Every finding on record at Highland Care Center of Redlands

Based on interview and record review, the facility failed to ensure informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained and maintained for two out of four sampled residents (Resident 4 and 68) receiving psychotropic medications (medications affecting brain activities associated with mental processes and behaviors). This failure had the potential for residents and/or their representatives to make treatment decisions without being fully informed of the risks, benefits, alternatives, and potential adverse effects associated with psychotropic medications. Findings:1. A review of Resident 4's Order Summary Report, indicated Resident 4 had a physician order, dated 4/13/26, for quetiapine (generic for Seroquel, a psychotropic medication to treat mental illness) 25 milligrams (mg - unit of measurement) by mouth two times a day for psychosis manifested by mood swing. During a concurrent interview and medical record review on 6/11/26 at 11:40 AM with the Medical Records Assistant (MRA), the MRA stated the facility was unable to provide documented informed consent for Resident 4's quetiapine. 2. A review of Resident 68's physician orders indicated Resident 68 received Seroquel (brand name for quetiapine) for schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by hallucinations and delusional thoughts (having false or unrealistic beliefs). The Seroquel dose was increased on multiple occasions, including:On 10/1/25, Seroquel 200mg by mouth at bedtime was ordered, increased from 100 mg; On 3/24/26, Seroquel 300 mg by mouth at bedtime was ordered, increased from 250 mg; On 5/13/26, Seroquel 400 mg by mouth at bedtime was ordered, increased from 300 mg; [NAME] 6/6/26, Seroquel 100 mg by mouth in the morning was added to the existing regimen. A review of Resident 68's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/1/26 - 3/31/26 and 5/1/26 - 5/31/26, indicated Resident 68 had physician orders for Wellbutrin XL (brand name for Bupropion extended-release [ER - a tablet designed to release drug slowly over an extended period of time], a psychotropic medication used to treat depression) as follows:Wellbutrin XL 150 mg by mouth daily, dated 3/24/26; andWellbutrin XL 300 mg by mouth daily, dated 5/13/26, increased from 150 mg. During a concurrent interview and record review on 6/11/26 at 11:40 AM with MRA, the MRA stated the facility was unable to provide documented informed consents for Resident 68's Seroquel dose increases, the initiation of Wellbutrin XL 150 mg and the subsequent dose increase from 150 mg to 300 mg. During a concurrent interview and medical record review on 6/11/27 at 2:40 PM with the Director of Nursing (DON), the DON confirmed the facility was unable to provide documentation demonstrating Resident 4 and 68 and/or their representatives had been informed of the risks, benefits, and alternatives associated with the psychotropic medications and agreed to treatments. The DON stated the expectation was for physicians to educate the resident and/or representative regarding the risks and benefits of treatment, obtain informed consent, and for facility nursing staff to verify the informed consent process was completed. A review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, indicated, .Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying and responding to adverse consequences.Residents (and/or representatives) have the right to decalin treatment with psychotropic medications.

Based on observation, interview, and record review, the facility failed to ensure residents' Minimum Data Set (MDS- a federally mandated resident assessment tool) assessments accurately reflected residents' status per Resident Assessment Instrument (RAI- comprehensive assessment and care planning process used by nursing home) guidelines for three of 24 sampled residents (Resident 68, 59, and 47) when:1. Resident 68's tobacco use in the annual comprehensive assessment was not accurately coded.2. Resident 59's restorative nursing program was not coded accurately in the recent quarterly assessment.3. Resident 47's visual abilities in the latest quarterly assessment were not accurately coded. These deficient practices had the potential for Resident 68, 59 and 47 not to receive the necessary care, treatment, and/or services to attain their highest practicable level of functioning.Findings: 1.A review of Resident 68's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 6/11/26, indicated the resident was admitted to the facility on [DATE] with diagnoses that included nicotine dependence (cigarettes). A review of Resident 68's Progress Notes, dated 6/5/26, indicated, Chief Complaint:.smoker. A review of the facility's Smoking List dated 6/8/26, indicated Resident 68's name. The list also indicated, Smoking times 8:30am, 10:00 am, 1:00pm, 4:00pm, and 8:00pm. Location: Station B Back Patio. During a smoking observation on 6/8/26, at 4:03 PM, in the station B back patio, Resident 68 was observed smoking cigarettes supervised by the Activities Assistant (AA) together with other residents. A review of the Quarterly Risk Data Collection Tool, dated 10/3/25, indicated, .V. Smoking Assessment A. Resident Smoking Status 1. Does resident smoke? .Yes. 2. Resident Uses: a. Tobacco (cigarettes, cigars, pipe) was checked off. A review of Resident 68's comprehensive annual MDS with an Assessment Reference Date (ARD- a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 10/3/25, indicated, Resident 68's J1300. Current Tobacco Use was coded as 0 (No). During a concurrent interview and record review on 6/10/26, at 3:27 PM, with the MDS Coordinator (MDSC), MDSC reviewed Resident 68's comprehensive annual MDS assessment with an ARD of 10/3/25, MDSC acknowledged that Resident 68 was a smoker and stated Sec. J1300 should have been coded as 1 (Yes). MDSC also stated that the MDS assessment was not coded accurately. MDSC added that her expectation was for staff to accurately assess residents, review resident clinical records and code MDS assessments accurately. MDSC stated that the MDS assessment should be reflective of the resident's health status which was important in developing the resident's plan of care. A review of Resident 68's Care Plan Report, initiated 2/21/25, indicated, Resident is at risk for noncompliance with smoking policy. Goal. Will maintain compliance r/t (related to) smoking policy daily.Interventions. Educate resident on the facility's smoking policy. The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated .Chapter 3: MDS Items (J). J1300: Current Tobacco Use.Steps for Assessment.3.review the medical record and interview staff for any indication of tobacco use by the resident.Coding Instructions.Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period. 2. A review of Resident 59's admission RECORD, dated 6/10/26, indicated the resident was admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis of one side of the body) affecting left nondominant side, essential hypertension (high blood pressure), and muscle spasm. During an initial tour observation and interview on 6/8/26 at 9:30 AM inside Resident 59's room, with Resident 59, Resident 59 was awake, verbally responsive, with bilateral lower legs orthotics (medical devices designed to support, align, or correct the function of a body part on both sides) while lying in bed. Resident 59 stated she was paralyzed on the left side of her body. A review of Resident 59's quarterly MDS assessment with an ARD of 5/11/26, indicated, Resident 59's Brief Interview for Mental Status (BIMS) score was 15 (cognitively [relating to the mental processes of acquiring, processing, and understanding information] intact). A review of Resident 59's Order Summary Report, dated 6/10/26, indicated, Resident 59 had the following orders: A. RNA (Restorative Nursing Assistant) program to include: AAROM (Assisted Active Range of Motion) to RLE (Right Lower Extremity) to maintain strength, mobility for duration as tolerated x 15 mins (minutes), 5x/wk (five times per week) x 90 days. One time a day every Mon, Tue, Wed, Thu, Fri for RNA for 90 days order date 05/06/2026. B. RNA