeding bag without looking in the computer. LVN 4 verified the staff did not put the date, time, or initial the GT feeding and flush bags when the feeding formula and water were added to the bags. On 2/2025 at 1332 hours, an observation was conducted of Resident 1. Resident 1 was observed in bed with an on going GT feeding. The date and time on the GT feeding and flush bags were noted as 2/20/25 at 0600 hours. RN 2 entered the room and stated the date and time on the bags referred to when the GT feeding and flush bags were changed. RN 2 verified the facility had no system for labeling the GT feeding bags with the date and time when the GT feeding formula was added to the bag.

Based on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150 B of the Social Security Act for one nonsampled resident (Resident 12) as evidenced by: * The facility failed to ensure the reporting of Resident 12's sexual abuse allegation to the local State and Federal agencies in a timely manner. This failure posed the risk for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Abuse revised 11/2024 showed the facility was required to complete the contact information sheet for state/local reporting agencies. Further review of the P&P showed the facility was to fax a written report to the local state survey agency. On 2/20/25 at 1400 hours, an interview was conducted with Family Member 1. Family Member 1 stated the facility was trying to discharge Resident 12 too soon. Family Member 1 stated the facility was doing this in response to Family Member 1 reporting Resident 12 was sexually abused by CNA 2. Family Member 1 stated she had reported the abuse allegation to the CEO in April 2024. Review of Resident 12's progress note dated 4/24/24, showed Family Member 1 had reported Resident 12 was afraid of CNA 2. On 2/21/25 at 0830 hours, an interview and concurrent medical record review was conducted with the CEO. When asked about a sexual abuse allegation of Resident 12, the CEO verified she was aware of Resident 12's sexual abuse allegation. The CEO stated she received information about the abuse allegation in May 2024 from the local police department. When asked about reporting the abuse allegation to the local State agency, the CEO stated she hand delivered the report to the local State agency but did not keep a copy of the documents submitted to the local State agency. When asked about a progress note dated 4/24/24, showing Family Member 1 reported Resident 12 was afraid of CNA 2, the CEO stated she was not notified of the sexual abuse allegation until May 2024. When asked if she had any documented evidence related to the reporting the abuse allegation to the local State agency or any other documents related to the abuse investigation, the CEO stated she did investigate the allegation and it was unsubstanted; however, she did not made or kept a copy of the documents related to the abuse allegation investigation. Cross reference to F610.

Based on interview, medical record review, and facility P&P review, the facility failed to develop and implement the individualized care plans for two of 12 sampled residents (Residents 4 and 19) and one nonsampled resident (Resident 12). * The facility failed to develop a care plan problem to address the resident's family member education regarding the use of gown and glove during high-contact interactions with the resident. This failure posed the risk for Resident 4 to be infected and spread the infection. * The facility failed to ensure the care plan problem for the use of the mechanical lift was implemented when Resident 12 was tansferred by one staff using the mechanica lift instead of two staff assistance. This failure posed the risk of Resident 12 for injury or fall. * The facility failed to develop a care plan problem for Resident 19 to address the use of anticoagulant and antibiotic medications. This failure posed the risk for Resident 19 to develop complications associated with the use of anticoagulant and antibiotic medications. Findings: 1. Medical record review for Resident 19 was initiated on 2/21/25 at 0811 hours. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 1/10/25, showed Resident 19 had no capacity to understand and make decisions. Review of Resident 19's Order Summary Report dated 2/19/25, showed a physician's order dated 1/10/25, for enoxaparin sodium (blood thinner medication) injection solution prefilled syringe 30 mg/0.3 ml, inject 30 mg subcutaneously two times a day for deep vein thrombosis (DVT) prophylaxis. Another physician's order dated 1/13/25, showed an order for amoxicillin (antibiotic medication) oral tablet 500 mg via J-tube two times a day for asplenia. Further review of Resident 19's medical record failed to show a care plan problem was developed for the use of anticoagulant and the antibiotics medications. On 2/21/25 at 0845 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified Resident 19 had the orders for an anticoagulant and antibiotic medications. RN 3 acknowledged the care plan problems should be developed for the anticoagulant medication to indicate what to monitor for a resident taking an anticoagulant, and for the infection associated with the antibiotic use. RN 3 was unable to locate the care plan problems in Resident 19's medical record for the anticoagulant and antibiotic use. On 2/21/25 at 0855 hours, an interview was conducted with RN 2. RN 2 stated she was responsible for entering the physician's orders and initiating the appropriate care plans. RN 2 stated there should be a care plan problem initiated when a resident was prescribed for an anticoagulant or antibiotic. RN 2 stated the nursing team did a weekly care plan check to verify the appropriate care plans have been initiated. RN 2 verified Resident 19 did not have a care plan for the anticoagulant or antibiotic and it was a mistake. 