Every finding on record at Hemet Hills Post Acute

Based on interview and record review, the facility failed to follow their grievance policy and procedure for one of three residents reviewed, (Resident 1) when Resident 1 expressed concerns about the care and conduct of two Certified Nursing Assistants (CNA 2 and 3).This failure may have contributed to a delay in response to verbal concerns submitted by Resident 1.Findings:On July 20, 2026, at 10:00 a.m., an unannounced visit was made to the facility to investigate an allegation of poor quality of care and neglect.On July 20, 2026, at 12:45 p.m. an interview was conducted with Resident 1. Resident 1 stated on the evening of July 4, 2026, she had been neglected by two CNA's when asking to be changed on multiple occasions and was not. Resident 1 alleged she remained wet for hours until the early morning of July 5, 2026. Resident 1 indicated she reported to the Registered nurse on the morning of July 5, 2026, that she did not wish to be assigned CNA 2 and CNA 3 again. Resident 1 believed she overhead CNA 2 speaking to another CNA dismissively about how Resident 1 informed her that she would file a complaint. Resident 1 stated she received care from CNA 2 for the entire evening of July 5, 2026, until morning shift change on July 6, 2026, and that she felt uncomfortable and ignored by nursing staff in general.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnosis which included osteomyelitis of the foot (a severe infection and inflammation of the bone and bone marrow). Resident 1 was assigned to room [ROOM NUMBER] bed B.The Minimum Data Set (MDS - an assessment tool), dated May 10, 2026, indicated, a BIMS (Brief Interview of Mental Status) score of 12 (moderate cognitive impairment). A review of the progress notes from July 4, 2026, to July 20, 2026, did not indicate that a discussion took place regarding Resident 1's allegations against the staff or the nature and type of interventions that would be put in place during the internal investigation.A review of the Grievance report dated July 5, 2026, indicated, .On July 4, 2026 CNA 3 was told by patient (Resident 1) several times that she needed to be changed. CNA told patient that he kept forgetting. At 9:41 p.m., she told CNA 3 that she needed a brief change and he never went back to her room. Night shift began, patient on several occasions informed CNA 2 that she needed a brief change and CNA 2 did not change her brief until about 1 a.m. CNA 2 had a bad attitude toward patient and was rude. When patient told CNA 2 she was going to file a complaint CNA 2 was talking to another CNA and made the following statement.'she is going to file a complaint about me but I don't give a S***.'.statement obtained from patient.disciplinary forms gathered for respective supervisors.response by department.DSD (director of staff development) to provide in-services and reinforce the timely changing of briefs and as requested per patient.Signed by DON (Director of Nursing) July 7, 2026.A review of the Grievance Log dated July 2026, indicated, .July 5, 2026 (name of Resident 1) .room [ROOM NUMBER] B .(name of RN1) .nature of concern .customer service .department .nursing .date resolved July 8, 2026 .A review of the document titled, CNA daily assignment, dated July 4, 2026, indicated, .PM (afternoon shift).name of CNA 3 assigned to room [ROOM NUMBER] A and B.and NOC (night shift).(name of CNA) CNA 2 assigned to room [ROOM NUMBER] A and B (Resident 1's room).A review of the document titled, CNA daily assignment, dated July 5, 2026, indicated, .NOC shift.(name of CNA) CNA 2 assigned to room [ROOM NUMBER] A and B (Resident 1's room).There was no indication the facility attempted to reassign CNA 2 to another unit or section of the facility on July 5, 2026.On July 20, 2026, at 3:23 p.m., a concurrent interview and record review was conducted with Registered Nurse 1 (RN1). RN 1 stated she received the grievance report from Resident 1 on the morning of July 5, 2026, and reported to the Director of Nursing (DON) and Director of Staff Development (DSD) regarding allegations made against two staff; CNA's 2 and 3 for lack of response to call lights and having poor attitudes. RN 1 indicated she reported to RN 4 during the shift change before leaving for the day on July 5, 2026. RN 1 stated the protocol was to receive a report from the resident, by filling out a grievance report form and then contacting the DON and DSD so that a response and interventions would be conducted. RN 1 stated she did not perform any disciplinary actions for CNA's involved but communicated with the RN on the evening (PM) shift. RN 1 stated she spoke to Resident 1 on the morning of July 5, 2026 and that Resident 1 indicated she communicated with CNA 3 she needed to be cleaned, but was ignored. RN 1 further stated Resident 1 mentioned CNA 2 was also aware and ignored her requests. A review of the grievance report was conducted with RN 1. RN 1 stated the DSD and DON along with the Assistant Director of Nursing (ADON) provided the interventions and deemed the concern resolved according to the grievance report dated July 8, 2026. RN 1 stated an in-service was provided for nursing staff on July 15, 2026 which reviewed call light response, customer service, such as abuse, answering the telephone, changing briefs, giving and receiving reports (CNA, LVNs, RNs) smoking and food storage.On July 21, 2026, at 9:03 a.m., an interview was conducted with CNA 2. CNA 2 stated she was assigned to Resident 1 on the night shift (NOC) July 4-5, 2026. CNA 2 indicated CNA 3 reported Resident 1 frequently used the call light for their roommate, which was answered promptly and only called once for herself to have a brief change in which CNA 3 did indicating Resident 1 was dry, but had a brief change anyway. CNA 2 stated Resident 1 slept from 9:30 p.m. (July 4) to 3:30 a.m. (July 5) and was checked hourly and that Resident 1 asked to be changed once at 3:30 a.m. Upon changing Resident 1 CNA 2 found the brief dry but changed it regardless. CNA 2 denied any conversation with Resident 1 about reporting her or dissatisfaction with care and that interactions were minimal that night on July 5, 2026. CNA 2 denied Resident 1 was found wet or awake during the shift. After allegations surfaced on July 6, CNA 2 was informed by Director of Staff Development (DSD) CNA 2 would no longer be assigned to Resident 1 and that two staff should enter Resident 1's room together to avoid misunderstandings.On July 21, 2026, at 2:48 p.m., an interview was conducted with CNA 3. CNA 3 stated he responded to a grievance report filed July 5, 2026, provided to him by the RN 1 and DSD regarding an allegation made by Resident 1 about not responding to call lights and changing briefs. CNA 3 stated the expectation for CNA's was conduct regular rounding which included checking on residents needs hourly such as toileting, incontinence, and personal items. CNA 3 stated he could recall responding to Resident 1's call light at approximately 9:41 p.m., and that the resident requested a brief change. CNA 3 found Resident 1 to be dry but changed the brief anyway to accommodate the request; then checked again at 10 p.m. during the last rounds before the shift change indicating Resident 1 had been resting. CNA 3 indicated he was informed by the RN that he would not be assigned to Resident 1. CNA 3 stated during the regular rounding on July 4, 2026, Resident 1 was not wet and remained dry during the shift and that he responded to each of the residents call lights and requests without any comments from the resident about being unhappy with care.On July 21, 2026, at 3:03 p.m., at 3:03 p.m. an interview was conducted with the DSD. The DSD stated after the grievance report was received on July 5, 2026, CNA 3 was removed from Resident 1's assignment and informed of the allegations. DSD could not recall if CNA 2 was removed. DSD stated the ideal protocol was to investigate all staff involved in the allegations and that they would be removed from the assignment until the completion of the investigation. DSD indicated a follow up with the resident was conducted on July 6, 2026, and that the resident was informed that both CNA's involved would not be assigned to care for the resident. The DSD stated CNA 2 should not have been assigned to Resident 1 until an investigation was conducted first. The DSD stated the RN supervisors should have communicated the grievance report received from Resident 1 and adjusted the assignment accordingly. DSD further stated that assigning the CNA involved in the grievance prior to completing the investigation could lead to the resident to become more upset after filing the grievance.On July 28, 2026, at 3:24 p.m., an interview was conducted with RN 3. RN 3 stated she was provided with an update regarding the grievance report filed by Resident 1 on the day shift July 5, 2026, and that she did not review the form until approximately 1 a.m., on July 6, 2026. RN 3 stated CNA 2 informed her that Resident 1 apologized on the evening of July 5, 2026, for any misunderstanding and that no concerns were brought to her attention regarding their interactions which was not documented. RN 3 stated she did not consider adjusting the assignment for Resident 1 according to the report provided to her by CNA 2. On July 29, 2026, at 11:55 a.m., an interview was conducted with RN 4. RN 4 stated she received the report from RN 1 regarding the allegations made by Resident 1 on the PM shift July 5, 2026, and that she did not speak with Resident 1 during the shift. RN 4 stated she did speak with CNA 3 and informed him that he would be reassigned due to the allegations and educated as to how to approach resident call lights and requests for brief changes. RN 4 stated CNA 3 denied resident was found wet and remained dry during the shift in question. RN 4 stated she could not recall making the assignment for the night shift on July 5, 2026, and that any CNA involved with allegations would have been reassigned by the NOC shift RN so that to prevent any further misunderstandings. RN 4 stated she did not communicate with any other CNA's regarding the grievance filed by Resident 1. There was no documented evidence the facility conducted an active investigation timely after a grievance was received on the morning of July 5, 2026, to prevent further distress to Resident 1 and provided corrective actions to resolve the concern until three days after the grievance was filed.A review of the facility policy and procedure titled, Grievances/Complaints, Recording and Investigating dated April 2017 indicated, .All grievances complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance.upon receiving the report, the grievance officer will begin an investigation into the allegations.the investigation and report will include.recommendations for corrective action.the designee will record and maintain on the Resident Grievance Complaint Log.the date the resident, or interested party, was informed of the findings; and the disposition of the grievance (i.e. resolved, dispute, etc.).A review of the facility policy and procedure titled, Resident Rights dated February 2021, indicated, .Employees shall treat all residents with kindness, respect, and dignity.basic rights to all residents of this facility.include.voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal.have the facility respond to his or her grievances.

Based on observation, interview, and record review, the facility failed to reassess and revise the resident's person-centered care plan to include effective interventions after repeated incidents of inappropriate sexualized behavior for one of four residents (Resident 1). This failure placed residents, staff, and visitors at risk for unwanted sexual contact, physical altercations, and psychosocial harm. Findings: A review of Resident 1's medical records indicated the resident was admitted on [DATE], with diagnoses which included epilepsy, (a disorder which causes repeated seizures [sudden changes in the brain activity which can cause shaking, confusion, or loss of consciousness) and dementia, (a condition that affects memory, thinking, and judgment). A review of Resident 1's History and Physical dated February 4, 2026, indicated the resident was unable to answer questions. A review of Resident 1's Progress Notes indicated the following: -Dated February 25, 2026, at 2:58 p.m., At approximately 1149, this writer was notified by another resident, this resident allegedly grabbed the resident's butt. per resident, he does not remember the incident. -Dated March 29, 2026, at 4:52 a.m., Loud voices heard in the hall, at approximately 0415. CNA noted pt [patient] attempting to grab the bilateral buttock of CNA that was bending over in the hall. Pt redirected by CNA present. Pt very upset that CNA was attempting to tell him that the action was inappropriate, telling her to mind her own business. This staff attempted to talk to pt to inform him the inappropriateness of this action, however pt refused to believe that what he tried to do was wrong. Pt redirected back to his room, however (sic) took several moments before this happened as pt was attempting to see of (sic) other pts or staff were going to make comments regarding his behaviors. No other person addressed pt, pt then retired back to his room. Will continue to monitor pt and pt behaviors very closely. -Dated May 21, 2026, at 1:35 p.m., .This afternoon noted approximately 1:02 PM by the licensed nurse going through the hallway, however, there was a male visitor standing and talkingto (sic) the RN supervisor at the counter of nurses' station, suddenly turned his back and confronted the resident behind him and allegedly stated that this resident 'touched his butt' . A review of Resident 1's Care Plan indicated the following: -Dated February 25, 2026, Focus. Resident was allegedly accused of having inappropriate touch behavior towards alert, oriented female resident. Allegedly stated she was grabbed on her buttock. Interventions . 1:1 x 72 hours starting 2/25/26.Goals: Resident will not have episodes of inappropriate behavior towards resident daily until next review date. -Dated May 21, 2026, indicated Focus. Resident was allegedly held on his neck by a male visitor with his 2 hands, stated that resident allegedly touched his butt. Further review of Resident 1's record indicated the resident demonstrated repeated inappropriate sexual behaviors toward residents, staff, and visitors which included sexually inappropriate comments and grabbing the buttocks. The facility did not revise the resident's care plan to include additional interventions to reduce the risk of further inappropriate contact. On May 29, 2026, at 12:18 p.m., an interview was conducted with CNA 2. CNA 2 stated that when she was putting a breakfast tray into cart, Resident 1 came up behind her stating I was going to smack your cheeks. CNA 2 stated she did not report the incident to anyone. On May 29, 2026, at 12:28 p.m., an interview was conducted with the visitor. The visitor stated that Resident 1 was in his wheelchair and grabbed his buttock when he was rolling past. On May 29, 2026, at 5:08 p.m., an interview was conducted with the DON. The DON stated that following Resident 1's March 29, 2026, incident of grabbing a CNA's buttocks, the resident should have been monitored for inappropriate behavior, and the care plan should have been updated to address the resident's behaviors. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered revised 2001, indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to maintain the environment free of accident hazards when the toilet seat in a resident-accessible restroom was not securely fastened.This failure had the potential to cause a resident to lose balance while transferring on or off the toilet, placing the resident at risk for a fall with injury. Findings:On July 1, 2026, at 10:44 a.m., an unannounced visit to the facility was conducted to investigate a physical environment issue. On July 1, 2026, at 12:34 p.m., an observation was conducted in resident accessible restroom [ROOM NUMBER], located across from the Activity Room. The toilet seat was observed to be loose due to a broken mounting bolt on the right side. On July 1, 2026, at 12:55 p.m., an observation and interview were conducted with the Maintenance Staff (MS). The MS inspected the toilet seat and stated that the right-side mounting bolt was broken, causing the toilet seat to be loose. The MS stated that the toilet seat mounting bolt would need to be replaced. A review of the facility's policy and procedure titled Quality of Life - Homelike Environment revised May 2017, indicated .Residents are provided with a safe, clean, comfortable and homelike environment.

Based on observation, interview, and record review, the facility failed to ensure food stored in the Unit 1 refrigerator was properly labeled, dated, and discarded when no longer safe for use. This failure had the potential to increase the risk of foodborne illness.Findings: On July 1, 2026, at 2:45 p.m., a concurrent observation and interview were conducted with the Licensed Vocational Nurse (LVN 2). In the Unit 1 refrigerator, on the first door shelf, an uncovered container of chicken or tuna salad was observed without a label or date. On the first shelf, a Yoplait Raspberry yogurt with a use-by date of June 23, 2026, was also observed available for consumption. LVN 2 stated that all staff assigned to the unit are responsible for ensuring that food in the refrigerator is covered, labeled, and dated. LVN 2 confirmed that the unlabeled and undated chicken or tuna salad should have been discarded or properly labeled before storage and should not have been available for consumption. LVN 2 further stated that the yogurt with a use-by date of June 23, 2026, should have been discarded and should not have been available for consumption. A review of the facility's policy and procedure titled Labeling and Dating of Foods revised 2023, indicated All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines within this section-specifically (sic). Refrigerated Storage Guidelines (page 6.16).All prepared foods need to be covered, labeled, and dated.

Based on observation, interview, and record review, the facility failed to ensure infection prevention protocols were followed when a nebulizer treatment mask (a medical accessory that fits over the nose and mouth, delivering aerosolized liquid medication directly into the airways and lungs) was stored uncovered on top of the nebulizer (a medical device that converts liquid medication into a fine mist, allowing patients to inhale it directly into their lungs), for one of eleven residents, (Resident 12). This failure had the potential to expose the nebulizer mask to environmental contaminants before its next use, increasing the risk of introducing microorganisms into the resident's respiratory tract.Findings: A review of Resident 12's medical records indicated resident was admitted on [DATE], with diagnoses of encephalopathy, (any diffuse disease of the brain that alters brain function or structure), chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure, and functional quadriplegia (the inability to use both arms and both legs due to severe physical weakness or another medical condition.) A review of Resident 12's History and Physical dated April 12, 2026, indicated resident had capacity to make decisions. A review of Resident 12's Order Summary Report dated March 28, 2026, indicated .Ipratropium-Albuterol Solution [a bronchodilator combination used in a nebulizer to open air passages] 0.5-2.5 (3) MG [milligram]/3ML [milliliter] 3ml inhale orally every 8 hours for SOB [shortness of breath]/Wheezing. On June 3, 2026, at 1:39 p.m., an observation was conducted in Resident 12's room. Resident 12 was observed in bed with the nebulizer treatment mask was resting uncovered on top of the nebulizer machine without a protective plastic bag or other covering. On June 3, 2026, at 3:59 p.m., a concurrent observation and interview was conducted with the Licensed Vocational Nurse, (LVN 1). LVN 1 observed Resident 12's bedside table with the nebulizer mask on top of the nebulizer machine. LVN 1 stated the nebulizer mask should have been stored in a plastic bag between treatments to keep it clean and prevent contamination. A review of the facility's policy and procedure titled Departmental (Respiratory Therapy) -Prevention of Infection revised November 2011, indicated .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol. 7. Store the circuit in plastic bag, marked with date and resident's name, between uses.

Based on observation, interview, and record review, the facility failed to ensure one of eleven residents, (Resident 12), had a call light pad. This failure had the potential for Resident 12 to have unmet needs due to difficulty with using the call light. Findings: On June 2, 2026, at 2:46 p.m., an interview was conducted with the Registered Nurse, (RN 1). RN 1 stated that she had cared for Resident 12 in the past and recalled that Resident 12 used a call light pad and would ask staff to ensure it was functioning. On June 3, 2026, at 1:39 p.m., a concurrent observation and interview were conducted with Resident 12. Resident 12 stated that prior to the most recent hospitalization, he had a call light pad button that was easier to use. Resident 12 demonstrated that using the standard call light button was difficult because his fingers were stiff and difficult to straighten due to curling towards the palm of his hand. Resident 12 was observed holding the standard call light button in his left hand and using the knuckle of his right index finger to depress the button to call for assistance. A review of Resident 12's admission Sheet indicated Resident 12 was initially admitted to the facility on [DATE], with diagnoses which included functional quadriplegia (the person cannot move or use all four extremities effectively). Resident 12 was readmitted on [DATE], following hospitalization and was transferred to a different room. The resident's new room was equipped with standard call light button and not the adaptive call light pad previously used. A review of Resident 12's Progress Notes dated February 2, 2026, at 3 p.m., indicated .Calling pad within reach. On June 3, 2026, at 2:37 p.m., an observation was conducted with the Maintenance Staff (MS), the MS was observed disconnecting the regular call light button from the wall and connecting a call light pad to the wall on the right side of Resident 12's bed. A review of the facility's policy and procedure titled Call System, Residents revised September 2022, indicated .If the resident has a disability that prevents him/her from making use of the call system, an alternative communication that is usable for the resident is provided and documented in the care plan.

