Every finding on record at Healthcare Centre of Fresno

Based on observation, interview and record review, the facility failed to follow professional standards and ensure for five of eight sampled residents (Resident 18, Resident 86, Resident 92, Resident 119 and Resident 131) were free from significant medication errors, when Resident 86, Resident 119 and Resident 131's insulin (insulin lispro/ insulin aspart: fast-acting with a quick onset of 5-15 minutes injectable medication that lowers blood glucose (BG- sugar)) and Resident 18 and Resident 92's insulin (regular insulin: short-acting with a slower onset of 30-60 minutes injectable medication) were administered more than an hour before meal.This failure had the potential to result in hypoglycemic (condition where sugar levels in the blood drop too low) episodes for Resident 18, Resident 86, Resident 92, Resident 119 and Resident 131 which could lead to confusion, dizziness, blurred vision, seizures, and loss of consciousness.Findings:During an interview with Licensed Vocational Nurse (LVN) 3 on 5/7/26 at 12:25 p.m. in Nursing station 3, LVN 3 stated she had six residents who received insulin medication. LVN 3 stated only 4 of the residents were in the facility and she had already checked their BG level. LVN 3 stated 3 of the 4 residents refused insulin administration and only 1 resident (Resident 119) was administered insulin.During a concurrent interview and record review on 5/7/26 at 12:26 p.m. with LVN 3 and LVN 4 in Nursing station 3 , Resident 119's Medication Administration Record (MAR) was reviewed with LVN 4, the MAR indicated Resident 119's BG level was checked, and 1 unit of insulin lispro was administered at 11: 47 a.m. LVN 3 stated she checked Resident 119's BG level at 11:30 a.m. LVN 3 stated when the lunch tray was announced, the Certified Nursing Assistants would bring the lunch trays up. LVN 3 stated lunch was usually between 12:30 p.m. and 1:30 p.m.During a review of Resident 119's admission Record (AR- a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/26, the AR indicated Resident 119 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus (DM-chronic condition where the body does not use insulin properly or make enough insulin, leading to high blood sugar levels), hyperlipidemia (abnormally high fat levels, or lipids, in the blood), chronic kidney disease (a long-term condition where the kidneys are damaged and gradually lose their ability to filter waste, toxins, and excess water from the blood), essential hypertension (high blood pressure) and history of falling.During a review of Resident 119's Order Summary Report (OSR), dated 5/1/26, the OSR indicated, Resident 119 had an active order for . Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML [milliliters- metric unit used to measure the volume of a liquid] (Insulin Lispro) Inject as per sliding scale.subcutaneously (administered beneath all the layers of the skin)two times a day for DM During an interview on 5/7/26 at 12:29 p.m. with LVN 5 in Nursing station 3 , LVN 5 stated she had three residents (Resident 18, Resident 86 and Resident 92) who received insulin medication. LVN 5 stated all three residents BG level were checked between 11.15 a.m. and 11:30 a.m. LVN 5 stated Insulin was administered to the three residents after their BG levels were checked.During a record review on 5/7/26 at 12:30 p.m. LVN 4 in Nursing station 3 , Resident 18, Resident 86 and Resident 92's MAR were reviewed, the MAR indicated Resident 18's BG level was checked, and 14 units of regular insulin were administered at 11: 22 a.m. Resident 86's BG level was checked, and 2 units of insulin lispro were administered at 11: 18 a.m. and Resident 92's BG level was checked, and 4 units of regular insulin were administered at 10: 54 a.m.During a review of Resident 18's AR dated 5/8/26, the AR indicated Resident 18 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus, hyperlipidemia, and essential hypertension.During a review of Resident 18's OSR, dated 5/8/26, the OSR indicated, Resident 18 had an active order for . Insulin Regular Human Injection Solution 100 UNIT/ML (Insulin Regular (Human)) Inject 14 unit subcutaneously three times a day for DM. Take with food During a review of Resident 86's AR dated 5/8/26, the AR indicated Resident 86 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus, hyperlipidemia, chronic kidney disease and essential hypertension.During a review of Resident 86's OSR, dated 5/5/26, the OSR indicated, Resident 86 had an active order for . Insulin Lispro injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale.subcutaneously before meals for DM .During a review of Resident 92's AR dated 5/8/26, the AR indicated Resident 18 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus, hyperlipidemia, chronic kidney disease and essential hypertension.During a review of Resident 92's OSR, dated 2/3/26 and 5/4/26, the OSR dated 2/3/26 indicated, Resident 92 had an active order for . Insulin Regular HUMULIN R INJ U-100 Inject as per sliding scale., subcutaneously before meals and at bedtime for DM. The OSR dated 5/4/26 indicated, Resident 92 had an active order for . Insulin Regular Human Inject 4 unit subcutaneously three times a day for DM WITH MEALS During an observation on 5/7/26 at 12:57 p.m. on the third floor, the food trays arrived on floor and were served to residents.During a concurrent interview and record review on 5/8/26 at 7:42 a.m. with LVN 6 in Nursing station 1 , Resident 131's MAR was reviewed. LVN 6 stated she had checked BG level and administered Insulin to one resident (Resident 131). The MAR indicated Resident 131's BG level was checked, and 16 units of insulin aspart were administered at 7: 33 a.m. LVN 6 stated breakfast was served between 8 a.m. and 8:30 a.m. LVN 6 stated nurses should follow the physician's order. LVN 6 stated Resident 131's order indicated with meals. LVN 6 stated Resident 131 had not gotten his meal, and she should not have administered the insulin. LVN 6 stated she was not following physician's order and Resident 131's BG level could go down, and he would be hypoglycemic which could lead to an emergency.During a review of Resident 131's AR dated 5/8/26, the AR indicated Resident 131 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus, hyperlipidemia, and essential hypertension.During a review of Resident 131's OSR, dated 5/8/26, the OSR indicated, Resident 131 had an active order for . Insulin Aspart Solution 100 UNIT/ML, inject 16 unit subcutaneously three times a day for Diabetes, Take with food .During an interview on 5/8/26 at 7:52 a.m. with LVN 1 in Nursing station 1 , LVN 1 stated insulin aspart and lispro were fast acting insulin with onset between 15- -30 mins. LVN 1 stated the insulin should be given when the breakfast tray was available. LVN 1 stated this was important because Resident 131's BG level could drop. LVN 1 stated breakfast was at 8: 30 a.m. LVN1 stated the nurses should follow the physician's orders. LVN 1 reviewed the physician's order in Resident 131's MAR and validated the insulin order. LVN 1 stated the nurse did not follow the physician's order for Resident 131 and that administering the insulin with the meal was not the same as administering insulin with a snack.During an interview on 5/8/26 at 8:20 a.m. with LVN 4, LVN 4 stated insulin lispro/aspart should be administered 30 -45 min before meals or with meals. LVN 4 stated administering insulin at the wrong time could result in side effects of low BG and the resident could become hypoglycemicDuring an interview on 5/8/26 at 4:27 p.m. with the Director of Nursing (DON), the DON stated she expected the nurses to follow the physician's order. The DON stated if the physician's order indicated with meals, then it should be given with meal. The DON stated resident could have hypoglycemia, and abnormal BG level. During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2be14cbb-197a-4da8-82c8-2443594e7f6f, titled, INSULIN LISPRO injection, solution, undated, the professional reference indicated .2.2 Administration Instructions for the Approved Routes of Administration-Subcutaneous Injection-Administer the dose of Insulin Lispro within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=bee5b358-c863-420b-be73-ced2e920c499, titled, INSULIN ASPART injection, solution, undated, the professional reference indicated .2.2 Preparation and Administration Instructions for the Approved Routes of Administration- Subcutaneous Injection-Inject Insulin Aspart subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm.During a professional reference review retrieved from National Library of Medicine/National Institute of Health- Daily Med found at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b519bd83-038c-4ec5-a231-a51ec5cc291f, titled, HUMULIN R- insulin human injection, solution, undated, the professional reference indicated .2.2 Route of Administration- Subcutaneous Injection-Inject HUMULIN R subcutaneously approximately 30 minutes before meals into the thigh, upper arm, abdomen, or buttocks.During a review of the facility's Policy and Procedure (P & P) titled, Medication Administration, dated 8/19/25, the P&P indicated, .Policy: All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner. Purpose- To establish standardized procedures for the safe, effective, and accurate administration of medications in compliance with state and federal regulations and best practice standards.Process- iii. Medications must be administered within one hour before or one hour after the scheduled time, unless a specific clinical reason requires a more rigid schedule (e.g., insulin.) . v. Right Time: Administer within ordered time window.

Based on interview and record review, the facility failed to ensure the Individual Narcotic Record (INR) for Controlled Drugs (medications that are highly regulated by the government because of the significant risk of abuse and dependence they pose) were maintained accurately for five of six sampled residents (Resident 26, Resident 74, Resident 139, Resident 158 and Resident 159) when:1. The Licensed Nurse (LN)s transferred controlled medications for Resident 26 and Resident 158 from one medication cart to another, and the INR was not accurately completed by two required witnesses as indicated on the INR. This failure had the potential for Resident 26 and Resident 158 controlled medications to be diverted (illegal transfer or use of prescription medication) and Resident 26 and Resident 158's pain not to be met.2. Resident 74, Resident 139 and Resident 159 were administered controlled medications, and the INR was not signed by the LNs for each of the residents according to the facility's policy and procedure (P&P) titled, Medication Administration- IIA7: CONTROLLED MEDICATIONS.This failure had the potential for lost, misuse or abuse of medications for Resident 74, Resident 139 and Resident 159's medication3. Controlled medications were not reconciled by LNs at the beginning and end of shift according to the facility's policy and procedure.This failure had the potential for controlled drugs to be diverted and documentation to be inaccurate, which could bring about LNs administering the wrong dosage or type of medication, thus putting residents at risk of severe adverse effects or fatal complications.Findings:1. During a concurrent record review and interview on 5/6/26 at 11:16 a.m., with Licensed Vocational Nurse (LVN) 7 on Station 3 medication cart 1, Resident 26's INR was reviewed, the INR indicated Resident 26 had 30 capsules of Pregabalin (Schedule V controlled medication that calms overactive nerves in your body)100mg which was received on 3/22/26. The INR indicated moved to other cart No.2. There was no date of transfer or signature of giving or receiving LN for the controlled medication. There was no information on the disposition of unused drug section at the bottom of the INR page for Resident 26. LVN 7 stated there should be double signature on the INR indicating the giving or receiving LN, and the amount of Pregabalin 100mg capsules transferred to Cart 2 should have been indicated.During a review of Resident 26's admission Record (AR- a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/26, the AR indicated Resident 26 was admitted to the facility on [DATE] with a diagnosis which included mononeuropathy of bilateral lower limbs (specific nerve in both legs is damaged, compressed, or inflamed).During a review of Resident 26's Order Summary Report (OSR), dated 3/20/26, the OSR indicated, Resident 26 had an active order for . Pregabalin oral capsule 100 mg (milligrams- unit of measurement) - give one capsule by mouth three times a day During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 26's MDS assessment indicated Resident 26's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 12 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 26 was moderately impaired.During a review of Resident 26's INR,, the INR indicated the Pregabalin Cap 100mg -Take 1 cap po TID was moved to other cart No. 2 and was not signed off by the LNs.During a concurrent Interview and record review with LVN 5 on 5/6/26 at 3:47 p.m., on Station 1 medication cart 1, Resident 158's INR was reviewed, the INR indicated there were 24 capsules of Pregabalin 50mg left on 11/6/25 and the medication was given to ALF (Assisted Living Facility- residential senior living option that provides support for older adults who need help with daily tasks but do not require the intensive care). The INR indicated there was only one signature appended on the INR, which was the receiving LN's signature. LVN 5 stated whenever a controlled medication was transferred, the INR should be signed by two LNs, the receiving LN and the LN giving the medication. LVN 5 stated Resident 158 had 24 medications left on 11/6/25 and the medication was given to ALF because Resident 158 transferred to ALF. LVN 5 stated it was important that the controlled medication should be signed by 2 LNs because it was a controlled substance and had the potential for diversion.During a review of Resident 158's AR, dated 5/8/26, the AR indicated Resident 158 was admitted to the facility from an acute care hospital on [DATE] with diagnoses which included . Neuropathy (damage to the nerves outside the brain and spinal cord, which act as the body's wiring system) .During a review of Resident 158's MDS, dated [DATE], the MDS section C indicated Resident 158 had a BIMS score of 13, which indicated Resident 158 was cognitively intact.During a review of Resident 158's OSR dated 9/20/25, the OSR indicated Resident 158 had physician orders . Pregabalin oral capsule 50 mg - give one capsule by mouth three times a day.During a review of Resident 158's INR,, the INR indicated the Pregabalin Cap 50mg -Take 1 cap po TID was given to ALF and was signed by only one LN with no date indicating when the medication was transferred to ALFDuring an interview on 5/8/26 at 8:25 a.m. with LVN 4, LVN 4 stated the expectation was for two LNs to sign for the transfer of the controlled drug from one medication cart to another medication cart.During an interview on 5/8/26 at 1:36 p.m. with LVN 2, LVN 2 stated the expectation was for the LNs to sign at the bottom of the page, there is designated spot for who was receiving and giving the medication. LVN 2 stated this was important because the medications are controlled medication, and to ensure they were safely transported from one area to another.During an interview on 5/8/26 at 4:19 p.m. with the Director of Nursing (DON), the DON stated at the bottom page of the INR, there was the disposition section and the expectation was the section should be completed by the receiver and the giver, so it keeps a trail of where the narcotics went2. During a concurrent record review and interview with LVN 7 on 5/6/26 at 11:01 a.m., on Station 3 medication cart 1, Resident 139's INR was reviewed, the INR indicated after medication administration on 11/13/25 there were 3 tablets of Phenobarbital (used to treat seizures and as a sedative )30mg tablets left. LVN 7 stated she did not know where the remaining medication was and would find out.During a review of Resident 139's AR, dated 5/8/26, the AR indicated Resident 139 was admitted to the facility on [DATE] with diagnoses which included . Epilepsy unspecified (a long-term brain condition that causes repeated seizures[sudden, uncontrolled burst of abnormal electrical activity in the brain]), .During a review of Resident 139's MDS, dated [DATE], the MDS section C indicated Resident 139 had a BIMS score of 2, which indicated Resident 139 was severely cognitively impaired.During a review of Resident 139's OSR dated 4/18/25, the OSR indicated Resident 139 had physician orders . Phenobarbital oral tablet 30 mg give 45 mg by mouth at bedtime for unspecified convulsion given 1-1/2 tab (total 45 mg) .During a review of Resident 139's INR,, the INR indicated Phenobarbital 30 mg tab with no direction for administration, no date received, and no information on who received the medication. The INR indicated Resident 139 received 3 doses of Phenobarbital 30 mg tab (total-30x3=90mg) for each administration at 2100 on 11/5/25, 11/6/25, 11/7/25, 11/8/25, 11/9/25, 11/10/25, 11/11/25, 11/12/25 and 11/13/25 though the OSR indicated phenobarbital oral tablet 30 mg give 45 mg by mouth at bedtime for unspecified convulsion given 1-1/2 tab (total 45 mg). The INR indicated the medication was last documented as administered 11/13/25 and there were three tablets left. The INR indicated there was no documentation of the medications administered or wasted and there was no documentation of the medications returned to the DON. During a review of Resident 139's MAR, the MAR indicated Phenobarbital 30 mg tab phenobarbital oral tablet 30 MG (Phenobarbital)-Give 45 mg by mouth at bedtime for unspecified convulsion given 1-1/2 tab (total 45 mg) . and was checked off as administered to Resident 139 on 11/13/25 and on 11/14/25.During an interview on 5/6/26 at 1:48 p.m. with LVN 4 in the conference room, LVN 4 stated Resident 139's Phenobarbital 30 mg tab was administered in the MAR on 11/14/25 but the LN forgot to sign the medication in the INR.During a concurrent record review and interview on 5/6/26 at 11:03 a.m., with LVN 7 on Station 3 medication cart 1, Resident 74's INR was reviewed, the INR indicated Morphine sulfate ((a Schedule II controlled medication used for relief of moderate to severe acute and chronic pain) 30mg ER- last administered 12/7/25 showing 1-tab remaining. LVN 7 stated she would assume the medication was administered but was not signed off.During a review of Resident 74's AR, dated 5/8/26, the AR indicated Resident 74 was admitted to the facility from an acute care hospital on 3/13/20 with diagnoses which included . Encounter for orthopedic aftercare following surgical amputation, polyneuropathy (condition where multiple nerves outside the brain and spinal cord become damaged, causing widespread numbness, tingling, or weakness), generalized osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), .During a review of Resident 74's MDS, dated [DATE], the MDS section C indicated Resident 74 had a BIMS score of 11, which indicated Resident 74 was moderately impaired.During a review of Resident 74's OSR dated 9/19/24, the OSR indicated Resident 74 had physician orders . Morphine Sulfate ER 30mg tablet extended release- take one tablet by mouth twice a day for chronic pain.During a review of Resident 74's INR,, the INR indicated Morphine Sul tab 30mg ER -Take 1 po BID was last documented as administered 12/17/25 and there was one tablet remaining. The INR indicated there was no documentation of the medication administered or wasted and there was no documentation of the medication returned to the DONDuring a review of Resident 74's MAR, the MAR indicated Morphine Sulfate ER 30mg tablet extended release- take one tablet by mouth twice a day for chronic pain and was checked off as administered to Resident 74 on 12/17/25 and on 12/18/25.During a concurrent interview and record review on 5/6/26 at 11:10 a.m., with LVN 7 on Station 3 medication cart 1, Resident 159's INR was reviewed, the INR indicated Buprenorphine dis(used to treat opioid addiction) 5mg - patch- 1 patch remaining on 3/2/26. LVN 7 stated she would assume whoever gave the patch after that day did not sign the patch out, the last date the patch was administered was 3/2/26 and Resident 159 was discharged on 3/10/26.During a review of Resident 159's AR, dated 5/8/26, the AR indicated Resident 159 was admitted to the facility from an acute care hospital on 5/1/25 with diagnoses which included .generalized osteoarthritis, .During a review of Resident 159's MDS, dated [DATE], the MDS section C indicated Resident 159 had a BIMS score of 12, which indicated Resident 159 was cognitively intact.During a review of Resident 159's OSR dated 10/22/25, the OSR indicated Resident 159 had physician orders . Buprenorphine Transdermal patch weekly 5mg/hr- apply 1 patch trans dermally in the afternoon every Mon for chronic pain.During a review of Resident 159's INR,, the INR indicated Buprenorphine Dis 5mg/hr-apply 1 patch q Monday was last documented as administered 3/2/26 and there was one patch left. The INR indicated there was no documentation of the patch administered or wasted and there was no documentation of the patch returned to the DONDuring a review of Resident 159's MAR, the MAR indicated .Buprenorphine Transdermal Patch Weekly 5 MCG/HR (Buprenorphine) Apply 1 patch trans dermally in the afternoon every Mon for chronic pain. and was checked off as administered to Resident 159 on 3/2/26 and on 3/9/26.During an interview on 5/8/26 at 8:25 a.m. with LVN 4, LVN 4 stated there was the potential controlled medication had been diverted. LVN 4 stated if the controlled medications were administered in the MAR and were not documented in the INR, then it was not done.During an interview on 5/8/26 at 1:42 p.m. with LVN 2, LVN 2 stated there was missing documentation. LVN 2 stated the LNs were violating the rights of the resident to receive their medication.During an interview on 5/8/26 at 4:03 p.m. with the DON, the DON stated the facility would have to come up with a process where there was proper audit of controlled medications. The DON stated the auditing of controlled medication was not done effectively.During an interview on 5/8/26 at 4:17 p.m. with the DON, the DON stated the failure to properly audit controlled medications could potentially lead to diversion of the controlled medications. 3. During a concurrent interview and record review on 5/6/26 at 11:19 a.m., with LVN 7 on Station 3 medication cart 1, the INR was reviewed with LVN 7. The INR indicated, there were 5 unsigned entries by LNs in the month of October 2025, 4 unsigned entries by LNs in the month of November 2025, 1 unsigned entries by LNs in the month of April 2026 and 2 unsigned entries by LNs in the month of May 2026. The INR indicated there were uncompleted entries (such as dates, comments indicating how many controlled medications were in the medication cart) 16 times from October 2025 to May 2026. LVN 7 stated the expectation was for two LNs to count the number of controlled medications on every shift and both LNs should sign. LVN 7 stated it was important to follow the process of counting controlled medications at the beginning and end of each shift because controlled substances are very important to be documented correctly, if any of them got lost it could be dangerous for other residents and it could get into a resident or staff's hands who the controlled medication was not prescribed to. LVN 7 stated the affected person could die from taking a medication not prescribed to them or overdose on the medication. LVN 7 stated this failure had the potential to also affect the resident who was prescribed the controlled medication because they would not receive their medication. LVN 7 stated this could potentially lead to unmanaged pain, or residents could have withdrawals symptoms.During a concurrent record review and interview on 5/6/26 at 3:47 p.m., with LVN 5 on Station 1 medication cart 1, the INR was reviewed with LVN 5. The INR indicated, there was 1 unsigned entries by LNs in the month of November 2025. LVN 5 stated the oncoming and the off going LNs were expected to sign the Controlled log. LVN 5 stated this was important because it was the accounting of the medication, once the LNs counts the controlled medications they are responsible for the medications.During an interview on 5/8/26 at 11:39 a.m. with LVN 2, LVN 2 stated when a LN is taking over a medication cart, they are taking responsibility for those controlled medications in the cart, hence the need to ensure accuracy of the count of the controlled medications. LVN 2 stated the expectation from the LN was they should be counting properly and signing the logs right away. LVN 2 stated the failure to count controlled medications at the beginning and end of each shift could create conflict at shift change. During an interview on 5/8/26 at 4:17 p.m. with the DON, the DON stated expectation was both LNs should sign the controlled log at the beginning and at the end of each shift. The DON stated this was important because the LNs are counting controlled medication and passing the information onto the next shift to prove the count was accurate.During a review of professional reference Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention, dated July 2012, (found at https://pmc.ncbi.nlm.nih.gov/articles/PMC3538481/) indicated, .Healthcare workers who are diverting drugs from the health care facility workplace pose a risk to their patients, their employers, their co-workers, and themselves. It is essential that all health care institutions have a robust system in place to identify and investigate suspected diversion as rapidly and efficiently as possible and that they implement policies and procedures that enable a standardized and effective response to confirmed diversion. Drug diversion by healthcare workers violates the core value that the needs of the patient come first. Clearly, if we are to optimize our approach to inpatient drug diversion and its consequences, we must look at such diversion not as a victimless act but as a multiple-victim crime.During a review of the facility's Policy and Procedure (P & P) titled, Medication Administration- IIA7: CONTROLLED MEDICATIONS, dated 3/26, the P&P indicated, .Policy- Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Procedures-A. The Director of Nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. a) Medications are obtained from the locked medication cart (if a Schedule III, IV, or V medication). b) Preparation of the dosage form occurs according to the medication administration policy. c) When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): Date and time of administration, Amount administered, Signature of the nurse administering the dose, completed after the medication is actually administered. d) When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to facility policy. and the disposal documented on the accountability record on the line representing that dose. f) Discrepancies of controlled medication counts. Count discrepancies shall be reported to the Consultant Pharmacist, Medical Director, Administrator and Director of Nursing. Director of Nursing shall conduct a review and determine cause of the discrepancy and take appropriate actions per facility policy. g) Theft of controlled medications. When a theft of a controlled medications from patient supply is discovered, Director of Nursing shall conduct a review and report her findings to the appropriate law enforcement authorities. Facility Administrator / Director of Nurses will notify the Consultant Pharmacist, Medical Director and appropriate local law enforcement authorities of her findings.During a review of the facility's P & P titled, Medication Administration- ID 3: CONTROLLED MEDICATIONS STORAGE, dated 3/26, the P&P indicated, .Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures A. The director of nursing and the consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. C. A controlled medication accountability record is prepared by the pharmacy for all Schedule II, III, and IV, medications (see Form 12: INDIVIDUAL RESIDENT'S CONTROLLED SUBSTANCE RECORD), including those in the emergency supply. The following information is completed: a. Name of resident .b. Prescription number. c. Name, strength, and dosage form of medication d. Date received e. Quantity received f. Name of person receiving medication supply D. At each shift change, a physical inventory of all controlled medications in Scheduled II-IV, including the emergency supply, is conducted by two licensed nurses and is documented on the controlled medication accountability record.F. Any discrepancy in controlled substance medication counts schedule II-IV is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. a. If a major discrepancy or a pattern of discrepancies occurs or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. b. The administrator, the consultant pharmacist, and/or the director of nursing determine whether other action(s) are needed, e.g., notification of police, licensing, nursing board, or other enforcement personnel. c. The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met (example: a resident receiving a pain medication complains of unrelieved pain) . J. The consultant pharmacist or designee routinely monitors controlled medication storage, records, and expiration dates during routine scheduled medication storage inspections.

Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for two of nine sampled residents (Resident 6 and Resident 83), when Resident 6 and Resident 83's copy of the Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete.This failure had the potential for Resident 6 and Resident 83's decisions regarding lifesaving treatment options and end of life wishes to not be honored.Findings:During a concurrent observation and interview on [DATE] at 1:20 p.m. with Resident 6 in Resident 6's room, Resident 6 was observed dressed and lying in bed. Resident 6 stated she did not know how long she was in the facility or why she was there. During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 6 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting the left non-dominant side, type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of muscle left thigh, acquired absence (surgical removal of finger, toe, hand, foot, arm or leg) of left leg above the knee, acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), dysphagia (difficulty swallowing), and cognitive communication deficit (difficulty with thinking and how someone uses language).During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS section C indicated Resident 6 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 9 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 6 was moderately impaired.During a concurrent interview and record review on [DATE] at 9:02 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 6's POLST, dated [DATE] was reviewed. The POLST indicated, Section C .Artificially Administered Nutrition.no artificial means of nutrition, including feeding tubes.trial period of artificial nutrition, including feeding tubes.long-term artificial nutrition, including feeding tubes. was not marked. LVN 1 stated a POLST was an Advanced Directive (a legal document indicating resident preference on end-of-life treatment decisions) that guided the nurse on what to do if a resident's heart stopped beating. LVN 1 stated the POLST was sent with residents if they were transferred to another facility or to the hospital. LVN 1 stated if the POLST was not complete, staff could do the wrong thing for the residents' end-of-life wishes. LVN 1 stated all sections of Resident 6's POLST should have been completed.During a concurrent interview and record review on [DATE] at 11:39 a.m. with the Medical Records Coordinator (MR), Resident 6's POLST, dated [DATE] was reviewed. Resident 6's POLST indicated Section C was not complete. The MR stated Section C of Resident 6's POLST was not filled in. The MR stated Section C determined if the resident would use artificial nutrition during end-of-life care. The MR stated it was important for resident's POLSTs to be complete. The MR stated the POLST indicated what a resident's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was so the nurse would know to do cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) or not. The MR stated all sections of the POLST should be completed.During an observation on [DATE] at 11:16 a.m. in Resident 83's room, Resident 83 was observed wearing a gown, lying in bed, awake. Resident 83 did not respond to any questions.During a review of Resident 83's AR, dated [DATE], the AR indicated Resident 83 was initially admitted to the facility from an acute care hospital on [DATE] and re-admitted to the facility on [DATE] with diagnoses of dysphagia following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a disorder that makes it difficult to speak) dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), acute kidney failure, quadriplegia (a form of paralysis [the loss of the ability to move and sometimes to feel anything] that affects all of a person's limbs and body from the neck down), contracture of right and left shoulder, right and left elbow, right hand, right and left hip, right and left ankle, and adult failure to thrive (a gradual, ongoing decline in physical and mental health).During a review of Resident 83's MDS, dated [DATE], the MDS section C indicated Resident 83 had a BIMS score of 1, which suggested Resident 83 was severely cognitively impaired.During a review of Resident 83's Order Summary Report (OSR), dated [DATE], the OSR indicated, .CPR with full treatment.order status.active.order date.XXX[DATE].During a concurrent interview and record review on [DATE] at 9:02 a.m. with LVN 1, Resident 83's POLST, undated was reviewed. The POLST indicated there was no signature from Resident 83, or Resident 83's Responsible Party (RP - individual authorized to act on a resident's behalf regarding care), which was an appointed Conservator (a judge appointed person to act or make decisions for the person who needs help) on the POLST or date the POLST form was completed. LVN 1 stated a signed copy of Resident 83's POLST was not in the computer or in Resident 83's hardcopy (paper) file. LVN 1 stated there should have been a copy of Resident 83's POLST in the computer or hardcopy file, signed by Resident 83 or by Resident 83's RP. LVN 1 stated a POLST was an advanced directive, which guided the nurse on what to do if Resident 83's heart stopped beating. LVN 1 stated if a resident's POLST was not complete, staff could do the wrong thing for Resident 83's end-of-life wishes. LVN 1 stated all sections of the POLST should have been completed.During a concurrent interview and record review on [DATE] at 11:39 a.m. with the MR coordinator, Resident 83's POLST, undated was reviewed. Resident 83's POLST indicated there was no date the POLST form was prepared and section D (Information and Signatures) did not have a signature from the Resident or Conservator. The MR stated the POLST was completed by the physician or Nurse Practitioner (NP) after discussing with the resident or the resident's RP. The MR stated once the POLST form was complete, the Medical Records Department tracked the form to confirm it was uploaded into the resident's chart. The MR stated Resident 83's POLST had a notation to see a copy with Resident 83's Conservator's signature, but the MR stated she was unable to find the copy. The MR stated someone needed to call the Conservator to see if they had a signed copy of Resident 83's POLST. The MR stated it was important for Resident 83's POLSTs to be complete. The MR stated the POLST indicated what a resident's code status was so the nurse would know to do CPR or not. The MR stated all sections of the POLST should be complete.During an interview on [DATE] at 5:18 p.m. with the Director of Nursing (DON), the DON stated a POLST was a physician's order that informed staff with the residents' or RP's wishes were for life sustaining treatment, to do CPR or not. The DON stated all sections of a resident's POLST should have been completed. The DON stated if a resident's POLST was not complete, staff might not be able to follow the residents' or RP's wishes. The DON stated the physician completed the POLST form with the resident or RP and signed the form with the resident or RP to verify their wishes. The DON stated the nurse reviewed the POLST form for completeness. The DON stated her expectation was for Medical Records to do auditing of the POLST forms before scanning into the resident's chart.During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated [DATE], the P&P indicated, .Upon admission, the Admissions Staff or Designee will provide written information to the resident concerning his or her right to make decisions concerning medical care; including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives.the Interdisciplinary Team will periodically review the Advance Directive, if applicable, with the resident or resident representative, to ensure that it still reflects the resident's wishes.During a review of the facility's P&P titled, Physician Orders, dated [DATE], the P&P indicated, .Physician orders will include the following.name of the ordering provider.resident's name.the date and time the order was received.treatment orders will include the following.a description of the treatment-the condition or diagnosis for which the treatment is ordered.other orders will include a clear and complete description to provide clarity on the physician's plan of care.documentation pertaining to physician orders will be maintained [in] the Resident's medical record.During a review of the facility job description document titled, Health Record Coordinator, undated indicated, .Assists in developing and maintaining an appropriate health record service and system for the facility.maintains Health Record System according to Federal, State and Community requirements.performs audits.coordinates physician documentation.During a review of the professional reference document titled, Physician Orders for Life-Sustaining Treatment Forms & Instructions (POLST), dated 2026, retrieved at: https://www.[NAME]-[NAME].org/programs/support-services/services/healthcare-ethics/polst.html, the document indicated, .The POLST form is completed by a patient ' s physician (or by someone who has undergone special training about POLST and who works with the patient ' s physician) in conjunction with thorough conversation with the patient regarding the patient ' s current and future health conditions and treatment preferences. Both the physician and patient must sign the POLST. If the patient lacks capacity to make medical decisions, the patient ' s legally recognized decision-maker can participate in both completing and signing the POLST form .

Based on observation, interview and record review, the facility failed to accommodate residents' preferences and allergies and to follow the meal ticket (list of food dislikes, allergies, and texture of food), for one of eight sampled residents (Resident 69), when Resident 69 was allergic to orange juice and was served orange juice for her lunch time meal. This failure had the potential for undesired side effects including weight loss, rash, hives, and anaphylaxis shock (a severe, rapidly progressing, and potentially life-threatening systemic allergic reaction that affects multiple body systems simultaneously, such as the skin, breathing, and blood pressure).Findings:During a concurrent observation and interview on 5/7/26 at 11:00 a.m. with Resident 69 in Resident 69's room, a container of orange juice was sitting on Resident 69's bedside table. Resident 69 stated she was allergic to orange juice and had to put the orange juice to the side. Resident 69 stated, . the kitchen is aware of my allergy, I do not want to drink it and die .During an interview on 5/8/26 at 9:09 a.m. with Licensed Vocational Nurse (LVN 4), LVN 4 stated, if an item on the resident's meal tray was an item on the Resident's allergy list, he would remove the item from the meal tray. If the resident ate or drank that item they could get an allergic reaction resulting in hives, rashes, or swelling of the throat leading to death. During a review of Resident 69's admission Record (AR), dated 5/8/26, the AR indicated, Residet 69 was admitted to the facility on [DATE] from an acute care hospital with the following diagnosis: Type II Diabetes Mellitus (DM II - a chronic condition where the body cannot effectively use insulin (insulin resistance) or make enough of it, causing sugar (glucose) to build up in the blood instead of powering cells), Peripheral Vascular Disease (PVD - is a slow, progressive circulation disorder caused by the narrowing, blockage, or spasms of blood vessels (arteries or veins) outside of the heart and brain, most commonly affecting the legs), and dysphagia (difficulty swallowing).During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/2/26, the MDS section C indicated Resident 69 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 69 was cognitively intact. During a concurrent interview and record review on 5/8/26 at 3:07 p.m. with the Certified Dietary Manager (CDM), Resident 69's meal ticket, dated 5/8/26 was reviewed. The meal ticket indicated in large font and capital letters with exclamation points, .!!!! NO ORANGES!!!! .Allergies: Oranges . Dislikes: Orange Juice .). The CDM stated, I am not sure if it was carelessness or an oversight but it is important that allergies listed get noted, some allergies can cause harm such as death . resident (Resident 69) should not have had orange juice or any citrus on her meal tray . During a review of Resident 69's Care Plan (CP), dated 1/27/26, the CP indicated, .The Resident has altered respiratory status r/t allergies . oranges . During a review of the facility's policy and procedure (P&P) titled, Dietary Profile and Resident Preference Interview dated 11/11/25, the P&P indicated, . The Dietary Department will provide residents with meals consistent with their preferences and Physician order as indicated on the tray card . if a preferred item is not available, a suitable substitute shall be provided .