32179 2. Medical Record review of Resident 4 was initiated on 2/19/25. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility's P&P titled Enhanced Based Precaution dated 8/2024 showed once a resident is placed on EBP, the staff members will promptly communicated the purposed of EBP to the family members/next of kin. Continue following barrier precaution including hand hygiene, the use of gown, gloves, mask or eye shields when contact with mosit bodily fluid is likely; injection safety practices, respiratory hygience/cough etiquette, recomended enviromental infection control practices in all care settings for all residents. Review of the Order Summary Report dated 2/20/25, showed a physician's order dated 9/6/24, to place in EBP for infection prevention. On 2/19/24 at 0815 hours, Resident 4's family member was observed entering the room without donning gloves and gowns, and had suctioned the resident a few times. In front of the room, a sign was posted indicating enhanced-based precautions. There was no staff member observed providing education to Resident 4's family member. On 2/19/24 at 1000 hours, an observation and concurrent interview for Resident 4 was conducted with LVN 1. LVN 1 was asked if the resident's family member was aware of donning gowns and gloves. LVN 1 stated in the past, she had informed Resident 12's family member. LVN 1 stated she did not educate the family member this morning. On 2/19/24 at 1015 hours, a concurrent interview and medical record review was conducted with RN 5. RN 5 were asked if there was a care plan problem to address the resident's family member education about wearing gowns and gloves during high-contact interactions with the resident. RN 5 was unable to provide documentation. RN 5 verified the findings. 35346 3. Review of the facility's P&P titled Hydro-Lift instructions dated 5/4/21, showed to always use two people when moving the lift with a resident. On 02/20/25 at 1600 hours, CNA 1 was observed transferring Resident 12 from the resident's bed to a wheelchair, using a mechanical lift. On 2/20/25 at 1630 hours, an interview was conducted with CNA 1. When asked about transferring residents using a mechanical lift, CNA 1 stated there should be two-person transfer assist when using a mechanical lift. Review of Resident 12's plan of care showed a care plan problem addressing Resident 12's transfers. One of the interventions was the resident required a mechanical lift with assistance from two staff members.

Based on observation, interview, and medical record review, the facility failed to revise the care plan for one of 12 final sampled residents (Resident 17) and one nonsampled resident (Resident 12). * Resident 12's plan of care was not revised to reflect an abuse allegation reported. * Resident 17's plan of care was not revised to reflect the resident's use of bilateral afo to lower extremity. These failures posed the risk of the residents to not receive the appropriate care. Findings: 1. On 2/20/25 at 1400 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 12 communicated that the resident was sexually abused by CNA 2. Family Member 1 stated she reported this allegation to the Administrator in April 2024. On 2/21/25 at 0830 hours, an interview was conducted with the Administrator. The Administrator verified she was aware of Resident 12's abuse allegation. When asked about a care plan problem addressing Resident 12's abuse report, the Administrator stated she would look for the care plan. The resident's plan of care was not revised to address Resident 12's abuse allegation. On 2/19/25, medical record review for Resident 12 was initiated. Review of Resident 12's plan of care failed to show Resident 12's plan of care was revised to reflect a care plan problem addressing Resident 12's abuse allegation. Cross references to F609 and F610 32179 2. Medical Record review of Resident 17 was initiated on 2/19/25. Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report dated 2/20/25, showed a physician's order dated 11/15/24, for the resident to wear the bilateral AFOs two hours on and two hours off from 0800 to 2200 hours as tolerated; maintain the ankle alignment and PROM exercises and prevent further contractures; check for skin integrity prior to and after the application; and inform the rehabilitation staff, nursing staff, or MD of any redness that not disappear within 30 minutes. On 2/20/25 at 1445 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 was asked if there was any care plan to address the use of bilateral AFOs. RN 1 was unable to provide the documentation. RN 1 acknowledged the plan of care would need to be revised. RN 1 verified the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the interventions to prevent decreased in range of motion were implemented for one of two sampled residents (Resident 1). This failure resulted in Resident 1 to have decreased range of motion in his right hand, develop a pressure injury of his right middle fingertip, and subsequently required a partial right middle finger amputation. * Resident 1 was admitted to the facility with hand splints from the acute care hospital. On initial evaluation by the OT showed Resident 1's right fingers were able to almost fully extend passively. On 8/19/20, his hand splints were ordered to be worn for two hours and taken off for two hours. The documentation failed to show this was done as ordered. * The facility failed to carry out and obtain the bilateral elbow splints for Resident 1 as ordered by the