program to include: BLE (Bilateral Lower Extremity) splinting for proper positioning and further contractures 7x/wk (seven times per week) x 30 days order date: 4/14/26 end date: 5/14/26. C. RNA program to include: PROM to LLE (Left Lower Extremity) to maintain mobility, prevent contractures for duration as tolerated, 5x/wk x 4 wks. (weeks), one time a day every Mon, Tue, Wed, Thu, Fri for RNA order date: 05/06/2026 discontinued on 05/21/26. D. RNA PROM (Passive Range of Motion) to BUEs (Bilateral Upper Extremities) to prevent contractures and maintain joint mobility x 15 mins. (minutes) one time a day every Mon, Tue, Wed, Thu, Fri for RNA for 90 days order date 05/06/26. During a concurrent interview and record review on 6/11/26, at 8:37 AM with the MDSC, the MDSC reviewed Sec. (Section) O0500. Restorative Nursing Program of Resident 59's quarterly MDS assessment with an ARD of 5/11/26, MDSC stated that the look-back period for this section was from 5/5-11/26. MDSC acknowledged that Sec. O0500 A (Range of motion [passive] was coded as 0. Sec. O0500 B (Range of motion [active]) was coded as 3. Sec. O0500 C (splinting or brace assistance) was coded as 1. During a subsequent interview and record review on 6/11/26, at 8:41 AM with the MDSC, the MDSC reviewed Resident 59's RNA Documentation Survey Report (legal document used to track RNA services provided) for the month of May 2026. MDSC stated that based on the report, Resident 59's Sec. O0500 A (Range of motion [passive] should have been coded as 5, Sec. O0500 B (Range of motion [active]) should have been coded as 0., and Sec. O0500 C (splinting or brace assistance) should have been coded as 0. MDSC added that the RAI Manual should be followed when coding MDS assessments. She also stated that Resident 59's quarterly MDS assessment for Sec. 0500A, B, and C were not coded accurately. A review of the Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated .SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS.O0500: Restorative Nursing Programs Steps for Assessment 1. Review the restorative nursing program notes and/or flow sheets in the medical record. 2. For the 7-day look-back period, enter the number of days on which the technique, training or skill practice was performed for a total of at least 15 minutes during the 24-hour period. 3. A review of Resident 47's admission Record dated 6/11/26, indicated the resident was admitted to the facility on [DATE]. During an interview on 6/8/26, at 4:22 PM, with Resident 47, Resident 47 stated having worsened blurry vision in both eyes due to cataracts (a clouding or opacity of the natural lens inside the eye, which normally acts to focus light on the retina). During a telephone interview with Resident 47's cousin on 6/10/26, at 4:31 PM, Resident 47's cousin stated Resident 47 was unable to see clearly and had been complaining of blurry vision in both eyes due to his cataracts. During a concurrent interview and record review with Registered Nurse 2 (RN 2), on 6/11/26 at 10:07 AM, an Ophthalmology Consultation Note, dated 3/3/26, was reviewed. The Ophthalmology Consultation Note indicated, Chief Complaint (CC): Blurred Vision. Location: OU (Latin term oculus uterque, which means both eyes). Duration of Problem: About 6 years. RN 2 stated Resident 47 had poor vision and had an upcoming cataract surgery scheduled. A review of Resident 47's Minimum Data Set, dated [DATE], under Section B1000 Vision was coded as 0 indicating vision was adequate. During a concurrent interview and record view with Minimum Data Set Assistant (MDSA) on 6/11/26, at 11:28 AM, Resident 47's MDS dated [DATE], Section B1000 Vision was reviewed. MDSA stated that Resident 47 complained about blurry vision and difficulty seeing clearly during the assessment. MDSA further stated that Resident 47 read only the large print during the assessment, and based on that result, B1000 was coded 0 (adequate vision). MDSA acknowledged that the smaller print was not assessed and B1000 should have been coded as 1 (impaired vision). A review of the facility's MDS Coordinator Job Description, undated, indicated, .ESSENTIAL DUTIES AND RESPONSIBILITIES.3. Perform healthcare assessments and reassessments.11. Utilize the Minimum Data Set (MDS) to code and record assessment data gathered from resident healthcare documentation review, including visual observations, discussions with direct care staff, and interviews with resident and family members. 12. Assess the content of each resident's MDS and medical record to ensure completeness and thoroughness of documentation.16.maintain all necessary documentation and resident records. Complete medical forms, charts, and reports in an accurate and timely manner. A review of the facility's Policy and Procedure (P&P) titled Resident Assessments, revised October 2023, indicated Policy Interpretation and Implementation.6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. 7. The interdisciplinary team uses the MDS form currently mandated by federal and state regulations to conduct the resident assessment.11. All persons who have completed any portions of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. A review of the facility's P&P titled Charting and Documentation, revised July 2017, indicated Policy Interpretation and Implementation.3. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Based on observation, interview and record review, the facility failed to ensure adequate and timely collaboration and coordination with the contracted hospice agency for one of two sampled residents (Resident 52) when:1. Resident 52's vaccines were not coordinated for timely administration.2. Resident 52's hospice nursing assessments in the hospice binder were not readily available to facility staff.3. The hospice agency did not have a copy of Resident 52's comprehensive plan of care from the facility.These failures resulted in the delay of care and had the potential to cause miscommunication among staff and unmanaged health concerns for Resident 52. Findings:1. A review of Resident 52's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 6/11/26, indicated the resident was readmitted to the facility on [DATE] with diagnoses that included unspecified dementia (loss of mental function such as thinking, memory, and reasoning skills), encounter for palliative care (specialized medical care for anyone living with a serious illness), and chronic obstructive pulmonary disease (a progressive lung disease which blocks air flow making breathing difficult).A review of Resident 52's History and Physical (H&P), dated 4/10/25, indicated, .Decision Making Capability: Resident is unable to make decisions concerning health care because of cognitive (relating to the mental processes of acquiring, processing, and understanding information) deficit and aphasia (disorder caused by brain damage that impairs one's ability to communicate).A review of Resident 52's Order Summary Report dated 6/11/26 indicated, Admit to [name of hospice agency] on routine level of care.order date 9/15/2025.During a concurrent observation on 6/11/26, at 10:43 AM, inside Resident 52's room, Resident 52 was awake, blinked her eyes but did not respond when spoken to while lying in bed.A review of Resident 52's quarterly MDS with an Assessment Reference Date (ARD- a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 3/12/26, indicated, .O0250. Influenza Vaccine (an annual immunization designed to protect against flu viruses).Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? (O0250A) 0 - No.O0350. Resident's COVID-19 (contagious respiratory illness caused by a virus) vaccination is up to date.0 - No, patient is not up to date.During a concurrent interview and record review on 6/10/26, at 4:01 PM, with the Infection Preventionist (IP), the IP reviewed Resident 52's vaccination informed consents (a process in which a healthcare professional educates a resident/patient about the risks, benefits, and alternatives of a given procedure or intervention so the Resident can make an educated decision). The IP stated that the influenza, pneumococcal (bacterial infection of the lungs), and COVID-19 vaccination consents were obtained on 12/4/25. The IP added that she faxed the orders to the facility's pharmacy [name of pharmacy] but was informed that the hospice agency should be the provider of these vaccines. The IP also stated that she missed informing and following up with the hospice nurse until April 2026. (4 months later)A review of Resident 52's hospice PHYSICIANS ORDER dated 4/6/26, indicated, Pneumococcal vaccine administer 0.5 ML (Milliliter- unit of measure for volume) IM (Intramuscular- into the muscle) x 1 dose in deltoid muscle (muscle of the shoulder) for pneumococcal immunization, COVID-19 vaccine administer 0.3 ML IM x 1 dose in deltoid muscle for COVID-19 immunization, Influenza vaccine administer 0.5 ML IM x 1 dose to deltoid muscle for seasonal influenza prevention.A review of Resident 52's Immunization Audit Report dated 6/10/26, indicated that the Influenza and COVID-19 vaccines were administered on 4/20/26 while the Pneumococcal vaccine was given on 5/4/26.During a subsequent interview on 6/10/26, at 4:10 PM, with the IP, the IP stated it was not acceptable that there was no follow-up made to the hospice agency regarding the vaccine issues that resulted in the delay in administration. The IP also stated that the delay could put Resident 52 at increased risk of contracting respiratory infections especially during the winter season which was from September to March.During an interview on 6/10/26, at 4:16 PM, with the Registered Nurse 3 (RN 3), RN 3 stated staff were expected to administer vaccines during the winter season. RN 3 also stated staff were expected to communicate and follow-up with the hospice agency on any concerns involving resident care needs in a timely manner. RN 3 stated the delay in administration could put Resident 52 at risk for infections.During an interview on 6/10/26, at 4:41 PM, with the Director of Nursing (DON), the DON stated the vaccines should have been administered to Resident 52 during the winter season to help prevent diseases. The DON also stated that staff were expected to administer the vaccines after the consents were obtained. The DON further stated that staff were also expected to communicate with the hospice agency in a timely manner.A review of Resident 52's Care Plan Report, undated, indicated The resident has altered respiratory status/Difficulty Breathing r/t (related to) Asthma, COPD.Interventions.Administer medications as ordered.A review of the facility's INFECTION PREVENTIONIST Job Description, undated, indicated, POSITION SUMMARY The Infection Preventionist is accountable for decreasing the incidence and transmission of infectious diseases between patients, staff, visitors and the community through strategic planning, leadership, and consultation, you will lead and direct a robust team in the identification and implementation of infection prevention goals and objectives throughout the facility.ESSENTIAL DUTIES AND RESPONSIBILITIES.Partners with the Medical Director develop, implement and evaluate annual infection prevention goals and action plan.Oversees the operations of the infection prevention, epidemiology and relevant safety programs.Accountable for surveillance of healthcare acquired and community acquired infections.A review of the facility's Policy & Procedure (P&P) titled Influenza Vaccine, revised March 2022, indicated Policy Statement All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.Policy Interpretation and Implementation 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents.A review of the facility's P&P titled Pneumococcal Vaccine, revised October 2023, indicated Policy Statement All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation 2. Assessment of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission.A review of the facility's P&P titled Coronavirus Disease (COVID-19)- Vaccination of Residents, revised October 2025, indicated Policy Statement Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated. Policy Interpretation and Implementation 2. COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist.2. A review of Resident 52's hospice binder indicated the nursing assessment tab was empty.During a concurrent interview and record review on 6/11/26, at 11:01 AM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 reviewed Resident 52's hospice binder. LVN 2 stated Resident 52 was a hospice patient of [name of hospice]. She also stated that hospice nurses came almost every day and assessed the resident. LVN 2 acknowledged the nursing assessment tab in the hospice binder was empty and stated that hospice nurses should have put their assessments in the binder as these served as a communication tool between the hospice and facility staff.During a concurrent interview and record review on 6/11/26, at 11:34 AM, with the DON, the DON reviewed Resident 52's hospice binder and acknowledged the nursing assessment tab was empty. The DON stated it was his expectation the hospice nursing assessments be filed in the hospice binder. The DON stated these assessments should be accessible to facility staff to facilitate communication and coordination between the two entities.3. During an interview on 6/11/26, at 11:45 AM, with the Minimum Data Set (MDS - a federally mandated resident assessment tool) Coordinator (MDSC), the MDSC stated Resident 52's comprehensive care plan was completed by the facility and the MDSC was not sure if the hospice agency had a copy.During a concurrent interview and record review on 6/11/26, at 1:56 PM, with the hospice agency's Director of Patient Care Services (DPCS), the DPCS stated the agency did not have a copy of Resident 52's comprehensive care plan from the facility. The DPCS stated the expectation was for the hospice agency to have a copy of the comprehensive care plan because it served as a communication tool between the two agencies and to ensure that the care and services needed by Resident 52 were provided. The DPCS stated the joint responsibilities/mutual promises stated in the hospice services agreement were not followed.During a concurrent interview and record review on 6/11/26, at 2:12 PM, with the DON, the DON reviewed Resident 52's hospice agreement and stated it was his expectation for the hospice agency to have a copy of the resident's comprehensive plan of care from the facility. The DON also stated the hospice agreement regarding mutual responsibilities was not followed when Resident 52's care plan was not provided to the hospice agency.A review of Resident 52's Hospice Services Agreement, signed 9/3/25, indicated, .III. SERVICES TO BE PROVIDED BY HOSPICE.3.6 Professional management includes assessing, planning, monitoring, directing and evaluating the Patient's hospice care.IV. SERVICES TO BE PROVIDED BY FACILITY.4.6.Facility shall ensure that services rendered by Hospice meet the needs of the Patient in a timely manner.V. JOINT RESPONSIBILITIES/MUTUAL PROMISES 5.1 Development and Implementation of Plan of Care.Hospice and Facility shall each maintain a copy of each Patient's Plan of Care in their respective clinical records.EXHIBIT A HOSPICE SERVICES.II. Nursing Services.1. Assessment of Patient/family total care needs.EXHIBIT E DELINEATION OF NURSING AND AIDE SERVICES HOSPICE RN RESPONSIBILITIES: 3. Collaboration with Facility Staff in delivery and updating Plan of Care.6. Communication and coordination of patient care services of Facility Staff and Hospice interdisciplinary team.FACILITY RN/LVN RESPONSIBILITIES.1. Cooperation with hospice Staff in implementing and updating of Plan of Care.6. Communication with Hospice RN regarding needs for medication refills, new medication orders, and supply needs.A review of the facility's Policy & Procedure (P&P) titled Hospice Program, revised July 2017, indicated Policy Interpretation and Implementation.5. Hospice providers who contract with this facility: a. must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency; and b. are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility.10. In general, it is the responsibility of the facility to.d. Communicating with the hospice provider to ensure that the needs of the resident are addressed.13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility.