Based on observation, interview, and record review the facility failed to ensure residents received food that was palatable, attractive and appetizing for three of five sampled residents (resident 43, resident 126, and resident 130) when the facility ran out of polenta (coarsely ground cornmeal (yellow or white) that is boiled in water or broth until it becomes a thick, creamy porridge), during the lunch meal service and it was replaced with mashed potatoes. The temperature of the potatoes had not been taken, and the potatoes had a water-like consistency with water visibly pooling in the corner of the pan. The potatoes were placed on the tray line and served to residents. This failure had the potential for resident choking, weight loss, and malnutrition due to residents not eating unpalatable mashed potatoes.Findings:During a concurrent observation and interview on 5/7/25 at 12:06 p.m. with the [NAME] (CK), in the facility's kitchen, a square metal pan of potatoes was placed on the tray line (an assembly line for food). The cook stated, . The potatoes are too runny, I can not tell my boss that he needs to make another batch of potatoes . I did not see anyone take the temperature . everyone was in a rush because we ran out of polenta . The cook continued to place the watery potatoes onto the plates, the potatoes spread to cover half the plate when placed on the plate.During an interview on 5/7/26 at 2:40 p.m. with Resident 130, in Resident 130's room. Resident 130 stated she did not eat the potatoes, the carrots, or the pork on her lunch tray. Resident 130 said the potatoes were runny, and she did not care for the taste of the carrots or the pork. Resident 130 stated she ate ice cream for her lunch. During a review of Resident 130's admission Record (AR), dated 5/8/26, the AR indicated Resident 130 was admitted on [DATE] from an acute care hospital with diagnosis of history of Cerebral Infarction (a type of [ischemic stroke] where a blockage in an artery interrupts blood flow to the brain, causing brain tissue to die from lack of oxygen and nutrients), Diabetes Mellitus (DM - a condition where your body either stops responding to insulin or doesn't make enough of it), and need for assistance with personal care.During a review of Resident 130's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/1/26, the MDS section C indicated Resident 130 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 05 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 130 had severe cognitive impairment.During an interview on 3/7/26 at 3:10 pm with Resident 43 in Resident 43's room. Resident 43 stated, he could not eat the food that was served to him for lunch it looked like runny dog food and called his wife to bring him food. Resident 43 stated he would talk to the Kitchen Manager when he comes to his room. During a record review of Resident 43's AR dated 5/8/26, the AR indicated Resident 43 was admitted to the facility on [DATE] with diagnosis of Quadriplegia (the partial or total paralysis of all four limbs and the torso, typically caused by a spinal cord injury or disease in the neck [cervical spine]), pressure ulcer (PU - damage to the skin and underlying tissue caused by constant, prolonged pressure on a specific area of the body) to right hip, right heel, left heel, and sacral (the area of your lower back, right between your hips and just above your tailbone) and protein calorie malnutrition.During a review of Resident 43's MDS section C dated 4/23/26 indicated Resident 43 had a BIMS score of 13 which indicated Resident 43 was cognitively intact.During an interview on 3/7/26 at 3:30 p.m. with Resident 126 in Resident 126's room. Resident stated the food often served to her was cold, the texture was too watered down, and the food was strange. 43 residents stated she hoped with the new kitchen manager there would be changes, but the lunch was horrible. She stopped complaining because she felt no one would listen to her.During a review of Resident 126's MDS section C dated 4/8/26 indicated Resident 126 had a BIMS score of 13 which indicated Resident 126 was cognitively intact.During a record review of Resident 126's AR dated 5/8/26, the AR indicated Resident 126 was admitted to the facility on [DATE] with diagnosis of Quadriplegia, DM, and depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities you usually enjoy).During an interview on 5/7/26 at 4:06 p.m. with the Regional Certified Dietary Manager (RCDM), in the facility's kitchen, the RCDM stated there was not enough polenta to finish serving the residents. The RCDM stated mashed potatoes were an acceptable replacement and the Certified Dietary Manager (CDM) made mashed potatoes and placed them on the tray line. The RCDM stated the staff did not take the temperature of the potatoes before serving the residents and the texture and consistency was not acceptable. RCDM stated the potatoes should not have been served to the residents with the thin watery texture. Having thin consistency could cause choking, weight loss and malnutritionDuring an interview on 5/7/26 at 4:30 p.m. with the CDM, the CDM stated he should not have placed the potatoes on the tray line to be served to the residents. The potatoes were runny, and he had forgotten to take the temperature prior to placing on the tray line. The CDM stated all food needed to have the temperature checked prior to placing it on the tray line. CDM stated if the food was not at the correct temperature, it provided an opportunity for bacteria to grow. Having the food at the wrong consistency or texture could cause a choking hazard to the residents.During a review of the Good for Your Health Menus dated 5/7/26, the Good for your Health Menus indicated, the lunch menu for 5/7/26 was Hawaiian Pork, Polenta, Ginger Carrots, Wheat Roll and Ice Cream.During a review of the facility's policy and procedure (P&P) titled, DD05 Dining Program dated 2/20/25, P&P indicated, . Dining program is a service organized, staffed and equipped to assure that food service to residents is safe, appetizing and provides for their nutritional needs .

Based on observation, interview, and record review, the facility failed to ensure the safe storage, supervision, and control of smoking materials for one of five sampled residents (Resident 37) when Resident 37 had a box of cigarettes with cigarettes inside placed on top of Resident 37's nightstand, accessible without staff knowledge or supervision.This failure had the potential to result in significant safety hazards, including unsupervised smoking, burn injuries, accidental fires, flash fires if smoking materials were used near oxygen equipment, and access to cigarettes by other residents.During a concurrent observation and interview on 5/5/2026 at 9:59 a.m. with Resident 37 in Resident 37's room, Resident 37 was observed lying in bed with a box of cigarettes with cigarettes inside, placed on top of Resident 37's nightstand. Resident 37 stated staff was unaware that the cigarette box was in his room.During a concurrent observation and interview on 5/7/2026 at 1:17 p.m. with Resident 37 in Resident 37's room, Resident 37 was observed sitting in his wheelchair (WC) in his room with a box of cigarettes with cigarettes inside, placed on top of Resident 37's nightstand. Resident 37 stated he goes on a smoke break with staff supervision and has always kept his cigarettes at bedside. Resident 37 stated the nurses provide lighter when he needs to smoke and stated he used to have a lighter in his room, but he misplaced it.During a review of Resident 37's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/26, the AR indicated Resident 37 was admitted to the facility on [DATE] with diagnoses of dysarthria ( a motor speech disorder characterized by slurred, slow, or difficult-to-understand speech) following cerebral infarction ( when a portion of the brain dies because it isn't receiving enough blood), type 2 diabetes mellitus with other specified complications (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), other asthma ( a long-term lung condition that makes it difficult to breathe), muscle weakness-generalized, nicotine dependence-cigarettes-uncomplicated, extrapyramidal (uncontrollable, involuntary movements that occur as a side effect of certain medications) and movement disorder-unspecified, and paranoid schizophrenia (a chronic mental health condition where a person loses touch with reality through intense, irrational distrust).During a review of Resident 37's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/13/26, the MDS section C indicated Resident 37 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 07 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 37 had severe cognitive impairment.During an interview on 5/7/2026 at 4:15 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated residents are not allowed to smoke inside the building only outside. CNA 5 stated cigarettes and lighters were stored by the nurses and given to residents when requested. CNA 5 stated it was important for the nurse to store cigarettes and lighters for precaution and for resident safety. CNA 5 stated cigarettes being stored on top of Resident 37's nightstand were accessible to any resident and for safety reasons, the cigarettes should not have been in Resident 37's room. CNA 5 stated CNA's were to report to the nurses if they observed cigarettes in resident rooms. During a concurrent observation and interview on 5/7/2026 at 1:21 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 37's room, LVN 1 stated the process for residents who smoked was that nurses kept the cigarettes and lighters in the medication room. LVN 1 observed Resident 37's nightstand and stated there was a cigarette box with cigarettes inside the box. LVN 1 stated Resident 37's room was not a safe place to store the cigarettes and cigarettes should have been kept at the nurses' station in the medication room for safety reasons because it could cause a fire and it was a safety hazard for other residents. During an interview on 5/8/2026 at 4:55 p.m. with the Director of Nursing (DON), the DON stated her expectations were that residents' cigarettes be kept by nurses at the nursing station. The DON stated residents should not have their own cigarettes at bedside to prevent injury and potential smoking in the room for safety reasons. The DON stated cigarettes on a resident's nightstand, was a safety concern for that resident as well as other residents that could gain access to the cigarettes. The DON stated Resident 37's nightstand was not a safe place to store cigarettes.During a review of the facility's policy and procedure (P&P) titled, Smoking Residents, dated 8/18/23, the P&P indicated, .Smoking by residents is allowed outside the facility in designated, marked smoking areas.The IDT will develop an individualized plan of care for safe storage, use of smoking materials.for residents who smoke.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of 13 sampled residents (Resident 5 and Resident 125) when:1. License Nurses (LN)s did not develop a detailed and person-centered care plan for Resident 5's pain. 2. LNs did not develop a care plan for Resident 125 indicating family preferences to not having the bedside table within reach due to safety concerns.These failures created the risk of inadequate care, potentially compromising Resident 5 and Resident125's safety and negatively affecting the overall quality of care and services provided.Findings:1. During a concurrent observation and interview on 5/5/25 at 3:50 p.m. with Resident 5 in Resident 5's room, Resident 5 was sitting in his wheelchair looking out the window. During a review of Resident 5's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/26, the AR indicated Resident 5 admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus Type II (chronic condition where the body cannot effectively use insulin (insulin resistance) or make enough of it, causing sugar (glucose) to build up in the blood instead of powering cells), Malignant neoplasm of the bone (an abnormal, uncontrolled growth of cells that forms a lump or tumor. Unlike harmless (benign) growths, malignant cells are aggressive-they can destroy healthy nearby tissue and spread to other parts of the body), generalized Osteo Arthritis (is a condition that cause an inflammation, pain, stiffness, and swelling in one or more joints), and depression (a common, serious mental health condition characterized by persistent sadness, low mood, and a loss of interest in activities that lasts for at least two weeks).During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/25/26, the MDS section C indicated Resident 5 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 5 was cognitively intact.During a concurrent interview and record review on 5/7/26 at 2:20 p.m. with Licensed Vocational Nurse (LVN) 5, Resident 5's Care Plan (CP) dated 5/7/26 was reviewed. The CP indicated that a person centered, detailed CP for the resident's pain medication was not created. LVN 5 stated, . a specific care plan for the resident's pain medication was not present, the generic pain medication care plan in the resident's chart does not indicate which medication to give when the resident was experiencing 7 out of 10 pain. It is important for the medication that is to be given be clearly indicated in the care plan to prevent the wrong medication from being given and possibly delaying the pain relief for the resident .During a concurrent interview and record review on 5/8/26 at 4:45 p.m. with the Director of Nursing (DON), Resident 5's CP dated 5/7/26 was reviewed. The CP indicated that a person centered, detailed CP for the resident's pain medication was not created. The DON stated it was her expectation for the resident's pain medication to be Care Planned. If a care plan is not created, the staff will not know how to effectively treat the resident.During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 4/24/25, the P&P indicated, .the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what is important to each resident with regard to daily routines and preferred activities.The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights.The comprehensive care plan must describe.services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.Any services that would otherwise be required under, but are not provided due to resident's exercise of rights, including the right to refuse treatment.2. During a concurrent observation and interview on 5/5/2026 at 9:55 a.m. with Resident 125 in Resident 125's room, Resident 125 was observed lying in bed with bedside table and water pitcher off to the side and not within Resident 125's reach. Resident stated she could not get out of bed independently and was not able to reach her water.During a review of Resident 125's AR dated 5/8/26, the AR indicated Resident 125 was admitted to the facility on [DATE] with diagnoses of central cord syndrome at unspecified level of cervical spinal cord (an incomplete neck spinal cord injury where the middle part of the cord is damaged), Alzheimer's disease unspecified (progressive brain disorder), encephalopathy (any disease, damage, or malfunction that causes the brain to stop working properly), muscle weakness, unspecified protein-calorie malnutrition (lack of both protein and total calories-the exact severity or specific cause not fully documented), and major depressive disorder.During a review of Resident 125's MDS dated 3/6/26, the MDS section C indicated Resident 125 had a BIMS score of 05 which indicated Resident 125 had severe cognitive impairment.During a concurrent observation and interview on 5/7/2026 at 3:37 p.m. with Certified Nursing Assistant (CNA) 5 in Resident 125's room, CNA 5 stated Resident 125 was able to follow simple commands, use pad-call light if needed, and was able to grab a cup with water in it and drink it independently if it was within reach. CNA 5 stated bedside table with water was not within reach. CNA 5 stated Resident 125 should have had bedside table with water within reach. CNA 5 stated all residents should have water within reach to drink when they are thirsty. CNA 5 stated Resident 125 swings her arms a lot and for safety concerns of items easily falling on her if resident 125 were to swing her arms, the bedside table was not within reach.During a concurrent observation and interview on 5/7/2026 at 3:47 p.m. with LVN 1 in Resident 125's room, LVN 1 stated bedside table was not within Resident 125's reach per family request. LVN 1 stated Resident 125 had frequent jerking/movement of arms and family requested for bedside table to be off to the side for safety concerns regarding the bedside table and items falling on top of the resident if she were to swing her arms. LVN 1 stated family is at the facility almost daily and voiced concerns about the bedside table and items falling on top of the resident due to Resident 125's frequent arm movements/swinging. LVN 1 stated the family verbally communicated to staff they did not want bedside table over the bed where Resident 125 could possibly get injured.During a concurrent interview and record review on 5/7/26 at 4:26 p.m. with LVN 1, LVN 1 stated communication with the family regarding the request to not have bedside table within Resident 125's reach for safety concerns, was a verbal and informal request and stated he was unable to locate a care plan that reflected families request and current services being provided to ensure resident received fluid intake. LVN 1 stated resident care plans should always be updated to reflect residents' needs.During an interview on 5/8/26 at 5:00 p.m. with the DON, the DON stated it was her expectation that the CPs be updated as needed whenever there is a change and stated CP should be centered to reflect individual resident needs, change of conditions, and preferences Including those preferences expressed by family. The DON stated the CP should have been updated at the time the family had the communication with the nurse regarding the bedside table being out of reach and stated the nurse should have care planned the preference at that time. The DON stated the care plan was not updated at the time and should have been. The DON stated it was important for CP to be updated so nurses know what the plan of care is, to provide proper care to residents, and to honor residents' wishes and preferences.During a concurrent interview and record review on 5/8/26 at 5:04 p.m. with the DON, the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 4/24/25 was reviewed. The DON stated the facility's P&P was not followed if a care plan was not implemented to reflect Resident 125's current preferences.During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 4/24/25, the P&P indicated, .the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what is important to each resident with regard to daily routines and preferred activities.The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights.The comprehensive care plan must describe.services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.Any services that would otherwise be required under, but are not provided due to resident's exercise of rights, including the right to refuse treatment.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, homelike environment for two of nine sampled residents (Resident 11 and Resident 69) when:1. Resident 11's bedside table had the plastic strip pulled away from the edge of the table with jagged rough edges on the bedside table.2. Resident 69's overhead bed light did not have a string attached that allowed Resident 69 to turn the light on and off.These failures had the potential to create a non-homelike environment for Resident 11 and Resident 69 and placed Resident 11 and Resident 69 at risk of injury and harm.Findings:1. During a concurrent observation and interview on 5/5/2026 at 9:52 a.m. with Resident 11 in Resident 11's room, Resident 11 was observed dressed, standing by her wheelchair. Resident 11 stated she had been at the facility since February 2026 due to having a stroke (cerebral infarction - damage to tissues in the brain due to a loss of oxygen to the area). Resident's bedside table observed with the side strip coming off the edge of the table with jagged, rough edges.During a review of Resident 11's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/26, the AR indicated Resident 11 was admitted to the facility from an acute care hospital on 2/12/26 with diagnoses of intracerebral hemorrhage (bleeding in the brain caused by a ruptured blood vessel), dysphagia (difficulty swallowing), hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting left non-dominant side, morbid severe obesity (a serious health condition that results from an abnormally high body mass) due to excess calories, encephalopathy (damage or disease that affects the brain), abnormalities of gait (walking) and mobility (movement), and muscle weakness.During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/19/26, the MDS section C indicated Resident 11 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 11 was cognitively intact.During a concurrent observation and interview on 5/7/2026 at 11:15 a.m. with Certified Nursing Assistant (CNA) 1, in Resident 11's room, Resident 11's broken bedside table was observed. CNA 1 stated Resident 11's bed side table had the siding coming off and the wood was chipped by the edge. CNA 1 stated Resident 11 could get hurt or pinched by the broken bedside table. CNA 1 stated a broken table was not a homelike environment for Resident 11. CNA 1 stated staff informed maintenance through an electronic system and a maintenance binder if something needed repair.During an interview on 5/8/26 at 9:19 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents notified staff, or staff informed the nurses if something was broken and needed repair. LVN 1 stated there was a binder at the nurses' station where staff entered repair requests. LVN 1 stated staff also entered repair requests into an electronic system or notified the maintenance department verbally.During an interview on 5/8/26 at 10:39 a.m. with the Maintenance Director (MAIND), the MAIND stated it was important for Maintenance to know if repairs were needed. The MAIND stated staff logged requests into a binder and through the computer. The MAIND stated the department managers inspected resident rooms during their rounds, and the MAIND stated he depended on staff to inform him and his department if repairs were needed. The MAIND stated Resident 11's broken table was a risk for Resident 11 to sustain an injury and needed to be repaired for her safety. The MAIND stated Resident 11's broken table did not create a homelike environment for Resident 11.During an interview on 5/8/26 at 5:18 p.m. with the Director of Nursing (DON), the DON stated any staff member should have informed Maintenance if something needed to be repaired. The DON stated her expectation was to replace Resident 11's broken table. The DON stated a broken table was a safety risk to Resident 11 and was not a homelike environment.2. During a concurrent observation and interview on 5/5/2026 at 9:14 a.m. with Resident 69 in Resident 69's room, Resident 69 was observed dressed, lying in bed. Resident 69 stated she had been at the facility since January 2026 due to a bad fall. Resident 69 stated her right arm was weak and she was unable to move her right leg. Resident 69 stated she had physical therapy and could do some things on her own but needed assistance. Resident 69 stated her light above her bed did not have a string for her to turn the light on and off. Resident 69 stated she needed a CNA or staff to turn her overhead bed light on and off.During a review of Resident 69's AR, dated 5/8/26, the AR indicated Resident 69 was admitted to the facility from an acute care hospital on 1/26/26 with diagnoses of fall from or off toilet with subsequent striking against an object, abnormalities of gait (walking) or mobility (movement), dysphagia (difficulty swallowing), peripheral vascular disease (the reduced circulation of blood to the arms or legs), peripheral autonomic neuropathy (damage to nerves that manage normally automatic body functions), morbid obesity (a serious health condition that results from an abnormally high body mass) due to excess calories, muscle weakness, and need for assistance with personal care.During a review of Resident 69's MDS, dated [DATE], the MDS section C indicated Resident 69 had a BIMS score of 14, which indicated Resident 69 was cognitively intact.During a review of Resident 69's MDS, dated 2/2/26, section GG (Functional Abilities) indicated, Resident 69 had impairment (diminishment or loss of function or ability) in the right and left upper extremities (shoulder, elbow, wrist, hand) and impairment on right and left lower extremities (hip, knee, ankle, foot). Section GG indicated, .substantial/maximal assistance - helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.oral hygiene.dependent - helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.shower/bathe self.upper body dressing.lower body dressing.putting on/taking off footwear.personal hygiene: the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands.roll left and right.sit to lying.lying to sitting on side of bed.tub/shower transfer: the ability to get in and out of a tub/shower.During a concurrent observation and interview on 5/07/2026 at 11:15 a.m. with CNA 1 in Resident 69's room, Resident 69's overhead bed light was observed without a pull string for Resident 69 to turn her light on and off. CNA 1 stated Resident 69 should have an overhead bed light. CNA 1 stated if Resident 69 was unable to turn her overhead bed light on, she called the CNA to turn it on for her. CNA 1 stated calling for assistance was difficult for Resident 69 since her call light was broken.CNA 1 stated if repairs were needed, staff informed maintenance through an electronic system or a Maintenance log in a binder at the nurses' station.Durning a concurrent interview and record review on 5/8/26 at 9:24 a.m. with LVN 1 at the nurses' station, the Maintenance binder was reviewed. The Maintenance binder log indicated there was no documentation of repairs needed for Resident 69's room. LVN 1 stated Resident's notified staff if something was not working or needed repair, and staff notified the nurses. LVN 1 stated staff notified the Maintenance department of needed repairs by logging requests into the maintenance binder, or staff notified the Maintenance department verbally. LVN 1 stated Resident 69 should have been able to turn her light on and off for Resident 69's safety and for her needs.During an interview on 5/8/26 at 10:39 a.m. with the Maintenance Director (MAIND), the MAIND stated it was important for Maintenance to know if repairs were needed. The MAIND stated staff logged requests into a binder and through the computer. The MAIND stated the department managers inspected residents' rooms. The MAIND stated he depended on staff to inform him and his department if repairs were needed. The MAIND stated Resident 69 should have been able to turn her overhead bed lights on and off. The MAIND stated Resident 69's room was not a homelike environment.During an interview on 5/8/26 at 5:18 p.m. with the DON, the DON stated her expectation was for Resident 69's overhead bed light should have had a string allowing Resident 69 to turn her light on and off and not have to ask staff to do it for her. The DON stated Resident 69's room was not a homelike environment. The DON stated any staff member should have been informing Maintenance of repairs.During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, dated 1/1/2012, the P&P indicated, .The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following.lighting that is comfortable [minimum glare] yet adequate.personalized furniture.Facility Staff work to minimize.the characteristics of the Facility that reflect a depersonalized, institutional setting.generic, mas produced bedding, drapes and furniture.the Facility provides comfortable and adequate lighting throughout the Facility to promote a safe, comfortable and homelike environment.During a review of the facility's P&P titled, Maintenance - Work Orders, dated 1/1/2012, the P&P indicated, .to protect the health and safety of residents, visitors, and Facility Staff.maintenance work orders shall be completed in an effort to sustain maintenance services as a priority.department directors/supervisors are responsible for completing such work orders and forwarding them to the Director of Maintenance.a supply of workorder forms is maintained at each nurses' station.work order requests are to be placed in a designated location at the nurses' station.work orders are picked up daily by Maintenance Staff.emergency requests are given priority.emergency requests should be delivered directly to the Director of Maintenance.the director of Maintenance will maintain completed Work Orders chronologically in a binder in the Director of Maintenance's office.