Based on interview and record review, the facility failed to ensure resident's medical records were accurate and complete in accordance with the accepted professional standards and practices, for two of three sampled residents (Residents 3 and 5) when: 1. For Resident 3, nursing weekly summaries and skin evaluations did not reflect changes in skin condition; and 2. For Resident 5, progress notes regarding the resident's status were not completed in accordance with facility protocols. These failures could negatively impact resident care and prevent staff and responsible parties from recognizing potential deterioration in residents' conditions. Findings:1.On December 30, 2025, Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses including lack of coordination (poor balance), and iron deficiency anemia (blood doesn't have enough healthy red blood cells). Resident 3's Minimum Data Set (an assessment tool), dated September 23, 2025, indicated a BIMS (Brief Interview of Mental Status) score of 10 (moderate cognitive impairment status). A review of Resident 3's change in condition dated December 16, 2025, at 11:19 p.m. indicated .At approximately 8:58 p.m. Visiting son approached nurses station and reported to LN (licensed nurse) that patient had discoloration to her left forearm along with a skin tear that is closed and dry . A review of the Care Plan titled Resident has skin discoloration on their left forearm, initiated December 16, 2025, indicated, .No emotional; distress, no crying and no report of anyone hurt or hurting her. The resident will not show s/s of emotional distress or any indication of any adverse effect of the allegation daily until next review date.Complete body check of the resident, notification of MD and family.Monitor for emotional distress, fearfulness, check the area of the skin discoloration, any further symptoms, refer to MD accordingly.Monitor resident's possible adverse effect of the allegation x 72 hours and accordingly. A review of Resident 3's progress notes dated December 17, 2025, at 2:29 p.m., indicated, .Presented to IDT members regarding resident was noted to have skin discoloration on her left forearm .Monitor the discolorations on her skin for skin breakdown and refer to MD for treatment as needed . A review of the Order summary report dated December 17, 2025, indicated, .Discoloration to left upper extremity - Monitor for changes in size, location and appearance. Notify MD if changes are noted. every shift for left upper extremity. A review of the Medication Administration Report (MAR) dated December of 2025, indicated incomplete documentation related to anticoagulant monitoring: -December 9 to 12, 2025: No Y or N documented -December 13, 2025: N documented without supporting notes -December 14-17, 2025: No Y or N documented A review of the Treatment Administration Report (TAR) dated December of 2025, indicated inconsistent monitoring documentation: -December 17 to 19, 2025: Day and Evening shifts documented; night shift missing on December 19, 2025. -December 20 to 21, 2025: Day shift documented -December 21 to 24, 2025: Evening and night shifts undocumented. A review of the Daily Skilled Charting indicated from December 15 to 24, 2205, licensed nurses documented skin normal without describing the left forearm discoloration. A review of the Weekly Nursing Summary from December 16 to December 23, 2025, indicated there was no documented observations of a new skin change to the upper left arm bruise for a resident with a new bruise. The Weekly Nursing Summaries did not reflect the resident's skin condition. On December 30, 2025, at 3:16 p.m. a concurrent interview and record review was conducted with the Registered Nursing (RN 1). RN 1 stated the daily skilled monitoring and weekly skilled charting should reflect the skin condition and identify any changes in condition so that any changes could be identified and reported. RN 1 stated the monitoring for bleeding was documented as Yes when signs are present and No when no signs are observed. RN 1 stated a Yes indicated a bruise or sign of bleeding was observed but does not specify the location, which is why detailed notes under the skin assessment are important. RN 1 stated no notes were documented from December 18 to December 22, 2205, and documentation should have been present. RN 1 stated licensed nurses were expected to chart the skin condition to show that it was being monitored, according to the physician orders and so that any changes in size, location, or signs of infection could be noted and the physician notified. On December 30, 2025, at 4:14 p.m. a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated that skin changes should have been documented in progress notes, MAR, TAR, daily charting, and weekly summaries. The DON stated that documentation should have reflected the resident's skin condition and any changes. The DON stated that licensed nurse's documentation did not consistently or accurately reflect the Resident 3's skin condition. The DON stated the weekly summary was a recap of the condition of the resident and it should have reflected any changes occurring during the review period and the daily skilled charting should have reflected the conditions of the skin to show improvement or decline and the current condition. The DON stated her expectation was that the nurses should have charted accurate assessments in daily and weekly charting and incomplete documentation would not be reflecting accurately the resident's condition. The DON further stated that skin conditions should have been documented accurately so that the ongoing assessments for the resident's skin conditions could have been communicated with the physician, family, and nursing staff. 2. A review of Resident 5's medical record was conducted. Resident 5 was admitted to the facility on [DATE], with a diagnosis which included, Multiple fractures of ribs, left side, subsequent encounter for routine healing and discharged on December 14, 2025. Resident 5's History and Physical Examination, dated December 14, 2025, indicated Resident 5 had the capacity to understand and make decisions. A review of Resident 5's progress notes from December 13 to December 14, 2025, indicated the following: -December 13, 2025, at 7:12 p.m., indicated, Resident 5, a [AGE] year old m ale, was admitted from an acute hospital with multiple rib fractures (broken bone) and pain to the left ribs and abdomen. Resident 5 was on bed rest receiving oxygen via nasal cannula (a small flexible plastic tube into the nostrils to deliver supplemental oxygen), alert and oriented, with stable respiratory status. Skin assessment revealed tenderness over the left chest wall, partial nail avulsion (an injury in which tissue is forcibly torn away from the body) to the left finger, abrasions (a scrape on the skin) to the left ankle and elbow, and a scab to the left knee. Further review of Resident 5's progress notes from December 13, 2025, at 11 p.m., through December 14, 2025, at 8 a.m., indicated there was no documented evidence regarding the resident's status or condition. -December 14, 2025, 8:58 a.m., indicated, .Patient resting on bed comfortably alert and oriented x 4, Patient is compliant to medication and treatment no complaints of SOB, breathing is even and unlabored. Medication well tolerated. -December 14, 2025, 1 p.m., indicated, .Approximately 1230 therapies notify writer to assess pt (patient) due to SOB, during therapy session. Upon assessment, pt noted to be in respiratory distress with increased work or breathing. Skin observed to be sweaty and cool. Patient oxygen sat decrease to 78% on NC, oxygen applied via non rebreather mask with immediate intervention that went to 87%. Pt stated that the stated its working that his getting air now. vitals sign assessed with BP (blood pressure)117/78. Called 911 to send out patient to hospital for further evaluation and management. Pt monitored continuously until EMS arrival . Approximately 1245 911 paramedics and patient leave the facility. MD and daughter made aware regarding the change of condition and the transfer. On December 31, 2025, at 1:20 p.m., a concurrent interview and record review were conducted with RN 2. RN 2 stated that facility protocol requires nurses to complete progress notes to document each resident's status during every shift. RN 2 stated the admission note was completed during the evening shift and the night shift progress note was missing and should have been documented. RN 2 stated progress were necessary to establish a baseline and communicate the resident's condition between shifts. On December 31, 2025, at 2:46 p.m. a concurrent interview and record review were conducted with LVN 2. LVN 2 stated the admission occurred during the evening shift and that a progress note should have been completed by the night shift to document the resident's status. LVN 2 stated there was no documentation of Resident 5's status during the night shift. On December 31, 2025, at 4:14 p.m., a concurrent interview and record review were conducted with the DON. The DON stated all new admissions were required to have progress notes for the first 72 hours to reflect the resident's condition. The DON stated the MAR reflected medication administration but did not describe the resident's condition. The DON stated that a night shift progress notes for Resident 5 was missing and that nurses were expected to document the resident's status in the electronic medical record each shift. A review of the facility policy titled, Charting and Documentation dated December 2022, indicated, .the service provided to the resident progress toward the care plan goals.any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff, should be documented in the resident's medical record.changes in the residents' condition.entries included should be made by licensed personnel (e.g. RN, LVN).the assessment data and or any unusual findings obtained during the procedure/treatment.

Based on interview, and record review, the facility failed to ensure the plan of care (POC) was updated to reflect changes in condition, for one of two residents reviewed for care planning (Resident 6), who had repeated episodes of pulling out her G-tube (a surgically implanted tube needed for feeding when unable to swallow) from October 11, 2025, to November 12, 2025. This failure had the potential to place the residents at risk for further harm and complications.Findings: A review of Resident 6's medical record was conducted. Resident 6 was admitted to the facility on [DATE] with diagnoses which included, Metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance or metabolic problem in the body.) The Minimum Data Set (MDS - an assessment tool), dated October 25, 2025, indicated a BIMS (Brief Interview of Mental Status) score of 99 (severe cognitive impairment status). A review of Resident 6's progress notes from October 10, 2025, to November 30, 2025, indicated Resident 6 pulled out her G-tube on: -October 10, 2025-October 13, 2025-October 21, 2025-October 29, 2025-November 12, 2025; and-November 13, 2025.Each episodes required transfer to the emergency room for G-tube replacement. A review of Resident 6's care plan dated October 2, 2025, October 10, 2025, October 13, 2025, and November 12, 2025, indicated: - The resident was identified being at risk for behaviors related to dementia and for G-tube dislodgement. Interventions included use of an abdominal binder, and monitoring of behaviors. -There were no care plan revisions after the October 21, 2025, episode and the resident continued to experience G-tube dislodgements. -The October 13, 2025, interventions were not reflected in the care plan until after the October 29, 2025, episode. -The care plan-initiated November 12, 2025, listed no new interventions. The care plan did not reflect changes in condition or effectiveness of interventions for each episode. On December 31, 2025, at 12:15 p.m. an interview was conducted with Licensed Vocational Nurse (LVN 4). LVN 4 stated he was assigned to Resident 6 and that he was familiar with her care needs. LVN 4 stated he was not aware of any behaviors related to Resident 6 pulling out her G-tube. On December 31, 2025, at 12:20 p.m. an interview was conducted with Certified Nursing Assistant (CNA 3). CNA 3 stated she was assigned to Resident 6. CNA 3 stated she was not aware of any behaviors related to the resident pulling out her G-tube. On December 31, 2025, at 2:18 p.m. a concurrent interview and record review was conducted with the Registered Nurse (RN 3). RN 3 stated Resident 6 had repeated G-tube pulling behaviors beginning October 10, 2025. RN 3 stated a new intervention was not implemented until November 13, 2025, after multiple episodes. On December 31, 2025, at 3:25 p.m., an interview was conducted with LVN 1. LVN 1 stated the care plan should be updated each time the resident pulled out the G-tube and confirmed there were no revisions after October 21, 2025. On December 31, 2025, at 4:27 p.m. a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the protocols for changes in condition would include an evaluation of the incidents during the interdisciplinary team conferences (IDT) and revisions to the care plans would be made at that time. The DON stated care plans should be revised with each change in condition. The DON stated there were only two IDT review despite six incidents. A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, .The interdisciplinary tea (IDT), in conjunction with the resident and his/her family or legal representative, develop and implements a comprehensive, person centered care plan for each resident.the comprehensive care plan reflects currently recognized standards of practice for problem areas and conditions.care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.the (IDT) reviews and updates the care plan.when there has been a significant change in the resident's condition.when the desired outcome is not met.when the resident has been readmitted to the facility from a hospital stay.

Based on interview and record review, the facility failed to ensure, for one of three residents reviewed for quality of care (Resident 3) the resident was monitored every shift for a change in condition involving left upper extremity bruising (skin discoloration) as ordered by the physician.This failure had the potential to result in a delay of the implementation of appropriate interventions to address the care and treatment for Resident 3. In addition, this failure had the potential to place Resident 3 at risk for injuries. Findings:On December 30, 2025, Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses which included, lack of coordination (poor balance), and iron deficiency anemia (blood doesn't have enough healthy red blood cells). The Minimum Data Set (MDS - an assessment tool), dated September 23, 2025, indicated a BIMS (Brief Interview of Mental Status) score of 10 (moderate cognitive impairment status). A review of the change in condition dated December 16, 2025, at 11:19 p.m. indicated .At approximately 8:58 p.m. Visiting son approached nurses station and reported to LN (licensed nurse) that patient had discoloration to her left forearm along with a skin tear that is closed and dry. LN and RN (Registered Nurse) assessed patient.When asked what happened to her arm she stated: 'all I know is that there was no bruise, then she grabbed me, and then there was a bruise'.physician recommendation.continue to monitor.A review of the Medication Administration Report (MAR) dated December of 2025, indicated the following: .ANTICOAGULANT MEDICATION.MONITOR FOR.BRUISING.Document: Y if monitored and none of the above observed. N if monitored and any of the above was observed.Further review of Resident 3's MAR for the month of December 2025, indicated the following:-December 9, 2025, to December 12, 2025, the licensed nurse did not document a Y or N response and documented - -December 14, 2025, to December 17, 2025, the licensed nurse did not document a Y or N response and documented - A review of Resident 3's Order Summary Report, for the month of December 2025, indicated, .Discoloration to left upper extremity - Monitor for changes in size, location, and appearance. Notify MD (physician) if changes are noted .A review of the Treatment Administration Report (TAR) dated December of 2025, indicated .Discoloration to left upper extremity - Monitor for changes in size, location and appearance. Notify MD if changes are noted. Every shift for left upper extremity.Further review of Resident 3's TAR for December 2025, indicated there was no documentation Resident 3 was monitored for changes in to left upper extremity discoloration on the following dates:-December 19, 2025 (night shift)-December 21, 2025 (afternoon and night shift)-December 22 to December 25, 2205 (night shift)-December 30, 2025 (morning shift)-December 31, 2025 (morning, afternoon, and night shift)A review of the Daily Skilled Charting was conducted from December 15, 2025, to December 24, 2025, indicated there was no additional notes describing Resident 3's skin condition and from December 16, 2025, to December 20, 2025, approximately four days after the allegations of a new left bruise was identified there was no documented evidence the presence of a bruise to the left upper extremity was assessed by the licensed nurses.A review of the Weekly Nursing Summary from December 16, 2025, to December 23, 2025, showed no documented observation, assessment, or monitoring of a new upper left arm bruise. On December 16, 2025, a new upper left arm bruise was identified, and the weekly summaries documented no skin changes or breakdown.A review of the Care Plan titled Resident has skin discoloration on their left forearm, initiated December 16, 2025, indicated, .No emotional; distress, no crying and no report of anyone hurt or hurting her. The resident will not show s/s of emotional distress or any indication of any adverse effect of the allegation daily until next review date.Complete body check of the resident, notification of MD and family.Monitor for emotional distress, fearfulness, check the area of the skin discoloration, any further symptoms, refer to MD accordingly.Monitor resident's possible adverse effect of the allegation x 72 hours and accordingly.On December 30, 2025, at 3:16 p.m. a concurrent interview and record review was conducted with the Registered Nursing (RN 1). RN 1 stated, any discoloration or bruise identified on a resident's skin requires an internal investigation, physician notification, care plan update, and documentation on the MAR, TAR, progress notes, and daily charting. RN 1 stated, Resident 3 should have been monitored every shift per physician orders and facility protocol.On December 30, 2025, at 4:14 p.m. a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated licensed nurses were expected to monitor skin conditions every shift when a change in condition was identified. The DON stated consistent monitoring was necessary to prevent delays in identifying worsening conditions requiring physician intervention.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, when an outside vendor ultrasound technician (UT) was observed providing care at the bedside to a resident on contact precautions (infection prevention precautions) without wearing appropriate PPE (personal protective Equipment - a gown and mask) according to the facility protocol. This failure had the potential to result in transmission of infectious illnesses to the vulnerable residents.Findings: On December 31, 2025, at 12:09 p.m., a sign posted outside the room indicated Contact Precautions, requiring staff and visitors to wear a gown, gloves, and mask prior to entering the room and to perform hand hygiene upon entry and exit. An outside vendor UT was observed at the bedside of Resident 6's room. The UT was using an ultrasound machine with the probe touching the resident's arm. The UT was wearing gloves and was not observed to be wearing a gown or mask. The outside vendor UT remained in the room for approximately five minutes. The outside vendor UT re-entered the room without performing hand hygiene or donning new gloves. On December 31, 2025, a review of Resident 6's records were conducted. Resident 6 was admitted to the facility on [DATE], with diagnosis including metabolic encephalopathy (a chemical imbalance of metabolic system which affects the brain). The Minimum Data Set (MDS - an assessment tool), dated October 25, 2025, indicated a BIMS (Brief Interview of Mental Status) score of one (severely impaired cognitive status). A review of Resident 6's physician order dated December 29, 2025, indicated, .contact precautions. On December 31, 2025, at 12:15 p.m., an interview was conducted with Licensed Vocational Nurse LVN. LVN 4 stated Resident 6 was on contact precautions and stated all staff and visitors were required to follow posted PPE instructions. LVN 4 stated the outside vendor UT should have been instructed on PPE requirements prior to entering the room. On December 31, 2025, at 12:20 p.m., an interview was conducted with the Certified Nursing Assistant CNA 3. CNA 3 stated Resident 6 was on contact precautions, and the protocol required gown, gloves, mask, and hand hygiene. On December 31, 2025, at 12:35 p.m., an interview was conducted with the Infection Preventionist LVN 5. LVN 5 stated the outside vendor UT should have followed the required PPE protocols and staff should make sure outside vendors comply with infection prevention measures prior to providing care. On December 31, 2025, 5:15 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the outside vendor UT should wear the required PPE. The DON stated not wearing the required PPE placed the resident at risk and all individuals entering precaution rooms must follow posted infection control instructions. A review of the policy and procedure titled Initiating Transmission-Based Precautions, dated August 2019, indicated, .Transmission based precautions.when a resident is at risk of transmitting the infection to other residents.when transmission-based precautions are implemented.the signage informs the staff of the type of CDC precautions(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room.signs ensures that protective equipment.(gloves, gowns, masks, etc.) is maintained outside the residents room so that anyone entering the room can apply the appropriate equipment.

Based on interview and record review the facility failed to ensure Levothyroxine was administered for one of one resident (Resident 6) reviewed for quality of care, when Resident 6 did not receive the scheduled dose of Levothyroxine on November 30, 2025 and December 4, 2025.This failure had the potential for Resident 6 not to receive the desired benefit of the medication and may cause adverse reactions.Findings:On December 5, 2025, at 10:44 a.m., an interview was conducted with Resident 6 in her room. Resident 6 stated she did not receive her daily scheduled dose of Levothyroxine on November 30, 2025 and December 4, 2025. A review of Resident 6's admission Record dated December 5, 2025, indicated an admission date of February 6, 2023, with a diagnoses which included hypothyroidism (condition where the thyroid gland does not produce enough essential hormones (like thyroxine) to regulate the body's energy use, slowing down metabolism and bodily functions like heart rate, breathing, and digestion).A review of Resident 6's History and Physical dated October 20, 2025, indicated resident had the capacity to understand and make decisions.A review of Resident 6's Physician Orders dated December 22, 2025, indicated Levothyroxine (thyroid hormone medication to treat hypothyroidism (an underactive thyroid gland)) Sodium Oral Capsule 150 micrograms (mcg - a unit of measurement), give 150 mcg by mouth in the morning for Hypothyroidism was ordered on August 28, 2025.A review of Resident 6's November 2025 Medication Administration Record (MAR) for Levothyroxine 150 mcg dated November 30, 2025, at 6 a.m., indicated the medication was not administered. A review of Resident 6's Medication Administration Note dated November 30, 2025, at 5:36 a.m. indicated, .Levothyroxine Sodium Oral Capsule 150 mcg Give 150 mcg by mouth in the morning for Hypothyroidism waiting on meds to be delivered.A review of Resident 6's December 2025 Medication Administration Record (MAR) for Levothyroxine 150 mcg dated December 4, 2025, at 6 a.m. was blank and did not indicate a checkmark, representing the medication was administered.There was no documented evidence that Levothyroxine was administered on November 30, 2025 and December 4, 2025.A review of the Electronically Transmitted Prescription dated December 4, 2025, indicated Resident 6's Levothyroxine 150 mcg 14 tablets was received and signed by Licensed Vocational Nurse (LVN) 1 on December 4, 2025, at 5:24 a.m.On December 17, 2025, at 4:47 p.m. an interview was conducted with LVN 1. LVN 1 stated Resident 6 missed a dose of Levothyroxine on November 30, 2025 due to not being available. LVN 1 stated she signed the Electronically Transmitted Prescription for Resident 6's Levothyroxine on December 4, 2025 at 5:24 a.m., which indicated Levothyroxine was received and available for administration. LVN 1 stated Resident 6's Levothyroxine was not administered on December 4, 2025, at 6 a.m. and it should have been. LVN further stated it was important to administer the medication to prevent any adverse reactions from a missed dose.On December 19, 2025 at 2:08 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 6 missed Levothyroxine dose on November 30, 2025 and was unsure why when it was administered prior to and after this date. The DON stated Resident 6's Levothyroxine was received and signed by LVN 1 on December 4, 2025 at 5:24 a.m. and was available for administration. The DON stated there was no reason not to administer the medication as it was delivered on time for the scheduled dose and the nurse should have administered the medication. The DON stated there was no documentation indicating the medication was administered. The DON stated it was important to administer the medication to prevent adverse reactions from a missed dose related to her diagnosis of hypothyroidism.A review of the facility policy and procedure titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review the facility failed to ensure, for one of nine resident reviewed for infection control (Resident 8), proper infection control measures were implemented when Certified Nursing Assistant (CNA) 1 did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) upon entering Resident 8's room, who was on contact isolation precautions (an infection control intervention to reduce transmission of multidrug-resistant organisms (bacteria that have become resistant to multiple antibiotics)).The failure had the potential to result in cross contamination and increasing the spread of infection among a vulnerable population.Findings:On December 5, 2025, at 11:40 a.m., an observation was conducted outside Resident 8's room. A contact isolation sign was posted outside Resident 8's room, along with a PPE cart containing gowns and gloves. The sign indicated, .STAFF MUST.Put on gloves before room entry.Put on gown before room entry.On December 5, 2025, at 11:47 a.m. an observation was conducted inside Resident 8's room. Resident 8 activated his call light. CNA 1 entered the room without a gown or gloves and turned off the call light by pressing the button beside the bed.On December 5, 2025, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE] with diagnoses including extended spectrum beta lactamase (ESBL - bacteria that are resistant to many antibiotics) to the right foot wound. A review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated September 24, 2025, indicated a Brief Interview for Mental Status (BIMS - a tool to assess cognitive function) score of 12 (moderate cognitive impairment). A review of the facility document titled, Order Listing Report, dated December 5, 2025 indicated, .Strict Single Room Isolation with: Contact Precautions due to ESBL.On December 5, 2025, at 2:30 p.m. an interview was conducted with CNA 1. CNA 1 stated Resident 8 was on contact isolation precautions. CNA 1 stated she did not wear a gown or gloves prior to entering Resident 8's room to clear the call light. CNA 1 stated she should have worn a gown and gloves prior to entering Resident 8's room. CNA 1 further stated this was important to prevent the spread of infection.On December 19, 2025, at 11:31 a.m. an interview was conducted with the Infection Preventionist (IP). The IP stated based on the CDC's contact isolation sign and the facility's policy, CNA 1 should have worn a gown and gloves prior to entering Resident 8's room. The IP stated it was important to follow the CDC guidelines and facility policy to protect others from infection or cross contamination.On December 19, 2025, at 2:08 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated it was the best practice to wear a gown and gloves prior to entering a resident's room who was on contact isolation precautions. The DON stated CNA 1 should have followed the facility policy of wearing a gown and gloves prior to entering Resident 8's room. The DON stated it was important to follow the facility's policy to reduce the transmission of infection.A review of the facility policy and procedure titled, Isolation - Categories of Transmission-Based Precautions, dated September 2022 indicated, .Contact Precautions.Staff.wear gloves.when entering the room.Staff.wear a disposable gown upon entering the room.