physician on 8/19/20. * Resident 1 was discharged from the OT services on 8/31/20, and RNA services were ordered for five times a week, 30 minutes each time. RNA was not started until 10/12/20 (a month and 11 days later). Resident 1 was in the acute care bed from 8/29 to 10/8/20, and RNA services were not provided in the acute care side of the facility. * New hand splints were ordered on [DATE], as the old hand splints no longer fit his hands. There was a delay in obtaining the new hand splints. * Resident 1 was sent to the acute care hospital on [DATE], for an evaluation of his right hand. Resident 1 underwent a partial amputation of his right middle finger due to a pressure injury of the finger as well as right arm tendon lengthening. Findings: Medical record review for Resident 1 was initiated on 10/24/20. Resident 1 was admitted the facility on 8/6/20, and discharged to the acute care hospital on [DATE]. He was readmitted on [DATE], and discharged to the acute care hospital on [DATE]. He was again readmitted to the facility on [DATE], and discharged to the acute care hospital on [DATE], for evaluation of his right hand. Review of Resident 1's MDS dated [DATE], showed he was totally dependent on the staff for his ADL care. Resident 1 had functional limitations in range of motion on the lower and upper extremities. On 10/24/20 at 0806 hours, an observation of Resident 1 and concurrent interviews were conducted with RNs 1 and 2, and the Administrator. Resident 1 was observed laying in bed with his right arm in a purple cast from the upper arm to his fingers. The ends of his right fingers were covered with a dressing. The Administrator stated Resident 1 had recently returned from the acute care hospital. Resident 1 was verbally nonresponsive to the staff speaking to him. RN 2 stated Resident 1's right fingers had been so contracted, they could not open them and his finger would dig into his hand. RN 1 stated two staff could not open his hand. Resident 1 was in Room B which was an acute care licensed bed. a. Review of Resident 1's Order Detail showed the physician's orders [REDACTED]. Review of the Care Activity - Assessments for Resident 1's splint wearing schedule from 8/20 to 8/26/20, showed Resident 1's hand splints were not applied every two hours as ordered. For example, on 8/21/20, the documentation failed to show the hand splits were applied to Resident 1. On 8/22/20, the documentation showed the hand splints were applied at 0800, 1200, and 1600 hours only. Further review of Resident 1's Care Activity - Assessment - for splint wearing schedule from 9/3 to 10/16/20, did not show any entries for the hand splints being on or off. Review of Resident 1's Care Activity - Intervention sheets for 8/29 to 10/16/20, failed to show any interventions listed for the use of hand splints. Review of Resident 1's OT assessment dated [DATE], showed the significant impairment of the bilateral upper extremity range of motion with no active movement observed during the evaluation. The documentation showed Resident 1 presented in bed lying supine with bilateral elbows flexed in crossed pattern on the chest. Resident 1's hands were in the fist position with digits flexed. Resident 1 was able to passively extend his bilateral digits within functional limits and increased tone in the bilateral upper extremities during passive range of motion assessment with significant aversion. On 10/28/20 at 1330 hours, an interview and concurrent medical record review was conducted with CNA 1. CNA 1 stated the Care Activity records for the splints did not show which splint was being applied or removed. CNA 1 stated she did not identify what splint she put on or took off. CNA 1 stated Resident 1's hand was really tight, was hard to open, and sometimes she could not open his hand. On 10/28/20 at 1345 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 toned which meant his hands were clenched, both his arms and legs were trembling, and he sweat a lot. LVN 1 stated they could not open his hands when he toned. LVN 1 stated the RNAs were in charge of putting on and taking off the hand splints and doing ROM exercises. When asked if Resident 1 had a hand splint, LVN 1 stated she did not think so. On 10/28/20 at 1407 hours, an interview and concurrent medical record review was conducted with CNA 2. CNA 2 stated the Care Activity records for the splints showed the splint was on or off and she thought it meant the splint for Resident 1's feet. CNA 2 stated she had cared for Resident 1 four or five times but did not know if he had the hand splints. On 11/9/20 at 0908 hours, an interview was conducted with OT 1. OT 1 stated they wrote the order on 8/19/20, for Resident 1's hand splints to be on for two hours and off for two hours. OT 1 stated they did not know how or when the nursing staff did it. When asked who would ensure it was done, she stated the RN or LVN would make sure the CNA applied the splints and take them off as ordered. On 11/9/20 at 0951 hours, an interview was conducted with OT 2. OT 2 stated she did the OT assessment for Resident 1 on 8/19/20, and she was able to almost fully passively extend his bilateral fingers within functional limits. OT 2 stated the joint at the base of the fingers and his left thumb's first joint could not be moved very well, but the rest of the finger joints could be almost fully extended. OT 2 stated she could put Resident 1 into his hand splints and they fit well. Resident 1 had good fitting hand splints. OT 2 stated on 10/2/20, she found out from nursing that they were unable to put Resident 1's hand splints on him, so the new ones were ordered. b. Review of Resident 1's SS (Social Service)/CM (Case Management) Initial Discharge Evaluation dated 8/7/20, showed Resident 1 would require the custom DME (durable medical equipment) - wheelchair and necessary orthotics (splints or braces used for the joints). Review of Resident 1's Order Detail showed the following physician's orders [REDACTED].