Based on observation, interview, and record review, the facility failed to ensure two of 14 residents (Resident 69 and Resident 93) had the ability to call for staff assistance through the call system (a communication system which relays the call directly to a staff member or to a centralized staff work area) when:1. Resident 69's call system was not working.2. Resident 93 was unable to reach her call button to access the call system while in their bed. These failures had the potential for Resident 69 and Resident 93 to not receive assistance or help from staff when needed and put Resident 69 and Resident 93 at risk of injury, harm and not having their needs met.Findings: 1. During a concurrent observation and interview on 5/5/2026 at 9:14 a.m. with Resident 69 in Resident 69's room, Resident 69 was observed dressed, lying in bed. Resident 69 stated she had been at the facility since January 2026 due to a bad fall. Resident 69 stated her right arm was weak and she was unable to move her right leg. Resident 69 stated she had physical therapy and could do some things on her own but needed assistance. Resident 69 stated it could take a while to get help since her call light did not work. Resident 69 stated she already pressed the call button and was waiting for assistance. Observed a red light lit on the wall with the outside light above the door not lit up. During a review of Resident 69's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/26, the AR indicated Resident 69 was admitted to the facility from an acute care hospital on 1/26/26 with diagnoses of fall from or off toilet with subsequent striking against an object, abnormalities of gait (walking) or mobility (movement), dysphagia (difficulty swallowing), peripheral vascular disease (the reduced circulation of blood to the arms or legs), peripheral autonomic neuropathy (damage to nerves that manage normally automatic body functions), morbid obesity (a serious health condition that results from an abnormally high body mass) due to excess calories, muscle weakness, and need for assistance with personal care. During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/2/26, the MDS section C indicated Resident 69 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 69 was cognitively intact. During a review of Resident 69's MDS, dated 2/2/26, section GG (Functional Abilities) indicated, Resident 69 had impairment (diminishment or loss of function or ability) in the right and left upper extremities (shoulder, elbow, wrist, hand) and impairment on right and left lower extremities (hip, knee, ankle, foot). Section GG indicated, .substantial/maximal assistance – helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.oral hygiene.dependent – helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.shower/bathe self.upper body dressing.lower body dressing.putting on/taking off footwear.personal hygiene: the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands.roll left and right.sit to lying.lying to sitting on side of bed.tub/shower transfer: the ability to get in and out of a tub/shower. During a review of Resident 69's Care Plan Report (CP), undated, the CP indicated, .the resident is [high] risk for falls related to [r/t] history of [h/o] fall, muscle weakness, gait/balance problems. date initiated: 1/27/2026.be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.date initiated: 1/27/2026. During an interview on 5/07/2026 at 11:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the CNAs received report from the night shift if a resident was totally dependent and needed assistance. CNA 1 stated if she saw a resident struggling, she helped them. CNA 1 stated if a resident needed assistance with repositioning, she checked on them every hour. CNA 1 stated she was aware of Resident 69's call light not working, and if Resident 69 needed assistance, her roommate pressed her call light to notify staff Resident 69 needed assistance. CNA 1 stated staff informed maintenance through an electronic system and a maintenance binder if something needed repair. During an interview on 5/8/26 at 9:24 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents notified staff if their call lights were not working, or staff informed the nurse. LVN 1 stated there was a maintenance binder the staff wrote in if something needed to be fixed, an electronic system they could put a request in, or verbally informed maintenance of repairs. LVN 1 stated there was a monitor at the nurses' station that lit up if a call light was pressed, but no noise was made from the monitor to alert staff of a resident requesting assistance. LVN 1 stated the call light was used for residents to ask for help, for staff requesting assistance to change the resident, for staff to report a change in resident's condition, and for resident safety such as a resident about to fall. LVN 1 stated Resident 69 should have had a functioning call light for the residents' safety and the residents' needs. LVN 1 stated residents should have some way of notifying staff of their needs. During a concurrent interview and record review on 5/8/26 at 10:39 a.m. with the Maintenance Director (MAIND), the MAIND stated he was not aware Resident 69's call light was not working. The MAIND stated staff used an electronic system to inform him if anything needed repair. The MAIND reviewed the electronic system log of repairs and stated there was no documentation of Resident 69's broken call light system, or that it was repaired. The MAIND stated the call light was for resident communication with staff, for concerns, if they needed something such as water, or were unable to stand and needed assistance to get up. The MAIND stated the facility had a no pass rule which indicated if a resident's call light was on, staff needed to go into the room, even if it was not their assigned area, to check on the residents. The MAIND stated the call light system was important for the residents and it was important for maintenance to be informed if it was broken and needed to be repaired. During an interview on 5/8/26 at 5:18 p.m. with the Director of Nursing (DON), the DON stated her expectation was for resident's call light system to be working. The DON stated if a resident's call light was not working, the facility provided a bell for the resident to ring when they needed assistance. The DON stated it was important for residents to have a way to call staff when they needed assistance or to communicate any needs. The DON stated any staff member could inform maintenance of repairs that were needed. During a review of the facility's policy and procedure (P&P) titled, Communication-Call System, dated 8/24/2024, the P&P indicated, .The facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities.to ensure that residents have a means of contacting facility staff for assistance.facility staff will answer call alerts promptly and in a courteous manner.if the call alert system is defective, it will be reported to maintenance for immediate repair, if the call system cannot be repaired immediately, an alternative call alert process will be put in place [i.e., tap bells, auxiliary aids, etc.]. During a review of the facility's P&P titled, Maintenance – Work Orders, dated1/1/2012, the P&P indicated, .To protect the health and safety of residents, visitors, and Facility Staff.maintenance work orders shall be completed in an effort to sustain maintenance services as a priority.department directors/supervisors are responsible for completing such work orders ad forwarding them to the Director of Maintenance.a supply of workorder forms is maintained at each nurses' station.work order requests are to be placed in a designated location at the nurses' station.work orders are picked up daily by Maintenance Staff.emergency requests are given priority.emergency requests should be delivered directly to the Director of Maintenance.the director of Maintenance will maintain completed Work Orders chronologically in a binder in the Director of Maintenance's office. 2. During a concurrent observation and interview on 5/5/2026 at 9:43 a.m. with Resident 93 in Resident 93's room, Resident 93 was observed lying in bed with call light on the floor and unable to reach or push the call light. Resident stated she was unable to reach her call light. Call light was observed clipped to the head of the bed and dangling under the bed mattress and on the floor. During a review of Resident 93's AR, dated 5/8/26, the AR indicated Resident 93 was admitted to the facility on [DATE] with diagnoses of unspecified combined systolic (congestive) and diastolic (congestive) heart failure (when the heart cannot pump blood efficiently [systolic] and cannot fill with enough blood between beats [diastolic]), unspecified atrial fibrillation (an irregular heart beat), hemiplegia (complete inability to move) and hemiparesis ( partial weakness or reduced strength on one side) following unspecified cerebrovascular disease (a group of conditions that disrupt blood flow to the brain starving brain cells of oxygen and nutrients) affecting unspecified side, and muscle wasting and atrophy ( the loss of muscle tissue causing muscles to become smaller, thinner, and weaker) not elsewhere classified-unspecified site. During a review of Resident 93's MDS, dated 2/25/26, the MDS section C indicated Resident 93 had a BIMS score of 8 , which indicated Resident 93 was moderately impaired. During a concurrent observation and interview on 5/5/2026 at 9:50 a.m. with the Nurse Consultant (NC) in Resident 93's room, The NC stated the call light was on the floor and not within Resident 93's reach. The NC asked Resident 93 if she needed help, and Resident 93 stated she needed to get changed. During a concurrent observation and interview on 5/08/2026 at 3:25 p.m. with CNA 6, outside of Resident 93's room, CNA 6 stated resident 93's call light was not within reach and should have been so that resident 93 could call staff if she needed assistance, she needed to be changed, or in case something fell and they needed help etc. CNA 6 stated call light should also be within resident reach for resident safety and communication between the resident and staff. During a concurrent observation and interview on 5/08/2026 at 3:31 p.m. with LVN 1, outside of Resident 93's room, LVN 1 stated residents' call lights should always be within reach and staff should ensure the call light is clipped in order for it to stay within reach and ensure that the call light is functional for resident safety. LVN 1 stated resident 93's call light was clipped onto the bed, was on the floor and not within resident 93's reach. LVN 1 stated it was important for the call light to be within resident 93's reach so that resident 93 could call for assistance if she needed it and for safety reasons. LVN 1 stated call light should be within reach so that residents could communicate and express their needs and wants. During an interview on 5/08/2026 at 5:05 p.m. with the DON, The DON stated her expectation was that call lights should be clipped (call light clip is used to keep call light within reach) and within residents reach so that residents could call for assistance. The DON stated it was important for the call light to be within resident reach so that residents could communicate their needs and wants. DON stated call light should always be within residents reach for safety. During a review of the facility's P&P titled, Communication-Call System, dated 8/24/2024, the P&P indicated, .The facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities.to ensure that residents have a means of contacting facility staff for assistance.The call alert device will be placed within the resident's reach.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to help prevent the development and transmission of infections for four of 14 sampled residents (Resident 58, Resident 17, Resident 31, and Resident 59) when:1. Resident 58's foley catheter drainage tubing (a tube that is inserted into the urinary bladder to collect urine into a bag) was touching the floor and Resident 58's urine drainage bag (a bag that collects urine from a urinary catheter) was on the floor.2. The connector end of the feeding bag tubing for Resident 17 was left open to air and did not have a tube cover cap.3. The appropriate Personal Protective Equipment (PPE) was not worn during care for Resident 31 who was on contact precaution.4. Resident 59's Peripherally Inserted Central Catheter (PICC line, tube inserted into a vein for medications, fluids, or nutrition to be delivered over weeks or months) dressing change was not completed within 7 days according to physician orders. This failure placed Resident 58, Resident 17, Resident 31, and Resident 59 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).Findings: 1. During a concurrent observation and interview on 5/05/2026 at 3:57 p.m. with Resident 58, in Resident 58's room, Resident 58 was observed wearing a gown in bed. Resident 58 stated she was not feeling well since yesterday, and today she felt worse with a fever. Resident 58's urinary catheter bag and tubing were observed on the floor on the right side of Resident 58's bed. During a review of resident 58's admission Record (AR - a summary of information regarding a patient), dated 5/8/26, the AR indicated Resident 58 was initially admitted to the facility from an acute care hospital on 7/27/21 and readmitted on [DATE] with diagnoses of traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of muscles or the right forearm (the part of the arm extending from the elbow to the wrist) and left forearm, contracture of right hand and left hand, contracture of muscles of the right lower leg and left lower leg, quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), obstructive and reflux uropathy (when urine cannot drain and backs up into the kidney), resistance to vancomycin (a medication used to treat bacterial infections), and artificial openings of the urinary tract (the organs that make urine and remove it from the body). During a review of Resident 58's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/16/26, the MDS section C indicated Resident 58 had a Brief Interview for Mental Status (BIMS, a test given to determine thinking, learning, and understanding), score of four (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 58 was severely cognitively impaired. During an interview on 5/07/2026 at 11:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 58's urinary catheter tubing and bag should not have touched or been on the floor. CNA 1 stated Resident 58's drainage bag should have been inside a dignity bag (a cover that conceals urinary drainage bags from public view to protect a resident's dignity) and the dignity bag should have been tied to the bed and off the floor. CNA 1 stated Resident 58's urinary catheter tubing should not have been on the floor. CNA 1 stated if the urinary drainage bag and drainage tubing were on the floor, it could have caused cross-contamination from the floor. CNA 1 stated the ground was dirty and Resident 58 could get an infection. During a concurrent interview and record review on 5/8/26 at 8:50 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 58's Order Summary Report (OSR), dated 5/8/26 was reviewed. The OSR indicated, .Levofloxacin tablet 500 milligrams (MG) give 1 tablet by mouth .for urinary tract infection (UTI).order date.05/07/2026. LVN 1 stated Resident 58's urinary catheter should not have been on the floor, it should have been hung on the bed railing off the floor for infection control. LVN 1 stated Resident 58's urine was observed to be cloudy on 5/5/26 and Resident 58 was started on an antibiotic yesterday for a UTI. LVN 1 stated his expectation was for the CNAs to drain the urinary drainage bag and place the bag and tubing back in the dignity bag and hang it on the bed rail. During an interview on 5/8/26 at 10:58 p.m. with the Infection Preventionist (IP), the IP stated residents' catheter tubing and bag should not be on the floor as there was a risk of cross contamination and infection to residents. During an interview on 5/8/26 at 5:18 p.m. with the Director of Nursing (DON), the DON stated her expectation was for residents' urinary catheter tubing and drainage bag to not touch the floor. The DON stated there was a risk of infection for the residents if the catheter tubing and bag were on the floor. The DON stated her expectation was for CNAs to put the drainage tubing and drainage bag inside the dignity bag and put the bags up off the floor after the CNAs completed draining the bag of urine. During a review of the facility's P&P titled, Infection Control – Policies & Procedures, dated 1/1/2012, the P&P indicated, .to provide infection control policies and procedures required for a safe and sanitary environment.and to help prevent and manage transmission of diseases and infections.prevent, detect, investigate, and control infections in the facility.staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. During a review of the facility's policy and procedure (P&P) titled, Indwelling Catheter, dated 7/22/2025, the P&P indicated, .only properly trained licensed and care staff who know the correct technique of aseptic catheter insertion and maintenance will be responsible for the insertion and care of indwelling catheters. During a review of the facility's training plan (TP) titled, Catheter and Perineal Care, dated 2022, the TP indicated, .following proper perineal and catheter care procedures can prevent contamination that can lead to urinary tract infections.ensure that the catheter bag is secured to a non-movable part of a bed or chair, the tubing is not dragging on the floor.following correct procedures for peri care and catheter care can prevent infections. 2. During an observation on 5/6/26 at 9:44 a.m. in Resident 17's room, there was a feeding pump with feeding formula set up. The tubing was hanging on the feeding pump and the pole. The connector end of the feeding bag tubing for Resident 17 did not have a tube cover cap and was left open to air. During a review of Resident 17's AR, dated 5/8/26, the AR indicated, Resident 17, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included .dysphagia (difficulty or discomfort in swallowing), . During a review of Resident 17's MDS, dated [DATE], the MDS section C indicated Resident 17 had a BIMS score of 13 out of 15. The BIMS indicated Resident 17 was cognitively intact. During a review of Resident 17's OSR, the OSR indicated .Enteral Feed Order two times a day [named brand] feeding formula 1.8 at 85 mL (milliliter- unit of measure)/hour x 20 hours, = 1700 ml/24h 3060 calories (calorie- a unit of energy used to measure the amount of energy provided by food and drinks) /24h via g-tube for dx(diagnosis) of dysphagia . order start date 5/5/25. During an interview on 5/8/26 at 10:28 a.m. with Registered Nurse (RN) 1, RN 1 stated there should be a cap at the end of the feeding tube. RN 1 stated this was important because Resident 17 could get gastrointestinal infection (GI- an infection/inflammation of the stomach and intestines caused by viruses, bacteria, or parasites) During an interview on 5/8/26 at 1:46 p.m. with LVN 2, LVN 2 stated there should have been a cap or the end of the tubing should have been bagged to prevent getting the tube dirty. LVN 2 stated Resident 17 could get infection if the tubing was left open, LVN 2 stated the tubing should be replaced During an interview on 5/8/26 at 2:30 p.m. with the IP, the IP stated the tubing should have been capped to prevent infection. The IP stated Resident 17 could get GI infection. During an interview on 5/8/26 at 4:34 p.m. with the DON, the DON stated if feeding bag tubing is not connected to the resident it should be covered with a cap. The DON stated the expectation from the nurses was that the tube should be covered with a cap or the feeding bag should be discarded. The DON stated this was to prevent GI infection for Resident 17. 3. During an observation on 5/5/26 at 11:09 a.m. outside Resident 31's room, a contact precaution signage was posted on the wall outside Resident 31's room. CNA 3 was observed in Resident 31's room with no PPE gown on. CNA 3 packed dirty linen into a plastic bag, brought the bag outside the room and put the bag into the linen basket. CNA 3 went back into Resident 31's room then proceeded to wheel the shower gurney (shower stretcher- is a mobile, water-resistant device designed for transporting and bathing individuals with limited mobility who cannot sit upright) out of Resident 31's room into the hallway. While in the hallway, brown colored substances were noted on the shower gurney and water from the gurney was dripping onto the hallway floor. CNA 3 stated the brown substance was fecal matter, that Resident 31 had diarrhea. CNA 3 was observed using two medium sized towels to clean the water from the shower gurney on the hallway floor. CNA 3 cleaned the hallway floor in a continuous motion all the way back into Resident 31's room. CNA 3 stated Resident 31 had diarrhea. During a review of Resident 31's AR, dated 5/8/26, the AR indicated, Resident 31, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included .infection and inflammatory reaction due to cystostomy catheter (suprapubic catheter- a tube placed directly into the bladder through a small opening in the lower abdomen to drain urine), resistance to multiple antimicrobial drugs (germs such as bacteria, viruses, or fungi have developed the ability to survive and thrive despite being treated with several different types of medications), sepsis due to methicillin susceptible staphylococcus aureus (MSSA- a life-threatening, whole-body emergency caused by common staph bacteria entering the bloodstream), urinary tract infection (UTI-an infection caused by bacteria entering the urinary system [bladder, urethra, or kidneys], leading to inflammation and discomfort), unspecified Escherichia coli (E.coli- a type of bacteria found in the intestines of healthy humans which can cause food poisoning, diarrhea, or urinary tract infections), pseudomonas (aeruginosa) (mallei)(pseudomallei- a germ that can cause infections in the blood, lungs, or other parts of the body after surgery), gross hematuria (visible blood in the urine), bacteremia (bacteria in your blood), resistance to carbapenem (certain bacteria (germs) have developed the ability to survive and grow despite being treated with antibiotics), bed confinement status, presence of other vascular implants and grafts (surgically placed device or artificial material inside their blood vessels), . During a review of Resident 31's MDS, dated [DATE], the MDS section C indicated Resident 31 had a BIMS score of 5 out of 15. The BIMS indicated Resident 31 was severely cognitively impaired. During an interview on 5/5/26 at 3:26 p.m. with CNA 3, CNA 3 stated Resident 31 had a foley catheter and a PICC line. CNA 3 stated the expectation was to put on the PPE gown before entering Resident 31's room. CNA 3 stated she did not follow protocol when she did not put on the PPE. CNA 3 stated she should have cleaned the shower gurney with disinfected wipes inside the room and ensured there was no spillage from the shower gurney in the room all the way to the hallway /bathroom. CNA 3 stated this was basic infection control and could potentially spread around if the fecal matter had anything in it. CNA 3 stated it was important to follow contact precautions to ensure infection was not transferred to other residents. During an interview and record review on 5/5/26 at 3:30 p.m. with CNA 4, the contact precaution signage on the wall was reviewed. The signage indicated .put on gown before room entry, discard gown before room exit. CNA 4 stated she had missed putting on the gown. CNA 4 stated It was a quick thing I was trying to do by cleaning the floor from the hallway to Resident 31's room with two medium sized towels. CNA 4 stated it was important to follow the contact precaution instructions because it was for the safety of residents, staff and visitors. CNA 4 stated the potential outcome of not following the instruction could be coming in contact with disease, which could have infected other people. During an interview on 5/8/26 at 10:25 a.m. with RN 1, RN 1 stated when residents were on IV medications, they were placed on contact precautions. RN 1 stated the expectation was that facility staff should wear PPE before entering Resident 31's room and remove the PPE before exiting Resident 31's room. The IP stated it was for infection control. RN 1 stated the infection could spread to other residents During an interview on 5/8/26 at 1:44 p.m. with the LVN 2, LVN 2 stated when residents were on contact precaution, the facility staff should put on the PPE to prevent cross contamination and spread of infection During an interview on 5/8/26 at 2:25 p.m. with the IP, the IP stated the expectation on contact precaution would be all facility staff perform hand hygiene, wearing gown and gloves upon entering the room, dispose gown and gloves properly and hand hygiene upon exit. The IP stated Resident 31 had MSSA bacteremia, had suprapubic catheter, that was why he was on contact precaution. The IP stated she expected the CNAs to wear their PPE and notify environmental services team to disinfect everything. The IP stated this failure could cause cross contamination During an interview on 5/8/26 at 4:29 p.m. with the DON, the DON stated she expected facility staff to wear the proper PPE for contact isolation room. The DON stated CNA 4 should not have wiped the fecal matter in the hallway but should have contacted housekeeping to disinfect the flooring to prevent the spread of infection. The DON stated this was important to prevent spread of infection to residents and staff During a review of the facility's P&P titled, Resident Isolation- Initiating Transmission- Based Precaution dated 4/22/2016, the P&P indicated, .V. When transmission-based precautions are implemented, the Infection Control Coordinator (or designee): A. Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; B. Posts the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel are aware of precautions, or aware that they must first see a nurse to obtain additional information about the situation before entering the room. C. Ensures that an appropriate linen barrel/hamper and waste container with a liner, is placed within reasonable distance of the resident's room; D. Places necessary treatment equipment and supplies in the room that are needed during the period of transmission-based precautions; E. Ensures there is an adequate supply of antiseptic soap and paper towels maintained in the room during the isolation period; . 4. During a concurrent observation and interview on 5/5/26 at 10:52 a.m. in Resident 59's room, Resident 59 stated she had a PICC line on her right upper extremity (RUE). The PICC line was observed to be dated 4/27/26. Resident 59 stated she was informed by hospital nurses that the PICC line dressing should be changed every seven days. Resident 59 stated the dressing was changed in the hospital on 4/14/26 and she was discharged from the hospital on 4/16/26. Resident 59 stated she was concerned the PICC line would get infected because since she came to the facility the dressing was not changed as expected. Resident 59 stated the PICC line dressing was changed by the nurses only once on 4/27/26 since she was admitted to the facility on [DATE]. During a review of Resident 59's AR, dated 5/8/26, the AR indicated, Resident 59, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included .methicillin resistant staphylococcus aureus infection (MRSA infection- caused by a type of staph bacteria that become resistant to many of the antibiotics used to treat ordinary staph infections), infection of amputation stump, left lower extremity, . During a review of Resident 59's MDS, dated [DATE], the MDS section C indicated Resident 59 had a BIMS score of 14 out of 15. The BIMS indicated Resident 59 was cognitively intact. During a review of Resident 59's OSR, the OSR indicated .Change dressing and cap to PICC line to right upper arm every Sunday noc (Night) shift as needed (PRN) for PICC Care. order start date 4/16/26. Change dressing and cap to PICC line to right upper arm every Sunday noc shift every day shift every 7day(s). order start date 4/16/26. During a concurrent interview and record review on 5/8/26 at 10:43 a.m. with RN 1, Resident 59's Treatment Administration Record (TAR) was reviewed, the TAR indicated Resident 59 had orders for PICC line dressing once a week every sun and PRN dated 4/16/26. RN 1 stated the TAR indicated there was a PICC line dressing change on 4/17/26 at 4:56 p.m., on 4/24/26 at 1:40 p.m. and on 5/1/26 at 10:15 a.m. During a concurrent observation, interview and record review on 5/8/26 at 11:11 a.m. with RN 1, Resident 59's PICC line dressing to her RUE was noted to be changed and dated 5/5/26 with no time of change indicated. Resident 59 stated the dressing was changed yesterday 5/7/26. Resident 59's Electronic Health record (EHR) was reviewed, the EHR indicated there was no record of the dressing change on 4/27/26 and on 5/5/26 as observed on Resident 59's RUE. RN 1 stated on 5/5/26 when the initial observation was made, the dressing to Resident59's RUE should have indicated 5/1/26 and not 4/27/26 if there was a dressing change on 5/1/26 as documented in the TAR. RN 1 stated Resident 59's PICC dressing was not changed as indicated in the MAR but was documented as changed. RN 1 stated the Licensed Nurse (LN)s were putting Resident 59 at risk for infection when the PICC line dressing was not changed according to the physician's orders. During a concurrent interview and record review on 5/8/26 at 1:48 p.m. with LVN 2, a picture of the PICC line dressing to resident 59's RUE was reviewed. The picture indicated the RUE was dated 4/27/26. LVN 2 stated the expectation with respect to a PICC line, the LNs should monitor the site, proper dressing changing, and ensure there was no infiltration. LVN 2 stated dressing change was expected to be completed every week or prn if soiled. During the record review, LVN 2 stated the order indicated . change dressing and cap to PICC line to right upper arm every sun, noc shift. LVN 2 stated since Resident 59 was admitted on [DATE], the first dressing change should have been on the Sunday 4/19/26. LVN 2 stated if the dressing was changed on 5/1/26, the date should have been reflected on the resident's dressing on 5/5/26. LVN 2 stated the picture indicated the dressing was changed on 4/27/26. LVN 2 stated the LN that changed the dressing on 4/27/26 did not document the dressing change. LVN 2 stated the dressing was never completed 5/1/26 as indicated in the charting because there was no evidence of that based on the picture of Resident 59's RUE taken on 5/5/26 at 10: 52 a.m. LVN 2 stated there are discrepancies in the documentation and the actual observations. LVN 2 stated when Resident 59's PICC line dressing was not changed as expected it could get infected and affect the resident. During concurrent interview and picture review on 5/8/26 at 2:30 p.m. with the IP, the IP stated the expectation was for the LN to monitor the PICC line site, wear the appropriate PPE during resident care and the PICC line dressing change to be done. The IP stated the dressing changes should have been completed as per the physician's orders. The IP stated the dressing change should have been completed on the 4/19/26. The IP stated as at 5/5/26 at 10:52a.m., the dressing change on resident arm should have indicated 5/1/26 if the dressing change was completed on 5/1/26. The IP stated the dressing change was dated 4/27/26 in the picture review. The IP stated the dressing was not changed on 5/1/26. The IP stated there were more than 7 days from 4/27/26 to 5/5/26 and the dressing change should have been completed within 7 days. The IP stated it was important to change the PICC line dressing to ensure Resident 59 did not get infection. The IP stated Resident 59 could get blood infection and sepsis (body's extreme, life-threatening response to an infection) which could possibly be fatal for the resident. During concurrent interview and picture review on 5/8/26 at 4:38 p.m. with the DON, the DON stated Resident 59's dressing change should be completed every 7 days and prn. The DON stated the dates on the PICC line dressing and the EHR were different. The DON stated the dressing change was not done every 7 days according to the physician's order. The DON stated PICC line dressings are important to be changed timely to prevent infection since it was an open site. During a review of the facility's P&P titled, Vascular Access Device Assessment, Care, and Dressing Changes no date, the P&P indicated, Policy- A post insertion care bundle in conjunction with a culture of safety and quality is implemented to reduce the risk of catheter-related infection during daily care and management. Site care is performed at established intervals, including skin antisepsis and dressing changes, and immediately if the dressing integrity becomes compromised (e.g., lifted/detached on any border edge or within transparent portion of dressing; visibly soiled; presence of moisture, drainage, or blood) or compromised skin integrity is present under the dressing.Dressing and Securement Change Frequency- Transparent semipermeable membrane (TSM) dressings and TSM dressings with an integrated securement device (ISD) should be changed at least every 7 days or immediately if dressing integrity is disrupted (e.g., lifted/detached on any border edge or within transparent portion of dressing; visibly soiled; presence of moisture, drainage, or blood) or compromised skin integrity is present under the dressing. 24. Label dressing with date performed. Documentation- Document in the patient's health record: Site assessment findings, Performance of procedure, including type of antiseptic solution, and dressing type, Patient response to the procedure, Patient education. During a review of the facility's P&P titled, Infection Control – Policies & Procedures, dated 1/1/2012, the P&P indicated, .to provide infection control policies and procedures required for a safe and sanitary environment.and to help prevent and manage transmission of diseases and infections.prevent, detect, investigate, and control infections in the facility.staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.

Based on observation, interview and record review the facility failed to document changes in resident health status according to professional standards of practice and the facility's policy and procedure titled Licensed Nurse Weekly Progress Notes, for one of three sampled residents (Resident 1) when the facility nursing staff did not accurately assess, document and monitor Resident 1's skin changes that included multiple bruising to bilateral (both) upper thighs, knees, buttocks and right ankle. This failure placed Resident 1 at risk for further injury, potential for falls, increased pain and further skin breakdown. Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Parkinsons Disease (disorder that causes nerve cells in the brain to die, affecting movement, balance, and mood), syncope (temporary loss of consciousness/fainting), orthostatic hypotension (a sudden drop in blood pressure upon standing), Anxiety (feeling of fear or worry that persists, interfering with daily life), muscle weakness, anemia (condition when red blood cells don't carry enough oxygen to the tissues causing fatigue, weakness, pale skin, and dizziness). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 3/12/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 11 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment.During an interview on 4/15/26 at 3:30 p.m. with Complainant, Complainant stated that on 4/14/26, Resident 1 was observed with multiple bruises to both lower legs, upper legs and buttocks. Complainant stated the bruises had not been observed prior to 4/14/26.During an interview on 4/16/26 at 8:30 a.m. with Resident 1, Resident 1 stated there were bruises to both arms due to a medical procedure and there were bruises to both legs due to a fall in the facility. Resident 1 stated she required assistance with transfers and walking as she would become dizzy and had the potential to fall.During an interview on 4/16/26 at 8:56 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had cared for Resident 1. LVN 1 stated Resident 1 had a diagnosis of Anemia which caused her to bruise easily. LVN 1 stated she had observed bruises to Resident 1's arms but had not observed any other bruises. LVN 1 stated Resident 1 did not have a history of falls in the facility since admission.During a concurrent observation and interview on 4/16/26 at 9:02 a.m. with certified nursing assistant (CNA) 1 in Resident 1's room, Resident 1's legs were observed with multiple bruises on the lower legs, upper legs and buttock. CNA 1 stated Resident 1 had bruises to the right ankle, both knees and both thighs extending to buttocks. Resident 1 stated the bruises were from a fall that had happened in her room in the facility but could not recall the date or time. CNA 1 stated she did not recall Resident 1 experiencing a fall or if a fall had been reported. CNA 1 stated she had observed the bruises the last time she worked with Resident 1 which had been on 4/13/26 and the bruises had been reported to the nurse. CNA 1 stated she did not recall which nurse she reported the bruises to. CNA 1 stated Resident 1 stated she had bumped herself on something or state she did not know how the bruises happened. CNA 1 stated the facility process was to report and document any new conditions to the nurse, and document it as a new alert in the CNA documentation on the electronic medical record (EMR).During a concurrent observation and interview on 4/16/26 at 9:10 a.m. with LVN 1 and CNA 1 in Resident 1's room, Resident 1's legs were observed with multiple bruises on the lower legs, upper legs and buttock. LVN 1 stated Resident 1 had bruises to left and right buttock, left/right thigh bruises, large bruise to right ankle with pain upon movement, bruise to both knees, small scabs to top of right toes. LVN 1 stated there was no documentation of bruises, falls or injuries in the EMR. Resident 1 stated she had a fall early in the morning and could not recall date or time. LVN 1 stated there should have been documentation of the observed injuries or a fall in Resident 1's EMR.During a concurrent interview and record review on 4/16/26 at 9:20 a.m. with the Nurse Unit Manager (NUM), Resident 1's, Skin Check, dated 4/12/26 and 4/15/26 and Resident 1's EMR were reviewed. The Skin check dated 4/12/26 and 4/15/26 indicated, . Skin warm & dry, skin within normal limits and turgor is normal. No skin issues identified. Skin issues note: no new skin issues noted. The EMR indicated there were no documented changes in Resident 1's status including no falls, no skin changes and no reported injuries since admission on [DATE]. The NUM stated the facility process was for the nurses to document any new changes including falls, skin issues and injuries. The NUM stated the skin changes should have been documented on the skin check assessments completed by the nurse.During a concurrent observation and interview on 4/16/26 at 9:51 a.m. with the NUM in Resident 1's room, Resident 1's legs were observed with multiple bruises on the lower legs, upper legs and buttock. The NUM stated Resident 1 had bruises to both lower and upper legs and thighs and bruises to the buttocks. Resident 1 stated she had a fall at night when staff were assisting her back to bed from the restroom in her room. The NUM stated the bruises and injuries should have been observed and documented by the nurses during their skin checks and during the skin check on 4/15/26. The NUM stated the injuries could have been missed during the skin check assessment by the nurse. The NUM stated the facility expectation was for the CNA to report the observation of injuries to the nurse, then the nurse should have notified the unit manager, complete and document a skin assessment, change in condition assessment and MD notification.During a concurrent interview and record review at 4/16/26 at 10:36 a.m. with the director of nursing (DON), Resident 1's EMR was reviewed. The EMR indicated there were no documented changes in Resident 1's status including no falls, no skin changes and no reported injuries since admission on [DATE]. The DON stated the facility expectation for new skin issues was for the CNA to report it to the nurses immediately. The DON stated the expectation was for the nurses to assess the resident with skin injuries immediately and document any new skin issues observed. The DON stated the expectation was for the nurses to document any change in resident status.During an interview on 4/16/26 at 12:03 p.m. with the administrator (ADM), the ADM stated the facility expectation was for the nurses to document any changes observed in resident health status. The ADM stated it was important to document findings to ensure staff were aware of resident changes in health status.During a review of the facility's policy and procedure (P&P) titled, Licensed Nurse Weekly Progress Notes, dated 10/9/24, the P&P indicated, .Weekly nurses' progress notes will be written by licensed personnel on each resident, specific to the psychological, emotional, social, spiritual, and recreational needs and consistent with the Plan of Care. Purpose: To reflect observations of the resident's response to their environment, physical limitations, independent activities, dependency status, behavioral changes, skin problems, dietary problems and restorative measures to characterize the functional status of progression and/or regression. The Licensed Nurse will document the resident's response and progress towards goals weekly. The Licensed Nurse will review, revise, update or develop the Plan of Care accordingly .During a review of the facility's P&P titled, Skin Integrity Management, dated 7/31/24, the P&P indicated, .The facility will identify, evaluate, and intervene to prevent further pressure injury and/or heal pressure ulcers and any other skin integrity conditions. A plan of care will be developed to provide guidelines for the treatment of skin integrity conditions to facilitate healing. A Licensed Nurse will complete a skin evaluation then there is a change in skin integrity. A Licensed Nurse will complete the skin evaluation weekly. The physician and responsible party will be notified when there is a change in the condition of the pressure injury or skin integrity condition. Licensed Nurses will document the effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis .During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry.

Based on observation, interview and record review the facility failed to meet professional standards of practice and follow the policy and procedure titled, Referrals to Outside Services, Resident Rights and NP04 Comprehensive Person-Centered Care Planning for two of five sampled residents (Residents 2 and Resident 3) when: 1. Licensed Nurse (LN) did not develop a care plan when Resident 2 refused all showers from 1/26/26-2/19/26.This failure had the potential to result in Resident 2 developing wounds and infections.2. Social Service department did not provide Resident 3 with transportation to his urology [a specialized branch of medicine that focus on diseases of the male and female urinary tract (the body's drainage system for removing waste and extra fluid, acting as a filter to produce, transport, store, and release urine)] appointment to assess removing his urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) for discharge and Resident 3 missed his appointment.This failure had the potential to result in Resident 3 discomfort, developing an infection, and delayed discharge.Findings:1.During a review of Resident 2's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis that included progressive neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of Resident 2's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/4/26, the MDS indicated, Resident 2's Brief Interview for Mental Status (BIMS -screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 2 had moderate cognitive impairment.During a concurrent observation and interview on 2/25/26 at 11:50 a.m., in Resident 2's room, Resident 2 was sitting on the side of his bed and Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 5 were providing care to Resident 2. LVN 1 stated Resident 2 refused showers and bed baths a lot. LVN 1 confirmed Resident 2 did not have a care plan for refusing showers. LVN 1 stated all residents should get two showers or baths in a week and if a resident was refusing, they should have started a care plan.During a concurrent interview and record review on 2/25/26 at 12:26 p.m. with RN 1, RN 1 stated Resident 2 refused showers a lot. RN 1 confirmed there was no care plan created for Resident 2 refusing showers. RN 1 stated a care plan should have been developed for Resident 2 refusing showers because repeated missed showers can lead to skin infections and other problems.During a concurrent interview and record review on 2/25/26 at 3:26 p.m., with Director of Nursing (DON), Resident 2's care plans and Skin Monitoring Comprehensive CNA Shower Review forms dated 1/27/26-2/24/26 were reviewed. DON stated Resident 2 refused showers and bed baths repeatedly. DON reviewed Resident 2's medical record of care plans and stated Resident 2 had no care plan for refusing showers past or present. Shower documentation from 1/27/26 through 2/24/26 indicated Resident 2 had refused all nine offered showers and consented to three bed baths (2/3, 2/13, and 2/24). DON confirmed the forms dated 1/26/26, 2/2/26, and 2/5/26 indicated Resident 2 had refused showers and bed baths three times but the areas on the form for charge nurse assessment, intervention, and forwarded to DON were all left blank. DON confirmed Resident 2 had partial bed bath documented on 2/12/26, 2/16/26, and 2/19/26 due to refusing shower. The areas on the form for charge nurse assessment, intervention, and forwarded to DON were all left blank. DON stated her expectation was for all residents to be bathed at least two times a week and if a resident refused to be bathed, a care plan should be created after the first refusal. DON stated possible outcomes from not bathing included infection, wounds, and other complications.2. During a review of Resident 3's AR, dated 2/25/2026, indicated, Resident 3 was admitted to the facility on [DATE] with diagnosis including Cerebral Infarction (brain tissue dies due to lack of oxygen) with hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body), type 2 Diabetes Mellitus, major depressive disorder, retention of urine, anxiety disorder, and urinary tract infection (UTI- an infection in the bladder and urinary tract).During a review of Resident 3's MDS, dated [DATE], indicated, Resident 3 had a BIMS score of 12 out of 15 which indicated Resident 22 had moderate cognitive impairment.During a concurrent observation and interview on 2/25/26 at 2 p.m., in the facility smoking area, Resident 3 was sitting in his wheelchair, smoking, and talking to a visitor. Resident 3 stated he was upset because he still had his urinary catheter. Resident 3 stated he was supposed to see a urologist (a medical doctor who specializes in treating urinary tract diseases) to take out his catheter so that he could go home but the facility did not have a ride for him, so he missed his appointment. Resident 3 stated the soonest his wife could get him another appointment was for almost in a month.During a concurrent interview and record review on 2/25/26 at 2:15 p.m., with Social Service Director (SSD) 2, Resident 3's social service notes were reviewed. SSD 2 stated the process for getting transportation for residents to outside appointments was for the nurses to put the appointment in the calendar and send the calendar to SSD each morning to set up transportation for that day. SSD 2 stated that Resident 3 had a follow up urology appointment on 2/13/26 at 10:45 a.m. that he missed due to not having transportation. SSD 2 stated he did not receive notice that Resident 3 had an appointment or needed a ride until it was too late to get Resident 3 to his appointment.During an interview on 2/25/26 at 2:25 p.m., with SSD 1, SSD 1 stated Resident 3's missed appointment was her fault. SSD 1 stated when Resident 3 was being admitted , she was made aware of his Urology appointment and told the nurse she would put it on the calendar but forgot to. SSD 1 stated the facility provided residents with transportation to appointments for services not provided in the facility. SSD 1 confirmed the facility did not have a Urologist. SSD 1 stated there was no written process for setting up transportation for the residents to reference.During a concurrent interview and record review on 2/25/26 at 3:26 p.m., with DON, Resident 3's social service and nursing notes dated 2/13/26 were reviewed. DON stated Resident 3 had missed his urology appointment on 2/13/26 because the facility had not provided transportation. DON stated Resident 3 was supposed to be assessed to have his urinary catheter removed so that he could return to his home in an Assisted Living Facility (ALF). DON stated Resident 3's ALF would not let him return with a urinary catheter. DON stated Resident 3 missing his urology appointment could result in delayed discontinuation of his urinary catheter and delayed discharge for Resident 3. DON confirmed Resident 3 did not have a care plan for providing transportation to outside appointments or for ensuring Resident 3 made it to those appointments.The facility Policy and Procedure (P&P) titled NP04 Comprehensive Person-Centered Care Planning dated 9/7/23 indicated, .a. a. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: i. The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. ii. Any services that would otherwise be required under, but are not provided due to resident's exercise of rights, including the right to refuse treatment. iv. In consultation with the resident and the resident's representative: 1. The resident goals for admission and desired outcomes. 2. The resident's preference and potential for future discharge.The facility P&P titled Referrals to Outside Services dated 8/31/22, indicated, .The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility.The facility P&P titled Resident Rights dated 1/1/12, indicated, . I. State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to . C. Choose a physician and treatment and participate in decisions and care planning; II. The Facility makes every effort to assist each resident in exercising his/her rights by providing. C. Transportation to community activities can be arranged (when possible) through the Activity or Social Service Departments.Ill. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: Personal care needs, such as bathing methods, grooming styles and dress.During a professional reference review retrieve from https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ the professional reference indicated, .Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Both the patient's status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed .

Based on observation, interview and record review the facility failed to ensure residents received necessary services for activities of daily living to maintain personal and oral hygiene for three of four sampled residents (Resident 1, Resident 2, Resident 3), when the facility staff did not provide oral care or grooming to Resident 1, Resident 2 and Resident 3 daily. These failures resulted in Resident 1, Resident 2 and Resident 3 to feel unclean and placed residents at risk for loss of dignity and potential tooth decay, oral, respiratory and skin infections.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for hemiplegia (weakness or complete loss of movement in the arm, leg, and sometimes face on that side) affecting left non-dominant side, Dysarthria (speech disorder making words hard to form due to weak, slow, or uncoordinated speech muscles), Contracture (stiff joints and reduced, painful mobility) of muscle multiple sites, muscle weakness, Contracture right hand, Contracture left shoulder, elbow, wrist.During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 1/14/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 10 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment.During an observation and interview on 2/4/26 at 11:53 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed to have long fingernails with brown substance inside, teeth were observed with white buildup and breath had foul odor, Resident 1 was observed with long facial hair. Resident 1 stated he could not remember the last time his teeth were brushed and nails were cut or trimmed. Resident 1 stated he does have a history of refusing showers but never refused to brush his teeth, shave or cut his nails. Resident 1 stated the facility staff should have automatically included teeth brushing and grooming as part of his activities of daily living as this was important to him. Resident 1 stated the staff did not offer to brush his teeth on a daily basis. Resident 1 stated he should not have to ask facility staff to assist him with performing activities of daily living as they were a part of his plan of care. Resident 1 stated at the time of the interview, he had not been assisted to complete his activities of daily living for grooming from any staff in the facility.During a concurrent observation and interview on 2/4/26 at 11:55 a.m. with certified nursing assistant (CNA) 1, Resident 1 was observed to have long fingernails with brown substance inside, teeth were observed with white buildup and breath had foul odor, Resident 1 was observed with long facial hair. CNA 1 stated Resident 1 appeared as if it had been longer than a few days since personal hygiene was completed as Resident 1 had long facial hair, long and dirty fingernails and dirty teeth with visible buildup.During a record review of Resident 1's document titled, Activities of Daily Living, dated 2/2026, the document indicated, Resident 1 had nail care completed on 2/1/26 and 2/2/26, oral hygiene completed on 2/2/26 and 2/3/26 and shaved on 2/3/26.During a concurrent observation, interview and record review on 2/4/26 at 12:03 p.m. with Registered Nurse (RN) 1 in Resident 1's room, Resident 1 was observed to have long fingernails with brown substance inside, teeth were observed with white buildup and breath had foul odor, Resident 1 was observed with long facial hair. During a record review of Resident 1's document titled, Activities of Daily Living, dated 2/2026, the document indicated, Resident 1 had nail care completed on 2/1/26 and 2/2/26, oral hygiene completed on 2/2/26 and 2/3/26 and shaved on 2/3/26. RN 1 stated Resident appeared to have not been shaved for a few weeks, teeth appeared to not have been brushed for more than a few days, and nails appeared dirty, long and uncut. Resident 1 told RN 1 that his nails had not been cut or trimmed for months. RN 1 stated the expectation was for the CNAs to complete all personal hygiene for every resident daily. During a review of Resident 1's document titled, Activities of Daily Living Care Plan, dated 2/11/2023, the care plan indicated, The Resident has an ADL self-care performance deficit and resident at risk for declining self-performance related to limited mobility. interventions. Oral hygiene: the resident requires maximum assistance by one staff with oral care. Personal hygiene: the resident is dependent on one staff for personal hygiene.During a review of Resident 2's admission Record, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for Visuospatial deficit (issues with depth perception, spatial orientation, and object recognition), hemiplegia affecting left non-dominant side, muscle weakness, Gastroesophageal reflux disease (GERD- a condition where stomach acid flows back into the throat, causing chest pain, and difficulty swallowing), need assistance with personal care.During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2's Brief Interview for Mental Status score was 12 out of 15 which indicated Resident 2 had moderate cognitive impairment.During an interview on 2/4/26 at 12:22 p.m. with Resident 2, Resident 2 stated she had been in the facility for a few months. Resident 2 stated part of her plan of care included teeth brushing and grooming which was not offered in the facility. Resident 2 stated she did not get her teeth brushed often as the staff had mentioned in the past that they did not have time. Resident 2 stated she would like to be able to brush her teeth every morning and night as part of her daily routine. Resident 2 stated she felt dirty and felt the lack of tooth brushing had caused her to experience tooth pain as her teeth were dirty.During a review of Resident 3's admission Record, the AR indicated, Resident 3 was admitted to the facility on [DATE] with diagnosis for spastic hemiplegia (chronic stiffness, muscle weakness, and poor motor control on one side of the body) affecting left nondominant side, arthritis (swelling and tenderness of one or more joints), muscle weakness, dependance on wheelchair.During a review of Resident 3's Minimum Data Set dated 1/21/2026, the MDS indicated, Resident 3's Brief Interview for Mental Status score was 12 out of 15 which indicated Resident 3 had moderate cognitive impairment.During an observation and interview on 2/4/26 at 12:43 p.m. with Resident 3 in Resident 3's room, Resident 3's teeth were observed with white and yellow buildup and breath had foul odor. Resident 3 stated he had not been offered supplies and staff had not offered to assist in brushing his teeth daily. Resident 3 stated brushing his teeth were part of his care that should have been completed without having to request it from the facility staff. Resident 3 stated he should not have to request basic care such as grooming or brushing teeth because the facility staff should have been completing that task. Resident 3 stated he felt dirty and could smell there was a foul odor on himself. Resident 3 stated he would like help and assistance in brushing his teeth every day.During an interview on 2/4/26 at 12:56 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the facility expectation was for the CNAs to ensure resident activities of daily living were completed. LVN 1 stated activities of daily living included grooming, teeth brushing, showering, shaving and nail cutting. LVN 1 stated teeth brushing should have been completed daily for each resident as part of their plan of care. LVN 1 stated, Residents should not have been asking for assistance with brushing their teeth but instead the CNAs should have completed the task as part of their care. LVN 1 stated when residents' teeth were not brushed there was a potential for buildup of decay, tooth pain and possible infections. LVN 1 stated personal hygiene was important for the residents to feel clean and to avoid preventable infections, skin breakdown and respiratory issues.During a concurrent observation and interview on 2/4/26 at 1:05 p.m. with CNA 1, in the hallway with Resident 2, Resident 2 stated she had not had her teeth brushed but was unable to open her mouth due to oral pain experienced. CNA 1 stated the facility process for resident personal care was for the CNA to assist each resident with bathing, grooming including brushing hair, shaving and tooth brushing. CNA 1 stated personal care should be completed before breakfast or as requested by each resident. CNA 1 stated Resident 1, Resident 2, and Resident 3 had not been offered to brush their teeth. CNA 1 stated it was important to complete oral hygiene to prevent infections. CNA 1 stated personal hygiene was important for each resident to ensure the residents felt clean and to prevent skin breakdown.During a record review of Resident 2's document titled, Activities of Daily Living, dated 2/2026, the document indicated that Resident 2's oral hygiene was completed 2/3/26 and 2/4/26.During a review of Resident 3's document titled, Activities of Daily Living, dated 2/26, the document indicated there was no documentation for Resident 3's oral hygiene since admission on [DATE].During a concurrent interview and record review on 2/4/26 at 1:26 p.m. with LVN 1, Resident 2's document titled, Activities of Daily Living, dated 2/2026 and Resident 3's document titled, Activities of Daily Living, dated 2/26 were reviewed. Resident 2's document indicated that Resident 2's oral hygiene was completed 2/3/26 and 2/4/26. Resident 3's document indicated there was no documentation for oral hygiene since admission on [DATE]. LVN 1 stated there should have been documentation for Resident 3 to ensure Resident 3's oral hygiene was completed daily.During an interview on 2/4/26 at 2:00 p.m. with the director of nursing (DON), the DON stated the facility expectation was for the CNAs to complete all personal hygiene for each resident. The DON stated personal hygiene should have been completed in the morning unless the residents requested a different time. The DON stated it was important to ensure oral hygiene was completed to prevent tooth decay or infections.During an interview on 2/4/26 at 2:16 p.m. with the administrator (ADM), the ADM stated the facility expectation was for the facility staff to provide all personal care needed to all residents in the facility. During an interview on 2/11/26 at 1:30 p.m. with the director of staff development (DSD), the DSD stated the facility expectation was for the CNAs to complete all activities of daily living for each resident daily including teeth brushing, bathing and grooming. The DSD stated the expectation was for the CNAs to complete personal hygiene tasks before breakfast for each resident, unless the resident requested a different time. The DSD stated it was the facility staff's responsibility including CNAs, Restorative Nurse Aide (RNA)s or nurses to ensure the activities of daily living task were completed. The DSD stated it was important for personal hygiene task to be completed to ensure residents were clean and groomed.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/1/12, the P&P indicated, .Purpose: To promote and protect the rights of all residents at the Facility. Residents of skilled nursing facilities have a number of rights under state and federal law. The Facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the Facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. Procedure. The Facility makes every effort to assist each resident in exercising his/her rights by providing the following services: The Facility's Staff encourages residents to participate in planning their daily care routines. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: Sleeping, eating, exercise and bathing schedules; Personal care needs, such as bathing methods, grooming styles and dress. Residents are provided assistance as needed to engage in their preferred activities on a routine basis.During a review of the facility's P&P titled, Oral Care, dated 1/1/12, the P&P indicated, .Purpose: All residents receive appropriate oral care, including denture care if applicable, daily. Policy: It is the responsibility of each staff member within the nursing department is to ensure good oral care for each resident. Each toothbrush of a resident must be labeled with resident's name, unless kept in the resident's bedside drawer.During a review of the facility's P&P titled, Grooming Care of Fingernails and Toenails, dated 10/21/21, the P&P indicated, .Purpose: Nail care is given to clean the nail bed and keep the nails trimmed. Fingernails are trimmed by Certified Nursing Assistants (CNAs), except for Residents with diabetes or circulatory impairments, this includes all toenails except for high-risk Residents.During a review of the facility's P&P titled, Showering and Bathing, dated 1/1/12, the P&P indicated, Purpose: A tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Policy: Residents are given tub or shower baths unless contraindicated. Observe the skin is performed during bath.

Based on observations, interview and record review, the facility failed to provide meals at regular times comparable to normal mealtimes in the community or in accordance with resident requests, preferences for 141 of 141 sampled residents, when the lunch meal on 1/7/25 was served 30 to 45 minutes after the scheduled mealtime and the dinner meal on 1/10/25 was served 50 minutes after the scheduled mealtime. These failures had the potential to trigger resident feelings of anger and frustration which could diminish a resident's ability to eat resulting in a resident not meeting hydration and nutritional needs which could lead to unexpected weight loss or delay the timely recovery of clinical illness or injury. Findings: During an interview on 1/6/25 at 10:17 a.m. with Resident 3 on the 1st Floor, Resident 3 stated the meals were served late and wished meals would be served on time. Resident 3 stated lunch is typically served around 2:00 p.m., dinner served late around 7:30 p.m. During a record review of Resident 3's Admission Record (AR) dated 1/9/25, the AR indicated, Resident 3 was admitted to the facility on [DATE]. During a review of Resident 3's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 12/18/24, the MDS section C indicated, Resident 3 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 out of 15 (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) which indicated Resident 3 had moderate cognitive impairment. During an interview on 1/6/25 at 12:40 p.m. with the License Vocational Nurse (LVN) 2 in the Social Dining area, LVN 2 stated early trays were delivered to the Social Dining first, then trays were delivered to individual rooms starting with 3rd Floor, then 2nd Floor, and 1st Floor. During an interview on 1/6/25 at 3:36 p.m. with Resident 48 on the 1st Floor, Resident 48 stated, dinner has been served late, between 7:30-8:00 p.m. for the past several months. Resident stated he wished meals were served on time. During a record review of Resident 48's AR, dated 1/9/25, the AR indicated, Resident 48 was admitted to the facility on [DATE]. During a review of Resident 48's MDS, dated [DATE], the MDS section C indicated, Resident 48 had a BIMS score of 12 out of 15, which indicated Resident 48 was moderate cognitive impairment. During an interview on 1/6/25 at 3:42 p.m. with Resident 78 on the 1st Floor, Resident 78 stated, dinner had been served late, but six months ago dinner used to be served earlier, now served between 6:30 p.m.-7:30 p.m. or as late as 8:00 p.m. During a record review of Resident 78's (AR), dated 1/9/25, the AR indicated, Resident 78 was admitted to the facility on [DATE]. During a review of Resident 78's MDS, dated [DATE], the MDS section C indicated, Resident 78 had a BIMS score of 13 out of 15, which indicated Resident 78 was cognitively intact. During an interview on 1/7/25 at 9:27 a.m. with Resident 112 on the 1st Floor, Resident 112 stated his meals were often served late and preferred to eat on time. Resident 112 stated breakfast has been served between 8:30 a.m.9:00 a.m., lunch served between 1:30 p.m.2:00 p.m., and dinner served between 7:00 p.m.7:30 p.m. or as late as 8:00 p.m Resident 112 stated he heard the kitchen overhead stating the trays for Station 1 were ready, but his tray was delivered 40 minutes later. During a record review of Resident 112's AR, dated 1/9/25, the AR indicated, Resident 112 was admitted to the facility on [DATE]. During a review of Resident 112's, dated 10/5/24, the MDS section C indicated, Resident 112 had a BIMS score of 15, which indicated Resident 112 was cognitively intact. During an observation on 1/7/25 at 12:50 p.m. in the facility, the facility served the lunch meal to the 3rd Floor residents at 12:59 p.m., the 2nd floor residents at 1:16 p.m., and the 1st floor residents at 2:00 p.m. During an interview on 1/8/25 at 2:25 p.m. with the Certified Nurse Assistant (CNA) 5 in the common area of the 1st Floor, CNA 5 stated breakfast was often served around 9:00 a.m. During an interview on 1/8/25 at 3:12 p.m. with Licensed Vocational Nurse (LVN) 6 in the common area of the 1st Floor, LVN 6 stated the other day (1/6/25 and 1/7/25) lunch was really late after 1:30 p.m., almost 2:00 p.m. During an interview on 1/08/25 at 3:48 p.m. with LVN 1 in the common area of the 1st Floor, LVN 1 stated lunch was served late the past two days, on Monday and Tuesday (1/6/25 and 1/7/25). During an interview on 1/9/25 at 10:47 a.m. with the Director of Nursing (DON) in the DON office, the DON stated each floor had posted targeted mealtime schedules so staff can predict meal distribution. The DON stated the facility did not have a formal audit form to track and monitor meal distribution. During an interview on 1/10/25 at 11:09 a.m. with Resident 48 on the 1st Floor, Resident 48 stated when he did not receive his meal as noted on the menu it makes us (the residents) feel like they (the facility) don't give a rats ass. Resident 48 stated if you don't get fed until 8:00 p.m. at night something is wrong. During an observation on 1/10/25 at 6:00 p.m. in the facility, the dinner meal was served to the 3rd floor residents at 6:18 p.m., 2nd floor residents at 6:33 p.m. and 1st floor residents at 7:00 p.m. During a concurrent observation and interview on 1/10/25 at 6:01 p.m. with Resident 94 on the 3rd Floor, Resident 94 had just received this dinner. Resident 94 stated dinner was usually served between 5:30 p.m. to 6:00 p.m. Resident 94 stated the quality and timing of when meals were served made him feel mad. Resident 94 stated he was lucky his niece was willing to bring him outside food but felt bad because he knew she can't come every day. During a record review of Resident 94's AR, dated 1/9/25, the AR indicated, Resident 94 was admitted to the facility on [DATE]. During a review of Resident 94's MDS, dated [DATE], the MDS section C indicated, Resident 94 had a BIMS score of 13, which indicated Resident 94 was cognitively intact. During an interview on 1/10/25 at 6:47 p.m. with the Certified Dietary Manager (CDM) in the Social Dining area, the CDM stated she expected meal trays to be delivered within 15 minutes of the scheduled time, no more than 30 minutes. If the meals were served late, there would be potential to affect med pass (nurses giving medication to residents who must take medication with meals) and may lead to resident feeling frustrated or dissatisfied. During a review of Resident Grievance/Complaint Investigation Report, dated 11/14/24, the Resident Grievance/Complaint Investigation Report indicated Resident 223 had a grievance because dinner was served at 7:15 p.m. and was cold and soggy .the grilled cheese was not toasted thoroughly, and cheese was not melted . The grievance investigation findings noted by the CDM dated 11/14/24, indicated, .Dietary [NAME] for 11/13/24 stated that all meals were out of the kitchen at 6:30 p.m . The same p.m. cook states that the grilled cheese had been made from lunch shift and all she had to do is reheat it. At time the cook was told to always make the grilled cheese fresh . During a review of Resident Grievance/Complaint Investigation Report, dated 12/30/24, the Resident Grievance Resident 112 reported .Dinner was served at 10:00 p.m. and it was cold ., The complaint investigation findings by the CDM , dated 12/31/24, indicated, . He (Resident 112) did receive his meal before 8:00 p.m. not 10:00 PM and the cook states that she did run behind due to the new hire was training . During a review of facility record titled Meal Times, (undated), indicated, the scheduled meal times for the Facility: BREAKFAST 3rd Floor 07:25 AM 2nd Floor 07:45 AM 1st Floor 08:15 AM LUNCH Social Dining 12:00 PM 3rd Floor 12:30 PM 2nd Floor 12:45 PM 1st Floor 1:15 PM DINNER 3rd Floor 5:20 PM 2nd Floor 5:35 PM 1st Floor 6:00 PM During a review of the Dietary Services Supervisor/Certified Dietary Manager (CDM) Job Description, (undated), the Dietary Services Supervisor/Certified Dietary Manager Job Description indicated a CDM's clinical principal responsibility is to ensure .The timely preparation and delivery of .meals . During a review of the facility's policy and procedure titled, Dining Program revised date 1/1/12, indicated, .The purpose of the policy is .to ensure that the Facility serves meals in a timely manner .

Based on observation, interview and record review the facility failed to store drugs in a safe manner for two of two medication rooms (Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER]), when seven pills (Five in Medication room [ROOM NUMBER] and two in Medication room [ROOM NUMBER]) were found on the floor without packaging or labels. This failure had the potential for drug diversion (when healthcare providers obtain or use prescription medicines illegally) and overall unsafe medication practices. Findings: During a concurrent observation and interview on 1/8/25 at 10:58 a.m., with the Nurse Supervisor (NS) 2 in the second-floor medication room, the medication room had five different (shapes and colors) unidentifiable pills on the floor. The NS 2 stated there should not have been pills on the floor. The NS 2 stated the pills were unidentifiable (impossible to recognize) and could be any medication the facility provided, even a narcotic (highly addictive drug used for treating pain). The NS 2 stated it was not safe for random pills to be on the floor. During a concurrent observation and interview on 1/8/25 at 11:33 a.m., with a Licensed Vocational Nurse (LVN) 3 in the third-floor medication room, the medication room had two different (shapes and colors) unidentifiable pills on the floor. LVN 3 stated they were random pills and we don't know what they are. LVN 3 stated pills should never be on the floor like that. LVN 3 stated the medications on the floor could be anything including a narcotic. LVN 3 stated the expectation was for those pills to be thrown away in the medication waste bin and that expectation was not met. LVN 3 stated the medications were not safe on the ground and someone could take them because the pills were unaccounted for. During an interview on 1/10/25 at 9:12 a.m., with the Pharmacy Consultant (PC), the PC stated the expectation was there should be no drugs on the ground in the medication rooms. The PC stated a staff member, or even a resident, potentially could have gone into the medication room and picked them up. The PC stated the medication on the floor had potential for a staff member abusing them (taking a medication in a manner or dose other than prescribed) and they needed to be secured. During an interview on 1/10/25 at 10:02 a.m., with the Infection Preventionist (IP- professional who make sure healthcare workers and patients are doing all the things they should to prevent infections), the IP stated staff members should have properly disposed of the medications and they should not have been on the floor. The IP stated the pills on the floor could have led to drug diversion by a staff member. The IP stated this would be safety issue for everyone in the facility. The IP stated the policy and procedure (P&P) was not followed for Medication Storage. During an interview on 1/10/25 at 1:43 p.m., with the Director of Nursing (DON), the DON stated the medications were not secured and should have not been on the floor. The DON stated there was potential for drug diversion with the medications on the floor. The DON stated this was not safe and the P&P was not followed for Medication Storage. During a review of the facility's P&P titled, Medication Storage, dated 2019, the P&P indicated, . Storage of Medications . Policy: medications and biologicals are stored safely, securely and properly . During a review of the California Department of Social Services Professional Reference titled, Medications Guide: Residential Care Facilities for the Elderly, dated 9/30/16, retrieved from (https://www.ccld.dss.ca.gov/res/pdf/MedicationsGuide.pdf) indicated, . All prescription and nonprescription PRN (as needed) medication for which the licensee provides assistance must have a pharmacy label on the medication .Medications are to remain in their original packaging until dispensed . When a medication dosage changes or is discontinued, the multi-dose customized packages must be returned to the issuing pharmacy, or otherwise destroyed . During a review of the professional reference titled, American Nurse: Drug Diversion in Healthcare, dated 5/6/21, (https://www.myamericannurse.com/drug-diversion-in-healthcare/), indicated, .Prevention and detection for nurses . Reducing the need to waste medications and properly wasting can help circumvent (deter) diversion . Signs of Diversion . Failing to waste [medication] . General signs of diversion include . medications .found . out of exterior packaging .

Based on observation, interview and record review, the facility failed to follow the policy and procedures Medication Storage, Disposal of Medications and Medication Related Supplies and have a secure medication destruction bin (MDB- a bin for unused medications that are set to be destroyed) for two of two medication rooms (Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER]), when the medication destruction bins' lids were not sealed. This failure had the potential for drug diversion (when healthcare providers obtain or use prescription medicines illegally) and overall unsafe medication practices. Findings: During a concurrent observation and interview on 1/8/25 at 10:58 a.m., with the Nurse Supervisor (NS) 2 in the second-floor medication room, the medication room had a MDB with a lid that was loose and crooked. The MDB lid was not sealed. The NS 2 stated the lid was not secure to the bin and staff could have taken medications out of it. The NS 2 stated narcotics (highly addictive drug used for treating pain) and other controlled medications (A drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) get wasted in this MDB after they were crushed and rendered into powder form. The NS 2 stated there was currently powder in the MDB and that could be a controlled medication. The NS 2 stated the MDB not secure put employee safety at risk and had the potential for drug diversion. During a concurrent observation and interview on 1/8/25 at 11:33 a.m., with a Licensed Vocational Nurse (LVN) 3 in the third-floor medication room, the medication room had a MDB with a lid that was loose and crooked. The MDB lid was not sealed. LVN 3 stated the MDB lid was not secure and it should be locked shut. LVN 3 stated nursing staff discard narcotics in that bin in powdered form and it would be easily identifiable for a staff member who wanted to divert medication. LVN 3 stated staff members could take any pills or powder from the MDB. During an interview on 1/10/25 at 9:12 a.m., with the Pharmacy Consultant (PC), the PC stated the MDB lid not secured was a problem. The PC stated best practice would be for the MDB to be sealed so staff members could not access the discarded medication. The PC stated an employee could have easily accessed the bin and took medication out. The PC stated that if narcotics were in powder form, staff would have had access to that as well. The PC stated drug diversion could have taken place and it was not safe. During an interview on 1/10/25 at 10:02 a.m., with the Infection Preventionist (IP-- professional who make sure healthcare workers and patients are doing all the things they should to prevent infections), the IP the stated MDB not being secured was an infection control issue. The IP stated the expectation would be for the MDB to be secured at all times, and it was not. The IP stated this was a drug diversion issue and anyone with access to that room could have taken medications from the MDB. During an interview on 1/10/25 at 1:43 p.m., with the Director of Nursing (DON), the DON stated the MDB lid was not on properly in both of the medication rooms. The DON stated the expectation was for the lid to be secure and it was not. The DON stated the policy and procedure (P&P) for Disposal of Medications and Medication Storage were not followed. During a review of the facility's policy and procedure (P&P)titled, Medication Storage, dated 2019, the P&P indicated, . Storage of Medications . Policy: medications and biologicals are stored safely, securely and properly . During a review of the facility's P&P titled, Disposal of Medications and Medication Related Supplies, dated 2019, the P&P indicated, .Controlled Medication Disposal . Medications . classification as controlled substances are subject to special handling, storage, disposal . when a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. Medication is placed in the designated Med (medication) waste container . the same process applies to the disposal of unused partial tablets . of controlled substances . During a review of the professional reference titled, Code of Federal Regulations: S 1317.75 Collection receptacles, dated 12/31/24, (found at https://www.ecfr.gov/current/title-21/chapter-II/part-1317/subpart-B/section-1317.75), indicated, .Collection receptacles shall be securely placed and maintained: . At a long-term care facility: A collection receptacle shall be located in a secured area regularly monitored by long term care facility employees . e. A controlled substance collection receptacle shall meet the following design specifications: . 2. Be securely locked . During a review of the professional reference titled, American Nurse: Drug Diversion in Healthcare, dated 5/6/21, (found at https://www.myamericannurse.com/drug-diversion-in-healthcare/), indicated, .Prevention and detection for nurses . properly wasting can help circumvent (deter) diversion . During a review of professional reference titled, Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention, dated July 2012, (found at https://pmc.ncbi.nlm.nih.gov/articles/PMC3538481/) indicated, .healthcare workers who are diverting drugs from the health care facility workplace pose a risk to their patients, their employers, their co-workers, and themselves. It is essential that all health care institutions have a robust system in place to identify and investigate suspected diversion as rapidly and efficiently as possible and that they implement policies and procedures that enable a standardized and effective response to confirmed diversion. Drug diversion by healthcare workers violates the core value that the needs of the patient come first. Clearly, if we are to optimize our approach to inpatient drug diversion and its consequences, we must look at such diversion not as a victimless act but as a multiple-victim crime .

Based on observation, interview and record review, the facility failed to ensure the meal served on 1/7/25 reflected the menu items for 49 of 54 residents on the first floor (Resident 122, 73, 66, 34, 109, 88, 110, 69, 7, 84, 79, 3, 31, 96, 70, 61, 130, 131, 126, 37, 59, 105, 72, 111, 113, 108, 114, 64, 103, 65, 6, 8, 24, 39, 13, 60, 92, 23, 133, 20, 14, 15, 112, 86, 119, 48, 78, 101, 42) when residents received an alternate food for lunch on 1/7/25 due to the kitchen ran out of spinach bake. The facility failed to ensure the food served to the majority of residents on the first floor reflected the menu items served to other residents. The facility did not ensure sufficient food was cooked to serve the main menu items to all residents. This failure resulted in Residents 122, 73, 66, 34, 109, 88, 110, 69, 7, 84, 79, 3, 31, 96, 70, 61, 130, 131, 126, 37, 59, 105, 72, 111, 113, 108, 114, 64, 103, 65, 6, 8, 24, 39, 13, 60, 92, 23, 133, 20, 14, 15, 112, 86, 119, 48, 78, 101, 42 not receiving the same food distributed to other residents in the facility which could result in residents not feeling valued by the facility. Findings: During a concurrent observation and interview on 1/6/25 at 3:36 p.m. with Resident 48 in his room, Resident 48 was sitting on the edge of his bed. Resident 48 was alert, oriented and able to understand and answer questions. Resident 48 stated dessert options on the menu was not available due to the kitchen serving other floors first. Resident 48 stated he felt the facility ran out of food (the menu items) three times a week. Resident 48 stated a couple nights ago he was given a salad wrap that was not listed on the menu. During a record review of Resident 48's Admission Record (AR) dated 1/9/25, the AR indicated, Resident 48 was admitted to the facility on [DATE]. During a review of Resident 48's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 12/4/24, the MDS section C indicated, Resident 48 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 out of 15 (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) which indicated Resident 48 had moderate cognitive impairment. During a concurrent observation and interview on 1/6/25 at 3:42 p.m. with Resident 78 in their room on the 1st Floor, Resident 78 was sitting next to his bed working on his personal computer. Resident was alert and oriented. Resident 78 stated the facility ran out of desserts. Resident 78 stated 1st Floor residents were served last and when the kitchen runs out of a menu items, they are the first to receive alternate foods. During a record review of Resident 78's AR, dated 1/9/25, the AR indicated, Resident 78 was admitted to the facility on [DATE]. During a review of Resident 78's MDS, dated [DATE], the MDS section C indicated, Resident 78 had a BIMS score of 13, which indicated Resident 78 was cognitively intact. During an interview on 1/7/25 at 8:09 a.m. in the kitchen with Certified Dietary Manager (CDM), the CDM stated she was unaware of incidents of running out of dessert. CDM stated the kitchen should not run out of food. During a concurrent observation and interview on 1/7/25 at 9:27 a.m. with Resident 112 on the 1st floor, Resident 112 was sitting upright in bed with right leg propped on a pillow, well groomed, alert, and oriented, able to understand and answer questions. Resident 112 stated a few weeks ago the menu listed turkey burgers for dinner. Resident 112 stated he was served a bun with two pieces of cheese without the turkey patty. Resident 112 was informed by staff that the kitchen Ran out of meat. Resident 112 stated he got upset and frustrated, threw his tray and started yelling asking Who is in charge. Resident 112 stated the menu did not match what was served and the 1st Floor was the last floor to get their meal trays. Resident 112 stated the floor served meal trays first will get what was on the menu, the floor served last will not get what was on the menu. During a record review of Resident 112's AR, dated 1/9/25, the AR indicated, Resident 112 was admitted to the facility on [DATE]. During a review of Resident 112's MDS, dated [DATE], the MDS section C indicated, Resident 112 had a BIMS score of 15, which indicated Resident 112 was cognitively intact. During a concurrent observation and interview on 1/7/25 at 1:29 p.m. with the Regional Registered Dietician (RRD) at the tray line in the kitchen, the RRD stated she and the CDM was informed the kitchen was low on spinach bake and replaced the spinach bake with an alternate, green beans. Observed the CDM deliver a tray of green beans to the stove top for the tray line. During a concurrent observation and interview on 1/7/25 at 1:40 p.m. with the [NAME] (COOK) in the kitchen, the tray of mechanical soft chicken on the tray line was empty and the COOK was asked to prepare more mechanical soft chicken. The COOK stated they ran out of mechanical soft chicken, and she needed to prepare five more mechanical soft diet servings for residents. During an observation and concurrent interview on 1/7/25 at 2:00 p.m. with the RRD in the kitchen, the RRD stated the kitchen ran out of Ranch Style Chicken Breast for the test tray and replaced with an alternate menu item beef patty. The test tray displayed a beef patty (alternate to Ranch Style Chicken Breast, green beans (alternate to spinach bake), and red roasted potatoes. During an interview on 1/8/25 at 2:25 p.m. on the 1st floor common room with Certified Nurse Assistant (CNA) 5, CNA 5 stated residents complained they did not receive what was on the menu. CNA 5 stated last week residents complained they did not receive pudding. During a phone interview on 1/9/25 at 2:30 p.m. with the Registered Dietician (RD), the RD stated the kitchen should not run out of food. During an interview on 1/10/25 at 10:17 a.m. with CDM in the conference room, the CDM stated the cook ran out of cooked burgers, there was a case of burgers in the freezer and the cook did not cook more burgers. The CDM stated the cook did not prepare enough burgers for serving the residents. During an interview on 1/10/25 at 11:09 a.m. on the 1st Floor with Resident 48, Resident 48 stated the dinner menu noted chicken and dumplings, but the kitchen ran out and he was served chicken and celery. Resident 48 stated, It makes us (residents) feel like they (the facility) don't give a rats ass . when he did not receive what was indicated on the menu. Resident 48 stated sometimes the lunch or dinner meals were not served as written on the menu. Resident 48 stated the food service was Alright if you aren't on the first floor, seems like they run out (of menu items) only on the first floor. During an interview on 1/10/25 at 2:18 p.m. in the kitchen with CDM, the CDM stated there was a risk of unexpected weight loss to residents if meal preference were not honored. During a review of the facility's Substitution List Nov-[DATE], dated 12/18/24, the Substitution List indicated sweet potatoes was replaced with pudding with reason ran out. During a review of the Facility's Substitution List Dec-2024, dated 12/19/24, the Substitution List indicated fruit fluff was replaced with pudding with reason not enough fruit fluff/not enough made. During a review of the Facility's Substitution List January 2025, dated 01/07/25, the Substitution List indicated spinach was replaced with green beans with reason Sysco out of spinach. During a review of Diet Spreadsheet Menu: Rockport Winter 2024 Week 1, dated 2025, the Diet Spreadsheet indicated .Tuesday (Day 3) lunch menu listed spinach bake on the regular, mechanical soft (easy to chew and swallow), mechanical soft chopped meat, pureed (a very smooth, crushed or blended food), consistent carbohydrate diet(CCHO-a diet aimed to maintain stable blood sugar levels); low salt spinach for the low fat/low cholesterol diet and 2 gram sodium diet; spinach for those on the renal (restricted diet that limits salt, phosphorus, calcium and protein for people with kidney disease) 80 gram protein, renal diabetic diet . During a review of Diet Spreadsheet Menu: Rockport Winter 2024 Week 1, dated 2025, the Diet Spreadsheet indicated .Wednesday (Day 4) dinner menu: Chicken & Dumplings on the regular, mechanical soft, mechanical soft chopped meat, pureed, CCHO diet, low salt Baked Chicken Breast w/Pasta on the low fat/low cholesterol, renal 80gm protein, renal diabetic and 2gm sodium diets . During a review of the residents Lunch Meal Tickets, dated 01/07/25, the Lunch Meal Tickets indicated 49 of 54 residents on the 1st Floor should have received spinach bake. During a review of Soft Chopped Spinach Bake (A) (No Bacon) recipe, dated 2024, the Soft Chopped Spinach Bake recipe indicated 11 pounds 10 ounces of chopped frozen, thawed, drained spinach is required to prepare 70 servings. During a review of facility's policy and procedure (P&P) titled, Menus, dated 4/1/14, P&P indicated, .Food served should adhere to the written menu .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP-a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Residents 94 and 63) when: 1. Licensed nurses (LNs) did not implement CP for Resident 94's foley catheter (a thin, flexible tube that is inserted into your bladder to drain urine) to monitor signs and symptoms of infectious disease process. This failure had the potential for Resident 94 to develop an infection and placed an increased risk on Resident 94's health and safety. 2. Resident 63 did not have a comprehensive care plan for his diagnosis of Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after witnessing or experiencing a terrifying event). This failure had the potential to result in Resident 63 to not received the care needed for his PTSD which could result in serious mental health. Findings: 1. During a review of Resident 94's Admission Record (AR) dated 1/9/25, the AR indicated, Resident 94 was admitted to the facility on [DATE] with diagnoses which included paraplegia (the inability to voluntarily move the lower parts of the body), neuromuscular dysfunction of the bladder (the nerves and muscles that control your bladder aren't working properly together), contracture of the left and right hand (a permanent tightening of the muscles, tendons, skin, or nearby tissues that limits the range of movement of a joint or body part) and muscle weakness (loss of muscle strength). During a review of Resident 94's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], Resident 94's MDS assessment indicated Resident 94's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 13 out of 15 (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit). The BIMS assessment indicated Resident 94 was cognitively intact. During a concurrent observation and interview on 1/7/25 at 10:38 a.m., with Resident 94 in his room, Resident 94 was lying in bed, semi-reclined with foley catheter tubing visible that had white cloudiness and possible sediment (small particles, tiny bits of mineral crystals or debris, that build up inside the catheter tube used, essentially causing a clog where the urine can't flow freely). Resident 94 stated he had a urinary catheter [foley catheter] because he could not control his bladder. During a review of Resident 94's CP, dated 12/4/24, the CP indicated, .Focus: The Resident has Chronic Indwelling Catheter with diagnosis of Neurogenic bladder (a condition that causes a person to lose bladder control due to nerve damage in the brain) . Goal: Resident will be/remain free from catheter-related trauma . Interventions: . Monitor/record/report to MD (Medical Doctor) for signs and symptoms of UTI (Urinary Tract Infections- infection that occurs when bacteria grow in the urinary tract): .blood tinged urine, urine cloudiness . During a review of Resident 94's Urinary Drainage Assessment (UDA), dated 1/10/25, the UDA indicated, .Assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood and odor . Chart Code: 0- Administered . Administration History: 1/10/25, 1:23 p.m. Code 0 . 1/9/25, 11:07 p.m. Code 0 . 1/9/25, 9:55 a.m. Code 0, Administration By: Wound Nurse (WN) . 1/8/25, 9:48 a.m., Code 0, Administration By: WN . 1/7/25, 9:01 a.m., Code 0, Administered By: WN . During a concurrent observation and interview on 1/9/25 at 2:41 p.m., with Licensed Vocational Nurse (LVN) 5 in Resident 94's room, Resident 94's urinary catheter was cloudy, white, and red with sediments. LVN 5 stated she was Resident 94's nurse. LVN 5 stated the red color in the catheter appeared to be blood. LVN 5 stated she did not follow the care plan and was not properly assessing the foley catheter during her shift. LVN 5 stated the interventions in the care plan were there to identify signs and symptoms of an infection for Resident 94 and she needed to contact a doctor. LVN 5 stated by not assessing properly the resident could have developed an infection that could turn into sepsis (a life-threatening condition that occurs when the body has an extreme response to an infection) and possible hospitalization . LVN 5 stated the WN charted the urinary drainage assessment today and it was not accurate. LVN 5 stated she was responsible for the missed assessment and this issue should not have been overlooked, it slip through the cracks. During an interview on 1/9/25 at 3:25 p.m., with Certified Nurse Assistant (CNA) 10, CNA 10 stated she emptied Resident 94's foley catheter that day and noticed the cloudiness and red color in the urinary catheter tubing. CNA 10 stated she did not notify the nurse because she had already notified her of the same issue a week earlier. CNA 10 stated they (CNAs) were also responsible for implementing residents' care plans. During an interview on 1/9/25 at 3:59 p.m., with the Director of Nursing (DON), the DON stated the urinary catheter was not monitored, assessed or documented accurately. The DON stated Resident 94's care plan was not followed. The DON stated nursing staff should have done an accurate assessment and notified the physician of the findings and they did not. The DON stated Resident 94 could have developed an infection and had further complications. The DON stated staff did not follow the policy and procedure Indwelling Catheter. During an interview on 1/9/25 at 4:50 p.m., with the Wound Nurse (WN), the WN stated she had completed Resident 94's urinary catheter care and assessment dated [DATE], 1/8/25, and 1/9/25. The WN stated she needed to look at the urinary catheter more carefully and she absolutely could have done better. The WN stated she did not do an accurate urinary catheter assessment. The WN stated she did not notify the physician as the care plan indicated. The WN stated due to the inaccurate assessment, Resident 94 could have developed an infection (occurs when germs, such as bacteria, viruses, or fungi, enter the body and multiply. Infections can cause illness, fever, and other health issues). During an interview on 1/10/25 at 10:02 a.m., with the Infection Preventionist (IP-professional who make sure healthcare workers and patients are doing all the things they should to prevent infections), the IP stated licensed nurses did not follow Resident 94's care plan. The IP stated that catheter had cloudiness and hematuria (blood) in the tubing. The IP stated this issue should have been reported to the physician and it was not. The IP stated this was an infection control issue and it could have caused UTI or other disease process that could have caused hospitalization . During a review of the facility's P&P titled, Indwelling Catheter, dated 9/1/14, the P&P indicated, Purpose: to relieve bladder distension, to obtain a urine specimen for diagnosis testing and/or to maintain constant urinary drainage. Policy: . indwelling catheters will be used only when medically indicated . Procedure: the attending physician's decision to use an indwelling catheter will be based on valid clinical indicators including . i. Urinary retention that cannot be treated or corrected medically or surgically and for which alternative therapy is not feasible . F. Document the following in the residents medical record: .iii. Turn and characteristics, color . any difficulties .D. Documentation of catheter care will be maintained in the residents medical record . During a review of professional reference from the National Library of Medicine, Nursing Process, dated 4/10/23 (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/), indicated, .The nursing process functions as a systematic guide to client-centered care with five sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation . Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care . 51345 2. During a concurrent observation and interview on 1/6/25 at 11:40 a.m. with Resident 63 in Resident's 63's room, Resident 63 was sitting in a wheelchair, clean and well groomed. Resident 63 stated he served in Vietnam War, I have PTSD. Resident 63 stated because of PTSD, the loud noise of television across his room bothered him. Resident 63 stated he preferred closing his door because of the loud noise outside his room. During a record review of Resident 63's Admission Record (AR), dated 11/8/24, the AR indicated, Resident 63 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (blood sugar levels in the body are too high), peripheral vascular disease (reduced circulation of blood to the arms or legs), hereditary and idiopathic neuropathy (a nerve damage), and acquired absence of right leg below knee. During a review of Resident 63's MDS, dated [DATE], the MDS section C indicated, Resident 63's BIMS score was 15 out of 15, which indicated Resident 63 was cognitively intact. During an interview on 1/8/25 at 11:16 a.m. with LVN 4, LVN 4 stated she did not remember receiving training regarding Trauma informed care. LVN 4 stated it was important to develop a care plan for PTSD to avoid the stressors and to prevent worsening of Resident 63's condition. During a concurrent interview and record review on 1/8/25 at 2:57 p.m. with the Social Services Director (SSD), the SSD reviewed Resident 63's Electronic Medical Record (EMR) titled, Social Services Assessment and Trauma Informed Care Assessment-PTSD, dated 10/14/24. The SSD stated Resident 63 had a low probability for PTSD which meant Resident 63 was still at risk for PTSD. The SSD stated PTSD care plan should have been developed after she completed Resident 63's assessment. The SSD stated she created the PTSD care plan on 1/6/25 and should have been initiated on 10/14/24 in order for nursing staff to take care of Resident 63's needs. During an interview on 1/9/25 at 9:35 a.m. with LVN 2, LVN 2 stated a care plan should have been created when PTSD was identified for Resident 63. LVN 2 reviewed Resident 63's EMR and indicated Resident 63 was admitted on [DATE] and care plan for PTSD was initiated on 1/6/25. LVN 2 stated care plan was required to provide appropriate care and treatment for the residents. LVN 2 stated if care plan was not developed, staff would be unaware of resident needs that could lead to a slower progression of resident's condition. LVN 2 stated Trauma for Veterans was important to monitor closely for a difference in behavior. During an interview on 1/9/25 at 11:08 a.m. with the Activity Director (AD), the AD stated she was not aware of any residents with PTSD and there were no activities specific for PTSD. During an interview on 1/9/25 at 6:05 p.m. with the DON, the DON stated licensed nurses received training on Trauma Informed Care last year. The DON stated the SSD completed assessment for PTSD to identify any issues related to the event or trauma and should have developed an individualized person-centered care plan. The DON stated the SSD should have communicated with licensed nurses upon identification of PTSD in order to provide the proper care for Resident 63. During a review of facility's P&P titled, Comprehensive Person-Centered Care Planning, dated 11/2018, the P&P indicated, .It is the policy of this facility to provided person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of resident to obtain or maintain the highest physical, mental, and psychosocial well-being .Each IDT member will then initiate their baseline care plan .The baseline care plan must be completed within 48 hours from the resident's admission which each problem specific care plan dated and timed .