Based on interview and record review, the facility failed to ensure blood glucose meters (glucometer - a blood sugar meter measures the amount of sugar in a small sample of blood) were calibrated and documented according to the facility protocol and current professional standards of practice on multiple days on November 2025. This failure had the potential to result in inaccurate blood glucose readings for residents requiring routine monitoring.Findings:A review of Station Three, Cart C November 2025 Quality Assurance Log indicated missing documentation for the following dates, with blank entries for time, staff performing, machine lot number, test strip lot number, low control, high control, and actions taken: -November 14, 2025;-November 15, 2025; and -November 19, 2025. On December 1, 2025, at 10:52 a.m., an interview and review of Station Three Quality Assurance Log were conducted with the Licensed Vocational Nurse (LVN 1). LVN 1 stated, glucometer calibration was the responsibility of the night shift nurse and was documented on the assurance logs located on the medication carts. LVN 1 stated there were two medication carts per station and stated we are good about doing the checks. LVN 1 further acknowledged the November 2025 log had missing documentation on November 14, 15, and 19, 2025, and there should not be any gaps on the logs. A review of the November 2025 Station One's Cart B Quality Assurance Logs indicated missing documentation on the following dates, with blank entries for time, staff performing, machine lot number, test strip lot number, low control, high control, and actions taken:-November 15, 2025;-November 16, 2025;-November 20, 2025;-November 21, 2025; andNovember 25, 2025 (low and high control and actions taken - blank). On December 1, 2025, at 11:18 a.m., a concurrent interview and record review were conducted with Registered Nurse Supervisor (RNS) at Station one. The RNS stated, LVNs on the night shift was responsible for completing glucometer calibration logs including lot numbers, control ranges and results. The RNS stated the logs were necessary to ensure accurate blood glucose readings. The RNS stated if there is nothing written you would not know if the glucometer was checked and then you would not know if your readings were accurate. The RNS stated the licensed nurses for the day shift should double check the logs during reports and make the corrections. RNS stated she was not previously aware of the gaps. On December 1, 2025, at 12:32 p.m., a concurrent interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated the night shift was responsible for completing the calibration logs and that oncoming shifts should review and complete the logs if missing to ensure accuracy. A review of the November 2025 Quality Assurance Log for Station Two Carts B and C indicated missing documentation as follows, with blank entries for time, staff performing, machine lot number, test strip lot number, low control, high control, and actions taken: -Station Two Cart B - November 19, and 25, 2025-Station Two Cart C - November 29, 2025 On December 1, 2025, at 12:53 p.m. an interview and record review were conducted with the Director of Nursing (DON). The DON stated the LVN's conducting the medication administration for the night shift should be doing the glucometer checks and when the checks are done that were to fill out the assurance log fully including the lot number and range and results. The DON stated the logs were necessary to ensure accurate readings of the blood sugars levels for the residents who need to have their levels checked. The DON confirmed there were four missing gaps for the month of November for Cart B and Cart C. The DON stated she did have a concern that if there is a blank portion of the assurance forms there should be a follow up by the day shift nurse and that day shift nurse should fill out the form as well to confirm that the glucometer check was done. The DON stated that if the forms were not filled out completely there was no way to know if it was done correctly or accurately. The DON stated if the forms are left blank there would be a risk for the residents' blood sugar readings to not accurately reflect the glucose levels. A review of the facility policy titled, Obtaining a Fingerstick Glucose Level dated October 2011, indicated, the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level.equipment and supplies.Reagent strip with color chart (e.g., Chemstrip) or blood glucose monitoring system (meter with test strips and calibration supplies).follow the instructions provided by the manufacturer of the glucose monitoring system to obtain a blood glucose reading, including the quality control monitoring of the glucometer.documentation.the person performing this procedure should record the following information in the resident's medical record.date and time the procedure was performed.name and title of individual who performed the procedure.all assessment data obtained during the procedure.results.follow facility policies and procedures.A review of the facility policy titled, Nursing Care of the Older Adult with Diabetes Mellitus dated November 2020, indicated, .to provide an overview of diabetes in the older adult.and the principles of glucose monitoring.Glycemic targets.use a glucometer for capillary blood sampling to measure current blood glucose levels.manage hypoglycemia according to protocols and provider orders.blood glucose monitoring.for resident on oral medication .who is well controlled and poorly controlled.resident receiving insulin.

Based on interview and record review, the facility failed to assess and verify the resident's history of obstructive sleep apnea (OSA - person's breathing repeatedly stops and starts during sleep due to a blocked airway) and coordinate necessary CPAP (Continuous positive airway pressure - a machined use to treat OSA) treatment with the physician, for one of five sampled residents (Resident A).This failure had the potential to result in untreated sleep apnea for Resident A, placing the resident at risk for respiratory complications, hypoxia (low oxygen), and sleep disruption. Findings:On July 7, 2025, at 10:18 a.m., an unannounced visit to the facility was conducted to investigate a quality-of-care issue.On July 7, 2025, at 4:28 p.m., during an interview with Resident A, Resident A stated she had been on CPAP for 20 years and last used it the day before she was admitted to the facility. Resident A stated she was not allowed to use her CPAP machine in the facility. Resident A stated she sleeps almost always in a sitting position and had told the social services and nurses about it.A review of Resident A's record indicated, Resident A was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a long-term progressive disease that makes it hard to breathe) and atrial fibrillation (irregular heart rhythm).A review of Resident A's hospital records dated May 24, 2024, indicated, .Past medical history .Morbid obesity (extremely overweight), OSA on CPAP .Further review of Resident A's record indicated there was no documentation that a CPAP machine was provided, nor any documentation verifying the resident's continued need for CPAP therapy. On July 10, 2025, at 4:15 p.m., during an interview with the Director of Nursing (DON), the DON stated there was no documented diagnosis of sleep apnea, no care plan addressing sleep apnea, and Resident A was not placed on a CPAP machine. The DON further stated that according to the resident the CPAP machine was broken prior to admission.On July 22, 2025, at 5:50 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she worked the night shift from 10:30 pm to 6:30 a.m. and was familiar with Resident A. LVN 1 stated, she had observed Resident A sleeping at times lying on her side and at other times sitting up in bed. On July 22, 2025, at 8:56 a.m., during a concurrent interview and record review of Resident 1's hospital records dated May 24, 2024, with the MDS Nurse, the MDSN stated during assessment, he reviews a resident's hospital records, including clinical and past medical history. The MDSN stated, Resident A's diagnosis of OSA was missed during the comprehensive assessment. The MDSN stated whoever is involved in the care of the resident should be responsible for the medical history of the resident. The MDSN stated, the diagnoses of sleep apnea should have been verified with the physician to determine if the diagnoses was active and that the resident should have been asked about current CPAP use. The MDSN stated this had the potential to affect the resident's overall respiratory condition.On July 23, 2025, at 2:48 p.m., during an interview with the Assistant Director of Nursing (ADON), the ADON stated if there was a medical history of obstructive sleep apnea, it should have been included in the development of baseline care plan. The ADON stated, the licensed nurses should have contacted the physician to verify the diagnosis and communicated with the resident to verify prior CPAP use. The ADON further stated if the facility was informed that the CPAP machine was broken, the physician should have been notified, and an order for a replacement should have been obtained.A review of the facility's policy and procedures titled CPAP/BiPAP Support, dated March 2015 indicated, .CPAP.to improve arterial oxygen (PaO2) in resident with obstructive sleep apnea.

Based on observation, interview, and record review, the facility failed to ensure interventions for fall prevention were implemented for two of seven residents, (Resident 1 and Resident 7).This failure had the potential for Resident 1 and Resident 7 to fall and sustain serious injuries. Findings:On July 30, 2025, at 11:07 a.m., an unannounced visit to the facility on a complaint investigation was initiated.1.A review of Resident 1's medical records indicated that resident was admitted on [DATE], with diagnoses of systemic lupus erythematosus, (SLE - a chronic autoimmune disease where the body's immune system mistakenly attacks its own healthy tissues and organs), chronic obstructive pulmonary disease, (COPD - a chronic inflammatory disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), dementia, (a chronic or persistent disorder of mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), muscle wasting and atrophy, (the loss of muscle mass and strength), and adult failure to thrive, (AFTT - a syndrome in older adults characterized by weight loss, decreased appetite, poor nutrition, and inactivity indicating a decline in physical and psychological health).A review of Resident 1's History and Physical dated July 17, 2025, indicated resident had intermittent capacity to make decisions.On July 30, 2025, at 12:20 p.m., an interview was conducted with Resident 1. Resident 1 stated she had been at the facility for a month. Resident 1 stated she recalled falling after tripping over her shoes. Resident 1 was unable to account for the date, or time of the incident. Resident 1 stated she did not have any injuries from the fall. Resident 1 stated she gets physical therapy every day and that she had been instructed to use the call light and call for assistance before getting out of bed. On July 30, 2025, at 3:10 p.m., an interview was conducted with Resident 1's Responsible Party, (RP). The RP stated that Resident 1 had been in the facility since March 2025 and had approximately four falls. The RP stated upon admission, he informed them that she was a fall risk. The RP stated in July 2025, Resident 1 slipped out of bed while reaching for her belongings placed on a wheeled table.On July 31, 2025, at 3:31 a.m., an interview was conducted with the Licensed Vocational Nurse, (LVN 1). LVN 1 stated, for all residents who are at high risk for fall, or who have had more than one fall, the interventions should include: bed in low position, call light within reach, all frequently used personal items should be within reach. On July 31, 2025, at 8:20 a.m., an interview was conducted with the Physical Therapist, (PT). The PT stated, on July 24, 2025, Resident 1 slipped out of bed while reaching for the over-bed table. The PT stated, personal items should have been kept within reach to prevent over-reaching and falling out of bed. A review of Resident 1's Care Plan initiated May 7, 2025, indicated Focus. Resident is at risk for falls with or without injury related to altered balance while standing and/or walking, altered mental status, antipsychotic medication, cardiovascular disease, diuretic medication, unsteady gait.Interventions. Keep personal items frequently used within reach.A review of Resident 1's Progress Notes dated July 24, 2025, at 07:25 a.m., indicated Resident was found on the floor on fall mat next to her bed by CNA. Resident was lying on her back on the fall mat. Resident denies hitting her head and denies any pain related to the fall. CNA immediately notified Nurse. RN and Nurse preformed a full body assessment, head-to-toe was completed. No skin tears, bruising or visible injuries were noted. Resident was able to move b/l [bilateral] upper extremities without difficulty. Resident reported that she was reaching for her bedside table when she accidentally slipped out of bed. Resident is A/Ox3 [alert and oriented to person, place, and time] cooperative, and denies any pain at this time.2. A review of Resident 7's medical records indicated Resident 7 was admitted to the facility on [DATE], with diagnoses of encounter for surgical aftercare following surgery on the digestive system, malignant neoplasm of colon, (a cancerous tumor that develops in the colon, which is part of the large intestine), secondary malignant neoplasm of liver and intrahepatic bile duct, (cancer that has spread to the liver and bile ducts from a primary cancer site elsewhere in the body), secondary malignant neoplasm of lung, (a cancerous tumor that has spread to the lung from a primary tumor located elsewhere in the body), metabolic encephalopathy, (a problem in the brain caused by a chemical imbalance in the blood), and muscle wasting and atrophy,A review of Resident 7's History and Physical dated June 17, 2025, indicated Resident 7 had the capacity to make decisions.On July 30, 2025, at 12:42 p.m., the Certified Nursing Assistant, (CNA 1) was interviewed. CNA 1 stated that fall-risk residents should always have the call light within reach. On July 31, 2025, at 3:31 a.m., an interview was conducted with the Licensed Vocational Nurse (LVN 1). LVN 1 stated, for all residents who are at high risk for falls, or who have had more than one fall, the interventions should include: bed in low position, call light within reach and all frequently used personal items should be within reach. On July 31, 2025, at 8:53 a.m., observed Resident 7 lying in bed, on her right side, with eyes closed, respirations even and unlabored. Resident 7's call light was observed on the right side of the bed on the floor. On July 31, 2025, at 8:58 a.m., a concurrent observation of Resident 7's call light on the right side of the bed on the floor and an interview was conducted with LVN 2. LVN 2 stated, Resident 7's call light was not within the residents' reach and it should be within reach at all times. A review of Resident 7's NURSING - FALL RISK OBSERVATION/ASSESSMENT dated June 19, 2025, at 8:30 a.m., indicated .Score of 14.Scoring: B. MODERATE RISK 9-15.A review of Resident 7's Care Plan initiated July 9, 2025, indicated Focus: Resident is at risk for falls with or without injury related to altered balance while standing and/or walking. disease, unsteady gait.Interventions. Keep call light within reach.A review of the facility's policy and procedure titled Falls - Clinical Protocol revised March 2018, indicated .Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on observation, interview, and record review, the facility failed for two of six sampled residents (Residents 1 and 2) to ensure: 1. The call light was placed within reach for Resident 1; and 2. The call light was answered timely for Resident 2. These failures had the potential to compromise the timely delivery of resident care. Findings: On June 10, 2025, at 10:48 a.m., during a concurrent observation and interview with Resident 1 in the resident ' s room, Resident 1 was observed to be unable to move her right arm. Resident 1 stated, she was cold and would like a blanket. Resident 1 stated, she could not reach her call light. Resident 1 ' s call light was observed to be placed on the right side of the bed rail, which was in the down position. On June 10, 2025, at 10:54 a.m., during a concurrent observation and interview with Certified Nursing Assistant (CNA) 1 in Resident 1's room, CNA 1 stated, Resident 1 had right-sided weakness and was able to use the call light only if it was placed on the left side. CNA 1 stated, the resident's call light was placed on the right side. CNA 1 stated, the resident would not be able to reach the call light as it was placed on the right side. On June 10, 2025, Resident 1 ' s admission Record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnosed which included cerebral infarction (a type of stroke) with right sided weakness. A review of Resident 1 ' s Care Plan dated September 27, 2024, indicated, .at risk for ADL (Activities of Daily Living)/mobility decline and requires assistance .Encourage to use call light for assistance . On June 27, 2025, at 2:35 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated, she was familiar with Resident 1. The DSD stated, Resident 1 ' s call light should be placed on the left side, as the resident has right sided weakness. The DSD stated, the resident would not be able to call for assistance if the call light was placed on the right side. 2. On June 12, 2025, at 12:50 p.m., during a concurrent observation and interview inside Resident 2 ' s room with Resident 2, Resident 2 stated, it took the staff 30 minutes or longer to answer her call lights. Resident 13 was heard yelling for help. Resident 13 ' s call light was observed turned on for about 17 minutes before CNA 2 responded. On June 12, 2025, Resident 2 ' s admission Record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (a type of stroke). A review of Resident 2 ' s care plan dated June 5, 2025, indicated, .ADL/Mobility .Resident .is at risk for ADL/mobility decline requires assistance .Will have needs anticipated and met by staff .Encourage to use call light for assistance . On June 12, 2025, at 1:12 p.m., CNA 2 was interviewed. CNA 2 stated, all staff should respond to call lights and the staff should respond when residents call out or yell for help. CNA 2 stated the call lights should be answered within 15 minutes. On June 27, 2025, at 2:35 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated, call lights should be answered right away. The DSD stated, if CNAs were not available to respond, other facility staff should answer the call light. The DSD stated, the facility practice is for call lights to be answered within seven minutes. A review of the facility policy and procedures titled, Answering the call light, dated October 2010, indicated, .The purpose of this procedure is to respond to the resident ' s requests and needs .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .Answer the resident ' s call as soon as possible .

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the California Department of Public Health within two hours for one of five sampled residents (Resident 1). This failure had the potential to leave Resident 1 unprotected, result in further abuse, and delay the initiation of an investigation. Findings: On June 12, 2025, Resident 1's admission Record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and protein-calorie malnutrition (deficient intake of protein and calories to meet the body ' s energy and tissue-building needs). A further review of Resident 1's HISTORY AND PHYSICAL EXAMINATION, dated September 29, 2024, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's SBAR (Situation, Background, Appearance, Review), dated May 17, 2025, indicated, Resident 1 had increased confusion, making allegation of prior abuse. A review of Resident 1's Nurse ' s Note, dated May 17, 2025, at 7 p.m. as documented by Registered Nurse (RN) 1, indicated, .LN [licensed nurse] reported resident alleging sexual assault, patient had made prior claim previously out of confusion .she stated the alleged sexual assault happened 9 months ago . A review of Resident 1's IDT (Interdisciplinary Team) NOTE, dated May 20, 2025, at 10:44 a.m., documented by the Director of Nursing (DON) indicated, .Presented to IDT regarding this behavior of having a rapist roaming around at night .Investigation was made regarding this matter, and resident mentioned this again on 5/17/25, same name presented to the nurse and happened 9 months ago . A review of Resident 1's Behavior Note, dated February 10, 2025, at 1:52 p.m., documented by the DON, indicated, .Visited resident on Saturday around 9:30-10:00 am, interviewed resident regarding her concerns of a person to her ' territory ' .She stated that she thought to tell the staff regarding a guy that has been going to their territory for multiple times .and thought he was roaming around in the facility and touched her .The facility did not have an employee by that name andno [sic] male CNA [Certified Nursing Assistant] assigned to her, and she stated that the nights he was in the facility was not sure, last week, 2 weeks or last night . There was no documentation that the allegation of sexual abuse on May 17, 2025, was reported to the California Department of Public Health within two hours. On June 27, 2025, at 1:35 p.m., the Director of Nursing (DON) was interviewed. The DON stated, on February 8, 2025, Resident 1 reported she was touched by a man roaming the hallway, however the resident did not provide details and became irritated during the conversation. The DON stated, it was not considered an allegation of abuse so it was not reported. The DON stated, on May 17, 2025, Resident 1 reported being raped multiple times by a man. The DON stated, this incident was not reported to the local state agency or the California Department of Public health (CDPH) because it was not considered an allegation due to resident's history of confusion and allegations. The DON stated, according to protocol, any allegation of abuse should be reported to CDPH within two hours. The DON stated, in these instances, the facility determined that the reports did not constitute actual allegations and therefore were not reported. On June 27, 2025, at 2:56 p.m., during a concurrent interview and review of Resident 1's SBAR dated May 17, 2025, were conducted with LVN 1. She stated, she documented Resident 1's statements alleging prior abuse, that the resident had been raped in the past. LVN 1 stated, Resident 1's statements were very specific and consistent, but they were interpreted as behavioral in nature rather that an allegation of abuse. LVN 1 stated, she did not report the incident to the CDPH at that time. LVN 1 stated all allegations of abuse should be reported to CDPH within two hours. On June 27, 2025, at 3:12 p.m., during a concurrent interview and review of Resident 1's nurse notes dated May 17, 2025 with the RN, the RN stated, LVN 1 reported to her on May 17, 2025, that the resident had allegedly been sexually assaulted. RN 1 stated, she informed the Administrator and the DON, but the incident was not reported to CDPH. The RN stated, she is a mandated reported and is required to report any allegation of abuse to CDPH within two hours. RN 1 stated, the incident was not reported because it was not considered an allegation of abuse. A review of the facility policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and investigating, dated September 2022, indicated, .Reporting allegations to the Administrator and Authorities .If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies .the state licensing/certification agency .The local/state ombudsman . ' Immediately ' is defined as .within two hours of an allegation involving abuse .