>- 8/19/20, for orthotic bilateral elbow contracture splints. The order showed Resident 1 presented with the bilateral elbows in fully flexed position at rest with significant increase in tone and decreased elbow PROM (passive range of motion) functions. Bilateral elbow contracture splints recommended to promote improved elbow PROM functions and reduce tissue tightness. - 10/2/20, for bilateral elbow contractures splints and bilateral hand splints. The order showed Resident 1 presented with the right elbow in flexed position at rest with significant increase in tone and decreased PROM functions. Resident 1's left elbow was in extended position with inability for therapist to perform PROM exercises due to increased tone. Elbow and hand splints recommended to promote improved elbow and digits PROM functions and reduce tissue tightness. Review of Resident 1's plan of care showed the care plan problems were created on 8/18/20, addressing the following: - Resident 1 was totally dependent on staff for all of his ADL care. The approaches included to provide ROM (range of motion) exercises during care unless contraindicated. - Resident 1's risk for skin breakdown and further skin breakdown. The approaches included to assess the skin integrity during care and document every shift, utilize a rolled towel/wash cloth in hands to prevent skin breakdown from existing contractures, increased tone and neurostorming, and apply bilateral elbow splints and hand splints when available. On 10/24/20 at 1045 hours, an interview was conducted with the Administrator and Case Manager. The Administrator and Case Manager stated on 8/29/20, Resident 1 was readmitted to the facility and this was when his hand problem started and hand splint did not work. They explained they could not get the authorization from Resident 1's insurance for the new splints. They had had two orthotic companies come to see Resident 1, but the splints were not fabricated due to lack of authorization from the insurance company. Up until he went out to the acute care hospital on [DATE], they were trying to get anything in Resident 1's hands, but nothing would work. They stated on 10/12/20, Resident 1's physician asked why they could not get the splints for Resident 1 as he needed some interventions. On 11/13/20 at 1200 hours, a follow-up interview was conducted with the Case Manager. The Case Manager confirmed it was approximately six weeks passed from the time the bilateral elbow splints were ordered until Resident 1 went to the hospital for his finger evaluation and the splints had not been obtained for Resident 1. The Case Manager confirmed the new hand splints were ordered on [DATE]. The Case Manager stated they had difficulty getting authorization from Resident 1's insurance company for the splints. When asked when the facility would take action to obtain the splints for Resident 1, the Case Manager stated at some point, you got to do something. Something would have to go through the owners. When asked if she had contacted the owners about purchasing the splints for Resident 1, she stated she had not. c. Review of the facility's Restorative Nursing Assistant job description approved 5/2017, showed the RNA would provide restorative care as recommended by the Rehabilitation Department Therapists, which would be under the supervision of the Nursing Department. Review of Resident 1's Order Detail showed the physician's orders [REDACTED]. Review of Resident 1's plan of care showed a care plan problem addressing Resident 1's impaired ability to perform range of motion related to total dependence with ADL care was created on 8/31/20. The approaches included to provide RNA services five times a week for 30 minutes as tolerated for the PROM exercises to all extremities to prevent further extremity contractures and improve bilateral upper extremities PROM functions. Review of the facility's Resident Census sheets from 8/29 to 10/7/20, showed Resident 1 was in an acute care hospital bed. Review of the facility's Clinical Assignment Log for 8/29/20 to 10/7/20, showed the acute care hospital's nurses cared for Resident 1. No CNAs were assigned to the acute care hospital during this time. Review of Resident 1's OT notes dated 8/31/20, showed he was lying in bed with bilateral upper extremities crossed at chest (bilateral elbows flexed fully with hands in fisted position; digits flexed). The documentation showed Resident 1 presented with significantly increased bilateral upper extremities tone, reduced bilateral upper extremities PROM functions and aversion during bilateral upper extremity PROM. The documentation showed Resident 1 presented with functional level similar to baseline. At this time, no OT services were recommended. Resident 1's care was handed off to the nursing department and Resident 1 was to receive RNA for all extremities to prevent further extremity contractures. Review of Resident 1's Care Activity - Intervention sheets for 8/29 to 10/16/20, did not show any interventions provided for RNA services. Review of Resident 1's Team Conference notes dated 9/1/20, showed the PT, OT, and nursing were some of the disciplines in attendance. Under the rehabilitation section, it showed Resident 1 was evaluated by the rehabilitation team on admission and recommended RNA services as the resident was not a candidate for rehabilitation as he was unable