Based on observation, interview and record review, the facility failed to follow the policy and procedure (P&P) to ensure the Care Plans (CP) were reviewed and revised for five of 23 sampled residents (Resident 45, 67, 74, 76, and 392) when: 1. The CP for Resident 45 was not reviewed and revised after Resident 45 had a fall and was sent to the acute care hospital. This failure placed Resident 45 at an increased risk for additional falls. 2. Resident 67's care plan was not updated and revised when his pressure ulcer (a wound which develops as a result of prolonged pressure to one area) progressed to a stage III (a deep skin wound where the full thickness of the skin is damaged, exposing the fatty layer underneath, but not reaching the muscle or bone) wound. This failure had the potential to result in Resident 67 to not receive the wound care needed. 3. Resident 74's care plan was not updated and revised for significant weight loss of above five percent in 30 days. This failure had the potential for Resident 74's nutritional needs to not be met and put Resident 74 at risk for further weight loss. 4. Resident 74's care plan was not updated and revised after a fall on 11/5/24. This failure had the potential for Resident 74's needs to not be met and put Resident 74 at risk for further falls 5. Resident 76's care plan was not updated when he returned from the hospital with a pressure ulcer. This failure had the potential to cause Resident 76's pressure ulcers to worsen and nurses to be unaware of the care he needed. 6. Resident 392's care plan for apixaban (a medication that prevent blood clots from forming) was not initiated until 1/6/25. This failure put Resident 392 at risk for harm by not identifying and monitoring for harmful side effects. 7. Resident 392's care plan for Enhanced Barrier Precaution [EBP-precautions to prevent infection transmission) was not initiated until 1/6/25. This failure had the potential for Resident 392's needs being unmet and could result to serious health condition. Findings: 1. During a concurrent observation and interview on 1/6/25 at 8:50 a.m. with Resident 45 in Resident 45's room, Resident 45 was observed lying in bed, in his gown. Resident 45 stated he had been at the facility for under one year. Resident 45 stated he fell at home and hit his head. Resident 45 stated his family could not take care of him at home. During a review of Resident 45's Admission Record (AR), dated 1/9/25, the AR indicated Resident 45 was admitted to the facility from the acute care hospital on 7/16/24 with diagnoses of dysphagia (difficulty swallowing), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysarthria (difficulty speaking due to weak speech muscles), cognitive communication deficit (difficulty with thinking and how someone uses language), and history of falling. During a review of Resident 45's Minimum Data Set (MDS -a federally mandated resident assessment tool) dated 11/22/24, the MDS section C indicated Resident 45 had a Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11 out of 15 (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) which suggested Resident 45 was moderately impaired. During a concurrent interview and record review on 1/8/25 at 3:44 p.m. with the Licensed Vocational Nurse (LVN) 3, Resident 45's Care Plan (CP) for falls, undated was reviewed. LVN 3 stated Resident 45's CP was not revised after his fall on 11/11/24. LVN 3 stated all nursing staff including the Director of Nursing (DON) should have been revising Resident 45's CP for falls. LVN 3 stated the CPs were important because the CPs notified staff what was going on with the residents. LVN 3 stated CPs allowed staff to follow up on preventative measures and improve residents' health. LVN 3 stated if Resident 45's CP was not revised, Resident 45 could have become weaker and was at risk for another fall. LVN 3 stated Resident 45's CP should have been revised. During a review of Resident 45's Progress Notes, dated 11/11/24, the Progress Note indicated, . Resident had an unwitnessed fall from wheelchair in the lobby . noted to have laceration to bridge of nose, right eyebrow, right hand second digit, and right posterior hand . During an interview on 1/9/25 at 6:05 p.m. with the DON, the DON stated if there was a change in a resident's condition, the floor nurse was to complete and revise the resident's care plan at the time the change of condition was identified. The DON stated her expectation was that care plans were individualized to each resident's needs, complete and person-centered. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, indicated . the comprehensive care plan will be reviewed and revised at the following times . onset of new problems . change of condition . to address changes in behavior or care . other times as necessary . During a review of the facility's P&P titled, Fall Management Program, dated 3/13/21, indicated, . The IDT (Interdisciplinary Team -group of people with different areas of expertise working together to achieve a common goal) will initiate, review and updated the Resident's fall risk status and care plan at the following intervals: . identification of a significant change of condition, post fall and as needed . following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the Resident's care plan as necessary . once the Post-Fall Huddle is completed the licensed nurse will immediately update the care plan with recommendations . in an effort to prevent more falls, the IDT will review and revise the care plan as necessary . the Residents' care plans will be updated with the IDT's recommendations . During a review of the facility job description document titled, LVN Staff Nurse, undated, indicated, . Assists in developing, reviewing, revising, and updating resident Plans of Care as indicated . During a review of the facility job description document titled, Director of Nursing Services, undated, indicated, . Assures that a resident Plan of Care is established for each resident and that the plan is reviewed and modified as needed . 51345 2. During a concurrent observation and interview on 1/6/25 at 10:45 a.m. with Resident 67 in Resident 67's room. Resident 67 was lying in bed watching television, clean and well groomed. Resident 67 was alert and oriented and understood questions clearly. Resident 67 stated she has a wound on her buttock and nurses are providing wound treatment. During a record review of Resident 67's AR, dated 1/9/25, the AR indicated, Resident 67 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease with Heart Failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), Morbid Obesity (overweight-weight is more than 80 to 100 pounds above the ideal body weight) , Quadriplegia ( a condition causes a partial or total loss of function of both arms and legs), and Spinal Stenosis. (the space inside the backbone is too small). During a review of Resident 67's MDS, dated [DATE], the MDS section C indicated, Resident 67 had a BIMS score of 14 out of 15, which indicated Resident 67 was cognitively intact. Resident 67's MDS dated [DATE] Section M indicated Resident 67 is at risk for developing pressure ulcers/injuries. During a concurrent interview and record review on 1/10/25 at 3:47 p.m. with Wound Nurse (WN), Resident 67's care plan dated 12/6/24 was reviewed by WN. WN indicated care plan for Stage 2 and Stage 3 pressure ulcers were initiated on 12/6/2024 and created date of 1/7/25. The WN stated she created Resident 67's care plan for Stage 2 and Stage 3 pressure ulcers. The WN reviewed the unresolved care plans for Resident 67 and indicated Stage 2 pressure ulcer to left buttock was initiated 12/1/24 and was resolved. The WN stated care plan should not have been resolved because Resident 67's pressure ulcer to left buttock was not healed. The WN indicated Resident 67 did not have a care plan for the Stage 2 pressure ulcer on the right thigh when it was identified. The WN stated Resident 67's care plan for Stage 2 and Stage 3 pressure ulcers was not initiated upon identification of pressure ulcers. The WN stated it was important to initiate care plan timely to prevent delay in care and treatment which can potentialy result in worsening of wounds. During an interview with DON on 1/09/25 at 6:05 p.m. the DON stated resident's comprehensive assessment and care plan must be initiated when pressure ulcers was identified. The DON stated resident's comprehensive person-centered care plan must be developed, updated, and revised to provide residents the right care to prevent delay in care and treatment. The DON stated if a change of condition for facility acquired pressure ulcers and care plan was not developed, updated, or revised, It can result in worsening of wounds. During a review of facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2028, the P&P indicated .Additional changes or updates to the resident comprehensive care plan will be made based on the assessed needs of the resident . During a review of facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 6/27/24, the P&P indicated .Review resident's care plan and update as necessary . 3. During a concurrent observation and interview on 1/6/25 at 8:47 a.m. with Resident 74 in Resident 74's room, Resident 74 was sitting on her walker seat in her room, alert and oriented and understood the questions clearly. Resident74 was clean and well groomed. Resident 74 stated she had been at the facility since June last year. Resident 74 stated she could not tolerate the food at the facility, food was undercooked and cold. Resident 74 stated her stomach was weak and anything could come up just looking at the food. Resident 74 stated she lost weight. Resident 74 stated she requested sandwich for lunch and dinner until she feels better and stated she did not received sandwich as requested. Resident 74 stated her daughter brought food that she could eat and tolerate. During a review of Resident 74's AR, dated 1/9/25, the AR indicated, Resident 74 was admitted to the facility on [DATE] with diagnoses Type 2 Diabetes Mellitus(when the blood sugar levels in the body are too high), Cirrhosis of Liver (permanent scarring that damages the liver and interferes with its functioning), Malignant Neoplasm of Left Breast (a disease in which abnormal cells divide uncontrollably and destroy body tissue), and Hypertensive Heart Disease with Heart Failure (the heart is unable to pump blood around the body properly). During a review of Resident 74's MDS dated [DATE], the MDS Section C indicated Resident 74's BIMS assessment score was 14 out of 15 which indicated Resident 74 was cognitively intact. During a concurrent interview and record review on 1/9/25 at 9:14 a.m. with Nurse Supervisor (NS) 2, NS 2 reviewed Resident 74's Nutrition Care Plan (NCP), dated 6/21/24, the NCP was not revised to reflect interventions about significant weight loss. NS 2 stated Resident 74's NCP was revised on 10/9/24. NS 2 stated nurses should have updated and revised Resident 74's NCP to reflect the significant weight loss and change of condition. NS 2 stated nursing staff was not aware of Resident 74's weight loss. During an interview on 1/9/25 at 10:00 a.m. with Certified Nursing Assistance (CNA) 9, CNA 9 stated she was assigned for Resident 74, and she was not aware of Resident 74's weight loss. During a telephone interview on 1/09/25 at 3:09 p.m. with the Registered Dietitian (RD), the RD stated Resident 74 had a significantly weight loss of 16 pounds in one month. The RD stated Resident 74's weight loss was unavoidable due to diagnoses of Cirrhosis of the Liver, Cancer, and diuretic use. The RD stated she interviewed Resident 74 on 1/6/25 and stated Resident 74 did not want anything at that time. The RD stated she was aware of Resident 74's request of sandwich for lunch dinner and the RD indicated a sandwich for lunch and dinner was not enough to meet her caloric needs. The RD stated the facility needed to honor and follow resident's food preference. The RD stated Resident 74's care plan should have been revised and reviewed for significant weight loss. During an interview on 1/9/25 at 4:59 p.m. with LVN 7, LVN 7 stated she did not received information from the morning nurse during report regarding Resident 74's change of condition for significant weight loss. LVN 7 reviewed Resident 74's NCP dated 6/21/24, and indicated the NCP care plan for significant weight loss was not updated and revised. During an interview on 1/9/25 at 6:05 p.m. with the DON, the DON stated floor nurses entered the weights in electronic medical record completes change of condition, create, revised, and update residents' care plans. The DON stated her expectation was for nurses to follow the facility's Policy and Procedure. The DON stated resident's comprehensive person-centered care plan must be developed, updated, and revised to provide resident the right care to prevent delay in care and treatment. The DON stated if a change of condition for weight loss and care plan was not developed, updated, or revised, It can result for further weight loss. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, indicated, .The comprehensive care plan will be reviewed and revised at the following times . onset of new problems . change of condition .to address changes in behavior or care . other times as necessary . 4. During a review of Resident 74's IDT note dated 11/6/24, the IDT note indicated Resident 74 had unwitnessed fall without injury on 11/5/24 at 1:05 p.m. The IDT' indicated, .Interventions: Refer to Rehab for safe wheelchair sitting position and mobility and Educate resident to ask for assistance using call light when needed . During an interview on 1/10/25 at 3:00 p.m. with the DON, the DON stated it was her expectation nurses/staff to follow the P&P for the Fall Program. The DON stated a fall care plan for Resident 74 should have been initiated, updated or revised after each fall. The DON stated Resident 74's fall care plan should have been updated based on IDT recommendations and interventions to prevent further falls. During a concurrent interview and record review on 1/10/25 at 4:02 p.m. with Registered Nurse (RN) 2, RN 2 reviewed Resident 74's At risk for fall care plan, dated 6/24/24 and indicated fall care plan was revised on 10/9/24. RN 2 stated Resident 74's care plan should have been revised after the fall to prevent Resident 74 from having additional falls. During a review of facility's policy and procedure (P&P) titled, Fall Management Program, dated 3/13/2022, the P&P indicated, . Following every resident fall, the licensed nurse will .initiate or revise the Resident's care plan as necessary; The residents' care plans will be updated with the IDT's recommendations . 48424 5. During a review of resident 76's AR dated 1/9/25, the AR indicated, Resident 76 was admitted with a stage two pressure ulcer to the sacral region (shallow open wound to the bottom of the back). During a concurrent interview and record review on 1/8/24 at 3:03 p.m. With LVN 1, Resident 76's Care Plan, dated 1/8/24 was reviewed. The Care Plan indicated Resident 76 did not have care plan for Resident 76's pressure ulcer. LVN 1 stated, Resident 76 was admitted to the facility with a pressure ulcer aquired while at the hospital. LVN 2 stated Resident 76 needed to have his pressure ulcer documented on the care plan as soon as he came back from the hospital. LVN 2 stated it was important to care plan Resident 76's pressure ulcer when he arrived from the hospital because nurses needed to accurately document any changes of conditions in the care plan. LVN 1 stated, The care plan was what drives what care the residents receive. LVN 1 stated an inaccurate care plan would not accurately alert nurses on how to care for the resident. During an interview on 1/10/24 at 3:01 p.m. with the DON, the DON stated Resident 76's pressure ulcer should have been care planned in order to prevent further complications from occurring. The DON stated care plans were important because they contained treatment orders and any other interventions which could help Resident 76. The DON stated the care plan should have been updated at the time nurses noticed the pressure ulcer. During a review of the facility's P&P titled Comprehensive person-Centered Care planning, dated 11/18, the P&P indicated, . The Baseline Care plan . will be developed and implemented . within 48 hours of the resident's admission . the baseline care plan must reflect the resident's stated goals and objectives, and include interventions that address his or her needs . During a review of the facility's P&P titled, Pressure Injury Prevention, dated 6/27/24, the P&P indicated, . Complete a skin risk evaluation upon admission/re-admission . based on the risk score, develop a plan of care for the resident's risk factors . implement interventions identified in the plan of care . 51284 6. During review of Resident 392's AR dated 1/9/25, indicated, Resident 392 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of right lung (a cancerous tumor that started in the lungs), peripheral vascular disease (a chronic condition that occurs when blood vessels narrow, block, or spasm) and atrial fibrillation (a type of irregular heartbeat). During a review of Resident 392's Order Summary Report (OSR) dated 12/12/24, the OSR indicated Resident 392 had an order for apixaban 2.5 mg (milligram-unit of measurement) tablet twice a day for blood clot prevention. During a concurrent interview and record review on 1/8/24 at 2:45 p.m. with LVN 1, Resident 392's Care Plan dated 1/6/25 was reviewed. LVN 1 stated Resident 392 was admitted to the facility with the anticoagulant (blood thinner) medication order. LVN 1 stated, Resident 392's anticoagulant care plan was initiated on 1/6/25. LVN 1 stated the care plan should have been initiated when the medication order was received (12/12/24) in order to monitor for medication side effects (unwanted reaction to a drug). During an interview on 1/9/25 at 10:23 a.m. with the MDSN 1, the MDSN 1 stated anticoagulant care plan should have been initiated immediately to monitor any possible side effects of the medications and to properly care for Resident 392. MDSN 1 stated it was the responsibility of the charge nurses to initiate care plans when residents were admitted to the facility and when new orders were received. During an interview on 1/10/25 at 5:24 p.m. with the DON, the DON stated it was important for care plans to be initiated and implemented timely to monitor and prevent drug complications. 7. During a concurrent interview and record review on 1/8/25 at 2:45 p.m. with LVN 1, Resident 392's EBP care plan dated 1/6/25 was reviewed. LVN 1 stated the EBP care plan should have been initiated when Resident 392 was admitted to the facility on [DATE] and not on 1/6/25. LVN 1 stated Resident 392's EBP care plan was not initiated at an acceptable time frame. During an interview on 1/8/25 at 2:45 p.m. with Nurse Supervisor (NS) 2, NS 2 indicated it was the responsibility of licensed nurses to create, review and update care plans as needed in the required timeframe. NS 2 stated care plans were to be resident centered to address their specific needs. NS 2 stated care plans should be initiated and completed immediately when residents were admitted to the facility. During an interview on 1/10/25 at 2:18 p.m. with Infection Preventionist (IP-professionals who make sure healthcare workers and health facilities are doing all the things they should to prevent infections from spreading), the IP stated he assumed the position as IP on 1/6/25 and was instructed to screen residents who needed to be placed on EBP. The IP stated he notified the doctor, obtained orders, and created the EBP care plan. The IP stated EBP were important for residents who were at an increased risk for infections and care plans were important in order for staff to provide necessary care to residents. During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated 11/18 P&P indicated, .It is the policy of the facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice .within seven days .

Based on observation, interview and record review, the facility failed to ensure professional standards of quality were met in accordance with the comprehensive care plan and facility policies and procedures for four of nine sampled residents (Residents 74, 67, 55 and 392) when: 1. Resident 67's change of condition and Nutritional Assessment for a facility acquired pressure ulcer (a wound which develops as a result of prolonged pressure to one area), Stage 2 pressure ulcer to right thigh and Stage 3 pressure ulcer to left buttock were not assessed. This failure had the potential for Resident 67's wounds to worsen which could result in more serious health condition. 2. Resident 74's change of condition for significant weight loss above five percent in one month was not developed and Interdisciplinary team (IDT-group of people with different areas of expertise working together to achieve a common goal) note was not completed. This failure had the potential to put Resident 74 at risk for further weight loss. 3. Resident 55's oxygen order of 2L (L- units of measurement) was not followed. This failure had the potential for Resident 55 to develop respiratory distress (difficulty breathing) which could lead to serous health condition. 4. The Activities Director (AD) allowed two activities assistants to document in Resident 392's activities using AD's credentials. This failure resulted in compromised accuracy of documentation and improper record management of Resident 392. Findings: 1. During a concurrent observation and interview on 1/6/25 at 10:45 a.m. with Resident 67, in Resident 67's room, Resident 67 was observed lying in bed watching television, clean and well groomed. Resident 67 was alert and oriented and understood questions clearly. Resident 67 stated she had a wound on her buttock and nurses were providing wound treatment. During a record review of Resident 67's Admission Record (AR), dated 1/9/25, the AR indicated, Resident 67 was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), morbid obesity (overweight-weight is more than 80 to 100 pounds above the ideal body weight), quadriplegia ( a condition causes a partial or total loss of function of both arms and legs), and spinal stenosis (the space inside the backbone is too small). During a review of Resident 67's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/13/24, the MDS section C indicated, Resident 67's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 14 out of 15, (0-15 scale- 0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) indicating Resident 67 was cognitively intact. Resident 67's MDS dated [DATE] Section M (Skin Condition) indicated Resident 67 was at risk for developing pressure ulcers/injuries. During a concurrent interview and record review on 1/8/2025 at 10:20 a.m. with the Wound Nurse (WN), the WN stated Resident 67 developed facility acquired pressure ulcers to left buttock and right thigh. The WN reviewed Resident 67's electronic medical record (EMR) titled, eINTERACT Change in Condition Evaluation, dated 12/1/24, WN stated Resident 67's left buttock wound started on 11/30/24 as Stage 2 pressure ulcer. The WN stated Resident 67 was assessed by the wound Doctor on 12/4/24 and Resident 67's Stage 2 pressure ulcer worsened to Stage 3.The WN reviewed Resident 67's electronic medical records and stated there was no change of condition assessments for Resident 67's facility acquired pressure ulcers-Stage 2 to right thigh and Stage 3 to left buttock. The WN stated it was important to document change of condition to monitor the progress of the wounds. During a concurrent interview and record review on 1/9/25 10:15 a.m. with Nurse Supervisor (NS) 2, NS 2 reviewed EMR and stated Resident 67's Stage 2 pressure ulcer to left buttock started on 11/30/24 and worsened to Stage 3 pressure ulcer on 12/4/24. NS 2 stated there was no change of condition and IDT note documented. NS 2 stated every decline in condition required a change of condition assessment and IDT note to determine if the pressure ulcer was avoidable or unavoidable. NS 2 stated completing a change of condition was important to alert the nurses of the change of condition and to prevent delay in care and treatment that could potentially result to worsening of the wound. During a concurrent interview and record review on 1/9/25 at 4:38 p.m. with Registered Nurse (RN) 2, RN 2 reviewed Resident 67's electronic medical record and indicated there was no change of condition assessments for Stage 3 left buttock pressure ulcer and Stage 2 right thigh pressure ulcer. RN 2 stated a change of condition should have been completed for facility acquired pressure ulcers to properly assess Resident 67 and prevent further decline. During an interview on 1/9/25 at 6:05 p.m. with Director of Nursing (DON), the DON stated a new change of condition was required when wound had worsened from Stage 2 pressure ulcer to Stage 3 pressure ulcer. The DON stated comprehensive assessment and care plan should have been initiated when Resident 67's pressure ulcers were identified. The DON stated her expectation was for nurses to follow the Policy and Procedures for change of condition to provide residents the proper care and no delay in care and treatment occurred, The DON stated this could have resulted in Resident 67's worsening of wounds. During an interview on 1/10/25 at 4:33 p.m. Minimum Data Set Nurse (MDSN) 2, MDSN 2 stated she was not aware Resident 67 had a facility acquired Stage 3 pressure ulcer. MDSN 2 stated comprehensive assessment was required for significant change in condition. MDSN 2 stated it was important to identify a significant change in condition to be able to provide the services -therapy or diet change to overcome the deficiency and to help residents get better. 2. During a concurrent observation and interview on 1/6/25 at 8:47 a.m. with Resident 74, in Resident 74's room, Resident 74 was sitting on her walker seat in her room, alert and oriented and understood the questions clearly. Resident was clean and well groomed. Resident 74 stated she had been at the facility since June last year. Resident 74 stated could not tolerate the food at the facility and she lost weight. Resident 74 stated her stomach was weak and anything could come up just looking at the food. Resident 74 stated her daughter brought her food she could eat and tolerate. Resident 74 stated she requested sandwich for lunch and dinner until she feels better. Resident 74 stated she did not received a sandwich as requested. During a review of Resident 74's Admission Record (AR), dated 1/9/25, the AR indicated, Resident 74 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus(when the blood sugar levels in the body are too high), cirrhosis of liver (permanent scarring that damages the liver and interferes with its functioning), malignant neoplasm of left breast ( a disease in which abnormal cells divide uncontrollably and destroy body tissue, and hypertensive heart disease with heart failure (the heart is unable to pump blood around the body properly). During a review of Resident 74's Minimum Data Set, dated dated dated [DATE], the MDS section C indicated, Resident 74 had a BIMS assessment score of 14 out of 15 , which indicated Resident 74 was cognitively intact. During a concurrent interview and record review on 1/9/25 at 9:14 a.m. with Nurse Supervisor (NS) 2, NS 2 reviewed Resident 74's change of condition titled eINTERACT Change in Condition Evaluation-V5.1, and indicated Resident 74's change of condition for significant weight loss was not documented. NS 2 stated Nursing was not aware of Resident 74's weight loss. During an interview on 1/9/25 at 10:00 a.m. with Certified Nursing Assistance (CNA) 9, CNA 9 stated she was assigned for Resident 74, and she was not aware of Resident 74's weight loss. During an interview on 1/9/25 at 4:59 p.m. with LVN 7, LVN 7 stated she did not received information from the morning nurse regarding Resident 74's change of condition for significant weight loss. During an interview on 1/9/25 at 6:05 p.m. with the DON, the DON stated floor nurses entered weights in electronic medical record complete a change of condition, created, revised, and updated resident's care plans. The DON stated her expectation was for nurses to follow the facility's Policy and Procedure. The DON stated if a care plan was not developed, updated, or revised for weight loss, It can result for further weight loss. The DON stated IDT note was not completed for Resident 74's significant weight loss. The DON stated IDT note should have been completed for Resident 74's significant weight loss to implement IDT recommendations to prevent Resident 74 for further weight loss. During a concurrent interview and record review on 1/10/25 at 4:02 p.m. with RN 2, RN 2 was not aware Resident 74 had a significant weight loss. RN 2 stated it was not communicated to her by the morning shift nurse. RN 2 reviewed Resident 74's weights and vitals, dated 1/3/25, and sated the DON entered the weight of 209 pounds on 1/3/25 and the previous month weight was 225 pounds. RN 2 stated Resident 74's change of condition assessment should have been completed and started on alert charting for the significant weight loss. RN 2 stated there was no alert charting for Resident 74's weight loss. RN 2 stated it was important for nursing staff to be aware of Resident 74's change of condition in order to monitor oral intake to prevent further weight loss. During an interview on 1/10/25 at 4:32 p.m. with CNA 8, CNA 8 stated she was familiar Resident 74, and she was not aware of Resident 74's weight loss. During a review of facility's policy and procedures (P&P) titled, Change of Condition Notification, dated 4/1/2015, the P&P indicated, . It is the responsibility of the person who observe the change to report to the Licensed Nurse .License Nurse will assess the change of condition and determine what nursing intervention are appropriate .a change in weight of five pounds or more within a 30 day period .Licensed will document a change of condition .License Nurse will communicate any changes in required interventions to the CNA's involved in resident care . During a review of facility's policy and procedures (P&P) titled, Skin Integrity Assessment, dated 6/27/24, the P&P indicated, .The dietary needs of the Resident will be evaluated by the registered dietitian upon any significant change in skin condition . 40641 3. During a observation on 1/9/25 at 8:48 a.m. with Resident 55 in Resident 55's room, Resident 55 observed siting up in bed, nasal cannula (NC- tube that delivers oxygen through the nose to people who have low oxygen levels) connected to concentrator (device that produces oxygen for breathing) and set to 3L. During a observation on 1/9/25 at 3:45 p.m. with Resident 55 in Resident 55's room, Resident 55 observed sitting up in bed watching tv. NC in use and oxygen levels set to 3L. During a review of Resident 55's AR, the AR indicated, Resident 55 was admitted to the facility on [DATE] with the admission diagnosis of chronic obstruction pulmonary disease (COPD- a condition of the airway and the difficulty or discomfort in breathing) and asthma (a chronic lung disease that causes the airway to swell and narrow making it difficult to breathe). During a review of Resident 55's MDS, dated [DATE] the MDS section C indicated Resident 55 had a BIMS assessment score of 13 out of 15 which indicated Resident 55 was cognitively intact. During a review of Resident 55's Order Summary Report (OSR), dated 8/23/24, the OSR indicated, .Oxygen at 2L/minute via nasal cannula continuously for COPD . During a concurrent interview and record review on 1/10/25 at 9:39 a.m. with Nurse Supervisor (NS) 1, Resident 55's AR dated 5/2/22 and OSR dated 8/23/24 were reviewed. NS 1 stated the physician orders were to be followed. NS 1 stated Resident 55 did not have a documented change in condition or an emergency situation for the oxygen to be increased. NS 1 stated Resident 55's oxygen order should have been followed and licensed nurses should have been monitoring to ensure Resident 55 was receiving the correct oxygen order. During an interview on 1/10/25 at 5:24 p.m. with DON, The DON stated the expectation was to inform the doctor of residents change in condition and obtain an order. The DON stated staff should not change oxygen rate without doctors' orders. During a review of facility policy and procedure (P&P) titled Oxygen Therapy, dated 11/17, the P&P indicated, .Administer oxygen per physician orders.If oxygen saturations fall .the physician will be notified immediately . 4. During a concurrent interview and record review on 1/9/25 at 9:22 a.m. with the AD, Resident 392's activities history was reviewed. The AD stated activies staff provided Resident 392 with 1:1 activities three times a week. The AD stated she did not provide 1:1, but her activies assistants worked with residents on 1:1. The AD stated two of her activities assistants did not have access to their electronic documentation system. The AD stated she had been allowing her two assistants to use her credentials to document activities provided to residents. The AD stated she should not have allowed the activies assistants to have documented using her credentials. During an interview on 1/9/25 at 9:22 a.m. with Activities Assistant (AA) 1, AA 1 stated she worked in the facility full time for one year as an AA. The AA 1 stated she provided activities to residents with 1:1 in their rooms and spent five to 10 minutes providing activities according to the residents' care plan. AA 1 stated at the end of each visit, she documented the activities provided in resident charts. During an interview on 1/9/25 at 2:56 p.m. with Activities Assistant (AA) 2, AA 2 stated she had worked at the facility for 2 years and had been documenting in resident charts using her own credentials. AA 2 stated it is not accurate documentation when another staff member documents in a residents chart using another staff members name and did not think it was allowed. During interview on 1/9/25 at 3:45 p.m. with Administrator (ADM), the ADM stated it is the responsibility of the ADM to grant computer access to non-nursing staff such as the activities assistant. The ADM stated the process of granting access should not take longer than a month. The ADM stated he was not aware AD had been allowing her two activities assistants to document care provided to residents under her name. During a review of facility's policy and procedure (P&P) titled Completion & Correction dated 1/12 .Documentation content .Significant observation related to resident. Each time the physician is notified . During a review of facility's document titled, Activity Director job description, undated, the job description indicated, . Maintains written records of residents attendance in activities . includes room visit/1:1 documentation, . interventions . During a review of facility document titled, Activity Assistant Job Description undated. The job description indicated .updates and maintains resident activity records .ensure .documentation, as required .