Based on interview and record review, the facility failed to notify the physician timely when one of eight sampled residents (Resident 1) had an oxygen saturation (measures of how effectively the body is transporting oxygen from the lungs to the tissues) of 35%. This failure caused a delay in provision of appropriate interventions resulting in prolonged discomfort and hypoxemia (abnormally low concentration of oxygen in the blood) for Resident 1, requiring transfer to the general acute care hospital (GACH). Resident 1 had an emergency endotracheal intubation (insertion of a flexible plastic tube called an endotracheal tube (ET) into the mouth or nose and then into the airway to hold it open and provide oxygen) upon arrival at the GACH, where the resident expired. Findings: On [DATE], at 11:42 a.m., an unannounced visit was conducted to the facility to investigate quality care issues. A review of Resident 1's admission records indicated the resident was admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), anxiety disorder (a chronic condition characterized by an excessive and persistent sense of apprehension), alcohol use disorder(impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences), and sepsis (occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body, that can lead to death). A review of Resident 1's History and Physical, dated [DATE], indicated the resident had the capacity to make decisions. A review of Resident 1's Order Summary Report, indicated: - Dated [DATE], indicated, O2 (oxygen) @ 3 LPM [liters per minute] VIA NASAL CANNULA (a thin tube inserted into the body for oxygen delivery) CONTINUOUS PER CONCENTRATOR/TANK every shift for SOB [shortness of breath] - Dated [DATE], indicated Send to ED, [emergency department] for further treatment and evaluation . A review of Resident 1's Progress Notes, dated [DATE], at 06:18 a.m., indicated .Late Entry .CNA (Certified Nursing Assistant) reported patients O2 level at 35, patient was noted not having his nasal cannula on. O2 was placed and went up to 80. Nasal cannula was switched to non-rebreather mask and O2 levels went up to 87 . On [DATE], at 3:19 p.m., during an interview, the Registered Nurse (RN 1) stated on [DATE], at approximately 10 a.m., Resident 1 had removed his oxygen, and his oxygen levels were low. RN 1 stated that they placed a non-rebreather mask on at 10 liters to get the oxygen levels up. RN 1 stated they notified the resident's physician, and the physician ordered for Resident 1 to be transferred to the GACH. On [DATE], at 1:41 p.m., during an interview, RN 2 stated that if a resident had low oxygen saturation of 57%, they would place oxygen at high flow oxygen (form of non-invasive respiratory support that delivers high volumes of oxygen directly to the patient through nasal cannulas), contact the resident's physician, and would transfer the resident to the hospital. On [DATE], at 3:21 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated that on [DATE], Resident 1 was removing his oxygen, and his oxygen saturation was at 57% before paramedics came. LVN 1 stated she was at the bedside with Resident 1 until the medics came to transport Resident 1 to the GACH. On [DATE], at 11:52 a.m., during a telephone interview, LVN 2 stated that normal oxygen saturation should be above 90%. LVN 2 stated that they should notify the physician if a resident's oxygen saturation is below 90%. LVN 2 stated that Resident 1 had an order for oxygen by nasal cannula at 3 liters, however, on [DATE], around midnight, she was alerted by the Certified Nursing Assistant that Resident 1's oxygen saturation was 35%, and he was removing his oxygen. LVN 2 stated that they should have contacted the physician to report Resident 1's low oxygen saturation. On [DATE], at 3:58 p.m., during a telephone interview with the Attending Physician (AP), the AP stated, he was not aware Resident 1 had an episode of low oxygen saturation level after midnight on [DATE], or that a non-rebreather mask was used. The AP stated he was informed by licensed staff at around 11 a.m. on [DATE]. The AP stated, he was not informed of the resident's earlier low oxygen saturation of 35%. The AP stated, if he had been informed of earlier episode of the low oxygen saturation level, he would have sent the resident to the hospital. On [DATE], at 4:26 p.m., during a telephone interview with the Director of Nursing (DON), she stated, Resident 1 had a change in condition around 1:37 a.m. on [DATE], due to low oxygen saturation, which dropped to 35. The DON stated, the resident should have been transferred to the hospital at that point. The DON stated that the licensed nurse should have closely monitored the resident, but there was no documentation that the resident was closely monitored. The DON stated, the physician was not notified until around 11 a.m. The DON stated the delay in notifying the physician could have affected the resident's treatment. A record review of Resident 1's eINTERACT SBAR [situation, background, assessment, recommendation], Summary for Providers, dated [DATE], at 11:57 a.m., indicated .At 11:20 AM, resident was noted not wearing his oxygen. Upon entering the room, resident's HOB [head of bed] was on fowlers (sic) position [a medical term for a body position in an upright in bed with head and back supported at an angle of 45 to 60 degrees]. Upon assessment, resident was pale, awake, alert but altered (thinking, awareness, or behavior is abnormal), skin was warm to touch, VS [vital sign] has significant O2 [oxygen] level of 56%, went up to ,d+[DATE]% after we put him on non-rebreather (sic) mask on 5L [liters] oxygen. MD made aware with an order to send resident to ED for further treatment and management. A review of Resident 1's Emergency Department Records, dated [DATE], at 1:25 p.m., indicated XXX[AGE] year-old male patient (Resident 1) presents to the ER (emergency room ) .for evaluation of difficulty in breathing. History is limited due to patient's altered level of consciousness. Patient is difficult to arouse and is unable to answer questions .Procedures in the Emergency Department .Procedure Narrative: Endotracheal Intubation . Intubation indications: respiratory failure and severe hypoxemia. It was felt the patient required emergency intubation . A review of Resident 1's hospital document titled, Discharge Summary, dated [DATE], indicated, Resident 1 was pronounced deceased following confirmation of asystole (complete absence of electrical activity in the heart), absent heart sounds, no spontaneous respirations, no pupillary or corneal reflex. Resident 1 was admitted with shortness of breath and lethargy (reduced alertness, slow response, or drowsiness). Resident 1's Plan of Care noted a diagnosis of Acute Hypercapnic Hypoxic Respiratory Failure (a serious medical condition where the lungs cannot provide enough oxygen to the body and cannot remove enough carbon dioxide [colorless and odorless gas]) likely secondary to Pneumonia (an infection of the lungs), Healthcare Associated Pneumonia (pneumonia that developed in a facility). The resident required reintubation and mechanical ventilation (a life-support technique that uses a machine to move air in and out of the lungs). The discharge diagnosis was cardiac arrest secondary to acute respiratory failure and pneumonia caused by ESBL (Extended-Spectrum Beta-Lactamase - bacteria resistant to many commonly used antibiotics). A review of the facility's policy and procedure titled Change in a Resident's Condition or Status revised February 2021, indicated .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an) . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .

Based on observation, interview, and record review, the facility failed to ensure one of eight residents, (Resident 3), was safe from a fall, when the Certified Nursing Assistant, (CNA 1), repositioned Resident 3 away from her while changing Resident 3's briefs. This failure caused discoloration to the top of the head accompanied with 4/10 pain, discoloration to the left side of cheek, and skin tear to the left elbow. Resident 3 was transferred to the hospital for evaluation. Findings: On March 21, 2025, at 11:42 a.m., an unannounced visit to the facility on four complaints and a Facility Reported Incident was initiated. A review of Resident 3's medical records indicated he was originally admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), Alzheimer's disease, (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), acquired absence of left leg below knee, and legal blindness. A review of Resident 3's History and Physical dated October 25, 2024, indicated he did not have the capacity to make decisions. A review of Resident 3's Minimum Data Set (an assessment tool), dated January 26, 2025, indicated, Resident 3 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with bed mobility (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). On March 21, 2025, at 3:44 p.m., a telephone interview was conducted with the Certified Nursing Assistant, (CNA 1). CNA 1 stated on March 16, 2025, between 8:30 p.m. to 9 p.m., she was changing Resident 3's brief. CNA 1 stated she was standing on the left side of the bed and Resident 3 was lying on his back. CNA 1 stated that she had instructed Resident 3 to turn to the right, and was preparing to walk to the right side, and Resident 1 turned and fell off the bed headfirst. CNA 1 stated, Resident 3 required moderate (the resident does more than half of the effort, but staff provided some physical help) to maximal assistance with bed mobility. On March 24, 2025, at 1:11 p.m., observed Resident 3 lying in bed on his back. There were no side rails in use, and he was on an air mattress. On March 24, 2025, at 1:11 p.m., an interview was conducted with Resident 3. Resident 3 stated on an unknown date, unknown persons pushed him out of bed, and he fell on his head. On March 24, 2025, at 3:37 p.m., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 3. CNA 2 stated that when repositioning Resident 3, she preferred having two person assistance to ensure a safe turn. CNA 2 stated, when repositioning residents alone, she would instruct the resident to turn towards her to prevent a fall from the bed. On March 25, 2025, at 1:47 p.m., an interview was conducted with the Assistant Director of Nursing, (ADON). The ADON stated that Resident 3 had experienced a fall on March 16, 2025. The ADON stated, it was determined CNA 1 had rolled Resident 3 away from her, which resulted in a fall. The ADON stated that Resident 3 was transferred to the hospital for evaluation and later returned to the facility. A review of Resident 3's eINTERACT SBAR, [situation, background, assessment, recommendation], Summary for Providers dated March 16, 2025, at 9:41 p.m., indicated .LN [licensed nurse] was notified by staff on shift that resident had a fall during patient care, LN rush to residents room, no cognitive changes, during skin assessment resident was noted with discoloration to the top of the head accompanied with 4/10 pain, discoloration to the left side of cheek, and skin tear to the left elbow. staff on shift safely assisted resident to bed. [name of doctor] was notified and order was receive (sic) to send patient to ER [emergency room ] for CT scan of the head . A review of Resident 3's IDT [Interdisciplinary Team] - Fall dated March 17, 2025, at 2:35 p.m., indicated . At risk for falls due to impaired balance/poor coordination, left BKA, [below the knee amputation] non-ambulatory and prefers to be in bed most of the time, potential medication side effects, sensory (blindness) deficit , (sic) dementia, forgetfulness, and psychosis . Resident was transferred to ER for CT scan of head and further evaluation. Staff education on technique for rolling resident when providing care in bed . A review of Resident 3's Progress Notes dated March 19, 2025, at 10:01 p.m., indicated Resident returned from [name of hospital] via gurney . A review of Resident 3's Care Plan initiated March 16, 2025, indicated Focus .Falls: Resident had a witnessed fall 3/16/25 and is at risk for injury .Interventions . Staff education regarding turning resident towards staff when providing care in bed . A review of the facility's policy and procedure titled Falls -Clinical Protocol revised March 2018, indicated .1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall . 5. Falls should be categorized as . c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) quarterly assessments were completed within 14 calendar days, as required by Center for Medicare and Medicaid Services (CMS - an agency that administers the nation's major healthcare programs), for 19 of 27 residents reviewed for resident assessment (Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141). This deficient practice resulted in late completion of quarterly assessments in Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141, potentially resulting in delay in updating and creating residents' care plan affecting residents' quality of care. Findings: 1a. A record review of Resident 3's MDS Quarterly assessment dated [DATE], indicated Resident 3's assessment was completed on January 8, 2025, 53 calendar days after the assessment reference date (the final day of the observation period during which the resident's status is assessed and documented); 1b. A record review of Resident 14's MDS Quarterly assessment dated [DATE], indicated Resident 14's assessment was completed on January 8, 2025, 53 days after the assessment reference date; 1c. A record review of Resident 25's MDS Quarterly assessment dated [DATE], indicated Resident 25's assessment was completed on January 9, 2025, 46 days after the assessment reference date; 1d. A record review of Resident 30's MDS Quarterly assessment dated [DATE], indicated Resident 30's assessment was completed on January 5, 2025, 53 days after the assessment reference date; 1e. A record review of Resident 41's MDS Quarterly assessment dated [DATE], indicated Resident 41's assessment was completed on January 8, 2025, 52 days after the assessment reference date; 1f. A record review of Resident 45's MDS Quarterly assessment dated [DATE], indicated Resident 45's assessment was completed on January 7, 2025, 58 days after the assessment reference date; 1g. A record review of Resident 76's MDS Quarterly assessment dated [DATE], indicated Resident 76's assessment was completed on January 3, 2025, 54 days after the assessment reference date; 1h. A record review of Resident 81's MDS Quarterly assessment dated [DATE], indicated Resident 81's assessment was completed on January 10, 2025, 49 days after the assessment reference date; 1i. A record review of Resident 83's MDS Quarterly assessment dated [DATE], indicated Resident 83's assessment was completed on January 10, 2025, 35 days after the assessment reference date; 1j. A record review of Resident 86's MDS Quarterly assessment dated [DATE], indicated Resident 86's assessment was completed on January 9, 2025, 41 days after the assessment reference date; 1k. A record review of Resident 89's MDS Quarterly assessment dated [DATE], indicated Resident 89's assessment was completed on January 3, 2025, 56 days after the assessment reference date; 1l. A record review of Resident 106's MDS Quarterly assessment dated [DATE], indicated Resident 106's assessment was completed on January 11, 2025, 34 days after the assessment reference date; 1m. A record review of Resident 124's MDS Quarterly assessment dated [DATE], indicated Resident 124's assessment was completed on January 10, 2025, 49 days after the assessment reference date; 1n. A record review of Resident 127's MDS Quarterly assessment dated [DATE], indicated Resident 127's assessment was completed on January 5, 2025, 51 days after the assessment reference date; 1o. A record review of Resident 128's MDS Quarterly assessment dated [DATE], indicated Resident 128's assessment was completed on January 8, 2025, 51 days after the assessment reference date; 1p. A record review of Resident 129's MDS Quarterly assessment dated [DATE], indicated Resident 129's assessment was completed on January 9, 2025, 49 days after the assessment reference date; 1q. A record review of Resident 130's MDS Quarterly assessment dated [DATE], indicated Resident 130's assessment was completed on January 7, 2025, 45 days after the assessment reference date; 1r. A record review of Resident 131's MDS Quarterly assessment dated [DATE], indicated Resident 131's assessment was completed on January 7, 2025, 53 days after the assessment reference date; 1s. A record review of Resident 141's MDS Quarterly assessment dated [DATE], indicated, Resident 141's assessment was completed on January 11, 2025, 34 days after the assessment reference date. On January 17, 2025, at 11:26 a.m. a concurrent interview and record review was conducted with the MDS Coordinator (MDSC). The MDSC reviewed the quarterly assessments for Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141 and stated all the resident's quarterly assessments were completed late, passed the 14 days requirement. The MDSC further stated it was important to complete the assessments on time to ensure accuracy and avoid delay in residents plan of care. On January 17, 2025, at 4:02 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the quarterly assessments for Residents 3, 14, 25, 30, 41, 45, 76, 81, 83, 86, 89, 106, 124, 127, 128, 129, 130, 131 and 141 should have been completed within 14 days to ensure each resident had individualized resident centered care plans. A review of the facility policy and procedure title, MDS Completion and Submission Timeframes, dated July 2017, indicated, .The assessment coordinator or designee is responsible for .resident assessments .submitted to CMS .in accordance with current federal and state guidelines. A review of the facility document titled, RAI OBRA-required Assessment Summary dated October 2024, indicated, Assessment Type: Quarterly (Non-Comprehensive) .MDS Completion Date (item Z0500B .No Later Than .ARD +14 calendar days .

Based on interview, and record review, the facility failed to ensure Resident 1 ' s urinary catheter, (a hollow tube inserted into the bladder to drain or collect urine), was secured in place for one of four residents, (Resident 1). This deficient practice caused skin erosion on the penis and pressure injuries, (injury to skin and underlying tissue resulting from prolonged pressure on the skin), on the testicles. Findings: On December 13, 2023, at 1:32 p.m., an unannounced visit to the facility on a complaint investigation was initiated. A review of Resident 1 ' s medical records indicated he was admitted on [DATE], and discharged on [DATE], with diagnoses of sepsis, (occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body, that can lead to death), COVID-19, bacteremia, (the presence of bacteria in the bloodstream), type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), obstructive and reflux uropathy, (a disorder of the urinary tract that occurs due to obstructed urinary flow), benign prostatic hyperplasia, (BPH - enlargement of the prostate gland), acute myocardial infarction, (heart attack), chronic kidney disease, subdural hemorrhage, (bleeding between the brain and the skull), urinary tract infection, (infection in the bladder), and hydronephrosis, (the back-up of urine into the kidneys). A record review of Resident 1 ' s History and Physical dated October 18, 2023, indicated he did not have decision making capacity. On December 13, 2023, at 3:10 p.m., an interview was conducted with the Treatment Nurse, (TN). The TN stated that Resident 1 had a urinary catheter in place. The TN stated Resident 1 was confused and would pull on the urinary catheter and would remove the securement device. The TN stated that on October 30, 2023, Resident 1 had a medical device related penile glans, (the head or tip of the penis), erosion, (the gradual wearing away of the skin causing a wound), and two pressure injuries underneath his scrotum. The TN stated the injuries could have been prevented if they checked on Resident 1 more frequently, and they should have known that he removed the securement device. On December 13, 2023, at 4:23 p.m., an interview was conducted with Licensed Vocational Nurse, (LVN 2). LVN 2 stated that it is important that the securement device is in place to prevent pulling of the catheter, which could be painful. A record review of Resident 1 ' s Order Summary Report indicated the following: dated October 17, 2023, Maintain foley catheter, (a hollow tube inserted into the bladder to drain or collect urine) with 18 F (French - size of the tube), 10 cc, (cubic centimeters), balloon, (tiny retention balloon which is filled with sterile water to prevent the catheter from slipping out of the bladder), (size) for obstructive uropathy and may reinsert for leaking, obstruction or dislodgement. every shiftdated October 17, 2023, Change catheter securement device q, (every), 7 days every day shift every 7 day(s) for Change catheter securement device q week. A review of Resident 1 ' s Care Plan dated October 18, 2023, indicated Use of indwelling urinary catheter needed due to obstructive uropathy . The care plan did not have any interventions regarding the securement device to prevent erosion. A review of Resident 1 ' s Progress Notes dated November 3, 2023, at 3:39 p.m., indicated Wound team completed wound evaluations on the following newly found wounds: WOUND#1 Wound Type: Penile erosion secondary to a medical device-related mucosal pressure injury-Foley Catheter, (pressure ulcers found on mucous membranes with a history of a medical device in use at the location of the ulcer),. Location: Glans penis Measurements: 2cm, (centimeter) x 2.5cm Partial thickness skin loss, (damage does not penetrate below the dermis and may be limited to the epidermal layers only), Wound base: Yellow sloughy, (dead tissue), and red beefy tissue. Exudate, fluid that leaks out of blood vessels into nearby tissues): Moist Edges: Irregular, defined, ragged Peri-wound, (tissue surrounding a wound): Moist, skin toned to ethnicity .Pain to site: Yes .WOUND#2 Wound Type: Pressure Injury stage 2, (open wound below the surface of the skin), secondary to a medical device-related pressure injury-Foley Catheter Location: Scrotum (superior - toward the head of the body) Measurements: 0.5cm x 1 cm Partial thickness skin loss Wound base: 100% viable, (skin tissue that is healing or capable of healing), deep pink moist epithelializing, (a process where epithelial cells migrate upwards and repair the wounded area), tissue Exudate: Moist Edges: Attached and defined Peri-wound: Moist, skin toned to ethnicity . WOUND#3 Wound Type: Pressure Injury stage 2 secondary to a medical device-related pressure injury-Foley Catheter Location: Scrotum (inferior - towards the bottom or away from the head-end of the body), Measurements: 0.7cm x 1cm Partial thickness skin loss Wound base: 100% viable deep pink moist epithelializing tissue Exudate: Moist Edges: Attached and defined Peri-wound: Moist, skin toned to ethnicity . Pt. tends to pull on catheter and remove adhesive anchor. Multiple anchors have been placed and pt. removes. Education provided although pt. has some confusion . A review of the facility ' s policy and procedure titled Indwelling urinary catheter (Foley) care and management revised: December 11, 2023, indicated . Make sure that the catheter is secured properly . Assess the securement device daily and only change it when clinically indicated and as recommended by the manufacturer . If a new securement device is necessary, connect it to the catheter before applying the device to the skin. If a securement device isn't available, use a piece of adhesive tape to secure the catheter. If you're using tape, retape the catheter on the opposite side of the body to where it was to prevent skin hypersensitivity and irritation . Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen, (a hollow tube positioned between the urinary bladder and opening at the tip of the penis which takes urine stored in the bladder out of the body), and bladder wall . Emphasize that the patient must leave slack in the catheter to minimize pressure on the bladder, urethra, and related structures. Excessive pressure or tension can lead to tissue breakdown . A review of the facility ' s policy and procedure titled Skin Management Guidelines dated March, 2022, indicated .Medical device related pressure Injury . Result from the use of devices designed and applied for diagnostic or therapeutic purposes .The resultant pressure injury generally conforms to the pattern or shape of the device .Staged as a pressure injury . A review of the Healthcare Infection Control Practices Advisory Committee guidelines titled Guideline for Prevention of Catheter-associated Urinary Tract Infections revised June 6, 2019, indicated .Category IB . A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice .E. Properly secure indwelling catheters after insertion to prevent movement .(Category IB) .