Based on observation, interview, and record review, the facility failed to ensure needed treatment and services were provided to maintain range of motion (ROM- full movement potential of a joint) for one of four sampled residents (Resident 59) when Resident 59's Restorative Nursing Program (a nursing-driven service in long-term care settings that helps residents maintain or improve their functional abilities to their highest possible level) orders were not followed in accordance with Resident 59's plan of care.These failures had the potential to cause further decline in functional mobility, ROM, and quality of life for Resident 59.Findings:During an initial tour observation on 6/8/26, at 9:30 AM, inside Resident 59's room, Resident 59 was awake, verbally responsive, with bilateral lower leg orthotics (medical devices designed to support, align, or correct the function of a body part on both sides) while lying in bed. Resident 59 stated she was paralyzed on the left side of her body.A review of Resident 59's admission RECORD dated 6/10/26, indicated the resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) affecting left nondominant side, polyneuropathy (condition where multiple nerves throughout the body malfunction simultaneously causing widespread numbness, tingling, pain and muscle weakness), and muscle spasm.A review of Resident 59's Minimum Data Set (MDS- a federally mandated resident assessment tool) with an Assessment Reference Date (ARD- a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 5/11/26, indicated, Resident 59's Brief Interview for Mental Status (BIMS) score was 15 (cognitively [relating to the mental processes of acquiring, processing, and understanding information] intact). The MDS assessment also indicated that Resident 59 had impairment on one side of the body for functional limitation in range of motion.A review of Resident 59's Order Summary Report, dated 6/10/26, indicated, Resident 59 had the following orders:A. RNA (Restorative Nursing Assistant) Program for PROM (Passive Range of Motion) to BLEs (Bilateral Lower Extremities) to maintain mobility, contracture (permanent or prolonged stiffening of muscles, tendons, skin or other soft tissues that restricts normal joint movement) prevention QD (every day), 5x/wk. (5 times per week) x 90 days. One time only for 90 days- order date: 05/28/26B. RNA Program to include: AAROM (Assisted Active Range of Motion) to RLE (Right Lower Extremity) to maintain strength, mobility for duration as tolerated x 15 mins (minutes), 5x/wk x 90 days. One time a day every Mon, Tue, Wed, Thu, Fri for RNA for 90 days- order date: 05/06/2026C. RNA Program to include: BLE splinting for proper positioning and further contractures 7x/wk x 30 days- order date: 4/14/26, end date: 5/14/26D. RNA Program to include: PROM to LLE (Left Lower Extremity) to maintain mobility, prevent contractures for duration as tolerated, 5x/wk x 4 wks., one time a day every Mon, Tue, Wed, Thu, Fri for RNA- order date: 05/06/26, discontinued on 05/21/26E. RNA Program to include: donning (the act of putting on an item) and doffing (the act of taking off or removing an item) of BLE orthotics for prevention of contracture and proper positioning QD, 7x/wk- order date: 05/28/26F. RNA PROM to BUEs (Bilateral Upper Extremities) to prevent contractures and maintain joint mobility x 15 mins, one time a day every Mon, Tue, Wed, Thu, Fri for RNA for 90 days. Order date: 05/06/26During an interview on 6/10/26, at 8:56 AM, with the RNA, the RNA stated that services provided to residents included splinting, active and passive ROM exercises. The RNA also stated RNAs were expected to document the services provided to residents in the cloud-based electronic health record on the same day or before the shift ended.During an interview on 6/10/26, at 9:37 AM, with the Registered Nurse (RN) 1, RN 1 stated it was her expectation for staff to follow doctor's orders and document before the shift ended because if it was not documented, it meant it was not done. RN 1 also added that this was important to ensure accuracy of the services provided to the resident.During an interview on 6/10/26, at 9:49 AM, with the Director of Rehabilitation (DOR), the DOR stated it was her expectation for RNAs to perform the tasks as ordered. The DOR also stated that staff were expected to inform them if there was a decline in the residents' mobility levels.A review of Resident 59's Care Plan Report, initiated 8/7/25, indicated Resident has an ADL Self-care/Mobility Performance Deficit r/t (related to) Hemiplegia, Stroke.Goal: The resident will demonstrate the appropriate use of adaptive device(s) to increase ability in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene.Interventions. RNA Program to include: AAROM to RLE to maintain strength, mobility for duration as tolerated x 15 mins, 5x/wk. RNA Program to include: PROM to LLE to maintain mobility, prevent contractures for duration as tolerated, 5x/wk x 4 wks. RNA PROM to BUEs to prevent contractures and maintain joint mobility 5x/wk.During a concurrent interview and record review on 6/11/26, at 8:18 AM, with the Director of Nursing (DON), the DON reviewed Resident 59's Order Summary Report