to participate. On 10/28/20 at 1305 hours, an interview was conducted with the Administrator. The Administrator stated Resident 1 may not have had RNA treatment as he had rehabilitation services. On 11/9/20 at 0908 hours, an interview was conducted with OT 1. OT 1 stated she and OT 2 evaluated Resident 1 and he was supposed to be receiving RNA, but the CNAs were not giving him RNA as ordered as Resident 1 was on the acute side. OT 2 stated the CNAs only did RNA on the long-term care side. OT 1 stated no one told them Resident 1 was not receiving RNA services. RNA services would have prevented him from getting flexed in his hands and upper extremities. Someone should have seen Resident 1 every day. OT 1 verified the RNA services were ordered on [DATE]. When asked who oversaw the RNAs, OT 1 stated it was the RN team lead for the day, but she was not sure how the RNA services worked at this facility. OT 1 stated no one told them that Resident 1 was not receiving RNA and no one checked to see how the RNA services was going for Resident 1. On 11/9/20 at 1135 hours, an interview and concurrent medical record review was conducted with RN 6. RN 6 confirmed RNA services was ordered for Resident 1 on 8/31/20. RN 6 stated there were no RNA notes for Resident 1 until 10/12/20. On 11/9/20 at 1145 hours, an interview was conducted with the Administrator. The Administrator stated the RN team lead and rehabilitation department followed up to make sure RNA services were done. The documentation by the RNA included the amount of the minutes spent with the resident and any complications. The Administrator stated the RNAs were expected to do both weekly and monthly summaries. She stated the resident had to be discharged from both PT and OT prior to receiving RNA services. The Administrator stated the order for RNA was entered into the resident's Intervention section on the computer so the CNA/RNAs could see it. The Administrator stated the facility had no P&P for RNAs, only the RNA job description. Review of Resident 1's ED (emergency department) Note dated 10/16/20, showed he was brought to the acute care hospital emergency department for surgical evaluation of the right hand infection. The nursing staff at the facility stated due to the resident's contractures, the wound on fingers was unable to be cleaned and had been bleeding with purulent matter for three to four days. The physical examination showed Resident 1's third right distal digit was swollen with circumferential [DIAGNOSES REDACTED] (redness encircling the finger), purulent (pus) draining with evident of darkened eschar (necrotic tissue) in middle finger. The documentation showed Resident 1's fifth digit had similar [DIAGNOSES REDACTED] and swelling to the digit aspect. On 11/19/20 at 0845 hours, an interview and concurrent medical record review was conducted with the Administrator. The Administrator verified Resident 1 was considered as a SNF resident for his entire stay even though he had been in the acute care bed. The Administrator verified RNA services had not been provided for Resident 1 as ordered while he was in the acute care bed. The Administrator stated the OT should have never signed off on Resident 1 because it was in the insurance agreement for the facility to provide the OT or PT services for him until he was discharged , and this was the reason why he did not get any RNA. The Administrator stated the DON oversaw the RNAs to ensure the residents would receive their RNAs as ordered. However, the facility was without a DON for approximately three months. When asked who ensured the residents received RNA services when there was no DON, the Administrator stated no one. The Administrator verified on 9/1/20, there was a Team Conference held which included the staff from the PT, OT, and nursing disciplines, and the attending physician; and they discussed the recommendation for RNA services for Resident 1. This was the day after RNA services was ordered. The Administrator stated if Resident 1's splints were not put on for two hours/taken off for two hours as ordered, the staff should have notified the physician, but that was not done. The Administrator stated she never knew the elbow splints were ordered for Resident 1. She stated no one ever came to her and said the splints needed to be paid for. The Administrator stated they needed to do what was best for the resident. The Administrator stated the rehabilitation department or case management could have asked her to pay for the splints. On 11/23/20 at 1325 hours, a telephone interview was conducted with Physician 1. Physician 1 stated when he saw Resident 1 at the acute care hospital, the resident had severe spastiscity in his right hand and he was clenching his hand so tight that the skin was pulled off of the bone. Physician 1 stated it was hard to see his right hand wounds as his fingers were so tight. Physician 1 stated Resident 1 had a necrotic open wound on his middle finger, but it was not infected. Physician 1 stated he had to lengthen all the tendons in Resident 1's fingers, elbows, and forearm (right arm) before he could open Resident 1's fingers. Physician 1 stated he removed the resident's middle finger at the middle knuckle - the PIP (interphalangeal, hinge joints between the bones of the fingers that provide flexion towards the palm of the hand) joint. When asked to clarify what a full-thickness wound was, Physician 1 stated it meant the skin was pulled off of the bone like a degloving injury (when the top layers of the skin and tissue are ripped from the underlying muscle, connective tissue or bone). Physician 1 was asked if Resident 1 had the splints on his hands from the