Based on observation, interview, and record review, the facility failed to ensure care and treatment for pressure injuries (P/Is - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) were provided, for five of five residents reviewed for pressure injuries (Residents 98, 92, 18, 357, and 49), when: 1. The facility staff did not assess or evaluate the staging of pressure injuries in accordance with standards of practice. In addition, there was a delay in providing further interventions/treatment of the P/Is; and 2. The facility did not have a process in the timely notification of the Interdisciplinary Team (IDT - a group of healthcare professionals), which included the Registered Dietitian (RD). The RD did not have a process to ensure accurate information of the P/Is were provided to apropriately assess and provide nutritional treatment and/or services to promote healing of the P/Is. On April 21, 2023, at 6:42 p.m., the Administrator (ADM) and the Director of Nursing (DON) were verbally notified of the Immediate Jeopardy (IJ- situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to accurately and timely assess/evaluate and provide the appropriate interventions to address the P/Is for five residents (Residents 98, 92, 18, 357, and 49). These failures resulted in the delay and provision of additional care and treatment which led to the worsening condition of the P/Is for Residents 98, 92, 18, 357, and 49. On April 22, 2023, at 3:51 p.m., the ADM presented an acceptable plan of actions which included the following: - Identified residents (Residents 98, 92, 18, 357, and 49) and other residents identified with pressure ulcers were reassessed and evaluated by the Wound Certified Registered Nurse; - Comprehensive assessment and an updated interdisciplinary care plan were completed for the identified residents and other residents with P/I; - Pain evaluations were completed for the identified residents and other residents with PI; - The RD reviewed the record of the residents with P/I and provided an updated nutritional assessment; - The treatment plan for the residents with PI were reviewed to ensure proper treatment were provided; - Braden assessment (an assessment tool to identify resident at risk for developing pressure injury) was completed for residents with P/I; - The residents with P/I's family and the physician were notified; - A house-wide skin sweep was initiated by the licensed nurses on April 21, 2023, to observe and validate skin status of current residents; - The care plan for residents with P/Is were reviewed and updated as needed by the IDT; - The RD initiated an assessment of the nutritional needs of the residents P/I; - Newly admitted residents would have an accurate comprehensive assessment performed by a Registered Nurse (RN) or evaluated by a Licensed Nurse (LN), followed by a second skin check performed by the member of nursing management (DON, RN Unit Manager) within 24 hours; - Newly admitted residents would have a Braden scale completed upon admission and weekly for 3 weeks and current residents Braden Scale were initiated by the LN to identify risk. Residents identified with moderate to high risk on the Braden Scale assessment would be reviewed to ensure appropriate preventative measures, intervention, and treatment orders were implemented; - LN and the Center's Wound Team were to be reeducated beginning April 21, 2023, by the DON/Designee on the facility's Skin Management Guidelines and the Skin Quick Reference Guide which includes monitoring the effectiveness of the wound treatment; - Wound rounds would be completed at least weekly by the wound team. The RN would ensure accurate assessment was conducted and the appropriate treatment and interventions were in place. Communication to the IDT would be done through the IDT report. The IDT would review the care plan weekly; and - The facility conducted a QA (Quality Assurance) meeting on April 21, 2023, and the Medical Director was notified. On April 24, 2023, at 6:58 p.m., the immediate jeopardy was removed in the presence of the ADM during the onsite survey, upon verification of the implementation of the plan of actions. The facility was notified an extended survey would be conducted due to substandard quality of care issues. Findings: A review of an article published by the National Pressure Injury Advisory Panel (NPIAP) titled, NPIAP Pressure Injury Stages, - .Stage 1 Pressure Injury .intact skin with a localized area of non-blanchable erythema (discoloration of the skin which does not turn white when pressed) .; - Stage 2 Pressure Injury .Partial-thickness loss of skin with exposed dermis (middle layer of the skin containing blood vessels and nerve endings) .The wound bed is viable (living tissue), pink, or red, moist .; - Stage 3 Pressure Injury .Full-thickness loss of skin in which the adipose (fat) is visible in the ulcer and granulation tissue (type of tissue that fill in the wound that is healing) .Slough (dead tissue usually light yellow/cream colored) and/or eschar (dead tissue appearing black or brown dry, thick, and leathery) may be visible .; - Stage 4 Pressure Injury .Full thickness skin and tissue loss with exposed or palpable fascia (connective tissue), muscle .bone in the ulcer. Slough and /or eschar may be visible .; - Unstageable Pressure Injury .Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar .; - Deep Tissue Pressure Injury .Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration . 1. On April 17, 2023, at 3:58 p.m., Resident 98 was observed awake and lying on her left side in bed. Resident 98 was observed to have facial grimacing and moaning when she moved while lying in bed. In a concurrent interview with Resident 98, she stated she preferred to lay on the left side because she had a bed sore (pressure injury) on her buttocks. She stated it would hurt when she lay on her back. On April 20, 2023, Resident 98's record was reviewed. Resident 98 was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - type of lung disease). A review of Resident 98's Progress Note, dated March 2, 2023, at 10:30 p.m., indicated, .Patient's skin is warm, intact, no rashes noted. Plan of care is to prevent skin breakdown . A review of Resident 98's Medical History/Physical Examination, documented by the attending physician, dated March 7, 2023, indicated intact skin condition. A review of Resident 98's progress notes indicated the resident was sent out to acute hospital on March 10, 2023 and readmitted back to the facility on [DATE]. A review of Resident 98's Progress Notes, dated March 14, 2023, at 10:15 p.m., documented by the Licensed Vocational Nurse (LVN), indicated, .Head-to-toe skin assessment completed, dry skin noted to BLE (bilateral extremities) and open are (sic) noted to coccyx (tail bone). Open area is dry with pink wound bed . A review of Resident 98's physician's order, dated March 14, 2023, indicated, .Apply to Coccyx topically one time a day for Open wound clean with NS (normal saline - a solution used to clean wounds), apply calazime paste (a skin protectant to treat skin irritation), and cover with foam dressing . A review of Resident 98's ETAR (Electronic Treatment Administration Record), for the month of March to April 2023, indicated the calazime paste was administered to Resident 98 from March 15 to April 6, 2023. A review of Resident 98's Progress Notes, dated March 15, 2023, at 6:02 p.m., documented by the LVN, indicated, .Pt (patient) has a small open area on left buttock measuring 1 cm (centimeter - unit of measurement) x (by) 0.5 cm x (by) 0.1 epithelial (thin tissues covering all the exposed surfaces of the body) wound bed, no exudate (drainage) no odor, no infection . A review of Resident 98's physician's order, dated March 15, 2023, indicated, .Cleanse open area on left buttocks with NS (normal saline) and past (sic) dry, apply medihoney (medication to aid with healing for P/Is) and cover with a foam dressing every day shift . A review of Resident 98's Progress Notes, documented by the Registered Dietitian (RD), dated March 15, 2023, at 6:17 a.m., indicated, .Nutrition/Weight .Patient admitted with open area to coccyx. Recommend MVI (multivitamins) with minerals for aid in healing and RD assessment to follow . A review of Resident 98's care plan, dated March 15, 2023, indicated, .Resident has open wound to coccyx .Goal .Show s/s (signs and symptoms) of healing within normal limits of disease .Administer treatment per physician orders .Dietary consult . A review of Resident 98's Minimum Data Set (MDS - an assessment tool), dated March 21, 2023, indicated the following: - BIMS (Brief Mental Status) score of 15 (cognitively intact - with sufficient judgment and able to manage normal demands of the environment); - Required extensive assistance with bed mobility, transfers, and toilet use; and - Incontinent with bowels. A review of Resident 98's Progress Notes, documented by the RD, dated March 22, 2023, at 2:02 p.m., indicated, .RD readmission/wound note .Patient readmitted with COPD exacerbation .Treatment continues to open are (sic) noted to coccyx and small open area on left buttock .Albumin (protein level in the body) 2.6 low .Recommend .Ensure daily for increased protein d/t (due to) low albumin and RD to f/u (follow up) prn (as needed) . A review of Resident 98's Progress Notes, documented by the LVN 1, dated March 23, 2023, at 2:40 p.m., indicated, .weekly wound measurement, pt (patient) has an open area that now presents with slough and clinically appears as a stage 3. Measures 3.5cm x 3cm x 0.2cm, moderate amount of serous drainage (thin water fluid that is produced in response to inflammation) .wound bed has 100% slough, edges are slightly macerated (occurs when skin is in contact with moisture for extended period) . The progress note did not indicate the location of the open area. A review of the NPIAP pressure injury staging, indicated a pressure injury with slough obscuring the wound bed is an unstageable P/I. The wound assessment for the P/I at Resident 98's coccyx, conducted on March 23, 2023, indicated stage 3 P/I instead of an unstageable P/I. A review of Resident 98's physician's order, dated March 27, 2023, indicated, .Cleanse open area on Coccyx with NS and pat dry, apply nickel thick layer of Santyl ointment (medication to remove damage tissue from long-term skin breakdown) and cover with DSD (dry sterile dressing) every day shift . A review of Resident 98's ETAR, for the month of March 2023, indicated; - cALAZIME - Santyl ointment treatment order was started on March 28, 2023 (five days after the unstageable P/I on the coccyx was identified on March 23, 2023). A review of Resident 98's Progress Notes, documented by the LVN 1, dated March 30, 2023, at 3:10 p.m., indicated, .weekly wound measurement, pt (patient) has an open pressure clinically appears as stage 3. Measures 2.5 cm x 4.5 cm x 0.1 cm, moderate amount of serous drainage .wound bed as 100% slough (yellowish dead tissue), edges are slightly macerated . The progess note did not indicate the location of the open area. A review of Resident 98's Progress Notes, documented by the LVN 1, dated April 4, 2023, at 5:29 p.m., indicated, .Pt has stage 3 pressure ulcer to coccyx, wound bed is 60% slough, 40% granulated tissue, moderate serous exudate (drainage) .edges are slightly macerated . The Progress Notes documented on April 4, 2023, did not include the measurement of the wound at Resident 98's coccyx. A review of Resident 98's Progress Notes, documented by the RD, dated April 5, 2023, at 1:18 p.m., indicated, .Current weight 105.2# (pounds - unit of measurement) -18.8# (15.2%) in 30 days. Loss may be from inadequate intakes and c/o (complaint of) poor appetite .Pt. received an Ensure daily and drinks it consistently. Treatment continues to coccyx PU (pressure ulcer) with MVI wit (sic) minerals in place for aid in healing. Ice Cream added to L/D (lunch and dinner) meals . A review of Resident 98's Progress Notes, documented by the LVN 1, dated April 11, 2023, at 4:31 p.m., indicated, .Stage 3 pressure ulcer to coccyx, 2 cm x 3.5 cm x 0.2 cm, wound bed is 100% slough, edges are macerated scar tissue. Moderate serous exudate .edges are slightly macerated . A review of Resident 98's Progress Notes titled Nutrition/Weight, documented by the RD, dated April 13, 2023, was reviewed. There was no documentation of any additional nutritional recommendation related to Resident 98's non-healing pressure ulcer. A review of Resident 98's record did not indicate any other additional interventions/treatment to address the coccyx PI. In addition, there was no follow up assessment or evaluation from the RD (after April 5, 2023) and/or the IDT conducted to address Resident 98's P/I when it was initially identified. In addition, there was no documentation the worsening condition of the P/I was referred to the physician and/or wound specialist for further evaluations and interventions. On April 20, 2023, at 12:35 p.m., a follow up observation and interview was conducted with Resident 98. Resident 98 was observed side lying in bed, awake, and alert. Resident 98 stated she continued to have pain when she would move in bed because of her bed sore on her buttocks. She stated her bed sore affected her ability to participate in activities. She further stated, I learned to work around it .It would be better if I didn't have these conditions. On April 20, 2023, at 3:26 p.m., an interview with the DON was conducted. The DON stated the status of Resident 98's coccyx wound had a deep tunneling with slough and macerated edges which appeared to have worsened since last wound assessment on April 11, 2023. She stated Resident 98's coccyx wound should have been referred to the physician sooner for further evaluation and treatment. She further stated the current treatment order for Resident 98's wound on the coccyx was not appropriate based on the current condition of the resident's pressure ulcer since it would require manual debridement. On April 20, 2023, at 5:20 p.m., Resident 98 was observed with LVN 6. Resident 98 was observed to have a white dressing on her coccyx area. When the dressing was removed by LVN 6, the resident's coccyx P/I was observed to have deep tunneling (a wound which progressed to form passageways underneath the surface of the skin) on the wound bed with macerated edges and slough. In a concurrent interview with LVN 6, she stated Resident 98's wound on the coccyx was unstageable because of the slough and had tunneling. She stated the last skin assessment for the open area on the coccyx was on April 11, 2023. She stated she was not sure why there was no current wound assessment. She stated Resident 98's wound on the coccyx had gotten worst from the previous assessment. She stated she should have done a better assessment of Resident 98's P/I. She said Resident 98's P/I needed to be debrided and further evaluated by the physician. She further stated the current treatment order for Resident 98's P/I was not appropriate and required further treatment interventions. On April 21, 2023, at 11:26 a.m., an interview with the RD was conducted. She stated she would get a list of residents with P/Is from the nursing staff weekly, but the list did not include any information of the status or severity of the wound. She stated her evaluation and nutritional plan of care could be different if she knew the accurate status of the resident's wound. The RD stated she was aware Resident 98 had a P/I on her coccyx but did not have specific information about the severity of the resident's P/I on the coccyx. She stated she did not see the wound herself and relied on the nursing staff to give her the information on the status of the P/I. She stated she was not aware of the severity of Resident 98's PI until today. She stated she would have added Juven (medication to aid with healing for P/Is) a lot sooner. The RD further stated the facility would conduct an IDT meeting which included the nursing staff members, the RD, and other staff to address weights issues and P/Is for the residents. However, she stated the IDT meeting had not been conducted for a while. She stated she would have made better recommendations and treatment plan for the resident if the staff would have communicated with her regarding the resident's current /PI status. On April 21, 2023, at 2:40 p.m., a group interview was conducted with the ADM, DON, Registered Nurse (RN) 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6. The interviews were as follows: - LVN 1 stated the licensed nurse would take the measurements of the PI, evaluate/assess the wound bed, drainage, edges, and peri wound appearance when a PI was identified. She stated the physician was to be notified for treatment orders, document in the resident's record and add the resident on the wound list. LVN 1 stated wound evaluation were to be done weekly and documented in the resident's record. She stated the physician was involved when the wound started and when the wound worsens. - LVN 1 stated they should fill out a spreadsheet indicating residents with PI with the description of the wound and location. She stated the spreadsheet was not accurately filled out to describe the status of the resident's wounds. She stated the Registered Nurse (RN) who was designated to oversee the wound team was rarely present in the wound team and they had several DONs (interim) who should ensure systems to address concerns were implemented. - LVN 1 stated she did not involve the RD with wound management of the residents with PI because she was more focused on the skin-physical interventions and not the nutrition component. - The DON stated the RD should be involved with the wound status to be able to give appropriate nutritional recommendations. - The RD stated she would recommend the following to residents with P/I: MVI with minerals, check on the resident's laboratory values, liquid protein or nutritional supplement, ensure the resident was eating well, and update the diet order as needed. She further stated nutritional interventions should have been started earlier. - The ADM stated they have not conducted IDT meetings to address wound management for more than three months as they had multiple interim DONs and confirmed wound management had fallen through the cracks. - LVN 1 stated Resident 98 had a lot of sloughs and tunneling on the wound. She stated they should have involved the Physical Therapist who was wound certified to debride the slough. She stated Resident 98 did not have a special cushion on her wheelchair and should have one. - The ADM, DON, RN 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6 all agreed Resident 98's P/I should have been addressed and evaluated appropriately if IDT meetings were done weekly. On April 21, 2023, at 6:25 p.m. the DON stated Resident 98's P/I to coccyx was reassessed and provided measurement of 2.8 cm x 2.7 cm, depth 1.3 cm, tunneling at 1-3 o'clock at 1 cm. The DON stated Resident 98's P/I had worsened since last assessment. 2. On April 18, 2023, at 12:24 p.m., Resident 92 was observed awake and sitting in her wheelchair. Resident 92 was observed to be slow to respond but able to answer simple instructions when a staff delivered her lunch tray. She was observed to be assisted by a staff with feeding. On April 21, 2023, Resident 92's record was reviewed. Resident 92 was admitted to the facility on [DATE], with diagnoses which included sepsis (severe infection) and diabetes mellitus (DM - abnormal blood sugar) A review of Resident 92's Progress Notes, dated February 9, 2023, at 7:32 p.m., did not indicate presence of any skin issues or wounds. A review of Resident 92's Progress Notes, documented by the LVN 1, dated February 10, 2023, at 1:53 p.m., indicated, .Pt (patient) also has an unstageable pressure ulcer on Coccyx (tailbone) with 100% slough on the wound bed, macerated edges, some odor, no s/sx (signs and symptoms) of infection, measures 5cm x 3cm . A review of Resident 92's care plan, dated February 10, 2023, indicated, .At risk for alteration in skin integrity related to limited mobility, incontinent .dependent on staff for bathing needs . There was no plan of care initiated for the unstageable pressure ulcer on Resident 92's coccyx. A review of Resident 92's physician's order, dated February 12, 2023 (two days after the coccyx wound was identified on February 10, 2023), indicated, .Cleanse coccyx stage 3 pressure ulcer with NS (normal saline), pat dry apply Santyl and cover with DSD (dry sterile dressing), every day shift . A review of Resident 92's ETAR (Electronic Treatment Administration Record, for the month of February 2023, indicated the treatment for Resident 92's pressure ulcer on the coccyx was initiated on February 13, 2023 (three days after the coccyx wound was identified on February 10, 2023). A review of Resident 92's Minimum Data Set (MDS - an assessment tool), dated February 16, 2023, indicated Resident 92 required two-person extensive assistance with bed mobility, transfers, and toilet use. The MDS also indicated Resident 92 was always incontinent with bowel and bladder. A review of Resident 92's Nutritional Assessment, conducted by the RD, dated February 17, 2023, indicated, .No Pressure related skin issues .Labs (laboratory) dated 2/9 (February 9, 2023) .Albumin low at 2.9, Ca (calcium) low at 7.3 .Recommend .Calcium supplement .30mls (milliliter - unit of measurement liquid protein (sugar Free) 1x (once) daily d/t (due to) low albumin of 2.9 and RD to f/u (follow up) prn (as needed) . A review of Resident 92's Progress Note, documented by the RD, dated February 22, 2023, at 12:24 p.m., indicated, .Nutrition/Weight .Treatment continues to coccyx wound .Recommend .MVI (multivitamin) with minerals for aid in healing of coccyx wound and RD to f/u prn) . There was no documented evidence the RD recommendation for MVI with minerals for Resident 92 to aid in wound healing was referred to the physician for implementation. A review of Resident 92's Progress Note, documented by RN 2, dated February 23, 2023, at 9:26 a.m. (13 days after initial skin assessment), indicated, .Patient seen today for weekly wound rounds. She continues to have an unstageable pressure ulcer to the coccyx area with various abrasions surrounding the unstageable pressure ulcer .Measurements: 5.1 cm x 5.0 cm (increased size from February 10, 2023) .Exudate (drainage): Heavy, serosanguinous (pink watery fluid due to presence of blood) .Tissue: 100% eschar (black hard dead tissue) .Odor: Yes .Infection: No . A review of Resident 92's Progress Note, documented by RN 2, dated February 25, 2023, at 1:56 p.m., indicated, .Texted (name of physician) requesting an order for Flagyl (antibiotic - medication to treat bacterial infection) to crush and put in the wound bed of the patients (sic) unstageable pressure ulcer to the coccyx. Awaiting for a response and will F/u (follow up) tomorrow . A review of Resident 92's ETAR, for the month of February 2023, included a physician's order, dated February 27, 2023 (two days after the physician was documented notified through phone text on February 25, 2023), which indicated, Flagyl Oral Tablet 500 MG (milligrams - unit of measurement) .Apply to coccyx wound topically every day shift for wound odor control to be used by wound care team/Use all 3 (three) t (tabs) for 10 days . A review of Resident 92's Progress Note, documented by RN 2, dated March 2, 2023, at 8:44 a.m., indicated, .Patient seen today for weekly wound rounds. She continues to have an unstageable pressure ulcer to the coccyx area with various abrasions surrounding the unstageable pressure ulcer .Measurements: 5.1 cm x 5.0cm . Exudate: Heavy, serosanguinous .Tissue: 100% eschar .Odor: Yes . A review of Resident 92's Progress Note, documented by RN 2, dated March 9, 2023, at 8:57 a.m., indicated .Patient seen today for weekly wound rounds. She continues to have an unstageable pressure ulcer to the coccyx area with various abrasions surrounding the unstageable pressure ulcer .Measurements: 5.1 cm x 5.0cm x 1.5cm depth . Exudate: Heavy, sero-sanginous .Tissue:50% eschar, 50% yellowish slough . A review of Resident 92's Progress Note, documented by RN 2, dated March 17, 2023, at 3:53 p.m., indicated, .unstageable pressure ulcer to coccyx .9cm x 6cm x 1cm (increased size from previous week) .wound bed is 75 percent (%) slough with 25 percent eschar in the middle .some odor present, no sign of infection . A further review of Resident 92's record indicated there was no documented evidence the physician was notified of the status of the pressure ulcer on Resident 92's coccyx when the size of the wound increased and still have 100% of dead tissue (eschar/slough). There was no documented evidence the RD conducted a nutritional reassessment of Resident 92 related to the increased wound size (23 days from last nutritional assessment conducted on February 22, 2023). A review of Resident 92's Progress Note, documented by LVN 13, dated March 20, 2023, at 3:20 a.m., indicated, .Percocet (narcotic pain medication) .c/o generalized body pain r/t (related to) pressure ulcer 5/10 (five out of 10 pain rating scale), med (medication) given . A review of Resident 92's Progress Note, documented by LVN 1, dated March 23, 2023, at 3:18 p.m., indicated, .weekly wound note .stage 4 Coccyx measures 6cm x 7cm x 0.9 cm, has 0.9cm undermining at 12 o'clock, and 1 cm tunneling at 7'o clock, edges are macerated, wound bed is granulated with 60% slough, no foul odor . A review of Resident 92's Progress Note, documented by the RD, dated March 29, 2023, at 7:40 a.m., indicated, .Nutrition/Weight .Treatment continues to coccyx PU for aid in healing .Recommend .MVI with minerals for aid in healing of PU and RD to f/u prn . A review of Resident 92's physician's order, dated March 29, 2023, which indicated, Multivitamin with Minerals Give 1 (one) tablet by mouth one time a day for supplement . The RD recommendation for MVI with minerals to aid in wound healing was implemented on March 29, 2023 (35 days after the initial RD recommendation on February 22, 2023). A review of Resident 92's Progress Note, documented by the LVN, dated March 30, 2023, at 2:16 p.m., indicated, .weekly wound note .stage 4 Coccyx measures 5.7 cm x 6.5 cm x 1cm, has 1cm undermining at 12 o'clock, and 1cm tunneling at 7'o clock .wound bed is granulated with 50% slough .Heavy serous exudate . There was no documented evidence the physician was notified when Resident 92's coccyx wound developed undermining and tunneling. A review of Resident 92's Progress Note, documented by RN 2, dated April 6, 2023, at 10:44 a.m., indicated, .Patient seen today for weekly wound rounds. She continues to have an unstageable pressure ulcer to the coccyx area with various abrasions surrounding the unstageable pressure ulcer .Measurements: 5.7 cm x 6.4 cm x 1.0cm depth .20% yellowish slough . There was no documentation of the measurement of undermining and tunneling on the coccyx pressure ulcer of Resident 92. A review of Resident 92's Progress Note, documented by RN 2, dated April 13, 2023, at 9:04 a.m., indicated, .DTI (deep tissue injury) to coccyx .Measurements: 6.0 cm x 6.0 cm x 1.0cm depth with 1.0cm undermining at 3 O'clock and 2.5cm undermining at 9 O'clock .Exudate: Heavy, serosanguinous, greenish . A review of Resident 92's progress notes indicated Resident 92 was given pain medication (acetaminophen or Percocet) for pain on the buttock on the following dates: -March 25, 2023, at 8:18 a.m.; -March 25, 2023, at 11:39 a.m.; -March 25, 2023, at 2:51 p.m.; -March 25, 2023, at 9:39 p.m.; -March 30, 2023, at 11:34 p.m.; -April 1, 2023, at 9:34 a.m.; -April 1, 2023, at 2:59 p.m.; and -April 8, 2023, at 8:24 p.m. A review of Resident 92's the ETAR, for the month of March 2023, did not indicate the treatment order for Resident 92's unstageable pressure ulcer on the coccyx was documented as completed on March 16, 18, 24, 27, 28, and 30, 2023. A review of Resident 92's ETAR, for April 1 to 22, 2023, did not indicate the treatment order for Resident 92's unstageable pressure ulcer on the coccyx was documented as completed on April 1, 10, and 19, 2023. On April 21, 2023, at 2:40 p.m., a group interview was conducted with the ADM, DON, Registered Nurse (RN) 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6. The interviews were as follows: - LVN 1 stated the licensed nurse would take the measurements of the PI, evaluate/assess the wound bed, drainage, edges, and peri wound appearance when a PI was identified. She stated the physician was to be notified for treatment orders, document in the resident's record and add the resident on the wound list. - LVN 1 stated wound evaluation were to be done weekly and documented in the resident's record. She stated the physician was involved when the wound started and when the wound worsens. - LVN 1 stated they should fill out a spreadsheet indicating residents with PI with the description of the wound and location. She stated the spreadsheet was not accurately filled out to describe the status of the resident's wounds. - LVN 1 stated she did not involve the RD with wound management of the residents with PI because she was more focused on the skin-physical interventions and not the nutrition component. - The DON stated the RD should be involved with the wound status to be able to give appropriate nutritional recommendations. - The RD stated she would recommend the following to residents with PI: MVI with minerals, check on the resident's laboratory values, liquid protein or nutritional supplement, ensure the resident was eating well, and update the diet order as needed. She further stated nutritional interventions should have been started earlier. - The ADM stated they have not conducted IDT meetings to address wound management for more than three months as they had multiple interim DONs and confirmed wound management had fallen through the cracks. - The ADM, DON, RN 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6 all agreed Resident 92's P/I should have been addressed and evaluated appropriately if IDT meetings were done weekly. 46509 3. On April 18, 2023, at 9:57 a.m., a concurrent observation and interview was conducted with Resident 18. Resident 18 was observed laying in bed using his computer. Resident 18 stated he had a wound on his bottom. On April 21, 2023, Resident 18's record was reviewed. Resident 18 was admitted on [DATE], with diagnoses of paraplegia (paralysis of legs and lower body) and sepsis (infection in the blood stream). A review of Resident 18's Medical History/Physical Examination, dated March 7, 2023, indicated Resident 18 was alert and oriented. A review of Resident 18's care plan titled, At risk for alteration in skin integrity, pressure ulcers, infection and slow healing related to: impaired mobility, contractures, history of pressure ulcers, weakness and paraplegia, dated March 6, 2023, indicated, .Goal [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure appropriate foot care was provided, for five of 32 residents reviewed for foot care, (Residents 98, 47, 84, 14 and 26). The facility did not consistently trim the residents' toenails, kept the residents' toenails clean and initiate referral to podiatrist for evaluation and further care. This failure resulted in the residents developing long, yellowed, and hypertrophied (thickened) toenails causing pain and discomfort, and did not promote the maximum ADL (activities of daily living) potential for Residents 98, 47, 84, 14 and 26. Findings: 1. On April 17, 2023, at 3:58 p.m., a concurrent observation and interview was conducted with Resident 98. Resident 98 was observed lying in bed, awake and alert. Resident 98 was observed to have long, curled, and with jagged edges toenails (approximately five centimeters long from the tip of the toenails) with yellowish/brownish discolorations on all toenails for both feet. In addition, Resident 98's big toenails on both feet was observed to have black debris underneath the bednail. In a concurrent interview, she stated she had asked someone to cut her toenails many times, but nothing ever happened. She stated the doctor had not looked at her toes since she was admitted nor had received any treatment. She stated she could not wear closed-toe shoes since it would hurt, so she would wear slippers instead. On April 20, 2023, Resident 98's record was reviewed. Resident 98 was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - type of lung disease). A review of Resident 98's Progress Notes, documented by Registered Nurse (RN) 5, dated March 2, 2023, at 10:30 p.m., indicated, .Patient's skin is warm, intact, no rashes noted. Plan of care is to prevent skin breakdown . A review of Resident 98's Minimum Data Set (MDS - an assessment tool), dated March 21, 2023 indicated resident's BIMS (Brief Mental Status Score) of 15 (cognitively intact). Further review of Resident 98's records showed no documented evidence an assessment was conducted regarding Resident 98's foot and toenail conditions or a care plan was initiated to address Resident 98's foot and toenail conditions since admission on March 2, 2023. On April 20, 2023, at 10:13 a.m., an interview and concurrent record review was conducted with LVN 9. She stated a full head-to-toe skin assessment was to be conducted for all residents upon admission to include the condition of the resident's foot and toenails, and followed by a weekly skin assessment. In addition, any foot and toenails issues should be assessed during shower days by the CNAs (Certified Nursing Assistant). She stated any foot/toenails issue should be referred to the physician for appropriate care and treatment, including a referral to a podiatrist (a physician specializing in foot care). LVN 9 stated Resident 98 was assessed by one of the Registered Nurse (RN) upon admission on March 2, 2023. She stated there was no documentation an assessment was done for Resident 98's foot or toenails. She stated she was not sure as to why Resident 98's foot and toenails discolorations were not identified upon admission, during weekly skin assessment, and/or during shower days. She stated Resident 98's foot and toenail discolorations should have been assessed, monitored, and referred to the podiatrist for further treatment and evaluation. On April 20, 2023, at 10:25 a.m., during observation of Resident 98's foot and toenails with LVN 1, Resident 98's toenails was observed to have been trimmed (compared to last observation on April 17, 2023). LVN 1 stated Resident 98's toenails on both feet to have yellow/brown discolorations. She stated she should have conducted a thorough assessment of resident's toenails as part of her weekly assessment during her last treatment on April 17, 2023. She stated the resident toenails on both feet should have been referred to the physician for further treatment and evaluation from the podiatrist. On April 20, 2023, at 12:35 p.m., a follow up observation and interview was conducted with Resident 98. Resident 98 stated she continued to have pain on her feet because of her toenails. She stated it would hurt when she puts on her socks or shoes. Resident 98 was asked how her current condition with her feet and toes affected her daily activities, she stated I learned to work around it .it would be better if I didn't have these conditions. On April 20, 2023, at 12:42 p.m., an interview with CNA 8 was conducted. She stated she was assigned to Resident 98 today and on April 17, 2023. She stated the resident could walk on her own and use the restroom. She stated the resident had discomfort when she would put socks on the resident. She stated Resident 98's toenails were long and discolored on April 17, 2023 and she trimmed the resident's toenails on April 17, 2023. She stated she informed the licensed nurse about it but did not document it. On April 20, 2023, at 3:26 p.m., an interview with the Director of Nursing (DON) was conducted. She stated Resident 98's toenails condition should have been identified upon admission, during weekly assessment, and or during shower days. She further stated Resident 98's toenails required immediate attention for further treatment and evaluation from podiatry. The DON further stated Resident 98's toenails should not have been trimmed by the CNA and should have been referred to podiatry due to its current status. On April 20, 2023, at 5:18 p.m., CNA 9 was interviewed. She stated she was the assigned CNA during afternoon shift. She stated she would get the resident up to transfer to and from the wheelchair. She stated Resident 98 was able to make steps but had difficulty due to her nails touching the floor. She stated Resident 98 had long thick and curled nails, approximately more than an inch from the tip of the toes. She stated the resident would jerk when socks were put on as Resident 98's feet were sensitive because of the long thick nails. She stated she could not trim Resident 98's toenails as they were thick and long. 36038 2. On April 17, 2023, at 4:31 p.m., Resident 14's family member (FM) was interviewed. The FM stated she noticed Resident 14's toenails were long and she notified the staff. She stated the staff told her they could not do anything for the long toenails when the resident refused. On April 19, 2023, Resident 14's record was reviewed. Resident 14 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). A review of Resident 14's physician's order, dated September 11, 2022, indicated, .Podiatry Consult for hypertrophic (hard and thick nails) . A review of Resident 14's Podiatric Evaluation & (and) Treatment, documented by the podiatrist, dated February 18, 2023, indicated the resident's toenails on both feet were long, discolored, thick, mycotic (presence of fungus), and painful. The document indicated manual debridement was performed by the podiatrist. There was no documented evidence Resident 14's hypertrophied toenails were assessed and monitored after the podiatry service was provided to the resident on February 18, 2023. There was no care plan developed to address Resident 14's hypertrophied toenails. On April 19, 2023, at 2:26 p. m., during a concurrent interview and observation of Resident 14's toenails with Registered Nurse (RN) 1, RN 1stated Resident 14's toenails were still long, hypertrophic, discolored, and painful. She stated there was no care plan to address Resident 14's long and hypertrophied nails. She stated there should have been a care plan developed to address Resident 14's foot/toenail problem. On April 19, 2023, at 3 p.m., the Social Service Director (SSD) and the DON were interviewed. The SSD stated the licensed nurse would notify her if a resident needed to be seen by the podiatrist then a referral would be made by the SSD. She stated the licensed nurse would be notified if a follow up with the podiatrist would be needed after evaluation was conducted by the podiatrist. On April 21, 2023, at 10:27 a.m., a follow up interview was conducted with RN 1. RN 1 stated the podiatrist would come to the facility every two months, and the podiatrist would check the residents. RN 1 stated the Certified Nurse Assistant (CNA) should check the resident's foot for any abnormal condition and would refer to the licensed nurse. RN 1 stated the physician should be notified of the resident's foot/toenail condition for appropriate referral for podiatry consult if needed. She stated the facility failed to assess Resident 14's toenails and make the appropriate referral to podiatry. On April 24, 2023, at 8:29 a.m., the DON was interviewed. She stated a head-to-toe assessment of the resident should be conducted on admision and weekly thereafter. She stated the podiatrist should be notified if a resident had thick toenails and needed trimming. She stated it should be documented and a plan of care be initiated if the resident refused podiatry care. On April 24, 2023, at 4:52 p.m., Medical Doctor (MD) 5 was interviewed. MD 5 stated the resident would tell him if they have issues with their toenails, and if they could not, the nurse would inform him the resident needed a podiatry consult. The AP stated for Resident 14, he was not aware of her issues on her toenails. He stated the FM and/or the licensed nurse did not notify him of the condition of Resident 14's toenails. 3. On April 21, 2023, at 9:28 a.m., Resident 26 was observed with thickened, deformed, discolored yellow, and long toenails. On April 21, 2023, Resident 26's records was reviewed. Resident 26 was readmitted to the facility on [DATE], with diagnoses which included heart failure (happens when the heart cannot pump enough blood and oxygen to support other organs in your body). A review of Resident 26's Medical History/Physical Examination, dated June 13, 2022, indicated the resident is alert and oriented. There was no documented evidence Resident 26's toenails were assessed, monitored, and referred to be seen by podiatry since readmission on June 12, 2022. On April 21, 2023, at 10:27 a.m., RN 1 was interviewed. She stated Certified Nursing Assistant (CNA) checked toenails of residents during shower and then would communicate with the licensed nurse regarding the status of the resident's toenails. RN 1 stated the licensed nurse would refer to social service for podiatry consult. RN 1 stated the podiatrist would come to the facility every two months. Resident 26's record was concurrently reviewed with RN 1. She stated Resident 26 refused podiatry care on December 15, 2021. She stated there was no documentation Resident 26 was re-offered podiatry care and treatment after December 15, 2021. On April 24, 2023, at 8:29 a.m., the DON was interviewed. She stated residents who had thick toenails should be trimmed by a podiatrist. She stated the facility should document if a resident refused podiatry services and develop a plan of care. She stated the facility should continue to re-offer podiatry consult to the resident. On April 24, 2023, at 9:47 a.m., during a concurrent observation of Resident 26 and interview with LVN 6, LVN 6 stated Resident 26's toe nails were thick and discolored, approximately one (1) cm from the tip of the toe. She stated Resident 26 should have been seen by a podiatrist. LVN 6 stated if the resident refused podiatry, the doctor should be notified. LVN 6 stated the family member should be notified and the podiatry consult should be rescheduled. Resident 26's record was concurrently reviewed with LVN 6. LVN 6 stated Resident 26 was not seen by a podiatrist. LVN 6 stated there was no documentation the resident was referred to a podiatrist. She stated there was no care plan initiated to address Resident 26's toenails. 40988 4. On April 24, 2023, at 9:40 a.m., Resident 84 was observed awake, alert, sitting upright in her wheelchair, and watching TV. In a concurrent interview with Resident 84, she stated she needed her toenails cut and the toenails on her right foot were really long. She further stated she had not seen anyone for her feet and toenails for about four to five months since she was admitted to the facility. She stated her feet would hurt sometimes. Resident 84's right foot was concurrently observed and the following were found: - The big toe toenail was yellow, thick, and was approximately 3/4 inch from the tip of the toe; - The second toenail was chipped, cracked, had jagged edges, and had brown and yellow discoloration; - The third toenail was yellow, thick, and was approximately half an inch from the tip of the toe; - The fourth toenail was yellow, thick, and was approximately 1/4 inch from the tip of the toe; and - The fifth toenail was yellow, chipped, cracked and had jagged edges. Resident 84's left foot was observed and the following were found: - The big toe toenail was yellow, thick, and was approximately half an inch from the tip of the toe; - The second toenail was chipped, cracked, had jagged edges, and had brown and yellow discoloration; - The third toenail was yellow, thick, and was approximately 1/4 inch from the tip of the toe; - The fourth toenail was yellow, chipped, cracked, thick, and had jagged edges; and - The fifth toenail was yellow, chipped, cracked and had jagged edges. On April 24, 2023, at 9:55 a.m., LVN 4 was interviewed. LVN 4 stated the CNAs and licensed nurses (LNs) would usually file the residents' toenails if they were not thick or diabetic (abnormal blood sugar). LVN 4 further stated when the LNs assessed the residents' toenails and podiatry services were indicated, they would make the referral for podiatry services. On April 24, 2023, at 10:34 a.m., Resident 84's record was reviewed. Resident 84 was admitted to the facility on [DATE], with diagnoses which included COPD (chronic obstructive pulmonary disease- condition characterized by difficulty breathing and constricted airways). A review of Resident 84's MDS, dated [DATE], indicated Resident 84 had a Brief Interview Mini Mental Status (BIMS- a brief screening tool that aids in detecting cognitive status) score of 15 (cognitively intact). The MDS further indicated Resident 84 required extensive one-person assistance for personal hygiene. There was no documented evidence an assessment was conducted regarding Resident 84's foot and toenail conditions, a podiatry referral was made, or a care plan was developed to address Resident 84's foot and toenail conditions. On April 24, 2023, at 4:15 p.m., RN 1 was interviewed. RN 1 stated CNAs could identify residents' skin and toenail issues during showers or when randomly observed, and were expected to notify the LNs regarding any skin issues including the condition of the toenails. She stated LNs should assess the residents' toenails and determine if they are hypertrophic, long, and/or diabetic in nature, and therefore needing podiatry services. She stated the LNs would notify the physician to get an order for a podiatry referral, and a plan of care needed to be initiated. RN 1 stated Resident 84's toenail issues should have been identified promptly so a referral for podiatry services could be coordinated by the facility to ensure care and treatment be provided to the resident timely. 5. On April 24, 2023, at 10:04 a.m., Resident 47 was observed awake, alert, sitting upright in her wheelchair, with a private caregiver (CG) beside her. In a concurrent interview with Resident 47, she stated she did not know who cut her toenails. The CG was observe to remove Resident 47's socks and her feet were observed. The following were found on Resident 47's right foot: - The tip of the big toe was reddened and swollen, with a small dark scab to the outer side of the toe at the cuticle base; - The big toe toenail was yellow, thick, had jagged edges, was approximately half an inch from the tip of the toe, and had residual dark matter underneath the nail; - The second and third toes were slightly swollen, and the knuckles were irritated and red; - The second toenail was yellow, thick, chipped, cracked, had jagged edges, and was approximately 1/4 inch from the tip of the toe; - The third toenail was yellow, thick, chipped, cracked, was pointing upward, had jagged edges, and was approximately 1/4 inch from the tip of the toe; - The fourth toenail was yellow, had jagged edges, and was approximately 1/4 inch from the tip of the toe; and - The fifth toenail was yellow and approximately 1/4 inch from the tip of the toe. Resident 47's left foot was observed and the following were found: - The big toe was swollen and reddish, with dry, cracked skin towards the tip of the toe. The big toe toenail was stubbed, yellow, thick, and had jagged edges; - The tip of the second toe was swollen and thickened out. The second toenail was yellow, had jagged edges, and was approximately 1/4 inch from the tip of the toe; - The knuckles of the second, third and fourth toe were darkly discolored and the second knuckle was slightly scabbed; - The third toenail was yellow, thick, and was approximately 1/4 inch from the tip of the toe; - The fourth toenail was yellow, thick, had jagged edges and was approximately 1/4 inch from the tip of the toe; and - The fifth toenail was yellow, chipped, was pointing upward, had jagged edges. On April 24, 2023, at 10:10 a.m., Resident 47's family member (FM) arrived to visit the resident and was interviewed. The FM stated no one has provided nail care to Resident 47 since she was admitted to the facility. The FM further stated the facility did not disclose who provided nail care for the resident or if podiatry services were available in the facility. On April 24, 2023, at 10:34 a.m., Resident 47's record was reviewed. Resident 47 was admitted to the facility on [DATE], with diagnoses which included S/P (status post) femoral neck fracture (broken hip). A review of Resident 47's, Medical History/Physical Examination, dated March 14, 2023, indicated Resident 47 was alert and oriented. A review of Resident 47's MDS, dated [DATE], indicated Resident 47 had severely impaired cognitive status. The MDS further indicated Resident 47 required extensive two-person assistance for personal hygiene. There was no documented evidence an assessment was conducted regarding Resident 47's foot and toenail conditions, a podiatry referral was made, or a care plan was developed to address Resident 84's foot and toenail conditions. On April 24, 2023, at 4:20 p.m., RN 1 was interviewed. RN 1 stated CNAs could identify residents' skin and toenail issues during showers or when randomly observed, and were expected to notify the LNs regarding any skin issues including toenail issues. She stated LNs should assess residents' toenails and determine if they are hypertrophic, long, and/or diabetic in nature, and therefore needing podiatry services. She stated the LNs should notify the physician to get an order for a podiatry referral, and a plan of care needed to be initiated. RN 1 stated Resident 47's feet and toenails issues should have been identified promptly so a referral for podiatry services could be coordinated by the facility to ensure care and treatment be provided to the resident timely . The facility's policy and procedure titled, Foot Care, dated May 20, 2022, was reviewed. The policy indicated, .Daily bathing of the feet and regular toenail trimming promotes cleanliness, prevents infection, stimulates peripheral circulation, and controls body odor by removing debris between toes and under toenails. It's particularly important for bedridden patients and those especially vulnerable to foot infection. Increased susceptibility to foot infection may result from peripheral vascular disease (decreased blood flow to the limbs), diabetes, poor nutritional status, arthritis, or any condition that impairs peripheral (away from the center) circulation .In patients at risk for foot infection, proper foot care should include meticulous cleanliness and regular observation for signs of skin breakdown .Unless it is performed by a practitioner or certified foot care nurse, toenail trimming may be contraindicated .Some facilities prohibit nurses from trimming toenails .While providing foot care, observe the color, shape and texture of the toenails. Notify the practitioner if you see redness, drying, cracking, blisters, discoloration, or other signs of traumatic injury, especially in a patient with impaired peripheral circulation. Because such patients are vulnerable to infection and gangrene, they need prompt treatment .Record and report any abnormal findings, any nursing interventions, and the patient's response .

Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards, for two of 28 residents reviewed (Residents 6 and 357), when: 1. For Resident 6, appropriate interventions were not identified and implemented to reduce the risk of further falls. This failure resulted in Resident 6's third fall which resulted in a laceration at the back of his head and subsequent admission to the general acute hospital with admitting [DIAGNOSES REDACTED]. This failure resulted in Resident 6's subsequent fourth fall. This failure increased the potential for Resident 6 to sustain further falls. 2. For Resident 357, one unidentified medication was left at her bedside. This failure placed Resident 357 at risk for adverse effects of ingestion of a wrong medication. Findings: 1. On February 25, 2020, at 9:42 a.m., Resident 6 was observed to be in a semi-sitting position in bed and leaning more on his right side while watching TV. His bed was observed to be at regular height. There were no grab bars observed at the side of his bed. On February 26, 2020, at 9:23 a.m., Resident 6 was observed sitting up in bed and watching TV. His bed was observed to be at a regular height and there were no grab bars observed at the side of his bed. His bed was observed to be close to the bathroom. On February 26, 2020, Resident 6's record was reviewed, and indicated the following: a. Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. b. The Minimum Data Set (MDS - assessment tool), dated November 13, 2019, indicated Resident 6 was continent (able to control urine and feces) in bowel and bladder function; c. The untitled document, revised December 31, 2019, indicated, .(Residents 6's name) is always continent of bowel and bladder but is at risk for incontinent (sic) due to limited assist with adl's (activities of daily living) .; d. The Progress Notes, dated January 20, 2020, at 9:01 p.m., indicated, .Patient found on floor sitting on his buttocks next to his bed. Patient will not verbalize what happened or why he was on the floor, he just kept saying hurry up and get me up .noted with skin tear to LT (left) elbw (sic) .LT hand skin tear .LT buttocks shearing (a break in the skin) .with moderate drainage r/t (related to) [MEDICATION NAME] (medication to treat blood clots) use .During assessment patient stated Come on hurry up and get my brief on. Speech was clear .; e. The Progress Notes, dated January 21, 2020, at 9:18 p.m., indicated, IDT (Interdisciplinary Team - a group of healthcare professionals who work together for the common goal of the resident) NOTE: Reported to IDT today the fall that happened on 1/20/2020 (January 20, 2020) at 9:00 pm (p.m.). Resident was found sitting on his buttocks next to his bed .Resident is alert and oriented .able to communicate his needs to the staff .He continues to be high risk for fall related to weakness and transfers without calling for assistance IDT recommends .bed in low position. Staff to frequently check resident if he needed assist with transfers or toilet use. Reinforce to call for assistance using the call light .; f. The Progress Notes, dated January 22, 2020, at 10:01 a.m., indicated, .At 9:39 am (a.m.) SS (social service) staff came to this nurse and stated pt. (patient) was on the floor. Upon entering room pt. was laying on his right side next to room door and bathroom door .Pt. stated he wanted to go to the bathroom .Pt. educated on call light use .; g. The MDS, dated [DATE], indicated Resident 6 was frequently incontinent (unable to control urine and feces) in bowel and bladder function; h. The Progress Notes, dated January 23, 2020, at 12:09 p.m., indicated, .At 11:40am (sic) CNA (Certified Nurse Assistant) notified LN (licensed nurse) that pt was on the floor in room. Upon entering room pt. was laying on his back in between bed and bathroom door. Upon assessment pt. noted to be bleeding from back of his head .MD (physician) was called and orders to send pt. out to ER for evaluation .; i. The untitled document, dated January 23, 2020, included a physician's order, which indicated to discontinue .[MEDICATION NAME] Tablet 5 MG (milligram) .Give 5 mg by mouth at bedtime for [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot) [MEDICATION NAME] .Sent to ER (emergency room ) .; j. The acute hospital records, dated January 24, 2020, indicated, .s/p (status [REDACTED].CT (computer tomography - an imaging procedure which used computer to produce cross-sectional images of organs or body parts) Head w/o (without) Contrast (dye) Result Date: 1/23/2020 (January 23, 2020) .There is a small subdural hematoma within the left frontal region measuring 5 (five) mm (millimeter). This has mildly increased in size since the prior CT scan .; k. The Progress Notes, dated January 24, 2020, at 5:56 p.m., indicated, .Presenting to IDT regarding fall incidents and with sustained injury 1/23/20 (January 23, 2020) Resident is able to communicate needs, however, choose to have minimal response to questions .Resident was placed on frequently monitoring him (sic), offer toileting, although he usually goes to bathroom independently .uses urinal .Resident stood up from bed, lost balance and fell that look like he fell backward when found with bleeding on the back of his head .; l. The Progress Notes, dated January 30, 2020, at 7:21 p.m., indicated, .readmitted .with [DIAGNOSES REDACTED].; m. The Progress Notes, dated February 9, 2020, at 11:37 a.m., indicated, .At 10:10 (a.m.) pt was found by staff on floor lying side with his back under bed. His left side of back was red .He was sitting on the bed pan so staff thinks he was trying to get up from the bed pan after he had a medium BM (bowel movement) and slid on the floor. He was not wearing non skid sock at the time of fall .He was covered up and put in bed in low position .; n. The Progress Notes, dated February 10, 2020, at 4:24 p.m., indicated, .IDT NOTE:Reported to IDT the fall that happened on 2/9/2020 (February 9, 2020) at 10:10 am .Upo (sic) interview of the resident about the fall,stated he was trying to get out of bed by himself and slid from bed to floor .Resident continues to be high risk for falls related to weakness,transfer without calling for assistance, history of fall and poor safety awareness .IDT recommends .Apply non skid socks/footwear.Reinforce the need to call for assistance using the call light. Report development of .change in mental status, ADL (activities of daily living) function .More frequent checks by staff than the norm. Frequent monitoring while in bed assist with turning, repositioning or toilet use .; and o. The untitled document, revised on February 10, 2020, indicated, .(Resident 6's name) is high risk for fall related to weakness, transfers without calling for assistance, history of falls, poor safety awareness .Minimize risk for falls .Minimize risk for injury r/t (related to) falls .Staff to frequently check resident more than the norm (normal) .Staff to frequently check resident,ask if he needed assist with transfer or toilet use . There was no documented evidence appropriate interventions were put in place after the January 20, 2020, fall to address the identified possible causes of fall to prevent succeeding falls. There was no documented evidence the care plan was revised to address Resident 6's identified risk factors. There was no documented evidence the intervention to place Resident 6 on a bed in the lowest position, as identified by the IDT, was included in the care plan. On February 27, 2020, at 3:38 p.m., Resident 6's record was reviewed with Registered Nurse (RN) 2. In a concurrent interview with RN 2, she stated a resident was assessed for risk for falls upon admission to the facility. She stated the facility should place a resident who was high risk for falls on a bed in a low position. She stated she had not observed Resident 6 to be on a bed in the lowest position. She stated Resident 6 should have been placed on a bed in the lowest position. She stated the IDT recommendation to place Resident 6 on a bed in the lowest position was not included in the care plan. She stated the intervention to place Resident 6 on a low bed should have been included in the care plan. She stated the facility reviewed fall incidents and initiated recommendations to minimize further falls. She stated Resident 6 had four episodes of fall and had IDT recommendations on the following dates: - January 20, 2020, at 9 p.m., when Resident 6 fell off the bed and sustained skin tears, the IDT recommended placing Resident 6 on a bed in low position, staff should frequently check resident's need for assistance during transfer or toilet use, and to educate Resident 6 to use the call light to call for assistance; - January 22, 2020, at 9:30 a.m., when the resident was found lying on the right side between the bed and the bathroom door, there were no new interventions put in place; - January 23, 2020, at 11:40 a.m., when Resident 6 fell off the bed when he got up from the bed and lost balance, sustained bleeding at the back of his head, was sent out to the acute hospital, was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. - February 9, 2020, at 10:10 a.m., when Resident 6 was found on the floor sitting on the bed pan, the IDT recommended to put Resident 6's bed placed in low position, apply non-skid socks, reinforce the use the call light for assistance, frequent checks by staff more than the normal, and frequent monitoring while in bed to assist for toilet use. On February 27, 2020, at 5:23 p.m., Resident 6's record was reviewed with the Director of Nursing (DON) and MDS Coordinator (MDSC) 1. In a concurrent interview with MDSC 1, she stated Resident 6 was continent with bowel and bladder function upon admission. She stated based on the ADL documentation, Resident 6 had episodes of incontinence with bowel and bladder function starting January 2020. In a concurrent interview with the DON, she stated Resident 6's fall incidents on January 22 and 23, and February 9, 2020, were related to bowel and bladder needs. She stated there was no documentation of new interventions to address the recurrent falls. She stated there was no documentation Resident 6 was assessed for changes in his bowel and bladder function. She stated there was no documentation interventions were implemented to address the decline in Resident 6's bowel and bladder function. She stated the facility should have further reviewed the risk factors involved in Resident 6's recurrent falls and should have implemented appropriate interventions accordingly. A review of the web article titled, .[MEDICAL CONDITION] AND INCREASED INTRACRANIAL PRESSURE, dated February 2017, published by Neuropathology, was conducted. The article indicated, .[MEDICAL CONDITION] (TBI) is caused by two mechanisms, impact, and movement of the brain inside the skull. Impact, (a blow to the head, a fall in which the head hits the ground) can cause a fracture (broken bone) or a sudden deformation of the skull without fracture .mechanical forces transmitted to the underlying brain, compress or lacerate its surface and cause ripples of shock waves that travel through it and injure parts remote from the impact .When the statutory head is suddenly accelerated from a blow .the brain goes into a violent, mostly sagittal (dividing left and right), but also side-to-side and swirling motion. This motion .tears blood vessels .TBI may involve any part of the brain .subdural hematoma .are caused by movement of the brain . The facility policy and procedure titled, Falls Practice Guide, dated December 2011, was reviewed. The policy indicated, .The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life .The approaches for fall interventions are clear, specific and individualized for the patient's need .Additional fall management interventions may include .rehabilitation programs .toileting programs .On the basis of the information obtained and analysis performed in the assessment and planning phases, the next step is to implement an organized approach for the management of the patient's falls or fall risk factors .Some risk factor management interventions that can be reviewed and considered as ongoing potential fall prevention strategies include .provision of therapies for balance, gait, strength training .incontinence management .It is recommended that a member of the Interdisciplinary team conduct a bedside evaluation after a fall occurs .The bedside evaluation may include .identification of any changes in patient's risk factors, condition and functional status .revision of the care plan to address the patient's current risk factors and needs . 2. On February 25, 2020, at 9:23 a.m., Resident 357 was observed awake and lying in bed. A clear plastic medicine cup containing a round orange-pink colored tablet was observed on the over bed table by the right side of her bed. There was no score (groove), symbol, or label observed on either surface of the tablet. In a concurrent interview, Resident 357 stated she was not aware there was a medication by her bedside. She stated she did not recall who placed it there or if she was offered this medication to take. She stated she did not know what kind of medication it was. On February 25, 2020, at 9:27 a.m., Resident 357 and the items at her bedside were observed with LVN 4. LVN 4 stated the tablet looked like a vitamin. She stated she did not give this medication to the resident. She stated she gave two medications to Resident 357 for the morning medication pass. She stated Resident 357 took an antibiotic, which she described as an oblong white tablet, and a multivitamin, which she described as identical in size, shape, and color as the tablet by Resident 357's bedside. She stated she did not notice there was a tablet left on the resident's over bed table. LVN 4 stated according to facility policy and procedure, the licensed staff were not allowed to leave any medication at the resident's bedside for the safety of the residents. On February 25, 2020, at 10:08 a.m., the Director of Nursing (DON) was interviewed. She stated the facility did not have a policy specifically for not leaving medications at residents' bedside, but the licensed nurses were expected to follow the standards of practice for safe medication administration and should not leave medications at a resident's bedside. She stated the medication should not have been left at Resident 357's bedside. A review of the facility policy titled, Medication and Treatment Administration Guidelines, updated March 2018, was conducted. The policy indicated, .Medications are administered in accordance with standards of practice and state specific and federal guidelines .MEDICATION STORAGE AND SECURITY .Medications and biologicals are securely stored in a locked cabinet, cart, or medication room, accessible to only licensed nursing staff and pharmacist or authorized pharmacy staff, and maintained under a lock system when not actively utilized and attended to by nursing staff for medication administration .