dated 6/10/26 and Documentation Survey Report from 5/1/26 to 6/10/26. The DON acknowledged that the following RNA services were not provided:A. RNA Program for PROM to BLEs to maintain mobility, contracture prevention QD, 5x/wk. x 90 days.one time only for 90 days order date: 05/28/26- No services were provided since it was ordered.B. RNA Program to include: AAROM to RLE to maintain strength, mobility for duration as tolerated x 15 mins, 5x/wk x 90 days. One time a day every Mon, Tue, Wed, Thu, Fri for RNA for 90 days order date: 05/06/2026 - No services were provided since it was ordered.C. RNA Program to include: BLE splinting for proper positioning and further contractures 7x/wk x 30 days order date: 4/14/26 end date: 5/14/26- No services were provided from May 1-14, 2026.D. RNA Program to include: PROM to LLE to maintain mobility, prevent contractures for duration as tolerated, 5x/wk x 4 wks., one time a day every Mon, Tue, Wed, Thu, Fri for RNA order date: 05/06/2026 discontinued on 05/21/26- No services were provided on 5/14/26, 5/15/26, 5/19/26, 5/20/26, and 5/21/26E. RNA Program to include donning and doffing of BLE orthotics for prevention of contracture and proper positioning QD, 7x/wk.: order date: 05/28/26 - No services were provided on 5/29/26, 5/30/26, 5/31/26, 6/1-10/26.F. RNA PROM to BUEs to prevent contractures and maintain joint mobility x 15 mins, one time a day every Mon, Tue, Wed, Thu, Fri for RNA for 90 days. Order date: 05/06/26. No services were provided on 05/14/26, 05/15/26, 5/19/26, 5/20/26, 5/21/26, 5/22/26, 5/25/26, 6/1/26,and 6/5/26.The DON also stated that it was his expectation for staff to follow the doctor's order and document as soon as the tasks were performed. The DON stated staff were expected to document that the task was done in the electronic health record and emphasized that the documentation was important because if it was not documented, it meant it was not done.A review of the facility's RESTORATIVE NURSE ASSISTANT Job Description, undated, indicated, POSITION SUMMARY. The purpose of your job position is to provide each resident with routine daily nursing care in accordance with the resident's assessment plan along with current federal, state, and local standards.The Restorative Nurse Assistant .will work cooperatively with all departments and multidisciplinary teams.they will be committed to always doing the right thing.ESSENTIAL DUTIES AND RESPONSIBILITIES.Assisting therapy department with resident mobility.Abiding with all facility policies and procedures.A review of the facility's Policy and Procedure (P&P) titled Restorative Nursing Services, revised July 2017, indicated Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation.3. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care.5. Restorative goals may include, but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining, or strengthening his/her physiological and psychological resources.A review of the facility's P&P titled Charting and Documentation, revised July 2017, indicated Policy Interpretation and Implementation.2. The following information is to be documented in the resident medical record:. c. Treatments or services performed.3. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; .e. whether the resident refused the procedure/treatment.

Based on interview and record review, the facility failed to notify the Long-Term Care Ombudsman of a resident discharge for one of three sampled discharged residents (Resident 80).This failure had the potential to limit ombudsman involvement and advocacy related to Resident 80's discharge. Findings:A review of Resident 80s admission Record indicated Resident 80 was admitted to the facility on [DATE], with the following diagnoses, acute respiratory failure with hypoxia ( Lungs cannot adequately transfer oxygen into the blood stream),Type II Diabetes Mellitus (a long term condition that causes high blood sugar levels) without complications , Essential Hypertension (high blood pressure that does not have a single identifiable medical cause).During a concurrent interview and record review on 06/11/26, at 9:15 AM, with Registered Nurse (RN 2), Resident 80's discharge records, dated 04/28/26, were reviewed. The discharge records indicated Notification Information- the facility must send a copy of this notice to a representative of the Office of the State Long Term Care Ombudsman. RN 2 stated Resident 80 was discharged home on [DATE] and discharge arrangements included home health services and durable medical equipment (DME).During a concurrent interview and record review on 06/11/26, at 12:05 PM, with the Medical Records Director (MRD), MRD stated nursing staff were responsible for faxing the notification for discharge to the Ombudsman and providing the transmittal notification to medical records. MRD stated that he was unable to locate the documentation that verified that the notification for discharge was faxed to the Ombudsman for Resident 80.During an interview on 6/11/26, at 2:45 PM, with the Director of Nursing (DON), the DON stated a discharge notification should have been faxed to the Long-Term Care Ombudsman upon discharge, as indicated in the Notice of Transfer or Discharge.