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1), when facility had knowledge of Resident 1's preference to sit outside, had a history of falls, and required assistance with personal care. Facility staff did not provide supervision while Resident 1 was outside and were unaware Resident 1 left the facility's premises on 10/1/24 unsupervised. These failures resulted in Resident wandering unsafely in the streets around the facility and suffering an avoidable auto versus pedestrian accident. Resident 1 sustained injuries which included injury to the right femur shaft fracture (break in the thigh bone between the hip and knee), closed inferior pubic rami fractures (break in one of the bones in part of the pelvis), traumatic pneumothorax (air leaks from the lung and fills the space between the lung and chest wall), closed fracture of multiple ribs, right phalanx fracture (a break in one or more of the small bones in right finger), L1 vertebra compression fracture (injury that occurs when too much pressure is applied to the spine), closed fracture of transverse process of lumbar vertebra (injury caused by high amount of force on a bone in the lower back). As a result, Resident 1 was hospitalized in the trauma unit with injuries that caused pain, suffering and mobility deficits. During an interview on 10/3/24 at 10:00 a.m. with the administrator (ADM), the ADM stated that on 10/1/24 at approximately 8:00 a.m., he was alerted by a facility staff member that a man, resembling Resident 1, was being transported by emergency medical services (EMS) two to three blocks away from the facility. The ADM stated when he arrived at the incident site, law enforcement was at the scene. The facility staff checked the facility to account for all residents and concluded Resident 1 was missing. The ADM stated Resident 1 was his own representative and made decisions for himself and had no prior history of leaving the facility premises. The ADM stated Resident 1 was considered an independent resident and did not require constant monitoring while being outside for daily exercises around the facility perimeter or sitting in the courtyard. During a review of Resident 1's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Hypertensive heart and kidney disease (condition that damages the heart and kidneys), peripheral vascular disease (circulation disorder), end stage renal disease (terminal illness when kidneys can no longer function), Chronic Kidney Disease (CKD- kidneys are damaged and don't filter blood properly), Alcohol abuse, hyperlipidemia, Anxiety disorder (feeling of worry, unease and nervous), Polyneuropathy (nerve damage), muscle weakness, dysphagia (difficulty swallowing), need for assistance in personal care, other abnormalities of gait and mobility, cognitive communication deficit, heart failure, cardiomegaly (heart is larger than normal), constipation, pain, acquired absence of the left leg, history of falling, edema (swelling caused by too much fluid). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 8/29/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 13 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a review of Resident 1's ADL care plan, dated 3/21/23, the care plan indicated, . The resident has an activities of daily living (ADL) self-care performance and resident is at risk for declining in ADL self-performance . interventions . toilet use . the resident requires supervision/touching assistance by 1 staff for toileting. Transfer the resident requires supervision/touching assistance (requiring person to observe transfers) by 1 staff for to move between surfaces . During a review of Resident 1's Falls care plan, dated 3/22/23, the care plan indicated, . The resident at risk for falls related to gait (manner of walking)/balance problems . interventions anticipate and meet the residents' needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . During an interview on 10/3/24 at 10:15 a.m. with the Receptionist, the receptionist stated the process for a leave of absence (LOA) included signing out the resident at the nurse's station on the floor they were located. The receptionist stated it was her responsibility to ask any resident who was exiting the facility through the lobby doors, where they were going. The receptionist stated it was also her responsibility to identify elopement (when a patient incapable of protecting themselves departs unsupervised and undetected) risk residents when they are near the exit doors in the lobby. The receptionist stated on the morning of 10/1/24, she was told Resident 1 had left the facility premises before her start of shift at 8:00 a.m. The receptionist stated there was no facility staff positioned to monitor the exit doors in the lobby before she arrived. The receptionist stated she was not responsible for monitoring residents when they were outside but was responsible for alerting staff when residents exited the facility. The receptionist stated it was important to monitor all residents and know where they are at all times to ensure their safety. During an interview on 10/3/24 at 10:35 a.m. with Resident 2, Resident 2 stated he had been in the facility for two and half years. Resident 2 stated he understood the facility process to sign himself out but would exit the facility and return without any issues of signing out. Resident 2 stated he knew Resident 1 and would often see him sitting outside. Resident 2 stated there were no employees seen outside when he would sit outside with Resident 1. During a review of Resident 2's Admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis for polyneuropathy, type 2 diabetes mellitus (body doesn't regulate insulin and causes high blood sugar), osteoarthritis (cartilage and bone break down over time), seizures (uncontrolled activities in the brain that cause changes in behavior, movement and awareness), major depressive disorder (mental illness that causes low mood and loss of interest in activity), alcohol abuse, lack of coordination, abnormalities of gait and mobility, muscle weakness, heart failure (heart is unable to pump enough blood and oxygen in the body), opioid (medication used to reduce moderate to severe pain) abuse. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 14 out of 15 which indicated Resident 2 was cognitively intact. During a record review of Resident 1's Physician Order dated 10/18/23, the Physician Order indicated, May go out on pass. During a record review of Resident 1's Physician Order dated 10/1/24, the Physician Order indicated, May go out on pass independently. During a concurrent interview and record review on 10/3/24 at 10:46 a.m. with LVN 1, Resident 1's Physician Order dated 10/18/23 and Leave of Absence Binder dated 2024 were reviewed. The Physician Order indicated, May go out on pass. LVN 1 stated the order indicated Resident 1 could have left the faciity on his own as long as he signed out in the LOA binder. The LOA binder indicated Resident 1 had not signed himself out of the facility on 10/1/24. LVN 1 stated she was the nurse in charge of Resident 1's care on 10/1/24. LVN 1 stated she knocked on Resident 1's bathroom door at approximately 7:15 a.m. as he was not in bed, and Resident 1 had verbally responded from the bathroom indicating he was there. LVN 1 stated she left the room and returned at approximately 7:45 a.m. to check Resident 1's blood pressure, but noted he was not in his room. LVN 1 stated she knew Resident 1 had a daily routine to wheel himself to the elevator of the third floor, wheel himself outside and sit in the facility front courtyard or wheel himself around the facility perimeter for exercise. LVN 1 stated she was not alarmed by Resident 1's absence from his room as the certified nursing assistant (CNA) caring for Resident 1 would have gone downstairs to alert Resident 1 that breakfast was being served or Resident 1 would have gone up to the third floor on his own by breakfast time served at around 7:55 a.m. to 8:00 a.m. LVN 1 stated usually Resident 1 would have been monitored by the facility receptionist while he was outside because there was no staff assigned to monitor residents while they are outside or surrounding the perimeter of the facility. LVN 1 stated, generally there were a lot of residents who sat outside at a time, and it would have been beneficial to assign a staff member to monitor them. LVN 1 stated it was important to monitor Resident 1 and all other residents for their safety. During an interview on 10/3/24 at 11:16 a.m. with CNA 1, CNA 1 stated the facility process was for all residents to sign out in the LOA binder prior to leaving the facility premises. CNA 1 stated when Resident 1 left the facility to sit in the courtyard or exercise around the facility premises, Resident 1 was not required to sign out because he was still on the facility premises. CNA 1 stated when Resident 1 was outside there was no one specifically assigned to monitor. CNA 1 stated when Resident 1 was sitting outside it was the CNA assigned to Resident 1's responsibility to monitor resident every hour. CNA 1 stated it would have been beneficial to have staff assigned to monitor residents who were sitting outside for their safety. During an interview on 10/3/24 at 11:50 a.m. with the social services director (SSD), the SSD stated it was all staff responsibility to monitor residents while they were sitting outside of the facility. The SSD stated when the residents were sitting outside the facility, staff kind of kept an eye on them. The SSD stated it was all facility staff's responsibility to monitor the residents who were outside. The SSD stated she was not aware of who would monitor residents in the early morning before the receptionist arrived at 8:00 am. During a concurrent interview and record review on 10/3/24 at 1:15 p.m. with the assistant director of nurses (ADON), Resident 1's Physician Order dated 10/1/24 and Physician Order dated 10/18/23 were reviewed. The physician order dated 10/1/24 indicated, . May go out on pass independently. The physician order dated 10/18/23 indicated, May go out on pass. The ADON stated Resident 1 was permitted to leave the facility independently without supervision but had not followed the LOA process in place when he was outside for his exercises. The ADON stated Resident 1 was independent and his own representative and did not require constant monitoring when he was outside. The ADON stated the two physician orders were the same and Resident 1 could have signed himself independently. The ADON stated the reason for the change in the orders specifically on 10/1/24 was because the facility was working on changing the orders not because they meant different things. During an interview on 10/3/24 at 1:24 p.m. with the administrator (ADM), the ADM stated Resident 1 was non-compliant with the facility policies. The ADM stated that during his investigation, the LOA binder located at the nurse's station on the third floor was reviewed. The ADM stated it was determined, Resident 1 had not signed himself out of the facility on 10/1/24. The ADM stated independent residents including Resident 1, were not monitored as they would go outside complete their daily routines and go back into the facility. The ADM stated that prior to the receptionist arrival, residents who were sitting outside were monitored by staff that were in and out of the facility, but no one was specifically assigned to monitor the residents. During a phone interview on 10/3/24 at 2:47 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 1 on 10/1/24 the day of incident. CNA 2 stated that on the day of the incident she had arrived late to her shift at around 7:40 a.m. and did not receive report as night shift CNA had ended her shift prior to CNA 2's arrival. CNA 2 stated she went to Resident 1's room and noted Resident 1 was not in his room. CNA 2 stated she was not alarmed with Resident 1's absence as Resident 1 was assumed to be downstairs in the courtyard or facility premises as per his routine. CNA 2 stated she was assisting other residents on the third floor when she was notified that something had happened to Resident 1. CNA 1 stated the facility process was for all residents leaving the facility premises to sign out at the nurse's station and alert staff. CNA 2 stated Resident 1 required set up help with dressing & toileting and required 1 person supervision assistance for transfers. CNA 2 stated when Resident 1 was outside it was assumed all staff was monitoring all residents and stated she would monitor Resident 1 every 30 minutes to an hour. CNA 2 stated it was important to monitor all residents when they were outside for safety and to know where they were at all times. During a review of electronic mail (Email) correspondence from the facility ADM titled Out on Pass Clarification dated 10/3/24, the email was regarding Resident 1's Physician Order dated 10/18/23, the Physician Order indicated, May go out on pass. The email was also regarding Resident 1's Physician Order dated 10/1/24, the Physician Order indicated, May go out on pass independently. The email indicated .I talked to director of nursing (DON) about the difference between out on pass and out on pass independently. The difference between the two is that both residents are able to go out on pass but one will require assistance to go out, while the Independent is able to go without the need of assistance . Review of the email from the ADM indicated Resident 1 required assistance when leaving the facility. During a concurrent observation and interview on 10/4/24 at 9:50 a.m. with Resident 1 at the acute care hospital room, Resident 1 was observed lying in bed eating breakfast, Resident 1 was observed smiling and talking. Resident 1 was observed with abrasion (rub or wearing off of the skin) to the right side of face, bilateral (both) bruising to upper extremities and bandage wrapped around his right thigh extending below the knee. Resident 1 stated he did not recall what had occurred during the accident and could not recall where he was located at the time of the interview. Resident 1 stated he recalled being at the facility for a few days not years. Resident 1 stated he recalled riding his bike and then suddenly being transported by EMS. Resident 1 was not able to state the year, location or situation but could recall his name. Resident 1 stated he had lost his legs in the acute hospital when they were cut by a laser. Resident 1 repeatedly asked if it was ok for him to stay in the acute hospital because he could not walk. Resident 1 appeared confused. During a record review of emergency medical services (EMS) report, dated 10/1/24, the EMS report stated, . EMS arrived on scene patient laying supine (lying on back) in middle of road, Glasgow Coma Scale (GCS- 13 a clinical scale used to measure a person's level of consciousness after a brain injury. Score levels 3-8 are sever traumatic brain injury [TBI], 9-12 moderate TBI, and 13-25 mild TBI) patient was involved in a vehicle versus pedestrian accident where he was struck by a vehicle, traveling approximately 25 miles per hour per driver of vehicle while crossing the road in his wheelchair. It's estimated that the patient was approximately six feet from his wheelchair patient presents with altered mental status, combativeness. Physical exam revealed a hematoma (blood collection under the skin) to the right side of forehead, abrasions to upper back, possible deformity to the right femur, and appeared to have vomited at least once . During a review of Resident 1's Intensive Care Unit Progress Note dated 10/4/24, the progress note indicated, . patient who presented to the emergency department after pedestrian versus auto. Patient was in middle of street in wheelchair when he got hit by car going 25 miles per hour. Was ejected off of wheelchair, positive head trauma, loss of consciousness. GCS 13 . injuries right femur shaft fracture, closed inferior pubic rami fractures, traumatic pneumothorax, closed fracture of multiple ribs, right phalanx fracture), L1 vertebra compression fracture, closed fracture of transverse process of lumbar vertebra Procedures right femur open reduction and internal fixation (ORIF- surgical procedure that realigns and stabilizes the bone), right foot nail avulsion (removal of a toenail or fingernail due to injury) and nailbed repair . During a review of the facility's policy and procedure (P&P) titled, Out on Pass, dated 1/11/2016, the P&P indicated, . it is the policy of the facility to meet residents' physical and psychosocial needs when going out on pass. The facility will make reasonable efforts to ensure the resident safety and uphold resident rights . the attending physician will write/give an order for a resident to go out on pass on the physician order sheet. The attending physician should include whether the resident should be accompanied by a responsible person while out on pass or may leave the facility unaccompanied . in the absence of a specific order that indicates the resident may go out on pass unaccompanied, the resident must be accompanied by a responsible person. If the resident is receiving skilled service, the resident may go out on pass for a therapeutic purpose (preventing, diagnosing, monitoring, treating for a disease or injury) only . During a review of the facility's policy and procedure titled, Elopement Risk Reduction Approaches, dated 11/2012, the P&P indicated, . ensure that residents are able to move about freely, are monitored and remain safe . During a review of the facility's P&P titled, Resident Safety, dated 4/15/21, the P&P indicated, . to provide a safe and hazard free environment . the interdisciplinary team (IDT- team that consists of various staff that are involved with resident's care) will establish a person-centered observation or monitoring systems for the resident to address the identified risk factors identified. To observe the safety and wellbeing of the residents, a resident check will be made at least every two hours around the clock by nursing service personnel. The person-centered care plan may require more frequent safety checks .

Based on observation interview and record review the facility failed to ensure an environment free of accident hazards for one of three sampled residents (Resident 1), when on 7/12/24 Resident 1 removed the window screw, opened the window, and jumped from the facility's second story. Certified Nursing Assistant (CNA) 1 noted a change in Resident 1's demeanor and heard Resident 1 stating she is done and did not report to licensed staff. This failure resulted in Resident 1 sustaining a fracture (broken bone) of multiple ribs on the right side, laceration (bleeding or tearing) of the liver, fracture of the right femur (bone of the thigh articulating at the hip and the knee), and right pneumothorax (when air builds up in the space between the chest wall and lung and puts pressure on the lung causing it to collapse). Findings: During an interview on 7/12/24 at 8:45 a.m., with the administrator (ADM). The ADM stated Resident 1 had opened the window in her room located on the second floor and jumped off to the ground on the first floor. The ADM stated Resident 1 was found by facility staff outside by the sidewalk. The ADM stated it appeared Resident 1 removed the protective screw from the window and pushed the window screen out to exit the window. The ADM stated he thought Resident 1 could have used a kitchen butter knife or utensil to unscrew the window screw as the window screws should have been tightly screwed in place. The ADM stated Resident 1 was transferred to the acute hospital for further evaluation. During a review of Resident 1's Admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis, systemic lupus erythematosus (long lasting disease that affects many parts of the body), hereditary and idiopathic neuropathy (nerve problem that causes pain, numbness, tingling, swelling or muscle weakness), spinal stenosis (causes pressure on the spinal cord or nerves), Major Depressive Disorder (mental health disorder causes persistent low or depressed mood), Borderline Personality Disorder (mental illness that causes loss of emotional control), anorexia (eating disorder that causes low body weight and intense fear of gaining weight), muscle weakness, post-traumatic stress disorder(disorder that develops when a person has experienced a scary, shocking, terrifying, or dangerous event), adult failure to thrive, homelessness, and patient noncompliance with other medical treatment and regimen due to unspecified reason. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/6/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 14 out of 15 (0 -7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 -12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an observation on 7/12/24 at 9:16 a.m., in Resident 1's room, the window was observed to have a broken window screen and a removed screw was located near the window seal. The window was observed through the glass and the window screen was noted to be out of place, bent and pushed outward. A dining table was observed against the wall under the window border. There was a window screw positioned by the window seal next to the screw hole on the window base. When the window was pulled open to the left, it was noted to open all the way through. The screen was observed outward, bent and broken. Outside the window the rooftop to the first-floor dining room was located extended out about 10 feet outward allowing a walking distance. No footprints or drag marks noted were observed on the first-floor rooftop. During a concurrent observation and interview on 7/12/24 at 9:22 a.m., with Resident 2 in Resident 2's room, Resident 2 was observed lying in bed dressed, cleaned and groomed. Resident 2 stated she was moved to Resident 1's room the day prior and was recently residing in another room of the facility. Resident 2 stated she was asleep when Resident 1 left the facility and had not heard anything from Resident 1. Resident 2 stated that the prior day CNA 1 was heard communicating with Resident 1 when she heard Resident 1 say I'm done, it's over, this is the end. Resident 2 stated CNA 1 continued speaking with Resident 1 and then CNA 1 left for the night. Resident 2 stated the last thing she remembered was Resident 1 asking to close her privacy curtain and then going into the restroom using her wheelchair. Resident 2 sated Resident 1 remained in the restroom for a long period of time and could not recall when she exited the restroom. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis major depressive disorder, anxiety disorder (mental health disorder characterized by feeling of worry), insomnia and repeated falls. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 7 out of 15, which indicated Resident 2 was had severe cognitive impairment. During an interview on 7/12/24 at 12:23 p.m., with CNA 1, CNA 1 stated he worked with Resident 1 often and was familiar with her care. CNA 1 stated he was assigned to care for Resident 1 the day prior and recalled talking with Resident 1 regarding her financial issues and how she needed to pay her cellphone bill and remove her car from the acute hospital parking lot. CNA 1 stated before dinner Resident 2 was moved into Resident 1's room. CNA 1 stated that following the roommate's arrival, Resident 1's demeanor changed appearing different and acting different. CNA 1 stated she began saying she is done. CNA 1 stated he asked Resident 1 what she meant and Resident 1 stated I am done with everything. CNA 1 stated he spoke with Resident 1 religiously and stated, only god decides when we leave this earth. CNA 1 stated he left Resident 1 after calming her and returned to Resident 1's room prior to the end of the shift. CNA 1 stated prior to the end of shift he asked Resident 1 if she needed anything, in which Resident 1 responded I don't need anything I am done with everything and CNA 1 proceeded to leave. CNA 1 stated during the last encounter with Resident 1 she was observed looking at her phone and writing on paper. CNA 1 stated he had not reported the change in Resident 1's behavior to the charge nurse and did not report it to the oncoming staff because he believed she was getting ready to leave the facility to retrieve her car as mentioned in a prior conversation. CNA 1 stated the screws on the windows were checked by the maintenance department and should have been screwed in place tightly and not removed easily. During an interview on 7/12/24 at 2:21 p.m., with RN 1, RN 1 stated she was in charge of Resident 1 on 7/11/24. RN 1 stated Resident 1's demeanor was not changed, and she had not noticed a difference with her care. RN 1 stated she was made aware that Resident 1 jumped from the second story through her room window. RN 1 stated the facility process was for CNA 1 to have notified the charge nurse to ensure Resident 1 was properly assessed and monitored for suicidal ideations. RN 1 stated all windows should have had a screw to lock them in place and keep them from opening more than 3-4 inches. RN 1 stated it was the maintenance department's responsibility to check all windows and screws were in place and secured. During an interview on 7/12/24 at 2:30 p.m., with the Nurse supervisor (NS), the NS stated the expectation was for CNAs to report any change in residents to the charge nurse immediately. NS stated it was important for CNA 1 to have notified the charge nurse for proper assessment, monitoring and proper care for Resident 1. During an interview on 7/12/24 at 2:43 p.m., with RN 2, RN 2 stated the facility expectation was for all CNAs to report any change in residents which included resident behavior. RN 2 stated the charge nurse should have been notified right away to assess the resident and ensure safety. RN 2 stated the facility windows should have a screw in place to securely keep the windows from opening all the way. RN 2 stated the maintenance department checked the windows to ensure they were secured. During an interview on 7/12/24 at 2:51 pm with CNA 2, CNA 2 stated it was the facility expectation for CNAs to report all changes including behavioral changes to the charge nurse immediately. CNA 2 stated if the resident was experiencing suicidal ideations, it was not appropriate for the CNA who was present to leave the resident. CNA 2 stated the facility maintenance department was in charge of ensuring windows were properly secured in all resident rooms. During a concurrent interview and record review on 7/12/24 at 3:01 p.m., with the Maintenance supervisor (MS), the facility's Maintenance Daily log dated 7/8/24-7/12/24 was reviewed. The log indicated the MS was checking doors, locks & alarms, and conducting test operations for doors and locks but there was no documentation of the MS checking the windows or window screws. The MS stated the log did not indicate windows locks or security, but it was implied that they were checked daily during rounds when the facility doors were checked. The MS stated the window screws were approved by the fire marshal as appropriate for the facility. The MS stated the window screws were checked every morning during daily maintenance rounds but could not provide documentation. The MS stated all the window screws were secured in the facility and Resident 1 was able to open the window because she was actively having suicidal ideations. The MS stated that if a resident was experiencing suicidal ideations, they would find a way. During a telephone interview on 7/12/24 at 3:24 p.m., with Licensed Vocational Nurse (LVN) 1, the LVN stated she was in the facility assigned to work on Resident 1's floor. LVN 1 stated that on 7/12/24 at around 1:16 am she received a call from the nurse's station on the first floor alerting her that there was a person lying on the sidewalk outside. LVN 1 stated she proceeded to notify all staff including CNAs and nurses present to check all resident rooms on the floor to account for all residents. LVN 2 stated she went to the first floor and walked outside to find an ambulance and noted Resident 1 was lying on the sidewalk. LVN 1 stated Resident 1 was awake and talking stating that her chest was in pain. LVN 1 stated the emergency medical technicians (EMT) assessed Resident 1 and immediately transferred her onto the ambulance to the acute care hospital. LVN 1 stated she had not observed any belongings or items around Resident 1 or in the area where Resident 1 was lying. LVN 1 stated when Resident 1 was transferred she proceeded to go back to the second floor where Resident 1's room was located. LVN 1 stated she entered Resident 1's room and observed three piles of letters which indicated Resident 1 was experiencing suicidal ideations and attempted jump out of the second story. LVN 2 stated Resident 1's room window was closed but observed the window screen was broken and Resident 1's wheelchair was positioned by the room window. LVN 1 stated she spoke with the CNA 3 who was in charge of Resident 1. LVN 1 stated CNA 2 last observed Resident 1 on 7/12/24 at 12:40 am, according to CNA 3 Resident 1 was in the restroom. LVN 1 stated it was the facility expectation for any CNA or staff member present when any resident is expressing behavioral/emotional changes to notify the charge nurse immediately to ensure safety and proper assessment. During a telephone interview on 7/12/24 at 3:38 p.m. with CNA 3, CNA 3 stated she was assigned to Resident 1 on 7/12/24. CNA 3 stated Resident 1 had requested to use the wheelchair to go to the restroom during the night. CNA 3 stated that at approximately 11:45 pm, she observed Resident 1 still in the restroom when assisting Resident 2. CNA 3 stated she did not return to Resident 1's room until she was alerted by facility staff that a resident was found outside by the sidewalk and was identified as Resident 1. CNA 3 stated that when she entered Resident 1's room, she noted Resident 1's privacy curtains were closed, wheelchair was positioned by the window and when Resident 1's bed was observed there were letters indicating Resident 1 was experiencing suicidal ideations. CNA 3 stated she had received change of shift report from CNA 1 at the start of the shift. CNA 3 stated that CNA 1 reported that Resident 1 was upset because she did not want a roommate in the room but made no indication that Resident 1 was experiencing suicidal ideations. CNA 3 stated that if Resident 1 was expressing feelings of suicidal ideations, the charge nurse should have been alerted immediately. CNA 3 stated the facility process was for the CNA to alert the charge nurse, complete a stop and watch form (form that alerts facility staff that there was a change in resident during the shift) and remain with resident until safe. CNA 3 stated it was not an acceptable practice for CNA 1 to walk away from Resident 1 if Resident 1 was expressing her feelings because there was a potential for harm. During a review of the facility's document titled, Stop and Watch Early Warning Tool, dated 2014, the document indicated, . if you have identified a change while caring for or observing a resident/patient, please circle the change and notify the nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. Seems different than usual, talks or communicates less, overall needs more help . agitated or nervous more than usual, tired weak, confused or drowsy . During an observation on 7/15/24 at 3:24 p.m., Resident 1 was observed in the general acute care hospital (GACH). Resident 1 was observed lying in bed, asleep and difficult to arouse opening eyes when spoken to and then would close eyes to sleep. Resident 1 was observed to have bruising to the right arm, right hand, left hand and swelling. Resident 1's right hip and right lower extremity were wrapped with bandage. During an interview on 7/15/24 at 3:35 p.m., with the GACH RN 4, RN 4 stated Resident 1 had been experiencing drowsiness and drops in oxygen saturations. RN 4 stated that during Resident 1's stay, Resident 1 had been banging on the bed frame and throwing objects. RN 4 stated that Resident 1 had made comments stating she wished her head would have hit the floor but denied she was experiencing suicidal ideations (define). RN 4 stated Resident 1 had sustained a right femur fracture, open reduction and internal fixation (ORIF- surgery used to stabilize and heal a broken bone) of the right hip and stated Resident 1's whole right side of body was injured. RN 1 stated Resident had a diagnosis of depression with history of suicide attempts. During an interview on 7/15/24 at 3:47 p.m., with Resident 1, Resident 1 stated she was admitted into the emergency room after she had jumped out of her window on the second floor of the facility where she resided. Resident 1 stated she had attempted to land on her head to kill herself. Resident 1 stated the suicidal ideations were a result of staff treatment in the facility where she resided but could not state the treatment she was referring to. Resident 1 stated she had thoughts of suicide previously during a stay in the GACH. Resident 1 stated that on 7/12/24 she had requested the wheelchair from the charge nurse to use the restroom, then the charge nurse proceeded to exit her room. Resident 1 stated she had observed one screw on the room window that was easily removable, removed the screw to open the window, pushed the window screen, and stood up from the wheelchair and jumped off the window. During a record review of Resident 1's, Emergency Department (ED) trauma Timeline Report, dated 7/12/24, the report indicated, . Per emergency medical services (EMS) report, patient was trying to commit suicide and jumped from the second-floor balcony of her room . patient was found by a bystander who called EMS . patient endorses pain to both hips, abdomen and right lower extremity . mechanism of injury . fall from second story building. She states she wanted to commit suicide . she crawled out of her window and fell around 30 feet with loss of consciousness. Complains of abdominal and hip pain. clinical impression, closed fracture of multiple ribs of right side, laceration of liver, closed displaced subtrochanteric fracture of right femur, closed displaced intertrochanteric (the bumpy parts at the top of the thigh bone) fracture of right femur and right pneumothorax . During a record review of Resident 1's document from GACH titled, Post-Op Check, dated 7/12/2024, the document indicated, the patient stated, .I jumped out of the nursing facility that I came from because they were abusing me. They were not giving me my medicine. I begged them to give it to me, and they would not listen. So, I climbed on top of the building and jumped to try and kill myself . During a record review of document titled, History of Present Illness, dated 7/12/2024, the record indicated the patient reported, .She was able to crawl to the window and then fell out of the window in an attempt to kill herself . On arrival to the ED, she complained of pain in her right left, lower back and abdomen During an interview on 7/15/24 at 4:15 p.m., with the facility's administrator (ADM), the ADM stated the maintenance department had verified all windows had tightly placed screws in every window of the facility. The ADM stated the facility windows should only open 2-3 inches and screws should not have been easily removable. During an observation on 7/15/24 at 4:45 p.m., the facility window screws for the second and third floor windows were observed. There were fourteen room with windows observed to have loose window screws. During an interview on 7/15/24 at 6:21 p.m., with the ADM, the ADM stated the facility's department managers and supervisors should have checked the window screws during the daily room rounds. The ADM stated it was the facility's expectation for staff to notify the maintenance department if any loose screws were observed. During a telephone interview on 7/16/24 at 11:15 a.m., with the director of staff development (DSD), the DSD stated she had provided the facility CNAs with a verbal in service regarding the use of the stop and watch and how it should have been utilized. The DSD stated she was unable to provide documentation to confirm in-service was completed. The DSD stated the facility expectation with a change of condition that included suicidal ideations was for the staff to take every statement seriously even if they are thinking in the back of their minds that the resident would not say or do something that involved suicide. The DSD stated the facility process was for the CNA who identified the change, to ensure resident safety and notify the nurse immediately for a resident assessment. The DSD stated it was not appropriate for CNA 1 to leave Resident 1 after Resident 1 was expressing thoughts of feeling like she was done. During a review of the facility's job description titled Director of Plant Maintenance, undated. The job description indicated, . principal responsibilities . ensures a safe, comfortable, sanitary environment for residents, staff, and visitors in accordance with federal, state, and corporate requirements. Performs preventative maintenance procedures . maintains equipment necessary to meet center needs . maintains written records and documents of services performed . During a record review of the facility's policy and procedure (P&P) titled Maintenance Service, dated 01/01/2012, the P&P indicated, . purpose to protect the health and safety of residents, visitors, and facility staff. Policy the maintenance department maintains all areas of the building, grounds, and equipment. Procedure, the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines . maintaining the building in good repair and free from hazards, providing routinely scheduled maintenance service to all areas . the director of maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds and equipment are maintained in a safe and operable manner . the director of maintenance is responsible for maintaining the following records/reports: inspection of building . maintenance staff follow established safety regulations to ensure the safety and well-being of all concerned .