Based on observation, interview, and record review, the facility failed ensure Resident A was free from daily verbal abuse from Licensenced Vocational Nurse 1 (LVN 1). This failure resulted in Resident A feeling uncomfortable, demeaned, intimidated, and afraid of retaliation. Findings: On (MONTH) 21, (YEAR), at 1:55 p.m., Resident A's daughter was interviewed. Resident A's daughter stated on (MONTH) 16, (YEAR), she telephoned the facility and spoke with the Unit Manager (UM). Resident A's daughter stated she told the UM that Resident A was verbally abused daily by LVN 1. Resident A's daughter stated she told the UM that Resident A had been crying because of LVN 1. Resident A's daughter stated the UM told her because she alleged abuse, she (UM) would have to report it, and that LVN 1 would not be Resident A's nurse anymore. Resident A's daughter stated when she visited on (MONTH) 19, and (MONTH) 20, (YEAR), LVN 1 was still her mother's nurse. On (MONTH) 23, (YEAR), at 11:45 a.m., an unannounced visit was conducted at the facility. Resident A's record was reviewed. Resident A was readmitted to the facility on (MONTH) 9, (YEAR) with [DIAGNOSES REDACTED]. Resident A's history and physical dated (MONTH) 12, (YEAR), indicated shortness of breath and anxiety as Resident A's chief complaint. The history and physical further stated Resident A was alert and oriented. The Minimum Data Set (MDS - an assessment tool) dated (MONTH) 16, (YEAR), indicated Resident A had a BIMS score of 15 (Brief Interview Mental Status--determines a resident's cognitive status, a score of 13-15 indicates cognitively intact). The document indicated Resident A required limited to extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The document further indicated Resident A had not had a bath or shower the last seven days. Review of the staffing assignment for (MONTH) 23, (YEAR), indicated LVN 1 was Resident A's nurse at the time of the visit. On (MONTH) 23, (YEAR), at 11:50 a.m., Resident A was observed in her room. Resident A was sitting up in bed receiving a breathing treatment through a nebulizer (respiratory drug delivery device used to administer medication in the form of mist inhaled, to relieve shortness of breath and difficulty breathing). Resident A was also observed with a nasal cannula (device applied in the nostrils used to deliver supplemental oxygen) connected a portable oxygen tank at 3 liters per minute. Resident A was interviewed. Resident A stated she had [MEDICAL CONDITION] and diabetic [MEDICAL CONDITION] (nerve damage caused by diabetes). Resident A stated because of shortness of breath from [MEDICAL CONDITION], and pain from diabetic [MEDICAL CONDITION], she was unable to perform her daily activities of living without extensive assistance. Resident A also stated she was dependent on her breathing treatments and pain medications to relieve her symptoms. Resident A stated LVN 1 told her she, Takes too much medication. Resident A stated LVN 1 told her she (LVN 1) would call my doctor to stop giving me too much medications. Resident A stated LVN 1 would comment, Oh yes it's that four hour thing.-- referring to her medication administration times, every time she had to come and administer her medications. Resident A stated she ended up crying every time. Resident A stated she had told the Social Worker (SW) and the UM that she did not want LVN 1 to be her nurse anymore but they told her they were short staffed. Resident A stated she felt uncomfortable with LVN 1. Resident A stated LVN 1 was demeaning. She said she felt intimidated and anxious because of LVN 1's comments. Resident A stated, I am afraid they will retaliate on me, I am scared of her (LVN 1) .they're in control of my medications. Resident A was observed having difficulty breathing while talking, teary, and anxious during the interview. On (MONTH) 23, (YEAR), at 12:30 p.m., the SW was interviewed with the Assistant Administrator (AA) in the room. The SW stated on (MONTH) 8, (YEAR), Resident A was giving her conflicting stories regarding her medications. The SW stated she could not remember the all the details of her conversation with Resident A. The SW stated she offered Resident A a room change but Resident A refused. The SW stated she talked to the UM about it and they both talked to Resident A. The SW stated she documented the conversation she and the UM had with Resident A in the resident's record on (MONTH) 8, (YEAR). Resident A's record was reviewed with the SW and the AA during the interview. Both confirmed Resident A's record contained only one note from the SW from (MONTH) 1, through (MONTH) 23, (YEAR). The note dated was dated, (MONTH) 9, (YEAR), at 2:57 p.m The note indicated, Social Services received phone call from daughter .stated resident was in tears. Social services went to see resident and redirected and calm as resident was feeling down . The SW and the AA confirmed there was no documented evidence of the conversation the SW and UM had with Resident A, on (MONTH) 8, (YEAR). The SW and the AA confirmed there was no other documented evidence detailing why Resident A was in tears and other interventions to address Resident A's mood on (MONTH) 9, (YEAR). On (MONTH) 23, (YEAR), at 1:15 p.m., the UM was interviewed with the AA in the room. The UM stated she remembers receiving a call from Resident A's daughter. The UM stated Resident A's daughter mentioned Resident A did not like the nurse .she mentioned abuse. The UM stated she told Resident A's daughter that she would have to report it (abuse). The UM stated she was unable to remember the date and time of when she received the phone call from Resident A's daughter regarding the abuse allegation. The UM confirmed that when she received the call from Resident A's daughter she did tell her that LVN 1 would not be working with Resident A anymore. The UM stated she reported the allegation of abuse made by Resident A's daughter to the Administrator. The UM stated she talked to Resident A about the abuse, but Resident A told her it was not true. The UM stated she did not document the interview with Resident A because, The SW usually does it. The UM stated if an allegation of abuse was made the alleged perpetrator, Should be removed right away and the allegation investigated. The UM stated Resident A's case was an exception because Resident A told them it was not true. The UM stated she told Resident A, The nurses do not do that (abuse). The UM stated she did not do anything anymore after she interviewed Resident A. Resident A's record was reviewed with the UM and the AA during the interview. Both confirmed there was no documented evidence of the interview or investigation conducted by the UM with Resident A regarding the allegation of abuse communicated by Resident A's daughter on (MONTH) 16, (YEAR) at the time of the visit. On (MONTH) 23, (YEAR), at 2:15 p.m., the DON was interviewed. The DON stated the SW and UM should have documented their conversation with Resident A. On (MONTH) 23, (YEAR), at 2:30 p.m. the staffing assignment from (MONTH) 1, through (MONTH) 23, (YEAR) was reviewed with the AA. The AA confirmed that LVN 1 continued to be Resident A's nurse after the allegation of abuse was communicate to the UM by Resident A's daughter on (MONTH) 16, (YEAR). The staffing assignment indicated, LVN 1 was Resident A's nurse on (MONTH) 17, 19, 20, and 23, (YEAR) (total of four days after the allegation of abuse was made). On (MONTH) 23, (YEAR), at 2:45 p.m., LVN 1 was interviewed. LVN 1 stated on (MONTH) 16, or 17, (YEAR), the UM talked to her about being rude and arguing with Resident A. On (MONTH) 29, (YEAR), at 10:30 a.m., a follow up visit was conducted at the facility. The Administrator was interviewed. The Administrator stated the UM never mentioned the allegation of abuse regarding Resident A to her. The Administrator stated if she knew Resident A's daughter had alleged abuse, she would have reported it right away to the Department. The Administrator stated she would also have initiated an investigation immediately. The Administrator stated when the DON and the SW re-interviewed Resident A after the unannounced visit on (MONTH) 23, (YEAR), Resident A denied the allegation of abuse. On (MONTH) 29, (YEAR), at 12:25 p.m., Resident A was observed in her room. Resident A was interviewed. Resident A stated the DON and SW came and talked to her on (MONTH) 23, (YEAR). Resident A stated she denied the allegation because she was scared. Resident A stated, They have control over my medications .they hurt me mentally. On (MONTH) 29, (YEAR), at 12:30 p.m., Resident A was re-interviewed with the Administrator. Resident A stated right after her interview with this surveyor on (MONTH) 23, (YEAR), LVN 1 came into her room and asked what she had said to the surveyor. Resident A stated she felt scared. Resident A stated she would be more comfortable if LVN 1 was not her nurse anymore. Resident A stated she felt frightened. Resident A admitted that she lied to the DON and SW on (MONTH) 23, (YEAR). Resident A apologized and stated she lied because she knew the SW was friends with LVN 1. Resident A was observed crying and anxious during the interview. After Resident A's interview, the Administrator stated the allegation made by Resident A was cause for concern. Review of the facility policy and procedure, Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropiration Prevention, dated (MONTH) (YEAR), indicated, .detection and prevention of abuse by implementing a process that supports immediate reporting of suspected abuse. The process should be available to patients, family members, advocates and staff to report abuse in a manner that elicits immediate attention without fear of retribution .Abuse against patients can be initiated by various people within the center. The center supports and protects patients, family members and staff from harm during an investigation of alleged abuse .Any allegation of abuse must be immediately reported to the supervisor and abuse prevention coordinator. The administrator follows the investigation process .in investigating the allegations of abuse a patient .Patient protection actions include immediately removing the patient from contact with the alleged abuser during the investigation .