Based on interview and record review, the facility failed to ensure timely completion and transmission of the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments in accordance with the Centers of Medicare and Medicaid Services (CMS) federal completion timeframes for two of three sampled residents (Resident 33 and 72) reviewed for Resident Assessments when:1. Resident 33's discharge MDS assessment was not done.2. Resident 72's quarterly MDS assessment was not transmitted after completion. These failures had the potential to result in inadequate monitoring of Residents 33 and 72's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring.Findings:1. A review of Resident 33's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 6/11/26, indicated the resident was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a severe brain disorder in which people interpret reality abnormally), chronic obstructive pulmonary disease (COPD- a progressive lung disease which blocks air flow making breathing difficult), and essential hypertension (high blood pressure).A review of Resident 33's Physician Telephone order dated 2/22/26, indicated, Order Summary: May transfer resident to [name of hospital] for further evaluation.During a concurrent interview and record review on 6/11/26, at 8:52 AM, with the MDS Coordinator (MDSC), MDSC reviewed Resident 33's MDS assessments and stated Resident 33 had the following MDS Assessments:1. Quarterly MDS Assessment with an Assessment Reference Date (ARD- a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 1/3/26. MDSC stated this assessment was completed on 1/15/2026 and accepted by CMS on 1/16/26.2. Quarterly MDS Assessment with an ARD of 10/03/2025. MDSC stated this assessment was completed on 10/15/2025 and accepted by CMS on 10/16/2025. 3. admission MDS Assessment with an ARD of 7/4/2025. MDSC stated this assessment was completed on 7/7/2025 and accepted on 7/8/2025.The MDSC stated that Resident 33 was transferred to the hospital on 2/22/26 and did not come back. MDSC added that a discharge MDS assessment should have been done when the resident was discharged .The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated .Chapter 2: Assessments for the RAI.2.5 Assessment Types and Definitions.Item Set refers to the MDS items that are active on a particular assessment type or tracking form. There are 9 item subsets for nursing homes.Discharge (ND) Item Set. This is the set of items active on a standalone OBRA (Omnibus Budget Reconciliation Act of 1987) Discharge assessment (either return anticipated or not anticipated) to be used when a resident is physically discharged from the facility. OBRA-Required Tracking Records and Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. These assessments are coded on the MDS 3.0 in items A0310A (Federal OBRA Reason for Assessment) and A0310F (Entry/discharge reporting). They include:.Discharge (return not anticipated or return anticipated).2. A review of Resident 72's admission RECORD dated 6/11/26, indicated the resident was readmitted to the facility on [DATE] with diagnoses that included toxic encephalopathy (a neurological disorder caused by brain damage, disease, or malfunction resulting from exposure to poisonous substances), chronic obstructive pulmonary disease (COPD- a progressive lung disease which blocks air flow making breathing difficult), and essential hypertension (high blood pressure).During a concurrent interview and record review on 6/11/26, at 9:00 AM, with the MDSC, MDSC reviewed Resident 72's MDS assessments and stated that Resident 72's latest MDS assessment was a quarterly MDS with an ARD of 4/27/26. MDSC stated that this assessment was completed on 5/1/26 but was not transmitted. MDSC added it was missed. MDSC stated that the assessment should have been transmitted within 14 days after the completion of the MDS assessment per RAI guidelines.The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated .Chapter 2: Assessments for the RAI.2.6 Required OBRA Assessments for the MDS.RAI OBRA-required Assessment Summary.Quarterly (Non-Comprehensive). Transmission Date No Later Than MDS Completion Date + 14 calendar days.A review of the facility's MDS Coordinator Job Description, undated, indicated, .ESSENTIAL DUTIES AND RESPONSIBILITIES.3. Perform healthcare assessments and reassessments.11. Utilize the Minimum Data Set (MDS) to code and record assessment data gathered from resident healthcare documentation review, including visual observations, discussions with direct care staff, and interviews with resident and family members. 12. Assess the content of each resident's MDS and medical record to ensure completeness and thoroughness of documentation.16.maintain all necessary documentation and resident records. Complete medical forms, charts, and reports in an accurate and timely manner.A review of the facility's Policy and Procedure (P&P) titled Resident Assessments, revised October 2023, indicated Policy Interpretation and Implementation.1. OBRA-Required Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include: b. Quarterly Assessments;.6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments.15. All residents admitted to the facility are notified that the data from the MDS is transmitted to and maintained in a federal data repository, the Internet Quality Improvement Evaluation System (iQIES).

Based on observation, interview and record review, the facility failed to develop a care plan for oxygen administration for one of 25 sampled residents (Resident 82).This failure had the potential to prevent Resident 82 from receiving individualized respiratory care and treatment.Findings:A review of Resident 82's admission Record (demographic information), indicated Resident 82 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (inadequate oxygen supply in the blood), pneumonia (infection/inflammation in lungs) and pleural effusion (when the fluid collects in the space around the lungs).A review of Resident 82's Order Summary Report (physician's orders) dated 6/2/26, indicated, Oxygen at 4 liter/minute [LPM- a unit that expresses flow rate] via nasal cannula [a flexible tube that delivers oxygen through the nose] continuously every shift.A review of Resident 82's Medication Administration Record for the month of June, indicated the oxygen at 4 LPM via nasal cannula was administered for Resident 82 from 6/3/26 to 6/8/26 on all shifts.A review of Resident 82's quarterly Minimum Data Set (MDS - a resident assessment tool), dated 6/6/26, section C1 Oxygen Therapy, indicated Resident 82's oxygen therapy was administered.During a concurrent observation and interview on 6/8/26, at 10:06 AM, with Licensed Vocational Nurse 3 (LVN 3), in Resident 82's room, Resident 82 was wearing a nasal cannula and had an oxygen concentrator set at 3 LPM. LVN 3 confirmed Resident 82's oxygen was set at 3 LPM. During an interview with the Medical Records Assistant (MRA) on 6/11/26, at 6:15 PM, MRA confirmed Resident 82 had no care plan for oxygen therapy. MRA also confirmed the licensed nurses were responsible for making the care plan for residents.A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, 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. A review of another facility P&P titled, Oxygen Administration, revised 10/2010, indicated, Preparation . 2. Review the resident's care plan to assess for any special needs of the resident.