Based on observation, interview and record review the facility failed to maintain an effective pest control program to keep the facility free of pests for 181 out of 181 residents, when on 7/9/2024 the dish washing station was observed with roaches crawling in the sink with dirty dishes, numerous roaches crawling up the walls and dishwasher. The floor to the dish washing room had roaches crawling into the dish racks located near the sink on the floor where dirty dishes were placed to go into the dishwasher. The clean dish area had roaches crawling around the counter and wall. The dishwasher itself had roaches swimming in the water inside. The walls of the dishwashing area had roaches nesting in the corners. This failure resulted in an unsanitary work environment where food was prepared and had the potential to cause harm to 181(the census during the survey) residents due to cross contamination and transmission of infections from cockroaches' infestation that could place residents at risk for food borne illnesses. Because of the serious potential harm for food borne illness and cross contamination of resident meals for all 181residents who received prepared meals from the kitchen related to the dish washing station which was observed with roaches crawling in the sink with dirty dishes, numerous roaches crawling up the walls and dishwasher. The floor to the dish washing room had roaches crawling into the dish racks located near the sink where dirty dishes are placed to go into the dishwasher. The clean dish area had roaches crawling around the counter and wall. The dishwasher itself had roaches swimming in the water inside. During an interview with the Infection Preventionist stated roaches are sanitary and had seen roaches in kitchen prior. During an interview with the administrator (ADM) and the Dietary supervisor both stated roaches had been seen prior but did not think it was an infestation. An Immediate Jeopardy (IJ a situation in which the provider's noncompliance with one or more conditions of participation have caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called on 7/9/24 at 5:28 p.m., under Code of Federal Regulations S483.90(i)(4) with the Administrator (ADM), Director of Nurses (DON), Director of Staff Development (DSD), Assistant Director of Nurses/Infection Preventionist (ADON/IP), House Keeping Supervisor (HSKS), and Dietary Services Supervisor (DSS). The facility submitted an acceptable Plan of Removal (POR Version 3) on 7/11/24 at 5:01 p.m., which addressed the actions needed to remove the IJ situation. The POR included but was not limited to the following: 1) pest control was notified and immediately went to the facility to spray affected areas using insecticides, an aerosol mist, injecting gel bait into open areas to attract pest to bait and then exterminate them and to leave bait packs in the wall and under kitchen tables and appliances. Chemical barrier was set up around the dishwashing area to prevent insects from crossing over into the kitchen area. 2) Kitchen began using disposable plating temporarily, including plates, utensils, and cups, to avoid any potential contamination of washed plating. 3) All pots and pans were handwashed in the sink basins in the back of the kitchen away from the contaminated area. 4) the Dietary Staff immediately discarded any opened food items. 5) Dietary sanitation was immediately initiated for deep cleaning and disinfection, Areas deep cleaned and disinfected included dish cleaning, food preparation, food cooking, meal tray line, appliances, and food storage area. 6) Dietary Services Manager, under the direction of the Registered Dietitian, initiated an in service for dietary staff regarding Pest Control, Kitchen Sanitation and Maintaining Cleanliness in the kitchen. 7) lower part of the drywall was replaced, and the inner parts of the wall were baited and sprayed to prevent the harboring of bugs inside the wall. 8) Work which included removing drywall and insulation from the floor up four feet on the wall and replacing it with new drywall and insulation was conducted by facility maintenance crew 9) California Department of Healthcare access and information (HCAI) was onsite and verbally approved on 7/10/24 at 1:30 pm for the work on the wall. 10) A PIN 72 Emergency Work Authorization form was submitted via email. 11) A review of changes of condition in the last 14 days was conducted by the DON and ADON to ensure that residents are free from any signs and symptoms of food borne illnesses related to cockroach infestation in the kitchen 12) Department Managers and Housekeepers conducted room rounds to ensure resident rooms were free from roaches. 13) Kitchen staff would continue to clean the kitchen nightly by wiping down all surfaces, draining steam tables and sweeping and mopping the floor. Deep clean will be conducted daily which included cleaning the inside of major appliances and moving of appliances to sweep area behind them until it was determined that roaches had been eradicated from the kitchen. 14) Kitchen staff would inspect all food, plates, cup and utensils prior to plating and placing on the food cart to ensure that they are all pest free. 15) the Administrator initiated an in-service education to the Facility Staff regarding the Policy and Procedures for Pest control and Maintaining Cleanliness in the facility. 16) Pest Control would bait known areas of roach sightings in the dishwash areas and then seal up areas to prevent roaches from exiting. Sealing included putting a silicone barrier on all seams where roaches would exit the walls. 17) Sighting of insects or bugs in the facility would be recorded in a general ledger and when pest control returns for weekly visit, they would spray the area where a sighting has occurred. The components of the POR, training, and competencies of staff were validated onsite through observations, interviews, and record review. The IJ was removed onsite on 7/12/24 at 1:00 p.m. with the facility ADM. Findings: During a concurrent observation and interview on 7/9/24 at 11:07 a.m. with the dietary aide (DA) 1 and DSS in the dishwashing area within the kitchen, the dishwashing area was observed infested with roaches crawling on the walls and in the dishwasher. The dishwasher sanitizing water was observed to contain live roaches swimming in the sanitizer. The walls of the dishwashing room had five roaches nesting in the corners. Roaches were observed in the dish racks located on the floor. The DSS stated she had seen roaches last year but never to this extent and was not aware that they were all over the dishwashing room. DA 1 stated the dishwashing room was cleaned, sanitized, mopped and wiped down after every use. DA 1 stated the dishwashing room was cleaned to its entirety once a day. During a concurrent observation and interview on 7/9/24 at 11:12 a.m. with the ADM, the dishwashing room was observed infested with roaches crawling on the walls and in the dishwasher. The dishwasher sanitizing water was observed to contain live roaches swimming in the sanitizer. The walls of the dishwashing room had roaches nesting in the corners. Roaches were observed in the dish racks located on the floor. The ADM stated he was aware there were some roaches seen in the kitchen but was not aware it was to this extent. The ADM stated the pest control company was in the facility last week to treat active roaches in the kitchen. During an observation on 7/9/24 at 11:20 a.m. in the kitchen. The kitchen counter tops and underneath the counters were observed with food debris in different areas of the kitchen. Observation behind the stove and oven revealed to have a black substance to the walls and floors with scattered food particles and trash. The kitchen walls had stained with an unknown yellow substance. The kitchen floorboards by the dishwashing room were detached from the wall with food particles. During an interview on 7/9/24 at 11:30 a.m. with DA 2, DA 2 stated he was in charge of the dishwashing room when scheduled. DA 2 stated when he arrived in the mornings, he observed there were many roaches. in the kitchen. DA 2 stated, when the dishwasher was turned off the roaches were noted to appear. DA 2 stated it was not sanitary to have the roaches all over the dishwashing room near all the clean dishes. DA 2 stated the roaches would at times get stuck in the dish racks. During an interview on 7/9/24 at 12:41 p.m. with Resident 5, Resident 5 stated he had seen roaches in the hallway and dining area on floors. Resident stated when the roaches were seen he had notified the facility staff. During a review of Resident 5's Admission record, the AR indicated Resident 5 was admitted on [DATE] with diagnosis, paraplegia (Paralysis of the legs), type 2 diabetes mellitus, cervical disc degeneration (spinal disc wear down), anxiety (feeling of worry or fear), cervicalgia (neck pain), falls, weakness, anemia (lack of oxygen in the blood), chronic kidney disease and hypertension (high blood pressure). During a review of Resident 5's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/5/24, the MDS indicated, Resident 5's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 13 out of 15 (0 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 15) cognitively intact) which indicated Resident 5 was cognitively intact. During a concurrent observation and interview on 7/9/24 at 1:19 p.m. with the pest control representative (PCR) in the dishwashing room located in the kitchen, the PCR was observed spraying underneath the dishwashing sink and spraying the open areas of the dishwasher leading into the back wall. The roaches were observed scattering and crawling in different directions which included the floor, walls and ceiling of the dishwasher room. The roaches were observed crawling on the base boards and the floors near the tray line area. The PCR stated the spraying of the area would cause the roaches to scatter as they were actively being exterminated. The PCR stated he was not able to get to the entire back wall due to the dishwasher being attached to the back wall. The PCR stated the chemical used to spray the roaches would begin to exterminate them. The PCR stated a chemical barrier had been placed to isolate the roaches to the dishwashing area and prevent them from scattering further into the kitchen. During a concurrent observation and interview on 7/9/24 at 1:29 p.m. with the infection preventionist (IP a professional that serve on the front lines of healthcare every day, working to eliminate healthcare associated infections), the dishwashing room was observed infested with roaches crawling on the walls and in the dishwasher. The walls of the dishwashing room had roaches nesting in the corners. Roaches were observed in the dish racks located on the floor. The IP stated he was aware there were roaches in the kitchen but not to that extent. The IP stated, roaches are sterile insects, no studies that indicate they spread infections. The IP stated the roaches in the kitchen were not acceptable. During an interview on 7/9/24 at 3:09 p.m. with Resident 3, Resident 3 stated he was a resident of the assisted living area of the facility. Resident 3 stated the year, current president, and city where he resides. Resident 3 communicated and answered all questions asked. Resident3 stated he was a resident in the facility for years. Resident 3 stated he had observed roaches crawling by the kitchen. Resident 3 stated he had reported the sightings to multiple staff members but could not recall who specifically. Resident 3 stated he reported the roaches because the roaches were always there. During a review of Resident 3's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses: type 2 diabetes mellitus (body has too much sugar in the blood), muscle weakness, hyperlipidemia (too much fats or lipids in the blood) and dorsalgia (back pain). During an interview on 7/9/24 at 3:23 p.m. with Resident 4, Resident 4 stated he was a resident of the assisted living area of the facility. Resident 4 stated the year, current president, and city where he resides. Resident 4 communicated and answered all questions asked. Resident4 stated he had seen roaches in the hallway on the first floor by the kitchen. Resident 4 stated he observed roaches every day and believed there might have been an infestation of roaches. During a review of Resident 4's Admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses: weakness, absence of left leg below knee, chronic kidney disease (kidneys are damaged and cannot filter blood), type 2 diabetes mellitus, acute kidney failure (kidneys stop working properly), absence of right leg below knee, hyperlipidemia, muscle weakness. During a telephone interview on 7/10/24 at 9:39 a.m. with the Registered Dietitian (RD), the RD stated she was aware that there were roaches in the kitchen because they had been there for years but not to the extent that was being presented. The RD stated it was not sanitary to have roaches in the kitchen and it was important to keep the kitchen clean. During an interview on 7/10/24 at 10:26 a.m. with the regional dietary manager (RDM), the RDM stated she was aware of the roach problem in the kitchen and recommended for weekly pest control. The RDM stated the roaches in the kitchen were not sanitary. The RDM stated the expectation was for the dietary staff to clean the kitchen and establish systems that will assist them in keeping the roaches away. During a record review of facility's Pest control Service report, dated 6/4/2024, the report indicated, .checked in with kitchen staff let them know that sanitation is gonna play a big role, keeping the roaches under control . During a record review of the facility's Pest Control Service Report, dated 5/13/24, the report indicated, . I treated the baseboards around the kitchen areas and replace the glue boards as well. I did notice a smell coming from the drainage area in the food prepping line that needs to be cleaned to avoid possible insect activity around that area . During a record review of the facility's Pest Control Service Report, dated 3/22/24, the report indicated, . went to kitchen and talked to staff about any pest problems having. Baited for roaches in cracks and crevices. Recommended that they caulk and seal all cracks and crevices in kitchen . During a record review of the facility's Pest Control Service Report, dated 3/28/24, the report indicated, . at today's service I treated interior kitchen placed glue boards as well do to roach activity . During a record review of the facility's Pest Control Service Report, dated 1/17/24, the report indicated, . checked in with staff and management, kitchen wall leak damage, reports of roaches in walls . During a record review of the facility's Pest control Service Report, dated 6/16/23, the report indicated, . spoke with kitchen supervisor and she said they saw activity coming from the prep line. Treated all bottom of prep line and base of kitchen to help eliminate activity . During an interview on 7/10/24 at 2:12 p.m. with Registered Nurse (RN) 1, RN 1 stated the roaches in the kitchen and possible food preparation areas was unsanitary. RN 1 stated the roaches were considered contaminated and introduce bacteria to food. RN 1 stated there was a potential for the contaminated food to cause gastrointestinal distress including food poisoning to all residents ingesting the food. During an interview on 7/11/24 at 1:28 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated it was important to maintain a clean and clutter free environment in order to not attract roaches. CNA 1 stated roaches had the potential to spread bacteria that could have potentially made residents sick. During an interview on 7/11/24 at 4:05 p.m. with DA 3, DA 3 stated the kitchen had an infestation in the past and had not seen the kitchen infested this bad until recently. DA 3 stated it was important to effectively clean the kitchen every day and checking hard to reach areas more proactively. DA 3 stated it was not sanitary to have roaches in the kitchen near clean dishes and food. During a telephone interview on 7/12/24 at 10:42 a.m. with the PCR, the PCR stated his recommendation was for the dietary staff to keep the kitchen clean. The PCR stated sanitation would play a big role in keeping the roaches away since the roaches live in cluttered dirty areas with food debris. During an interview on 7/12/24 at 11:22 a.m. with DA 4, DA 4 stated all staff had known about the roaches in the dishwashing room including the dietary supervisor. DA 4 stated it was an ongoing problem that needed to be addressed. DA 4 stated the dietary supervisor had informed dietary staff that if she was blamed for the roaches everyone in the kitchen was going down with her since everyone knew about them. During a review of the facility's job description titled, Dietary services Supervisor/Certified Dietary Manager, undated. The job description indicated, . principal responsibilities . maintains a safe and sanitary working environment in compliance with Federal and State of California guidelines . ensures exchange of essential information with all departments as necessary to ensure quality resident care . During a review of the facility's job description titled, Registered Dietitian, dated 10/9/23. The job description indicated, . essential duties and responsibilities . routinely inspect the food service area and practices for compliance with company policies, procedures, standards, and applicable federal, state, and local regulations . this position has kitchen oversight responsibility for safe food service . During a review of the facility's job description titled, Dietary Assistant/Dishwasher, undated. The job description indicated, . principal responsibilities . maintains a safe and sanitary work environment . reports problems and needs to the supervisor in a timely manner . During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated 1/1/12, the P&P indicated, . The facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests . procedure garbage and trash are not permitted to accumulate in any part of the facility . the maintenance department assists, when appropriate and necessary, with pest control services . pest control service provider the company will perform the following services . submit a site specific work plan for each area/department with recommendations on how to keep the facility pest free, department and area staff are responsible for carrying out these recommendations to prevent pests in their respective areas and keeping documentation in accordance with department and facility policies . During a review of the facility's P&P titled, Dietary Department General, dated 6/1/14, the P&P indicated, . The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs . the primary objectives of the dietary department include . maintenance of standards for sanitation and safety; maintenance of standards for quality of food . the dietary manager and/or dietitian are responsible for planning and providing dietary staff with in service education . the dietary manager is also responsible for the day-to-day education of dietary staff with regard to topics such as sanitation, food preparation . During a review of the facility's P&P titled, Dish Machine Operation and Cleaning, dated 10/1/14, The P&P indicated, . Purpose to establish guidelines for the use and cleaning of the dish machine . the dish machine will be sanitized between uses . sanitation of equipment the dish machine will be cleaned after each meal . remove debris and rinse the interior of the machine . on a weekly basis, clean the dish machine exterior with de liming solution . During a review of the facility's P&P titled, Food Storage, dated 6/25/19, the P&P indicated, . Procedure . keep work surfaces clean and orderly . the walls, ceilings, and floor should be maintained in good repair and regularly cleaned . monitor area routinely for pest activity .

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one of five sampled residents (Resident 1) when Resident 1 fell out of bed during provision of care by Certified Nurse Assistant (CNA) without assistance from another staff member in accordance with the Comprehensive Assessment and needs of the resident. This failure resulted in Resident 1 having an avoidable fall, sustaining injuries of a Fractured Occipital Condyle (break at the base where skull meets spine), laceration (cut) to her nose, bruising, swelling to her left eye and experienced pain. Findings: During a review of Resident 1's Admission Record (AR), dated 11/29/23, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, Dementia (loss of cognitive functioning, thinking remembering, and reasoning), Muscle Weakness, Difficulty in Walking and Other Specified Disorders of Bone Density and Structure (disease of the bone). During a review of Resident 1's Minimum Data Set (MDS) assessment (assessment of functional and cognitive abilities), dated 11/09/23, the MDS Section C indicated, Resident 1 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 4 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15-cognitively intact). During a review of Resident 1's MDS assessment, dated 11/09/23, the MDS Section GG (Functional Abilities and Goals) indicated, Resident 1 was dependent (requiring assistance from staff) to roll from left and right, for a Tub/shower Transfer, completion of Oral Hygiene, upper and lower body dressing, personal hygiene and eating. During a concurrent observation and interview on 11/29/23 at 9:45 a.m. in Resident 1's room, Resident 1 was lying in bed awake. Resident 1 had an [brand name] Collar (device used to prevent movement of head and neck) around her neck. Resident 1 stated she was having difficulty speaking due to the presence of the device. Resident 1 stated she was having pain. During an interview on 11/29/23 at 11:20 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 required extensive assistance by two staff members at all times. CNA 2 stated prior to Resident 1's fall on 11/6/23 Resident 1 was able to feed herself and brush her teeth. During a concurrent interview and record review on 11/29/23 at 12:10 p.m. with the Assistant Director of Nursing (ADON), Resident 1's Care Plan (CP) dated 6/22/23 was reviewed. The CP indicated, .provide assistance and care to resident with two staff members . The ADON stated CNA 1 was changing Resident 1's brief on 11/6/23 when Resident 1 was rolled out of bed and onto the floor. The ADON stated Resident 1 sustained injuries from the fall. The ADON stated he spoke with CNA 1 after the fall and CNA 1 was aware Resident 1 required the assistance of two staff members to assist when care was being provided. During a record review on 11/29/23 of untitled undated document, signed by CNA 1, document indicated, at 5:44 a.m., .when doing my last round, I knocked on resident door and asked to come into complete my last round, as I was changing resident I pulled the draw (half) sheet toward me so I can turn resident on side to change her brief, but she continued to roll and fell off bed . During an observation on 11/29/2023 at 12:50 p.m. outside of Resident 1's room with the ADON. In the doorway of the room, there was a picture of two hand shaking. The ADON stated the meaning of this picture was to alert staff that resident was two-person care. ADON stated there should be two persons providing care for Resident 1. ADON stated the picture of two hands shaking was outside of Resident 1's room since the care plan was implemented on 6/22/2023. During a concurrent observation and interview on 11/29/23 at 12:55 p.m. with CNA 2, outside of Resident 1's room, CNA 2 stated there was a picture of a handshake by Resident 1's name outside the doorway of her room. CNA 2 stated, the picture of the handshake had been there for a long time. CNA 2 stated the picture indicated Resident 1 required two persons to assist with Resident 1's care in order to meet any of her needs. During an interview on 11/29/23 at 1:00 p.m. with CNA 4, CNA 4 stated she was aware Resident 1 required the assistance of two staff members when providing care. CNA 4 stated the picture of the handshake was there for staff to provide two-person care at all times. CNA 4 stated when staff provided care without following the two-person assistance, it placed Resident 1 at risk for falls and injuries. During an interview on 11/29/23 at 1:10 p.m. with CNA 3, CNA 3 stated Resident 1 was unable to feed herself or brush her teeth due to the supportive device around her neck. CNA 3 stated Resident1's care and needs had changed because of the injuries from the fall. During an interview on 11/29/23 at 1:30 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 1 required the assistance of two staff when care was provided. LVN 2 stated Resident 1 was at risk for falls, injuries, or death when care was not provided according to the care plan interventions in place. LVN 2 stated prior to the fall, Resident 1 was able to feed herself, and was currently unable to feed herself because of the injuries. LVN 2 stated Resident 1 fell off her bed and sustained injuries that were life threatening. During an interview on 11/29/23 at 1:45 p.m. with the Director of Nursing (DON), the DON stated Resident 1 needed assistance and care for brief changes, showers, repositioning. The DON stated, CNA 1 did not follow protocol for a two person assist when care was provided. DON stated, the outcome resulted in Resident 1 falling out of bed and sustaining major injuries. DON stated, the fall and injuries could have been prevented. DON stated the intervention in the care plan were put in place to keep Resident 1 from harm. DON stated CNA 1 did not follow the care plan. During an interview on 11/29/23 at 2:10 p.m. with Administrator (ADM), ADM stated, Resident 1's fall was avoidable. The facility Administrator (ADM) stated CNA 1 did not follow the facility policy and care plan that were in place for Resident 1. The ADM stated during the investigation, CNA 1 admitted she provided care to Resident 1 by herself. The ADM stated CNA 1 admitted it was wrong to provide care for Resident 1 without assistance from a second staff member. During a telephone interview on 11/30/23 at 12:15 p.m. with LVN 3, LVN 3 stated he was assigned to Resident 1 during his shift on 11/06/23. LVN 3 stated he noticed the door to Resident 1's room was closed and thought staff were providing care to the resident. LVN 3 stated CNA 1 came out of Resident 1's room and alerted him that Resident 1 had fallen out of bed. LVN 3 stated when he immediately went into the room CNA 1 was alone in the room with Resident 1. LVN 3 stated he saw Resident 1 lying on the floor next to her bed face down. LVN 3 stated there was blood on the floor around Resided 1's face and she was moaning in pain. LVN 3 stated he then assisted Resident 1 back into bed and performed an assessment. LVN 3 stated Resident 1 was bleeding from her nose and there was a laceration across her nose and swelling to her left eye. LVN 3 stated Resident 1 was moaning in pain during the physical assessment. LVN 3 stated prior to the fall Resident 1 was able to feed herself and brush her teeth. LVN 3 stated Resident 1 was now unable to feed herself and needed feeding assistance. LVN 3 stated Resident 1 was now unable to brush her teeth and had limited movement of her head and neck. LVN 3 stated Resident 1's fall could have been prevented if CNA 1 had provided care assisted by with another staff person. During a review of Resident 1's general acute hospital record, titled, AFTER VISIT SUMMARY, dated 11/6/2023, the AFTER VISIT SUMMARY indicated Resident 1 received an x-ray of the cervical spine (neck region of your spinal column or backbone) due to a fall. The X-Ray indicated Resident 1 was found to have an occipital condyle fracture. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program undated, the P&P indicated, .To provide residents a safe environment that minimizes complications associated with fall .the facility will implement a Fall Management Program that supports providing an environment free from fall hazards .staff will develop a care plan according to the identified risk factors and root causes . During a review of the facility's P&P titled, Resident Safety, undated, the P&P indicated, .To provide a safe and hazard free environment .Residents will be evaluated to identify circumstances that pose a risk for the safety and wellbeing of the Resident .After a risk evaluation is completed .a Resident-centered care plan will be developed to mitigate safety risk factors . During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning undated, the P&P indicated, .It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain their highest physical, mental and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) when Resident 1 was assessed as and determined him to be at risk for elopement (leaving the premises or safe area without authorization or permission) and staff did not provide him with adequate supervision to prevent elopement. As a result of this failure Resident 1 was unsupervised and not redirected when he wheeled himself out of the facility on 11/3/19 date. Resident 1 was missing for 28 hours and was found on 11/4/19 incontinent, disheveled, hungry and with an elevated blood pressure. Resident 1 was transported to the general acute care hospital (GACH) for higher level of care. Findings: During a review of the clinical record for Resident 1, the Face Sheet (a document containing resident profile information) indicated Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 1's Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment dated [DATE], indicated Resident 1 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS- assessment of memory function and recall) score of 9 out of 15 (0-7 severe impairment, 8-12 moderately impaired, 13-15 cognitively intact). The MDS indicated Resident 1 had functional limitations in range of motion to one side of his upper and lower extremities. The MDS indicated Resident 1 used his wheelchair as a mobility device and required extensive assistance (weight bearing support) with transfers, toilet use and personal hygiene. During an interview on 11/5/19, at 8:45 a.m., with the Director of Nursing (DON), the DON stated Certified Nurse Assistant (CNA) 1 informed her Resident 1 was on the third floor in front of the nursing station on 11/3/19 at 3:15 p.m. The DON stated the same day at 4 p.m., Licensed Vocational Nurse (LVN) 1 looked for Resident 1 to administer his afternoon medications. LVN 1 searched for Resident 1 in the third floor then in the first floor activity room. The DON stated LVN 1 activated the elopement code Adam on 11/3/19 to alert staff Resident 1 was missing. The DON stated all the staff searched the whole building, room by room, the hallways, backrooms and outside the facility grounds. The DON stated when Resident 1 was not found, LVN 1 called the family to ask if the family took Resident 1 on an outing, but the family did not. The DON stated LVN 1 reported the incident to the police by phone and then called up three acute hospitals but the hospitals did not have Resident 1. The DON stated LVN 1 called her the next day on 11/4/19 at 7:49 p.m., to inform her the local police called the facility to inform them Resident 1 was found in the street. The DON stated Resident 1 had the capability of propelling himself in his wheelchair despite of his [DIAGNOSES REDACTED]. During a review of the police report dated 3/4/2020 at 2:14 p.m., indicated, On 11/4/2019, I was working uniformed patrol in the (area of town) . At 0727 hours (7:27 a.m.), I was dispatched to (Skilled Nursing Facility) .I (patrol officer) arrived at the location and contacted Licensed Vocational Nurse. (LVN 1) advised he was the missing resident day nurse. (LVN 1) said he wanted to report that the resident identified as (Resident 1) left the faciity on his wheelchair on 11/3/19 at about 1:30 p.m., (LVN 1) said it was unknown where (Resident 1) left too. He said it was not unusual for (Resident 1) to leave unannounced and then return several hours later .A record check showed he had not previously been reported missing, therefore he will be placed as an at risk missing adult .On 11/4/19, I was working uniformed patrol in the (area of town) .At approximately 1930 hours (7:30 p.m.,) I was dispatched to (Skilled Nursing Facility) to (area of town 9 miles away from the facility) regarding a male in wheelchair who may have been lost. I arrived a short time late and spoke with to (Resident 1) .Dispatch was able to find a record showing (Resident 1) was currently missing person and if he was located, he needed to be returned to (Skilled Nursing Facility) .Upon contacting him, (Resident 1) stated he wanted to go to the hospital to get a check up and make sure everything was okay with him . During a concurrent interview and record review on 11/5/19, at 11 a.m., with the DON, the DON stated Resident 1 was at risk for elopement when he was re-admitted to the facility on [DATE]. The DON reviewed Resident 1's elopement risk assessment dated [DATE], 5/24/19, and 6/7/19, indicated an elopement risk score of 8. The DON stated if the total score was 8 or greater, the resident should have been considered at, Risk for Potential Elopement from the Facility. The DON stated Resident 1 attempted to elope from the facility on 5/24/19 and on 6/7/19. The DON stated Resident 1 was moved to the third floor of the facility after the Interdisciplinary Team (IDT) (a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) met to discuss Resident 1's elopement attempt on 6/7/19. The DON stated the purpose of Resident 1's move to the third floor was to provide further distance between Resident 1 and the exit doors. The DON stated Resident 1's elopement risk information was added in the, Risk for Elopement Binder used in case a resident eloped. The DON stated the information inside the binder included Resident 1's picture and was kept at the front desk. The DON reviewed Resident 1's elopement risk care plan and stated the elopement risk care plan was not person centered and did not include specific goals nor interventions needed to be implemented in response to his elopement risk. The DON stated the elopement risk care plan did not indicate how staff would need to respond to divert Resident 1's wandering behavior. The DON stated Resident 1's elopement care plan was not updated by the IDT or nursing staff after Resident 1 attempted to elope on 5/24/19 and 6/7/19. The DON stated Resident 1's care plan did not reference the move made to the third floor. The DON stated Resident 1's elopement care plan should have been reviewed and revised every three months to determine if the plan and interventions were effective or not. The DON stated the care plan interventions should have focused on the safety of Resident 1. The DON stated the facility did not have a wander guard system (alarm system used to alert staff of potential wandering to unsafe areas) in the facility. During a review of Resident 1's elopement risk care plan dated 10/10/19, indicated, Resident is at risk for wandering or elopement related to Cognitive status .Resident is unaware of safety needs .Approach Assess resident's elopement risk at the following intervals admission, readmission, quarterly, identification of Significant Change of Condition .Provide resident with a consistent routine, provide emotional support and meaningful activity, utilize validation techniques to understand behavior behind attempts to leave facility, provide education to resident, responsible party and staff regarding special care needs, provide adequate physical and social environments that provide activities appropriate for the resident's cognitive functioning and interests as well as opportunities for walking, exploring and social interaction. During an interview on 11/5/19, at 11:15 a.m., with the Activity Director/Elopement Chairman (AD/EC) the AC/EC stated he was responsible to review and update Resident 1's care plan on elopement. The AD/EC stated Resident 1 had an elopement risk score of 8 on 5/24/19 and 6/6/19. The AD/EC stated Resident 1 was moved to the third floor to put distance between the resident and the exit doors in the ground floor. The AD/EC stated Resident 1's care plan on elopement should have been reviewed and updated, and was not. The AD/EC stated the care plan should have been updated quarterly and as often as needed to determine if the plan was effective and find ways on how to keep Resident 1 safe. During an interview on 11/5/19, at 12:09 p.m., with Resident 1 in the presence of the Social Service Director (SSD) and Resident 1's family members, Resident 1 stated, I left the facility because I was so bored and hungry and I was looking for food. Resident 1 was asked what exit door he used to elope from the facility, but Resident 1 did not answer. During a concurrent observation and interview on 11/5/19, at 12:30 p.m., with Family Member (FM) 1, FM 1 stated she visited Resident 1 every week and Resident 1 was accustomed to a weekly outing. FM 1 stated she would take Resident 1 to a restaurant during the weekly outing but was unable to take Resident 1 out the day he eloped. During a concurrent observation and interview on 11/5/19, at 1:25 p.m., with the Maintenance Director (MD), the MD stated there were four exit doors on the first floor near the DON's office. The MD stated the exit door in the south wing of Station 1 and the exit door near the laundry room were equipped with alarms that would alert staff each time a resident tried to exit. The MD stated the other two exit doors which lead to the smoking area, and the to the main entrance would not alarm during the day (during business hours 8 a.m., through 5 p.m.) The MD stated the alarms to the two exits would be set between 5-6 p.m. in preparation for the night shift. The MD stated Resident 1 could have exited through any of the unalarmed doors. During an interview on 11/5/19, at 2:21 p.m., with Housekeeping Staff (HS) 2, HS 2 stated she was on duty Sunday 11/3/19 when Resident 1 eloped from the facility. HS 2 stated she saw Resident 1 on his wheelchair downstairs in the hallway of the first floor and assumed Resident 1 was headed to the activities in the big dining room. HS 2 stated she did not know Resident 1 was at risk for elopement. During an interview on 11/5/19, at 2:43 p.m. with the LVN 2, LVN 2 stated he worked the morning shift when Resident 1 eloped on 11/3/19. LVN 2 stated the last time he saw Resident 1 was at 2 p.m., and knew Resident 1 was headed to the activities in the first floor because Resident 1 told him. LVN 2 stated he did not accompany Resident 1 down to the first floor. LVN 2 stated during the change of shift, he reported to the afternoon nurse Resident 1 was in the activity room. LVN 2 stated he should have taken the PM nurse to visually see Resident 1 was attending activities but did not do so. LVN 2 stated he knew Resident 1 was at risk for elopement and he did not take the precautions to prevent Resident 1's elopement. During an interview on 11/5/19, at 3:10 p.m., with the DON, the DON stated each time staff completed endorsement during a shift change, the outgoing and incoming LVN should have physically looked for Resident 1 to ensure Resident 1 remained in the facility. The DON stated both nurses should have considered Resident 1's risk of elopement and verified Resident 1 was still in the facility on 11/3/19 and did not do so. The DON stated activity staff should have been alert and kept an eye on Resident 1 throughout the activity session. The DON stated activity staff should have escorted Resident 1 back to the third floor after he was done with activities. The DON stated each nurses' station and the front desk were provided with information to indicate which resident was at risk for elopement. The DON stated the binders alone were not enough to prevent Resident 1 from wandering and elopement. The DON stated there should have been an adequate level of supervision provided to Resident 1 to prevent elopement. During a telephone interview with LVN 3 she stated on 11/6/19, at 8:56 a.m., Resident 1's routine medications were not administered on the night of 11/3/19 and on the morning of 11/4/19 because Resident 1 was missing from the facility. LVN 3 stated Resident 1 did not receive [MEDICATION NAME] (medication used to treat high blood pressure) 30 mg, carvedilol (medication used to treat heart failure) 12.5 mg, [MEDICATION NAME] (medication used to help water retention in people with high blood pressure and heart failure) 20 mg and [MEDICATION NAME] (medication used to treat elevated blood sugar) on 11/3/19 and 11/4/19. LVN 3 stated Resident 1's blood pressure and blood sugar could have risen and caused him a headache or confusion from not taking his prescribed medication on 11/3/19 and on 11/4/19. During a review of Resident 1's Medication Administration Record [REDACTED]. (Ideal blood pressure is 120/80). During a review of Resident 1's ambulance report dated 11/4/19 at 8:50 p.m., indicated, .a passerby notice (Resident 1) in wheelchair on sidewalk and called 911. (local police department) found (Resident 1) to be a missing person. (Resident 1) stated he got angry with (Skilled Nursing Facility) staff this AM and left. (Resident 1) to bus north . (Resident 1) is incontinent and hungry .On arrival we found patient seated in wheelchair, oriented, incontinent, and disheveled . (Blood Pressure) 207/97 . During a review of Resident 1's GACH clinical record dated 11/4/19 indicated, Physical Examination .Systolic BP 188 Diastolic BP 92 .Medical Diagnosis: [REDACTED].Impression and Plan: Diagnosis- Anxiety (feeling of worry and nervousness) . During a review of the facility's undated policy and procedure titled, Wondering & Elopement indicated, Purpose: To enhance the safety of residents of the Facility . Procedure .IV. The IDT will develop a plan of care considering the individual risk factor of the resident. Specific cues to which the resident may respond to divert wandering behavior will be included in the plan of care. During a review of the facility undated policy and procedure titled, Elopement Risk Reduction Approaches indicated, .1. Planning . C. Provide adequate physical and social environments that provide activities appropriate for the resident's cognitive functioning and interest, as well as opportunity for walking, exploring and social interactions. E. Ensure that residents who wander have adequate nutrition and hydration which may include offering food and drinks while they are on the go . III. Communication. A. Develop a care plan and an update process to promote choice, mobility and safety. Base on the care plan assessment and family and care giver involvement .