Based on observation, interview, and record review. the facility failed, for seven out of 24 sampled residents (Resident 112, 43, 36, 46, 137, 145, and 106), and 21 unsampled residents (Residents 15, 109, 136, 148, 135, 35, 37, 40, 47, 38, 4, 13, 31, 123, 2, 69, 98, 99, 56, 27, and 96), to ensure pharmacy services were provided in a timely manner when: 1a. For Resident 27, the medication hydrocodone-acetaminophen (Norco- a Schedule II controlled medication for pain), were not readily available to administer; and 1b. For Resident 96, the medication Norco was not readily available to administer. 2a. For Resident 136, the medication Norco, which was discontinued by the physician on September 26, 2016, was not removed from the medication cart. From November 2016 through March 2017, 23 doses of Norco were signed out as wasted (medications that are removed and not administered to the resident) by the licensed nurses; 2b. For Resident 106, the medication Tramadol (narcotic ( substance that blunts the senses that when used constantly can cause habituation or addiction) pain medication), which was discontinued by the physician on January 26, 2017, was not removed from the medication cart. In February 2017, eight doses of Tramadol were signed out as wasted by the licensed nurses; and 2c. Resident 15, the medication Norco, which was ordered to be used until February 19, 2017, was not removed from the medication cart. In March 2017, six doses of Norco were signed out as wasted by the licensed nurses. 3. A review of the Controlled Drug Record for 26 residents (Residents 2, 4, 13, 15, 31, 35, 36, 37, 38, 40, 43, 46, 47, 56, 69, 98, 99, 106, 109, 112, 123, 135, 136, 137, 145, and 148), indicated multiple narcotic medications were signed out by 23 licensed nurses and documented as wasted. In addition, the facility failed to have a system for accurate reconciliation and accounting of all controlled medications. These failures had the potential to cause a delay in medical treatment when needed for the residents, potential for the residents to receive medications without a physician's orders [REDACTED]. On March 7, 2017 at 10:30 p.m., the facility's Administrator and Director of Nursing (DON) were verbally notified of the system failure which resulted in Immediate Jeopardy. This system failure placed the residents at risk for delay in receiving necessary medications for pain. The Immediate Jeopardy was removed on March 9, 2017 at 6:42 p.m., in the presence of the facility Administrator and the DON, after the facility's acceptable plan of action was reviewed and it was verified that the plan of action was implemented. 4. Four IV (intavenous- administered through the vein) emergency kits, and one refrigerator emergency kit, were opened and not replaced within 72 hours. These failures had the potential to a delay in medical treatments when needed for the residents. Findings: 1a. On March 9, 2017, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain . The pharmacy's Proof of Delivery- Shipment Detail receipt indicated Norco was received by the facility on March 5, 2017 at 4:14 a.m. The eMAR (Electronic Medication Administration Record), dated March 1 to 31, 2017, indicated the medication Norco was administered to Resident 27 by the licensed nurse on March 4, 2017 at 5:05 a.m.; 11:38 a.m.; 8:59 p.m.; and March 5, 2017 at 3:37 a.m. The medication Norco was administered to Resident 27 by the licensed nurses four times prior to the delivery of the medication to the facility. The Controlled Drug Record for Norco indicated the medication was first signed out by the licensed nurse on March 5, 2017. The record did not indicate the time the medication was signed out. On March 9, 2017 at 5:38 p.m., the Administrator was interviewed. The Administrator stated she was unable to trace where the licensed nurses took the medication from when they administered Norco to Resident 27 on March 4, 2017, at 5:05 a.m.; 11:38 a.m.; 8:59 p.m.; and March 5, 2017, at 3:37 a.m. The Administrator further stated she and the Director of Nursing (DON) will contact the licensed nurses involved. On March 13, 2017, signed statements from the licensed nurses who gave the Norco to Resident 27 on March 4 and March 5, 2017, were reviewed: - On March 9, 2017 at 10:45 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed by the DON. LVN 1 indicated on her statement that she gave the Norco to Resident 27 on March 4, 2017 at 5:06 a.m. LVN 1 further stated she borrowed the Norco from another resident and gave it to Resident 27. LVN 1 cannot recall where she borrowed the medication from because she was very busy. - On March 12, 2017, at 6 p.m., LVN 2 was interviewed by the DON. LVN 2 indicated on her statement, .If I gave the patient as I signed, I must have borrowed it from someone but I don't remember. LVN 2 further stated she was aware she cannot borrow medication from one patient and give it to another patient but, it is fast and easy, and probably being lazy. Pharmacy is too long to give the authorization to pull from the Omnicel (drug dispensing equipment authorized by the pharmacy). - On March 9, 2017 at 11:15 p.m., Registered Nurse (RN) 1 was interviewed by the DON. RN 1 acknowledged in her statement that she gave the Norco to Resident 27 on March 5, 2017, at 3:37 a.m. RN 1 indicated in her statement, .I must have borrowed it (referring to the Norco). Honestly, I have borrowed meds those 2 last times I worked in the med cart. The statement further indicated RN 1 did not recall where she borrowed the Norco from but she knew she did not take it from the Omnicell. 1b. On March 9, 2017, Resident 96's record was reviewed. Resident 96 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain . The pharmacy's Proof of Delivery- Shipment Detail receipt indicated the medication Norco was received by the facility on March 5, 2017 at 6:24 p.m. The eMAR, dated March 1 to 31, 2017, indicated the medication Norco was administered to Resident 96 on March 4, 2017 at 6:33 p.m., and March 5, 2017 at 8 a.m. The medication Norco was administered to Resident 96 two times prior to the delivery of the medication to the facility. On March 9, 2017, at 3:24 p.m., LVN 3 was interviewed. LVN 3 acknowledged she gave the Norco to Resident 96 on March 4, 2017, at 6:33 p.m. LVN 3 stated the Norco was not available so she probably borrowed the Norco from another resident, then gave it to Resident 96 and she did not remember who she borrowed it from. LVN 3 stated she knew she was not supposed to borrow medication from another resident and then give it to another resident. On March 9, 2017, at 11:15 a.m., the DON was interviewed. The DON stated she was aware of the issues with the delay of acquiring medications and that she was not aware of the licensed nurses borrowing medications from residents and giving it to other residents because of medication unavailability. The DON further stated these issues were not brought up in their meetings. On March 7, 2107, at 8:44 p.m., the Administrator was interviewed. The Administrator stated the facility had a policy and procedure on what to do in case of medication shortage or unavailability of medications. The Administrator stated the licensed nurses were not allowed to borrow medications from other residents. 2a. On March 7, 2017, Resident 136's record was reviewed. Resident 136 was admitted to the facility on [DATE]. The physician's orders [REDACTED]. Resident 136's Controlled Drug Record for Norco indicated from November 2016 to March 2017, 23 doses were signed out by the licensed nurses after the medication was discontinued on September 26, 2016. Out of the 23 doses, 14 were documented as wasted by the licensed nurses. There was no documented evidence Resident 136 received the Norco after it has been discontinued, and there was no documentation as to why the Norco was being wasted by the licensed nurses. On March 7, 2017, at 6:15 p.m., LVN 5 was interviewed. LVN 5 stated she gave Norco to Resident 136 on December 8, 2106 at 7 p.m. LVN 5 confirmed there was no order to give Norco in Resident 136's eMAR. On March 7, 2017, at 9:01 p.m., Licensed Vocational Nurse (LVN) 4 was interviewed. LVN 4 stated she had signed out the Norco from Resident 136's bubble pack in the narcotic drawer on several occasions to give to other residents that needed it. LVN 4 stated a wasted medication, meant borrowed to use for other residents. LVN 4 stated she was aware the medication Norco had been discontinued for Resident 136. 2b. On March 7, 2017, Resident 106's record was reviewed. Resident 106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Resident 106's Controlled Drug Record for Tramadol indicated, eight doses had been signed out by the licensed nurses in February 2017 after the medication had been discontinued on January 26, 2017. One out of the eight doses had been documented as wasted by the licensed nurse. There was no documented evidence Resident 106 received the Tramadol in February 2017 after it had been discontinued. On March 7, 2017, at 1:25 p.m., LVN 7 was interviewed. LVN 7 confirmed she had signed out 6 doses of Tramadol on February 15 at 6 a.m., February 16 at 6 a.m., February 17 at 6 a.m., February 18 at 6 a.m., February 21 at 6 a.m., and February 22 at 6 a.m. LVN 7 stated, Obviously I made a mistake. On March 7, 2017, at 5:36 p.m., Registered Nurse (RN) 2 was interviewed. RN 2 stated LVN 7 gave the Tramadol to Resident 106 because the Norco was not available. On March 9, 2017, at 4:40 p.m., LVN 6 was interviewed. LVN 6 stated he took out the Tramadol on February 6, 2017 at 10 p.m. and gave it to the Resident 106 without ensuring if there was an order. LVN 6 further stated he was not aware the order for Tramadol was discontinued. 2c. On March 7, 2017, Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Give 1 tablet by mouth every 6 hours as needed for pain until 02/19/2017 .for 20 days. Resident 15's Controlled Drug Record for Norco indicated seven doses of Norco had been signed out since the medication had been discontinued on February 19, 2017. The seven doses were documented as wasted by the licensed nurses for the month of March 2017. On March 7, 2017 at 7:40 p.m., Licensed Vocational Nurse (LVN) 8 was interviewed. LVN 8 stated there was no documentation in Resident 15's record to indicate why the Norco would have been continued. LVN 8 stated Resident 15 did not have an active order for Norco. LVN 8 stated the licensed nurse probably signed out the Norco, documented it as wasted, then gave it to another resident. LVN 8 stated that practice commonly happens in the facility. The facility's policy and procedure titled, MEDICATION AND TREATMENT ADMINISTRATION GUIDELINES, dated December 2014, was reviewed. The policy indicated, .Controlled substances when discontinued, expired, or the patient is no longer at the center are destroyed in the center according to state and federal guidelines .the medication is removed from the medication cart .Controlled substances are destroyed as soon as physically possible upon discontinuation, expiration, or patient discharge 3. On March 7, 2017, multiple Controlled Drug Record reviews were conducted on approximately 26 residents (Residents 2, 4, 13, 15, 31, 35, 36, 37, 38, 40, 43, 46, 47, 56, 69, 98, 99, 106, 109, 112, 123, 135, 136, 137, 145, and 148). The records were as follows: - For Resident 2, four doses of the medication Percocet (Oxycodone-Acetaminophen- a narcotic pain medication) 10-325 mg (milligrams) were signed out and documented as wasted by the licensed nurse from February to March 2017; - For Resident 4, three doses of the medication Norco were signed out and documented as wasted by the licensed nurses for the month of February 2017; - For Resident 13, five doses of the medication Norco were signed out and documented as wasted by the licensed nurses from December 2016 to January 2017; - For Resident 15, five doses of the medication Norco were signed out and documented as wasted by the licensed nurses in March 2017; - For Resident 31, the narcotic record 1 indicated three doses of Norco were signed out and documented as wasted by the licensed nurse for the month of February 2017; the narcotic record 2 indicated six doses of Norco were signed out and documented as wasted by the licensed nurses for the month of March 2017; - For Resident 35, seven doses of the medication Norco were signed out and documented as wasted by the licensed nurses from February to March 2017; - For Resident 36, three doses of the medication Norco were signed out and documented as wasted by the licensed nurses for the month of March 2017; - For Resident 37, three doses of the medication Norco were signed out and documented as wasted' by the licensed nurses for the month of March 2017; - For Resident 38, one dose of the medication Ativan (medication used to treat anxiety) was signed out and documented as wasted by the licensed nurses on March 4, 2017; - For Resident 40, one dose of Norco was signed out and documented as wasted by the licensed nurse on March 5, 2017; - For Resident 43, two doses of the medication Norco was signed out and documented as wasted by the licensed nurses for the month of March 2017; - For Resident 46, nine doses of the medication Percocet was signed out and documented as wasted by the licensed nurses from January to March 2017; - For Resident 47, three doses of the medication Norco was signed out and documented as wasted by the licensed nurses for the month of December 2016; - For Resident 56, three doses of the medication Ativan was signed out and documented as wasted by the licensed nurses for the month of February 2017; - For Resident 69, two doses of the medication Norco were signed out and documented as wasted by the licensed nurses from December 2016 to January 2017; - For Resident 98, two doses of the medication Percocet were signed out and documented as wasted by the licensed nurses in February 2017; - For Resident 99, three doses of the medication Norco was signed out and documented as wasted by the licensed nurses for the month of February 2017; - For Resident 106, two doses of the medication Tramadol was signed out and documented as wasted by the licensed nurses for the month of February 2017; - For Resident 109, 13 doses of the medication Norco was signed out and documented as wasted by the licensed nurses from December 2016 to January 2017; - For Resident 112, two doses of the medication Ativan and one dose of the medication Norco was signed out and documented as wasted by the licensed nurses from January to February 2017; - For Resident 123, one dose of the medication Norco was signed out and documented as wasted by the licensed nurses for the month of February 2017; - For Resident 135, one dose of the medication Ativan was signed out and documented as wasted' by the licensed nurses on January 9, 2017; - For Resident 136, 15 doses of Norco was signed out and documented as wasted by the licensed nurses from September 2016 to March 2017; - For Resident 137, one dose of Norco was signed out and documented as wasted by the licensed nurses in December 2016; - For Resident 145, two doses of Norco was signed out and documented as wasted by the licensed nurses for the month of March 2017; and - For Resident 148, one dose of Norco was signed out and documented as wasted by the licensed nurse in December 2016. During the record reviews for the 26 residents (Residents 2, 4, 13, 15, 31, 35, 36, 37, 38, 40, 43, 46, 47, 56, 69, 98, 99, 106, 109, 112, 123, 135, 136, 137, 145, and 148), the licensed nurses who documented these medications as wasted did not document the reason for wasting the medications. On March 7, 2017, at 9:01 p.m., Licensed Vocational Nurse 4 was interviewed. LVN 4 stated she had borrowed narcotic pain medications from other residents then gave it to another resident for the reason of medication unavailability. LVN 4 stated the licensed nurses document wasted on the narcotic record but they had actually borrowed it. LVN 4 stated it was a practice of convenience and they were trying to provide something that they do not have. On March 7, 2077, at 8:44 p.m., the Administrator was interviewed. The Administrator stated the facility had a policy and procedure on what to do in case of medication shortage or unavailability of medications. The Administrator stated the licensed nurses were not allowed to borrow medications from other residents. The Administrator further stated the borrowing of medication was going on without her knowledge. On March 7, 2017, at 10:24 p.m., the Administrator was interviewed. The Administrator stated the pharmacy consultant and the facility did not identify the drug irregularities and that multiple licensed nurses wasting and/or borrowing narcotic medications to give to another resident because the medications were unavailable. The facility's policy and procedure titled, 7.0 Medication Shortages/Unavailable Medications, dated January 1, 2013, was reviewed. The policy indicated, .Upon discovery that Facility has an inadequate supply of medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from the Pharmacy . If a medication shortage is discovered during normal Pharmacy hours: .Facility should call the Pharmacy to determine the status of the order. if the medication has not been ordered, the licensed Facility nurse should place the order or reorder for the next scheduled delivery . If the next available delivery causes delay or missed a dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose . If the medication is not available in the Emergency Medication Supply, Facility staff should notify the Pharmacy and arrange for an emergency delivery . If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions . If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact the Facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage . The facility's policy and procedure titled, MEDICATION AND TREATMENT GUIDELINES, dated December 2014, was reviewed. The policy indicated, .contolled substances are destroyed by the ADNS, or licensed nurse designee and pharmacist or a second licensed nurse per a center specified schedule .Disposal is documented on the Controlled Substance Proof of Use form .controlled substances that are refused or otherwise require wasting are witnessed by at least one or other licensed nurse or pharmacist. Both individuals document the wasting and sign the Controlled Substance Proof of Use form . On March 7, 2017, at 10:30 p.m., the Administrator and the Director of Nursing (DON) were verbally informed of the system failure which resulted in Immediate Jeopardy. This system failure placed the residents at risk for delay of necessary treatments and/or medications. This system failure also had the potential for possible narcotic medication diversion. On March 8, 2017, at 8:40 a.m., the Administrator was interviewed. The Administrator stated that after their investigation, the facility had determined the root cause of the wasting and/or borrowing of medications was the unavailability of the medications. The Administrator stated the facility had established 23 licensed nurses had borrowed medications for other residents. The Administrator stated it was a system failure because too many nurses were involved. The Administrator stated the authorization part (authorization needed by the pharmacy from the physician to dispense the narcotic medication) especially for CII drugs such as Norco and Percocet, were causing the delay in the delivery of the medications which had resulted in the licensed nurses borrowing medications from other residents. On March 8, 2017 at 9:01 a.m., the Administrator was interviewed. The Administrator stated the licensed nurses who were interviewed stated they could not remember which residents received those borrowed narcotic medications. On March 9, 2017, at 10:19 a.m., the facility provided the following immediate plan of actions: - The identified residents' narcotic medications were removed from the cart, and the physician and families were notified; - A house-wide audit of the narcotic counts were completed and narcotic count sheets on all shifts were audited by the DON/designee; - Licensed nurses were educated on medication administrations, 5 rights, misappropriation, controlled substance counts, borrowing medications, wasting narcotics, and medications; - Licensed nurses were also in-serviced on medication availability and obtaining a medication that is not available; - Education will be provided to the licensed nurses on the immediate removal of narcotics once it is discontinued; - Medication pass administration audits will continue five times a week for four weeks, weekly for four weeks, and monthly thereafter; - Newly admitted residents' orders will be checked by the DON/designee to verify that controlled medications are available; new controlled medication orders will be reviewed to ensure the medication is available in the med cart and documented correctly on the Proof of Use forms; - The DON/designee will audit the report from Electronic Orders on discontinued controlled medications daily and validate the narcotic is removed from the med cart; - Any concerns with controlled medication availability will be addressed immediately by the DON/designee; - The pharmacy consultant will review the proof of use forms for patterns of waste two times a month and report findings to the DON and Administrator; and - The consultant pharmacist will review the controlled drug system with each visit to validate that narcotics are not being documented as wasted, shift to shift nursing count is being documented and counts are correct. On March 9, 2017, at 6:42 p.m., after the immediate plan of action was verified to have been implemented, the facility Administrator and DON were verbally notified that the Immediate Jeopardy was removed. 4. On March 7, 2017, at 10:49 a.m., during inspection of Station 2 medication room with Registered Nurse (RN) 4, the following were observed: -One IV (intravenous) hydration (giving fluid directly into a vein) Emergency Kit (E-Kit) (emergency supply of IV hydration medications) was observed sealed with a red tie. When opened by RN 4, the IV hydration medications in the E-Kit did not match the contents listed on the outside of the E-Kit. In a concurrent interview, the RN 4 confirmed one Liter bag of 0.9% NaCl (Sodium Chloride) and one Liter bag of 0.45% D5W/NaCl (Dextrose/Sodium Chloride) were missing from the E-Kit. She further stated the red seal indicated the E-Kit was opened. The RN 4 stated opened E-Kits should contain a completed Omnicare IV E-Kit Usage Report indicating the date the E-Kit was opened, quantity of medication taken, for what resident the medication was used for, and by whom the medication was taken. The RN 4 confirmed the opened E-Kit did not contain an Omnicare IV E-Kit Usage Report. The RN 4 stated she could not confirm when the E-Kit was opened and explain why it was not replaced by pharmacy. -One IV E-Kit containing IV antibiotics was observed sealed with a red tie. In a concurrent interview, the RN 4 explained the red tie indicated the E-Kit had been opened and medications and/or supplies had been removed. When opened by the RN 4, the E-Kit contained an incomplete Omnicare IV E-Kit Usage Report inside. The report did not indicate the date the E-Kit was opened. The RN 4 stated she was unable to trace the date when the E-Kit was opened. The RN 4 was unable to trace when the E-Kits were opened, what medications were taken and which residents the medications were used for. The RN 4 did not know if the opened E-Kits were reordered from pharmacy. The RN 4 further stated the facility did not have an additional log or a system for tracking opened E-Kits that needed to be replaced by pharmacy. The RN 4 stated opened E-Kits should be replaced by pharmacy within 72 hours. On March 7, 2017 at 3:58 p.m., during inspection of Station 1 medication room with RN (Registered Nurse) 5, one IV hydration E-Kit and one IV Medications E-Kit were observed sealed with a red tie. When opened by RN 5, the E-Kits did not contain an Omnicare IV E-Kit Usage Report. In a concurrent interview, RN 5 confirmed the red ties indicated the E-Kits were opened. RN 5 further stated an Omnicare IV E-Kit Usage Report should have been completed and placed in the opened E-Kit. -One IM (intramuscular - in the muscle) E-Kit was observed sealed with a red tie and labeled with the following, .Date Opened 2/7/17 .Med Taken N-Humulin .Quantity 1 vial . RN 5 did not know if the IM E-Kit was reordered from the pharmacy. RN 5 further stated the facility did not have an additional method for tracking open E-Kits that needed to be replaced by the pharmacy. On March 9, 2017, at 4 p.m., an interview was conducted with the facility's Pharmacy Consultant (PC) 2. The PC 2 stated the facility practice was for the facility to notify pharmacy when E-Kits were opened and pharmacy will exchange the opened E-Kits within 72 hours. A review of the policy and procedure titled, 6.6 Emergency Medication Supplies, dated 2013 was reviewed. The policy indicated, .The Emergency Medication Supply should be maintained either by a mechanism or replacement or exchange, as mutually agreed upon by Facility and Pharmacy .Facility should complete the Interim/Stat/Emergency Box Withdrawal Form .and contained in the Emergency Medication Supply .to report for which resident the medication was withdrawn .Facility should ensure that Emergency Medication Supplies remain in the nursing unit until an item is withdrawn or one of its contents is about to expire .Facility should contact Pharmacy for a replacement .