Based on interview and record review, the facility failed to ensure professional standards of practice were followed when:1. For one of five residents observed during medication administration (Resident 84), nursing staff failed to identify and clarify a physician order for enoxaparin (an anticoagulant [blood thinner]) that specified intramuscular (injected into a muscle) administration, which was inconsistent with manufacturer instructions for subcutaneous (injection into the fatty tissue beneath the skin) administration.This failure had the potential to result in unresolved medication order discrepancies and inaccurate clinical documentation regarding the route of administration, and medication administration inconsistent with the physician order and manufacturer instructions. The incorrect intramuscular order also had the potential to increase the risk of bleeding and hematoma (a collection of blood under the skin or within tissue that may cause swelling, bruising, and pain) formation if administered by the intramuscular route.2. For one of four residents reviewed for psychotropic medication use (Resident 6), nursing staff entered and utilized a diagnosis of psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality) without supporting clinical documentation.This failure had the potential to result in inaccurate clinical documentation, care planning, behavioral monitoring, and clinical decision-making based on unsupported diagnosis. Findings:During a medication administration observation on 6/9/26 9:43 AM, in Resident 84's room, Licensed Vocational Nurse (LVN) 2 administered seven medications, including enoxaparin (generic name for Lovenox, anticoagulant [blood thinner]) 40mg/0.4mL (milligram per milliliter - unit of measurement) by subcutaneous injection to Resident 84's left lower abdomen. A review of Resident 84's hospital record titled, Active Medication Interfacility Transfer Report, undated, indicated, Resident 84's home medications, including enoxaparin 40mg subcutaneously once daily with a documented start date of 2/25/26. A review of Resident 84's physician order, dated 6/5/26, indicated, Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML, inject 40 mg [milligram - unit of measurement] intramuscularly one time a day for PPX [prevention] DVT [deep vein thrombosis - blood clot]. A review of Resident 84's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/1/26 - 6/30/26, indicated nursing staff documented administration of enoxaparin as intramuscular on 6/6/26, 6/7/26, 6/8/26, and 6/9/26. During a concurrent interview and record review on 6/9/26, at 12:43 PM, LVN 2 acknowledged the physician order specified intramuscular administration. LVN 2 stated she administered the medication subcutaneously to Resident 84 because she knew enoxaparin should be administered by the subcutaneous route. LVN 2 acknowledged the physician order incorrectly specified intramuscular administration and confirmed nursing staff did not contact the physician to clarify the order. During a concurrent interview and record review on 6/9/26, at 2:11PM, with the Director of Nursing (DON), the DON reviewed Resident 84's physician order and MAR, and stated nursing staff should have clarified the physician order and corrected the route of administration. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for enoxaparin sodium injection, dated 1/2026, retrieved from Dailymed (internet database operated by the U.S. National Library of Medicine providing labeling for prescription and nonprescription drugs) indicated: .Do not administer enoxaparin sodium injection by intramuscular injection. Administer enoxaparin sodium injection by subcutaneous injection only. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, indicated: .If.a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 2. A review of Resident 6's admission Record (a document showing a summary of the resident's information) indicated the resident was admitted to the facility on [DATE] with diagnoses, including depression. A review of Resident 6's MAR, dated 4/1/26 - 4/30/26, indicated a physician order, dated 4/10/26, for aripiprazole (an antipsychotic medication to treat mental illness) 30 mg by mouth at bedtime for depression manifested by persistent low mood. A review of Resident 6's medical record titled, IDT [interdisciplinary] Behavior Management, dated 4/13/26, indicated the current medication aripiprazole 30 mg by mouth at bedtime for depression manifested by persistent low mood. A review of Resident 6's medical record titled, Preadmission Screening and Resident Review ([PASRR] - federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) level I screening, dated 4/18/26, indicated .Serious Mental Illness.Specify the diagnosis or describe the symptoms: Depression. A review of Resident 6's Care Plan Report, dated 4/22/26, indicated .the resident has depression. A review of Resident 6's Minimum Data Set ([MDS] - a standardized assessment tool) Assessment, Section I - Active Diagnoses, dated 5/16/26, indicated depression was documented as an active diagnosis. The MDS did not identify a psychotic disorder. A review of Resident 6's physician orders in the MAR, dated 6/1/26 - 6/30/26, indicated the diagnosis associated with aripiprazole was changed on 6/3/26 from depression manifested by persistent low mood to psychosis manifested by persistent low mood. A review of Resident 6's clinical record indicated the diagnosis of psychosis was subsequently incorporated into the resident's diagnosis list, care plan, PASRR documentation, and behavioral monitoring, as follows:Resident 6's medical record titled, Medical Diagnosis, undated, indicated a new diagnosis of Psychosis was added to Resident 6's medical record on 6/8/26 with date of diagnosis documented as 4/10/26 and the classification documented as present on admission. Resident 6's Care Plan Report, dated 6/8/2026, indicated the care plan for aripiprazole was updated on 6/8/26: .Potential for adverse side effects secondary to psychotropic drug use (Aripiprazole) secondary to (psychosis) manifested by the target behavior of (persistent low mood) .Administer Antipsychotic medication per order. Resident 6's PASRR level I screening, dated 6/8/26, indicated Schizophrenia/schizoaffective disorder or symptoms of psychosis was selected under the Serious Mental Illness section. Resident 6's MAR, dated 6/1/26 - 6/30/26, indicated a physician order, dated 6/4/26, for .Monitor behavior(s) of Psychosis q (every) shift for use of Aripiprazole. A review of Resident 6's clinical record did not identify documentation supporting a diagnosis of psychosis at the time the diagnosis was entered and utilized, including a physician assessment, psychiatric evaluation, consultation, or other clinical documentation supporting such diagnosis. During a concurrent interview and medical record review on 6/11/26, at 9:58 AM, with the DON, the DON stated Registered Nurse (RN) 3 mistakenly associated aripiprazole with a diagnosis of psychosis and entered the diagnosis without obtaining clarification regarding the resident's diagnosis from the physician. A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017, indicated: .The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. A review of the facility's P&P titled, Psychotropic Medication Use, dated July 2022, indicated: .Residents will not receive medications that are not clinically indicated to treat a specific condition.Psychotropic medication management includes.indications for use.Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.

Based on observation, interview and record review, the facility failed to follow the physician's order for oxygen administration and place an oxygen in use sign outside the room, in accordance with the oxygen administration policy for one of 25 sampled residents (Resident 82).This failure had the potential to result in ineffective oxygen therapy, potential respiratory distress, or compromised safety for Resident 82. Findings:A review of Resident 82's admission Record (demographic information), indicated Resident 82 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (inadequate oxygen supply in the blood), pneumonia (infection/inflammation in lungs) and pleural effusion (when fluid collects in the space around the lungs).A review of Resident 82's Order Summary Report (physician's orders) dated 6/11/26, indicated an order for Oxygen at 4 liter/minute [LPM- a unit that expresses flow rate] via nasal cannula [tubing that delivers oxygen through the nose] continuously every shift on 6/2/26.A review of Resident 82's Medication Administration Record for the month of June, indicated the oxygen at 4 LPM via nasal cannula was administered for Resident 82 from 6/3/26 to 6/8/26 on all shifts.A review of Resident 82's quarterly Minimum Data Set (MDS - a resident assessment tool) dated 6/6/26 section C1 Oxygen Therapy, indicated Resident 82's oxygen therapy was administered.During a concurrent observation and interview on 6/8/26, at 10:06 AM, with Licensed Vocational Nurse 3 (LVN 3), in Resident 82's room, Resident 82 had a nasal cannula attached to oxygen concentrator (a device that provides extra air oxygen) set at 3 LPM and with no oxygen in use sign outside Resident 82's room. LVN 3 confirmed Resident 82's oxygen was set at 3 LPM instead of 4 LPM and no oxygen in use sign was found outside Resident 82's room.A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, indicated, Preparation 1. Verify that there is a physician's order for this procedure . Steps in Procedure . 