beginning, would it have helped, Physician 1 stated absolutely, it would have helped. When asked if having a neurosurgery consultation and [MEDICATION NAME] pump would have helped, he stated absolutely, it would have made a difference. Review of the facility's conclusion for Resident 1 showed lack of effective communication between the rehabilitation team, staff providing direct care to Resident 1, and the case management/administrative team contributed to a delay in obtaining proper orthotic devices deemed necessary for this resident's care. The nursing staff and the rehabilitation team did not notify the case management/administrative team of the urgency in getting the orthotic devices. The conclusion showed if the administrative team was made aware of the severity of the resident's injury, the orthotic devices would have been purchased by this facility without delay. The conclusion showed the team approach to resident care was not utilized between the nursing staff and rehabilitation team. Cross references to F684 and F836.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the interventions to prevent a pressure injury for one of two sampled residents (Resident 1). When Resident 1 developed open wounds on his right hand, the wounds were not consistently assessed as per the facility's P&P for wound management. * On 8/22/20, the neurosurgery consultation was ordered for a [MEDICATION NAME] (medication to treat muscle spasm) pump. This was not obtained prior to Resident 1's need for partial right middle finger amputation and tendon lengthening in his right arm. * On 9/29/20, the peeling skin was noted on Resident 1's right middle and pinky fingers. The facility failed to ensure a care plan problem was developed to address the peeling skin and the wound was assessed according to the facility's P&P. * On 10/3/20, wounds were noted on Resident 1's right fourth and fifth knuckles. The wounds were treated with [MEDICATION NAME] (antibiotic) for 13 days prior to going to the acute care hospital on [DATE]. However, the facility did not assess the wounds during this period as per the facility's P&P. * On 10/4/20, an open wound was identified on Resident 1's right middle fingertip. From 10/4 to 10/15, the wounds were not thoroughly assessed as per the facility's P&P. * The facility did not have a P&P for nail care. Their staff were not allowed to cut the residents' nails and relied on the family members to cut a resident's nails. Resident 1 had severe right hand contractions and his fingers dug into the palm of his hand which caused a full-thickness pressure injury. These failures contributed to Resident 1's right hand wounds worsening which required the surgical intervention at the acute care hospital. Findings: Medical record review for Resident 1 was initiated on 10/24/20. Resident 1 was admitted to the facility on [DATE], and discharged to the acute care hospital on [DATE]. He was readmitted on [DATE], and discharged to the acute care hospital on [DATE]. He was readmitted to the facility again on 8/29/20, and discharged to the acute care hospital on [DATE], for evaluation of his right hand. Review of Resident 1's MDS dated [DATE], showed he was totally dependent on staff for ADL care. It also showed he had functional limitations in range of motion on the lower and upper extremities. On 10/24/20 at 0806 hours, an observation of Resident 1 was conducted with RNs 1, 2, and the Administrator. Resident 1 was observed lying in bed with his right arm in a purple cast from the upper arm to his fingers. The ends of his right fingers were covered with a dressing. The administrator stated Resident 1 had recently returned from the acute care hospital. He was not verbally responsive to the staff speaking to him. RN 2 stated Resident 1's right fingers had been so contracted, and they could not open them and his fingers would dig into his hand. RN 1 stated two staff could not open his hand. a. Review of Resident 1's Order Detail showed the physician's orders [REDACTED]. The order showed after discussion with the acute care hospital's neurosurgery, Resident 1 would benefit from a [MEDICATION NAME] pump (consists of a pump and a catheter that brings the medication from the pump into the spinal fluid). Review of Resident 1's Team Conference Notes dated 8/25/20, showed attempts of getting the neurosurgery follow- up had been unsuccessful. Review of Resident 1's Case Management Notes dated 10/8/20, showed the authorization was requested from the insurance company so Resident 1 could be seen by the neurology/neurosurgery. Another note dated 10/14/20, showed the case management was still working with the patient's insurance to obtain authorization for the neurology/neurosurgery consult. On 11/13/20 at 1200 hours, an interview was conducted with the Case Manager. The Case Manager verified the above findings and stated when a resident was so tight with his muscles, a cocktail of medications was tried. The pump would constantly provide muscle relaxants so the resident's limbs could be positioned, and they could adjust the dosage of the medication remotely. On 11/19/20 at 0845 hours, an interview and concurrent medical record review was conducted with the Administrator. The Administrator stated the reason for the neurosurgery consultation for the [MEDICATION NAME] pump was for Resident 1's toning and contractures. She stated it was hard to give enough [MEDICATION NAME] via GT to help. The Administrator stated the physician thought it might help the resident's toning, but his contractures were already bad. The Administrator stated the neurosurgery consultation had not yet been done for the [MEDICATION NAME] pump. On 11/23/20 