Based on observation, interview and record review, the facility failed to ensure residents who require [MEDICAL TREATMENT] receive such services for one of six sampled residents (Resident 1) when licensed nurses did not coordinate the care and arrange for transportation to the [MEDICAL TREATMENT] center and Resident 1 missed two consecutive prescribed [MEDICAL TREATMENT] treatments and one additional [MEDICAL TREATMENT] treatment. This failure resulted in missed [MEDICAL TREATMENT] treatments on 10/22/19, 10/24/19, and 11/2/19. After the missed consecutive [MEDICAL TREATMENT] treatments on 10/22/19 and 10/24/19, Resident 1 experienced pain in the left arm, [MEDICAL CONDITION] (potassium level in the blood is higher than normal and may cause muscle weakness or paralysis, slow heartbeat, and weak pulse) related to missed [MEDICAL TREATMENT] and was transported to the hospital Emergency Department on 10/24/19 where [MEDICAL TREATMENT] was performed. The missed [MEDICAL TREATMENT] on 11/2/19 was followed by admissions to the hospital on [DATE] related to Resident 1's [MEDICAL CONDITION] (low blood pressure) and on 11/5/19 due to altered mental status and generalized weakness. Findings: During an interview with Director of Nursing (DON), on 11/21/19, at 10:02 a.m., she stated Resident 1 missed [MEDICAL TREATMENT] treatments on 10/22/19, 10/24/19, and 11/219. She stated the facility failed to arrange Resident 1's transportation service to the [MEDICAL TREATMENT] center and licensed nurses should have set up Resident 1's transportation to [MEDICAL TREATMENT] center on scheduled treatment appointments on 10/22/19, 10/24/19, and 11/2/19. During a record review of Resident 1's face sheet (a document with demographic, personal and medical information) dated 11/8/19, the record indicated Resident 1 was readmitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. During an interview with Licensed Vocational Nurse (LVN) 4, on 11/21/19, at 11:40 a.m., she stated Resident 1 was sent to the hospital Emergency Department on 10/24/19 due to missed scheduled [MEDICAL TREATMENT] treatment on 10/22/19 and 10/24/19. LVN 4 stated Social Services Department should have arranged Resident 1's transportation service on 10/22/19 and did not. During a review of the clinical record for Resident 1, on 11/21/19, at 11:42 a.m., Resident 1's admitting physician's orders and MAR indicated [REDACTED]. During an interview with Social Service Coordinator (SSC), on 11/21/19, at 3:58 p.m., he stated Resident 1 missed [MEDICAL TREATMENT] treatments on 10/22/19 (Tuesday), 10/24/19 (Thursday), and 11/2/19 (Saturday) because transportation services were not arranged for Resident 1 by nursing department. He stated the admission nurse should have set-up Resident 1's [MEDICAL TREATMENT] transportation services on the day of admission (10/19/19). During a review of the clinical record for Resident 1, the Physician and Telephone Orders dated 10/24/19, at 5 p.m., indicated, . sent to hospital for evaluation . due to missed [MEDICAL TREATMENT]. During a review of the acute care hospital (ACH) for Resident 1, the History and Physical Report dated 10/24/19, indicated, .chief complaint patient presents with [MEDICAL TREATMENT] Treatment per SNF (skilled nursing facility) staff missed [MEDICAL TREATMENT] .and pain in the left arm so sent to ED (Emergency Department) . patient (Resident 1) had not been having [MEDICAL TREATMENT] since from 10/19 (date of admission in nursing facility) last discharge . During a review of the clinical record for Resident 1, the [MEDICAL TREATMENT] facility progress notes dated 10/24/19, indicated, . Patient (Resident 1) has missed approximately 1 week of treatment as he apparently had a transportation issue .Advised to send patient (Resident 1) out to ER (emergency room ) to get [MEDICAL TREATMENT] treatment as patient (Resident 1) had missed a week of treatment . During an interview with (name of Transport Service) Office Manager (OM), on 1/7/20, at 9:30 a.m., she stated there were no arranged [MEDICAL TREATMENT] transportation services for Resident 1 on 10/22/19, 10/24/19, and 11/2/19. The OM stated the facility did not notify their office that Resident 1 returned back to the SNF from the acute hospital on [DATE] and 11/1/19 for them to pick up Resident 1 for [MEDICAL TREATMENT] scheduled treatments. During a phone interview with LVN 1, on 1/15/20, at 7:50 a.m., she stated she was assigned to Resident 1 on the morning of 10/22/19 (date of scheduled [MEDICAL TREATMENT]) when Resident 1 missed the scheduled [MEDICAL TREATMENT] appointment. She stated she reviewed Resident 1's clinical records and Medication Administration Record [REDACTED]. LVN 1 stated she checked the 24-hour communication log (24-hour report system used by licensed nurses in each nursing station to facilitate inter-shift communication) and indicated no data was placed for Resident 1's [MEDICAL TREATMENT] follow-up or transportation appointments on 10/22/19. She also stated she informed SSC about Resident 1's [MEDICAL TREATMENT] appointment schedule and assumed SSC arranged the transportation for Resident 1 on 10/22/19. During a phone interview with LVN 1, on 1/15/20, at 7:50 a.m., she stated she did not document and notify Resident 1's MD for missed [MEDICAL TREATMENT] on 10/22/19 and 10/24/19. LVN 1 stated any missed [MEDICAL TREATMENT] should be placed on Resident 1's progress notes and she should have notified Resident 1's MD for missed [MEDICAL TREATMENT] treatments on 10/22/19 and 10/24/19 and did not. During a phone interview with LVN 1, on 1/15/20, at 7:50 a.m., she stated she was assigned to Resident 1 on the morning of 10/23/19 (a day after the missed scheduled [MEDICAL TREATMENT]). She stated she did not ask Resident 1's [MEDICAL TREATMENT] schedule from NOC (night) shift nurse (outgoing nurse) and she did not call Resident 1's transportation service on 10/23/19 to follow up Resident 1's [MEDICAL TREATMENT] transportation service. LVN 1 stated she assumed Resident 1 went to [MEDICAL TREATMENT] treatment on 10/22/19 and was taken care of by SSC. During an interview with [MEDICAL TREATMENT] Facility Administrator (DFA) 1, on 1/15/20, at 1:55 p.m., she stated Resident 1 missed the [MEDICAL TREATMENT] treatment on 11/2/19. The DFA 2 stated the risk of illnesses increased when resident missed [MEDICAL TREATMENT] treatments which may include nausea, vomiting, low blood pressure. During a review of the clinical record for Resident 1, the (name of [MEDICAL TREATMENT] Center) progress notes dated 11/4/19, indicated, .Per niece, pt (Resident1) was d/c (discharged ) from hospital last Friday (11/1/19) . and not sure why he (Resident 1) didn't come in on his regular tx (treatment) day of Saturday (11/2/19) .concerns with pt's (Resident 1) transportation on Saturday, therefore pt (Resident 1) was rescheduled today (11/4/19). During a concurrent interview and record review with the DON, on 1/16/20, at 3:53 p.m., she reviewed Resident 1's admitting physician's orders and MAR indicated [REDACTED]. She stated Resident 1's MD orders were not specific for Resident 1's appointment [MEDICAL TREATMENT] schedule. DON stated the admitting nurse should have coordinated the [MEDICAL TREATMENT] appointment time and transportation to the [MEDICAL TREATMENT] center. During a concurrent interview and record review with the DON, on 1/16/20, at 3:53 p.m., she reviewed Resident 1's progress notes and indicated there were no assessments on Resident 1's [MEDICAL TREATMENT] (a catheter inserted into veins in the groin, chest, or neck to reach the blood for [MEDICAL TREATMENT]) on admission by the admitting nurse and no documentation for [MEDICAL TREATMENT] appointment. DON stated licensed nurses did not notify the MD of Resident 1's missed [MEDICAL TREATMENT] treatments on 10/22/19 and 10/24/19. She stated the licensed nurses should have assessed Resident 1's condition, documented and notified MD on Resident 1's missed [MEDICAL TREATMENT] treatments to ensure physicians were informed of Resident 1's sudden changes in condition. DON stated the licensed nurses were responsible in arranging Resident 1's transportation to [MEDICAL TREATMENT] center. During a concurrent interview and record review with the DON, on 1/16/20, at 3:53 p.m., she reviewed Resident 1's [MEDICAL TREATMENT] care plan dated 10/24/19 and she stated Resident 1's care plan did not indicate missed [MEDICAL TREATMENT] treatments as a concern and there were no new approaches or interventions in placed for Resident 1's missed [MEDICAL TREATMENT]. During a concurrent interview and record review with the DON, on 1/16/19, at 3:53 p.m., she reviewed the facility policy and procedure titled, Comprehensive Person-Centered Care Planning dated 11/18, indicated, .c. The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment .ii. Change of condition .iv. To address changes in behavior and care; and v. Other times as appropriate or necessary . DON stated Resident 1's [MEDICAL TREATMENT] care plan should have been revised and updated to reflect new interventions based on resident-centered care needs. During a concurrent interview and record review with LVN 2 (admitting nurse), on 1/16/20, at 4:42 p.m., she stated she was the admitting nurse of Resident 1 on 10/19/19. LVN 2 reviewed her nurse's notes and stated there was no documentation about Resident 1's [MEDICAL TREATMENT] appointment schedule. LVN 2 stated she did not call the transportation service and [MEDICAL TREATMENT] center to confirm [MEDICAL TREATMENT] treatment. LVN 2 stated she have written it (Resident 1's [MEDICAL TREATMENT]) on 24-hour communication sheet on 10/19/19 as endorsements or follow-up to incoming shift nurses of the day. During a concurrent interview and record review with DON, on 1/16/20, at 4:50 p.m., she reviewed the 24-hour communication sheet on Station 1 dated 10/19/19 and stated there were no written notes by admitting nurse or licensed nurses about Resident 1's [MEDICAL TREATMENT] appointment schedules or follow-up and there should have been. During a concurrent interview and record review with LVN 3, on 1/16/19, at 5:08 p.m., she stated she was assigned to Resident 1 on the afternoon shift of 10/22/19 (date of scheduled [MEDICAL TREATMENT]) and reviewed Resident 1's nurse's notes on 10/22/19. She stated, It does not look like I charted it (missed [MEDICAL TREATMENT] on 10/22/19). I will chart it if only I was made aware. LVN 3 stated she did not get a report from the morning shift nurse on 10/22/19 about Resident 1's missed [MEDICAL TREATMENT] treatment. During an interview with LVN 4, on 1/16/19, at 5:58 p.m., she stated she was assigned to Resident 1 on the morning shift of 11/2/19 (date of scheduled [MEDICAL TREATMENT]) and she stated she called the transportation service for Resident 1 at 8:30 a.m. on 11/2/19. LVN 4 stated the transport service for Resident 1 was not aware that Resident 1 came back from a recent admission in acute hospital and no driver was available to pick up Resident 1 on 11/2/19. During a concurrent interview and record with LVN 4, on 1/16/19, at 5:58 p.m., she reviewed her nurse's notes for Resident 1 dated 11/2/19, indicated, . Patient (Resident 1) unable to attend [MEDICAL TREATMENT] at (name of [MEDICAL TREATMENT] center) today (11/2/19). Writer called Transport and Transport Company informed writer that no one informed the company that the patient returned back from the hospital. Therefore they do not have a driver at this time . next opening would be Monday 11/4/19 . During a concurrent interview and record review with LVN 4, on 1/16/19, at 5:58 p.m., she reviewed Resident 1's [MEDICAL TREATMENT] care plan and stated Resident 1's care plan was not updated to reflect missed [MEDICAL TREATMENT] treatments in order to implement a resident centered focused plan of care for Resident 1. During a concurrent interview and record review with DON, on 1/23/19, at 11:25 a.m., she stated licensed nurses should have coordinated Resident 1's care and arranged the transportation to [MEDICAL TREATMENT] center. The DON reviewed the facility policy and procedure titled, 24 Hour Communication Log dated 1/1/12, indicated, .The facility will utilize a 24-hour report system in the form of 24 Hour Communication Log as a means of communicating changes in condition, other important aspects of residents' care .The Licensed Nurse will record changes that include but are not be limited to: 1. New admissions/readmissions .ix. Appointments/transportation .G. The Director of Nursing Services, IDT members, and Administrator, will review the log on a daily basis and report significant information at the daily stand-up meeting . The DON stated the licensed nurses should have written Resident 1's [MEDICAL TREATMENT] appointment schedule consistently in 24-hour communication sheet to communicate and collaborate with facility staff (licensed nurses and certified nursing assistants). During a review of the clinical record for Resident 1, the licensed nurse record dated 11/4/19, indicated, . Resident B/P (blood pressure) was too low to complete [MEDICAL TREATMENT] and they were sending resident to (acute hospital). During a review of the Acute Care Hospital records for Resident 1, the Case Management Discharge Summary/Orders Report dated 11/7/19, indicated, . admitted : 11/5/19 discharge date : 11/7/19 .patient presents with Altered Mental Status, from [MEDICAL TREATMENT] .Pt (patient) presenting with some confusion and gen (generalized) weakness likely related to uremic [MEDICAL CONDITION] (a complication of [MEDICAL CONDITION] leading to cerebral dysfunction) (damage or malfunction of the brain) due to missed [MEDICAL TREATMENT] for 1 week . During a review of the facility policy and procedure titled, Referrals to Outside Services dated 12/13, indicated, . V. The Director of Social Services or his or her designee will coordinate with Nursing Staff to ensure that the Attending Physician's order and referral to outside provider is documented in the resident's medical record . During a review of the facility policy and procedure titled, Change of Condition Using Triage Trace dated 10/24/17, indicated, The facility will promptly inform the resident, consult with the resident's Attending Physician .when the resident endures a significant change in their condition caused by .C. A significant change in treatment . Clinical Documentation: D. A Licensed Nurse will document .The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received will be included .iv. The Care Plan will be updated to reflect the resident's current status and interventions. v. The incident and brief details will be recorded in the 24-hour Report . During a review of the facility policy and procedure titled, [MEDICAL TREATMENT] Care dated 1/1/12, indicated, . I. [MEDICAL TREATMENT] Arrangements A. The Facility will arrange for [MEDICAL TREATMENT] care for such residents on a weekly basis. B. The Facility will arrange transportation to and from the [MEDICAL TREATMENT] provider .and a method of communication between the [MEDICAL TREATMENT] provider and the Facility . During a review of the facility policy and procedure titled, [MEDICAL TREATMENT] Care dated 1/1/12, indicated, .II. Care Plan . i. The resident's Care Plan will be updated as needed .C. If the resident does not comply with his or her care plan, the Facility will document this non-compliance with following Care Plan and make the necessary adjustments, including providing additional education to the resident . During a review of the facility service agreement titled, Nursing Home [MEDICAL TREATMENT] Transfer Agreement dated 4/16/17, indicated, .The Nursing Home [MEDICAL TREATMENT] Transfer Agreement is made and entered into by and between (name of nursing facility) and (name of [MEDICAL TREATMENT] center) . 4. Transportation of Designated Resident. Facility shall have the responsibility for arranging suitable transportation of the Designated Resident to and from Center, including the selection of the mode of transportation, qualified personnel to accompany the Designated Resident . During review of a professional reference retrived from https:// www. kidneymedicinejournal. org/article/S2590-0595(19) -3/fulltext, dated 2/20, indicated, . Missed treatments that occur when the patient is not admitted to the hospital have significant implications with respect to clinical outcomes. They are associated with markedly higher rates of hospitalization , emergency department (ED) visits and mortality. Missed treatments are also associated with unfavorable [MEDICAL CONDITION] outcomes, including lower hemoglobin levels .These adverse outcomes are likely due to the accumulation of excess fluid, electrolytes . imposed by the missed treatment.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards for one of three sampled residents (Resident 5) when Certified Nursing Assistant (CNA) 1 failed to remove Resident 5's elastic compression stockings as ordered by Resident 5's physician. Resident 5 was unable to feel discomfort from the stockings bunching up on her feet during the night which caused pressure and skin damage to the bottom of her right foot. This failure resulted in the formation of a purple-red fluid-filled blister, ten and one half centimeters (cm - a metric measurement; 2.54 cm equals one inch) long by nine cm wide discovered the following morning, 11/8/18. The blister on Resident 5's right foot popped leaving exposed underlying tissue from the ball of the foot to the heel of the foot. As a result of the wound on the right foot, Resident 5 required skin monitoring and daily dressing changes, and was no longer able to bear weight on her right foot or walk. Findings: Review of Resident 5's clinical record titled, Face Sheet (document containing resident personal information), indicated Resident 5 was a [AGE] year-old female with [DIAGNOSES REDACTED]. It typically happens in the evening or nighttime hours when you're sitting or lying down. Moving eases the unpleasant feeling temporarily) who had resided in the skilled nursing facility (SNF) since (MONTH) (YEAR). Review of Resident 5's clinical record facsimile (fax) sent to Resident 5's physician dated 10/19/18, indicated, Resident (Resident 5) is requesting (elastic compression) hose on during AM (morning) shift at 8 a.m. and off at 8 p.m. to control [MEDICAL CONDITION] (nerve) pain. Review of Resident 5's physician orders dated 10/27/18 indicated, Apply (elastic compression) hose to Rt (right) leg, on at 8:00 a.m., off at 8:00 p.m. Apply (elastic) hose to Lt (left) leg, on at 8:00 a.m., off at 8:00 p.m. On 11/26/18 at 10:21 a.m., during an interview, the Assistant Director of Nursing (ADON) stated Resident 5 was prescribed elastic compression stockings to help with her diabetic [MEDICAL CONDITION] (nerve disorder due to diabetes causing decreased or abnormal sensation in the feet and legs). The ADON stated the stockings had been left on over-night on 11/7/18 and had migrated and got bunched up mid-foot which caused a seven-inch blister to develop by the morning of 11/8/18. Review of Resident 5's clinical record titled, C[NAME] (Change of Condition)/SBAR (Situation-Background-Assessment-Recommendation) ASSESSMENT FORM, dated 11/8/18 at 7:15 a.m., indicated, (Resident 5) noted with 10.5 (cm long) x 9 (cm wide) fluid filled purple blister to bottom of (right) foot .During CNA changing of patient it was noted that (Resident 5) had purple discoloration and reported to charge nurse. Upon assessment (elastic compression stockings) hose were on (Resident 5's) legs and not properly fitting. 10.5 (long) x 9 (wide) fluid filled purple blister noted and entire foot [MEDICAL CONDITION] (swollen) . Review of Resident 5's physician's orders dated 11/8/18, indicated Apply skin prep to right foot blister every shift for 14 days, then re-evaluate. Stop date 11/21/18. Monitor R (right) foot blister for s/s (signs and symptoms) of infection Q (every) shift and re-evaluate in 14 days. Stop date 11/21/18. Review of Resident 5's physician's order, dated 11/14/18, indicated, Cleanse diabetic right foot arch with normal-saline (salt water compatible with blood and body tissue), pat dry, and apply (wound product that removes dead tissue from wounds) and calcium alginate (moist wound management product that forms a soft gel to absorb wound drainage), cover with dry dressing every day and as needed. Monitor diabetic right foot arch for signs and symptoms of infection and notify MD (physician) of any changes. Review of Resident 5's clinical record titled, Weekly Non-Pressure Ulcer (open wound) Progress Reports (WNPUPR), dated 11/14/18, indicated the onset of Resident 5's right foot wound was 11/8/18. The progress report indicated the wound was not present on admission to the SNF. The progress report indicated the size of Resident 1's wound was 10 cm long; by 15 cm wide; by 0.4 cm deep. On 11/26/18 at 10:25 a.m., during an observation and interview with Licensed Nurse (LN) 2 and Resident 5, Resident 5 was sitting up in a wheelchair in her room. Resident 5 was wearing an elastic stocking on her left leg and a wound dressing on her right foot. Resident 5 agreed to allow staff to help her lie down and remove the dressing on her right foot. Resident 5 stated she was unable to remember details related to the cause of the wound that began as a blister on her right foot. Resident 5 denied discomfort and stated she only felt twinges in her right foot. LN 2 removed Resident 5's right foot dressing and a large open wound was observed on the bottom of Resident 5's right foot. LN 2 stated the bottom and inside arch of Resident 5's right foot had an open wound, seven inches by five inches, with no skin covering the area and the underlying tissues were exposed. On 11/26/18 at 11:24 a.m., during an interview and concurrent review of Resident 5's (MONTH) (YEAR) TAR, the ADON stated LN 1 documented on the treatment record that Resident 5's elastic compression stockings were removed on 11/7/18, at 8 p.m. The ADON stated the documentation was an error. The ADON stated Resident 5's elastic compression stockings were not removed at 8 p.m. on 11/7/18 and they were still on the next morning, 11/8/18. The ADON stated, I was with (LN 2) when she assessed (Resident 5's) (right) foot (on 11/8/18). The (elastic compression stockings) were still on. The open toe (of the stocking) had slipped down to mid-foot and the stockings were bunched up. On 11/26/18 at 11:50 a.m., during an interview, LN 2 stated Resident 5's elastic compression stockings were not removed at 8 p.m. on 11/7/18, as the doctor had ordered. LN 2 stated Resident 5's elastic stockings were left on overnight. LN 2 stated she and the ADON went together on the morning of 11/8/18 to assess Resident 5's right foot. LN 2 stated there was a purple-red blood blister partially exposed and partially covered by elastic stockings. LN 2 stated, The open toe of the elastic stockings had migrated to the mid-arch (instep) and heel area of (Resident 5's) right foot and caused the blister. LN 2 put her thumbs and index fingers of both hands together to form a large oval shape to demonstrate the size of the blister. On 11/27/18 at 1:22 p.m., during a telephone interview, LN 1 stated, When I came in on the p.m. shift (on 11/8/18) I was told (Resident 5) had developed an issue due to the (elastic compression stockings) being left on (overnight). LN 1 stated she was referring to the blister Resident 5 developed on her right foot. LN 1 stated she was the p.m. nurse on 11/7/18, during the time when the stockings should have been removed at 8 p.m. LN 1 stated she documented incorrectly that the stockings were removed at 8 p.m. on 11/7/18. LN 1 stated the stockings should have been removed each day at 8 p.m. LN 1 stated, (CNA 1) should have known (to remove them) and I told her (to remove the stockings). LN 1 stated, Normally, I would go back and look to see if (the elastic compression stockings) had been removed. I trusted the CNAs to do their job. Most likely, in my opinion, the (elastic stockings) did not get removed that night, and most likely the blister was caused by the elastic stockings. It (the blister) was not there before. The blister was more likely than not caused by the mal-adjusted (elastic stockings). If I had seen (the elastic stockings) I would have straightened them out or taken them off. On 1/7/19 at 10:20 a.m., during a telephone interview and concurrent record review, the ADON stated Resident 5's WNPUPR WHAT IS THIS dated 12/26/18 at 3:04 p.m., indicated Resident 5's right foot wound measured 9.3 cm long by 6 cm wide by 1.7 cm deep. The ADON stated the documentation indicated Resident 5's right foot wound dressing was changed twice a day. On 1/24/19 at 12:23 p.m., during a telephone interview and concurrent record review, Resident 5's wound care Medical Doctor (MD) 1 reviewed Resident 5's wound care records. MD 1 stated he first saw Resident 5's right foot wound on 11/14/18. MD 1 stated the right foot wound was already an open wound at that time; there was no longer an intact blister. MD 1 stated he called it a diabetic non-pressure injury because Resident 5 had diabetes and it was an open wound. MD 1 stated he assessed the wound weekly beginning 11/14/18 and ordered the wound care. MD 1 stated although Resident 5's wound was healing, she had not been able to bear weight on her right foot due to the open wound. On 1/24/19 at 1:20 p.m., during a telephone interview and concurrent record review, Restorative Nursing Assistant (RNA1), (a specially trained aide to help residents maintain mobility) stated she worked with Resident 5 three times a week prior to 11/8/18, when Resident 5 obtained the wound to her right foot. RNA 1 stated Resident 5 had a physician's order, dated 10/26/18 for the RNA to walk Resident 5 three times a week with a front-wheeled-walker, as tolerated, to maintain functional mobility. RNA 1 stated the order included Sit to Stand activity for Resident 5 as tolerated. RNA 1 stated Resident 5 walked five to 10 feet with her help using a front wheel walker. RNA 1 stated the order to assist Resident 5 to walk was discontinued on 11/8/18, after Resident 5 developed a blister on her right foot. On 1/24/19 at 1:22 p.m., during a telephone interview, Physical Therapist (PT) 1 stated, (Resident 5) is not walking. She is non-weight bearing on the right due to the (right) foot wound. On 1/24/19 at 2:44 p.m., during a telephone interview, the ADON stated Resident 5 was unable to bear weight or walk on her right foot since the blister and wound developed on 11/8/18. Review of Resident 5's clinical record titled, Care Plan Diabetes Mellitus initiated 7/28/18, and updated 10/14/18, indicated, Actual / Potential risk for injury related to autonomic (regulates the involuntary nervous system) and peripheral neuropathies (disorder of the nerves that affect the extremities especially the hands and feet causing decreased sensitivity to irritants or pain). Actual/Potential risk for impaired skin integrity related to diminished sensitivity .Approach .Monitor skin for redness, breakdown and decreased circulation every shift .provide education to resident, responsible party and staff regarding special care needs . Review of the facility policy and procedure titled, Diabetic Care dated 1/1/12, indicated, .The Facility will provide the necessary care and services to permit each diabetic resident to attain or maintain optimal well-being while monitoring their care in accordance with their individualized Comprehensive Assessment and Care Plan .Licensed Nurses will provide diabetes education to residents and family, covering the topics: .How to prevent pressure areas; .Removing shoes and socks at night . The facility policy and procedure titled, Elastic Stockings, dated 1/1/12, indicated, Policy: It is the policy of the Facility that elastic stockings are worn only upon the order of an Attending Physician. Procedure: I. Explain the procedure to the resident. II. Check the condition of the resident's skin before applying the stockings and document VI. Smooth away any wrinkles on the stockings. VII. Check the physician's orders for removal instructions. VIII. Elastic stockings should be removed per shift, skin assessed with [REDACTED]. The facility policy and procedure titled, Comprehensive Person-Centered Care Planning dated 7/20/18, indicated, .It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being . Review of professional reference Side Effects of Compression Stockings; British Journal of General Practice @ HTTPA://www.ncbi.nlm.nih.gov/pmc/articles dated 5/27/14, indicated, .Although the application of compression stockings can appear simple, it must be remembered that inappropriately worn stockings have the potential to cause significant problems. Unevenly distributed and excess pressure may break the skin, especially in older, malnourished patients and those with thin, brittle skin .If not managed accordingly compression stockings may cause unintended harm .It is of particular importance to ensure that there are no folds in the fabric, allowing even distribution of pressure throughout the limb and to avoid creating a focus of higher pressure over one specific area .While an almost everyday intervention, compression stockings are not without potential risks and therefore require correct application and close monitoring, especially in those who are at greater risk of skin damage .

Based on observation, staff interview, and clinical record and administrative document review, the facility failed to ensure two of four sampled Residents (Residents 1 and 2) received sufficient fluid intake to maintain proper hydration and health when: 1. Resident 1's fluid intake declined severely over 30 days and the resident was not evaluated by the nursing staff for further intervention. This failure left Resident 1 at risk of complications. Resident 1 was admitted to the acute hospital with a urinary tract infection [MEDICAL CONDITION], dehydration (decrease in total body water), and acute kidney injury. 2. Resident 2's fluid intake declined significantly over 30 days and the resident's hydration status was not evaluated by the nursing staff for further intervention. This failure left Resident 2 at risk of complications. Resident 2 was diagnosed with [REDACTED]. Findings: 1. On 7/31/12 at 8:30 a.m., Resident 1's current Nutritional Status care plan revised on 3/8/12 indicated the resident was at risk for dehydration. No specific interventions to prevent dehydration from occurring were included in the Nutritional Status care plan. The Registered Dietician's (RD's) Dietary/Nutritional Notes dated 8/1/12 indicated Resident 1 required an estimated fluid need of 1475-1770 milliliters (mls) per day. The Meal and Fluid Detail Report dated 6/1/12-7/4/12 indicated the following: Resident 1 had a total fluid intake of 480 ml/day for 3 of 33 days (6/10, 6/24 and 6/28/12). This was 32% of her estimated minimum daily fluid requirements. There was no documented evidence fluid refusals were reported. Resident 1 had a total fluid intake of 360 ml/day for 7 of 33 days (6/9, 6/14, 6/15, 6/18, 6/21, 6/25 and 6/30/12). This was 24% of her estimated minimum daily fluid requirements. There was no documented evidence fluid refusals were reported. Resident 1 had a total fluid intake of 240 ml/ day for 12 of 33 days (6/1, 6/2, 6/4, 6/6, 6/8, 6/12, 6/13, 6/20, 6/22, 6/23, 6/27 and 6/29/12). This was 16% of her estimated minimum fluid requirement. There was no documented evidence fluid refusals were reported. Resident 1 had a total fluid intake of 120 ml/day for 2 of 33 days (6/5 and 6/16/12). This was 8% of her estimated minimum fluid requirements. There was no documented evidence fluid refusals were reported. Resident 1 had no fluid intake on 6/7/12. There was no documented evidence fluid refusal was reported. The BMP (Basic Metabolic Panel - a group of blood tests used as a screening tool) dated 7/9/12 indicated Resident 1 had an elevated BUN (Blood, Urea, Nitrogen - a test to evaluate kidney function) of 34 mg/dL (normal range: 7-25 mg/dL). Creatinine (a test to evaluate kidney function) was elevated at 1.49 mg/dL (normal 0.60 to 1.20 mg/dL). These high test results indicated potential complications such as dehydration (loss of total body water). Review of the article titled "CONSIDER: HYDRATION MANAGEMENT" dated 2/05 from the Hartford Institute For Geriatric Nursing indicated, "... Common symptoms of Dehydration... Elevation in BUN (best measure)..." On 8/3/12 at 10:30 a.m. during a concurrent interview, clinical record and administrative document review, the Director of Nursing (DON) stated there was no documented evidence of any communication about Resident 1's fluid refusals on the logs. The DON stated Resident 1 had not received any additional fluids or any nutritional supplements during the month of June 2012. The DON confirmed the Meal and Fluid Detail Report was the only record of Resident 1's fluid consumption. On 9/4/12 at 1:58 p.m., during a phone interview, Licensed Nurse (LN) 2 stated the facility protocol for residents who continued to refuse fluids included: Certified Nursing Assistants (CNAs) notified the LNs, LNs notified the resident's physician of intake/output, alert charting (LN staff charted on a resident's condition every shift for 72 hours), encourage fluids, and start a care plan. LN 2 stated the resident might be placed on IV hydration as ordered by the physician. LN 2 stated the above information would be documented in the nurse's notes (NN). On 9/4/12 at 2:05 p.m. during an phone interview, LN 3 stated the facility protocol was to notify the physician when a resident refused fluids. LN 3 stated the resident would be placed on monitoring and alert charting, and the CNAs would document refusals of fluid in the communication log. LN 3 stated if a resident continued to refuse fluids, the physician was notified for treatment options that might include IV hydration and labwork. Resident 1 received 32% or less per day of her minimum estimated fluid needs for 25 of 33 days reviewed (6/1/12-7/4/12). There was no documented evidence the LNs assessed Resident 1 for refusing fluids and intervened. There was no documented evidence the physician was notified of Resident 1's repeated refusals. There were no plans in place to prevent dehydration. Resident 1's acute hospital History and Physical (H&P) notes dated 7/9/12 at 10:10 p.m. indicated, "...Pt. had lab work done since she is loosing (sic) weight...She was sent to (acute hospital) for further evaluation...Assessment: ...4. UTI (Urinary Tract Infection)...5. Acute kidney injury - could be from dehydration resulting from not eating well...6. [MEDICAL CONDITION] (high blood potassium level) - could be from [MEDICAL CONDITION]: Admit...IV (Intravenous) hydration... " The facility Policy and Procedure (P&P) titled, "HYDRATION" dated 5/04 indicated, "Purpose: To ensure that each resident is encouraged to consume adequate fluids in order to maintain proper hydration for optimum functioning of various body systems... Each resident will receive a minimum of 1000 cc of fluid... The nursing staff will encourage each resident to consume all fluids provided on their meal trays... Residents suspected of or exhibiting signs of dehydration, or consuming less than their fluid needs will have an evaluation of hydration... d. Assessment and documentation of hydration will be documented in the licensed nursing notes..." 2. On 7/31/12 at 8:40 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 2 had been refusing fluids. The current Nutritional Status care plan initiated 5/27/12 indicated Resident 2 was at risk for dehydration secondary to a [DIAGNOSES REDACTED]. An intervention dated 6/21/12 indicated, "POLST full treatment..." The POLST prepared 5/26/12 indicated Resident 2's medical interventions included "Full Treatment," which included IV (intravenous) fluids as indicated. Resident 2's Meal and Fluid Detail Report and MAR (Medication Administration Record) dated 6/1/12 - 7/3/12 indicated the resident's fluid intake was 50% or less (780 milliliters - ml or less) of her minimum fluid requirements of 1560 ml/day on 17 of 33 days reviewed (6/3/12, 6/5/12 - 6/17/12, 6/19/12, 6/24/12 and 6/29/12). The LN Weekly Summary dated 6/13/12 indicated Resident 2 had an average intake of 120-240 ml every 24 hours, and had an average output of of 100 ml every 24 hours. The summary dated 6/20/12 indicated Resident 2 had an average intake of 200 mls every 24 hours and had no documented average output. The summary dated 6/27/12 was blank in the area of the resident's average intake and output. The NN dated 6/19/12 at 7:30 p.m. indicated Resident 2 had a urinary tract infection [MEDICAL CONDITION]. The NN dated 6/21/12 at 11 p.m. indicated the physician was at the facility. The same note indicated Resident 2 had a decreased urinary output of 50 ml. There was no documented evidence that Resident 2's decreased intake & output had been discussed with or evaluated by the physician. There was no documented evidence the LNs assessed Resident 2 for refusing fluids and there was no plan in place to prevent dehydration. On 8/3/12 at 9:45 a.m., during a concurrent interview and clinical record review, the DON stated IV hydration had not been discussed as an option by the IDT (Interdisciplinary Team), with Resident 2 or with the attending physician when Resident 2's intake had been less than her minimum fluid needs. On 8/3/12 at 11:15 a.m., the DON confirmed Resident 2 was to receive full treatment, to include IV hydration, based on Resident 2's POLST form. On 9/4/12 at 1:58 p.m., during a phone interview, LN 2 stated a resident who continued to refuse fluids had their intake brought to the LN's attention by the CNA caring for the resident, was placed on 72 hour monitoring and alert charting, and might be placed on IV hydration as recommended by the physician. LN 2 stated this information would be documented in the nurse's notes (NN). On 9/4/12 at 2:05 p.m. during a phone interview, LN 3 stated the physician would be notified when a resident refused meals or fluids. LN 3 stated the resident would be monitored and put on alert charting. LN 3 stated if a resident continued to refuse fluids, the physician would be notified for treatment options that might include labwork and IV hydration. LN 3 stated such notifications would be documented in the NN. There was no documented evidence LNs assessed Resident 2 for potential dehydration due to fluid refusals. There was no documented evidence to indicate treatment options to address the resident's decreased fluid intake was considered. The facility Policy and Procedure (P&P) titled, "HYDRATION" dated 5/04 indicated, "Purpose: To ensure that each resident is encouraged to consume adequate fluids in order to maintain proper hydration for optimum functioning of various body systems... Each resident will receive a minimum of 1000 cc of fluid provided by the dietary department... The nursing staff will encourage each resident to consume all fluids provided on their meal trays... Residents suspected of or exhibiting signs of dehydration, or consuming less than their fluid needs will have an evaluation of hydration... d. Assessment and documentation of hydration will be documented in the licensed nursing notes..."