at 1325 hours, a telephone interview was conducted with Physician 1. Physician 1 was asked if the neurosurgery consultation and [MEDICATION NAME] pump would have helped Resident 1. Physician 1 stated absolutely, it would have made a difference. b. Review of the facility's Wound Management P&P revised 6/20/20, showed the wound assessment includes wound history, location of wounds, wound stage, layers of wound involved, wound measurements in centimeters, color and appearance of the wound, exudate/drainage, amount and color, surrounding tissue, margins, [MEDICAL CONDITION], peripheral tissue indurations, and odor. Staging is only done in wounds derived from pressure. Impaired skin integrity will be addressed on the care plan when the problem is identified. All nursing staff that provides wound care will document daily the condition and appearance of the skin, integrity, and site, measurements and treatment being used. Review of Resident 1's List Patient Notes showed the following nursing entries dated: - 9/29/20, the licensed nurse changed Resident 1's handrolls and noticed red abrasions on the middle finger and pinky finger where the nail was, and the skin was peeling off and red. The nail on Resident 1's pointer (index) finger was black. His hands were contracted in a tight fist all day and the handrolls were placed to keep him from digging his nails into his palm. - 10/3/20, the skin of Resident 1's right fourth (measuring 1.0 cm by 1.0 cm) and fifth (measuring 1.0 cm by 0.5 cm) knuckles were open due to him rubbing at his [MEDICAL CONDITION] mask. The documentation showed there was no bleeding or drainage noted. Resident 1's physician was notified and [MEDICATION NAME] ointment was ordered. - 10/5/20, the licensed nurse noted Resident 1's right hand and fingers were strongly contracted and the right middle finger had an open wound at the tip. The documentation showed it was concluded that Resident 1's nail was digging into the skin. Scant blood was noted, but there was no active bleeding. The wound measured 1.5 cm by 1.0 cm. - 10/9/20, Resident 1 had the right hand bleeding. The documentation showed the skin around Resident 1's fingers were denuded with nail bed starting to come off from his fingers. The physician was made aware and gave new wound care orders. - 10/10/20, the fingers of Resident 1's right hand were digging into his palm. The skin of the palm and fingers were sweaty and denuded. - 10/11/20, Resident 1's wound on the knuckles were still open with drainage noted. - 10/11 and 10/12/20, the treatments to Resident 1's right knuckles, pinky and middle fingers were done as ordered. The documentation showed bleeding was noted to the site with increased (skin) breakdown. - 10/14/20, Resident 1's physician ordered a wound consultation due to increased (skin) breakdown. - 10/16/20, the licensed nurse spoke with Resident 1's physician and received an order to send Resident 1 out to the emergency department via 911 for further evaluation of the finger wound. Review of Resident 1's Physical Assessment showed the following entries dated: - 10/4, 10/5, and 10/6/20, Resident 1's nail on the third digit of the right hand was digging into the fingertip causing the epidermis (outer layer of the skin) to peel off. The documentation showed this could be due to the digit contractures of the right hand. The wound measured 1.5 cm by 1 cm. - 10/7, 10/8, and 10/9/20, Resident 1 had an open wound to the right third digit. On 10/9/20, his fingers were very contracted and digging into the palm of his right hand. -10/10 and 10/12/20, Resident 1 had an open wound to the right third digit, with serosanguineous drainage (wound drainage containing blood and clear yellow liquid). -10/13/20, Resident 1's right fourth and fifth knuckles, open wound, serosanguineous. It showed the right third digit was discontinued. -10/14 and 10/15/20, the right 4th and 5th knuckles, open wound, serosanguineous. There was no note about the right middle and pinky fingers. None of these assessments showed the stages of the wounds, or odor. Not all of the assessments showed the measurements of the wounds to determine if the wounds were improving or worsening. Review of the plan of care failed to show a care plan problem was developed to address Resident 1's red abrasions on the middle and pinky fingers, nor for the peeling skin. On 10/28/20 at 1420 hours, an interview was conducted with RN 4. RN 4 stated if treatment was being done to a resident's wound, there should be a daily wound documentation so they could tell if the wound was getting better or worse. The wound documentation should describe the wound and any drainage. On 11/19/20 at 1130 hours, an interview and concurrent medical record review was conducted with RN 7. RN 7 stated she called Resident 1's physician on 10/9/20, because of his right hand. RN 7 stated denuded meant the skin was peeling off his finger, and she really could not measure it as the skin was coming off of his whole right middle finger. Resident 1's right pinky and middle fingers' nail beds skin were coming off. RN 7 stated when she called the physician, the physician was surprised at what she said as she only knew about wounds on his knuckles so far. RN 7 stated she cared for Resident 1 a week later and was the nurse who sent him out to the acute care hospital. Resident 1's hand was significantly different than the week before. It was gross. Resident 1's right middle finger was swollen and smelled bad, and that nail was almost gone. RN 7 stated when she squeezed on his right middle finger, she observed yellow pus come out. RN 7 stated she got the physician to see his hand and the physician took action. RN 7 stated the night shift told her Resident 1's finger had drainage; it was bad and something needed to happen. Review of Resident 1's Emergency Department Note - Physician dated 10/16/20, showed per staff at the facility, due to Resident 1's contractures, the wound on his fingers could not be cleaned and had been bleeding with purulent (pus) matter for the past three to four days. The documentation showed upon examination, Resident 1's right third distal digit was swollen with circumferential [DIAGNOSES REDACTED] (redness encircling the finger), purulent drainage with evidence of darkened eschar (dark necrotic/dead tissue) in the middle. The fifth digit had similar [DIAGNOSES REDACTED] and swelling to digit aspect. The physician's [DIAGNOSES REDACTED]. Review of Resident 1's Orthopedic Progress Notes dated 10/20/20, showed he was admitted for concerns with the right hand contracture with full thickness pressure ulcers. Resident 1 was now status [REDACTED]. On 11/19/20 at 0845 hours, an interview and concurrent medical record review was conducted with the Administrator. The Administrator stated a resident's care plan should be updated by the floor nurses for any newly discovered problems, especially if the physician was called. The Administrator stated she doubted the floor nurse updated the care plan when the resident's right middle finger was found to have an open area on 9/29/20. The Administrator stated she expected staff to update the care plan and assess the resident's wound daily which included measuring, staging, photographing the wound as well as describing any drainage in their documentation. The Administrator stated this was not done for Resident 1's right hand wounds but should have been done. The Administrator stated she saw Resident 1's hand on 10/14/20, and stated the middle finger and nail was unrecognizable. It was so swollen. The nail was hanging there. The Administrator stated they could not move Resident 1's fingers. Resident 1's pinky finger was pressing into his hand, and his middle finger was white from pressure. The nail was black. The Administrator stated there was a washcloth in Resident 1's hand but washcloths don't always work. The Administrator stated she depended on the nurses for update. She was the last one to know how bad Resident 1's hand was. The Administrator stated if she had been told, it would have been a non-issue with getting authorization from Resident 1's insurance company. The Administrator stated none of this should have happened. c. On 10/28/20 at 1515 hours, an interview was conducted with RN 5. RN 5 stated the staff would not cut any residents fingernails. They would only file the residents' nails. RN 5 stated she did not know who should cut a resident's nails and it was difficult to open Resident 1's hands. RN 5 stated she could not even see Resident 1's fingernails as his fingers were pressed into his palm when he was clenching his fist. On 11/9/20 at 1120 hours, an interview was conducted with LVN 2. LVN 2 stated she took care of Resident 1 for a few days prior to Resident 1 going to the acute care hospital. LVN 2 stated Resident 1's wound was actively bleeding and the right middle fingernail was lifted up at the end and pushed back into his finger. The tip of the finger was raw and the side of the finger was peeling from moisture. The skin on his palm was intact. The right pinky fingernail was also lifted up some at the end and pushed up a little into the finger. The middle fingertip was a little bit black. LVN 2 stated she was afraid of breaking Resident 1's finger when she tried to open his hand. On 11/13/20 at 0900 hours, an interview was conducted with CNA 5. CNA 5 stated she cared for Resident 1 either late September or early October. CNA 5 stated Resident 1's right middle finger was pretty bad. CNA 5 stated something smelled as she walked into the room, and it smelled weird. It smelled like flesh and was terrible. CNA 5 stated when they tried to open Resident 1's hand, it was wrinkly like when you hold your hand under water for so long, and smelled really bad. It looked like the skin was going to come off. CNA 5 stated when she washed Resident 1's hand, she didn't know if it was skin or dirt that came off. Resident 1's skin was peeling and he was bleeding a little from his pinky finger. It looked like his middle fingernail was going to come off or already had came off. CNA 5 stated they were not supposed to cut fingernails, only file them. It would have been a two-person job to file Resident 1's nails. On 11/13/20 at 0925 hours, an interview was conducted with PT 1. PT 1 stated she assessed Resident 1 with the orthotics representative and they were only able to move his right pointer finger a little. PT 1 stated she was unable to see Resident 1's other fingernails, but this one was long and needed to be cut down for sure. On 11/13/20 at 1230 hours, an interview was conducted with the Administrator. The Administrator stated there was no facility P&P for nail care as the staff did not cut residents' nails. The Administrator stated the families were requested to cut the residents' nails when they came to visit, but with this COVID-19 virus, the families were not coming to the facility like they used to. Review of the facility's conclusion dated 11/24/20, showed areas of concerns were identified such as staff providing direct care of the resident did not adequately assess the resident's deteriorating skin integrity of the right hand. The case management/administrative team was not made aware of the deterioration of the resident's right hand skin integrity until surgical intervention became necessary. Cross references to F688 and F836.