2. Place Oxygen in Use sign on the outside of the room entrance door.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 52) was assessed for the appropriate use of grab bars (safety devices anchored to bed to provide stability, maintain balance and prevent falls) based on acceptable standards of practice and per facility policy.This failure placed Resident 52 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaced around the bed) and injury from the use of the affixed grab bars.Findings:A review of Resident 52's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 6/11/26, indicated the resident was readmitted to the facility on [DATE] with diagnoses that included unspecified dementia (loss of mental function such as thinking, memory, and reasoning skills), encounter for palliative care (specialized medical care for anyone living with a serious illness), and chronic obstructive pulmonary disease (a progressive lung disease which blocks air flow making breathing difficult).A review of Resident 52's History and Physical, H&P dated 4/10/25, indicated, .Decision Making Capability: Resident is unable to make decisions concerning health care because of cognitive (relating to the mental processes of acquiring, processing, and understanding information) deficit and aphasia (disorder caused by brain damage that impairs one's ability to communicate).A review of Resident 52's quarterly MDS with an Assessment Reference Date (ARD- a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 3/12/26, indicated, Resident 52 was dependent on staff for eating, toileting, oral hygiene, personal hygiene, and rolling in bed.A review of Resident 52's latest Side Rail Utilization Assessment, dated 3/19/26, indicated, A. Side Rail Usage 1. Type of Assessment c) Quarterly 2. Are siderails currently in use or being requested? C. Not in use or requested.During an initial tour observation on 6/8/26, at 12:08 PM, inside Resident 52's room, Resident 52 was asleep lying in bed. Resident 52's bed was placed in low position and with bilateral padded grab bars.During a concurrent observation and interview on 6/11/26, at 10:43 AM, inside Resident 52's room, with Resident 52, Resident 52 was awake, able to slightly move both upper extremities but did not respond when spoken to. Resident 52's bed was in low position and with bilateral padded grab bars.During an interview on 6/11/26, at 2:20 PM, with the MDS Coordinator (MDSC), the MDSC stated that residents were assessed for side rail/grab bar use using the Side Rail Utilization Assessment form during admission, quarterly, and as needed. MDSC also stated that an assessment, doctor's order, consent, and care plan were needed whenever side rails or grab bars were used.During a concurrent observation and interview on 6/11/26, at 2:34 PM, inside Resident 52's room, with the MDSC, the MDSC acknowledged Resident 52 had bilateral padded grab bars affixed to the bed.During a subsequent interview and record review on 6/11/26, at 2:40 PM, with the MDSC, the MDSC reviewed resident 52's electronic health record and stated there were no doctor's orders, informed consent, or care plan for the use of grab bars. MDSC also stated that since the resident could not use grab bars based on her ADL levels, the grab bars should not have been installed. MDSC added that the grab bars could place the resident at risk for entrapment and potential injury.During an interview on 6/11/26, at 2:55 PM, with the Director of Nursing (DON), the DON stated that residents using siderails/grab bars needed to have a doctor's order, consent, risk assessment, and care plan. The DON also stated that based on these findings, the facility's policy and procedure was not followed for Resident 52.A review of the facility's Policy and Procedure (P&P) titled Bed Safety and Bed Rails, revised August 2022, indicated Policy Statement. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Policy Interpretation and Implementation.2. Consideration is given to the resident's safety, medical conditions,.as well as input from the resident and family.Use of Bed Rails 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. For the purpose of this policy :bed rails include:.c. grab/assist bars.The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including.informed consent.5. The interdisciplinary evaluation includes:.d. consultation with the attending physician.8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled substances (medications with a high potential for abuse and dependence) for one of five randomly selected residents reviewed for controlled substance accountability (Resident 83). The facility's Controlled Drug Record (CDR - inventory records used to document receipt, use, and count of controlled substances did not match the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).This failure resulted in inaccurate accountability of a controlled substance and had the potential to result in diversion (controlled substances used by someone other than the resident for whom the medication was prescribed) or misuse of controlled substances and compromised resident medication safety. Findings:During an inspection of Medication Cart 1 at Nursing Station A on 6/9/26 at 1:01 PM in the presence of Licensed Vocational Nurse (LVN) 1, Resident 83's blister card (a type of medicine packaging where individual doses of medication are sealed in small, clear plastic bubbles (blisters) and attached to a rigid card or foil backing) for tramadol (an opioid medication used to treat moderate to moderately severe pain) 50 mg (milligram - unit of measurement) and corresponding records were reviewed. A review of Resident 83's physician orders, dated from 6/1/26 through 6/5/26 indicated the resident had multiple tramadol 50 mg orders, including as-needed and routine dosing schedules. A review of Resident 83's CDR, dated 6/3/26 through 6/9/26, indicated nursing staff removed one tramadol 50 mg tablet from the blister card on 6/8/26 at 1:30 PM and documented the removal in the CDR. A review of Resident 83's June 2026 MAR did not identify corresponding documentation that nursing staff administered the tramadol dose removed from the blister card on 6/8/26 at 1:30 PM. The MAR also did not identify corresponding pain assessments associated with that dose. During a concurrent interview and record review on 6/9/26 at 1:01 PM with LVN 1, LVN 1 stated Resident 83 had multiple changes to tramadol 50 mg orders, including changes to the as-needed dosing frequency and the addition of a routine tramadol 50 mg order. LVN 1 stated the pharmacy instructed nursing staff to continue using the tramadol 50 mg blister card already stored in the medication cart because the medication and strength remained the same. LVN 1 reviewed the CDR entry dated 6/8/26 at 1:30 PM and stated she removed the tramadol tablet from the medication cart, recorded the removal in the CDR and administered the medication to Resident 83. LVN 1 further stated, I don't know why I didn't document it in the MAR. LVN 1 confirmed the CDR and MAR did not match. During a concurrent interview and record review on 6/9/26 at 1:50 PM with the Director of Nursing (DON), the DON reviewed the records and confirmed the discrepancy between the CDR and the MAR for Resident 83. The DON further stated the expectation was for nursing staff to document removal of controlled substances in the CDR and document administration in the MAR after administering the medication. A review of the facility's policy and procedures (P&P) titled, Administering Medications, dated April 2019, indicated: .the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility failed to remove a discontinued medication from active medication storage in one of two medication rooms (Nursing Station A Medication Room).This failure had the potential to result in inadvertent administration of a discontinued medication. Findings: During a medication room inspection on 6/9/26 at 12:13 PM in the presence of the Director of Nursing (DON), a prefilled syringe of Spikevax 2025-2026 (COVID-19 vaccine) labeled for Resident 17 was observed in the medication refrigerator located in Nursing Station A Medication Room with a date of 5/14/26. A review of Resident 17's physician's telephone order, dated 5/13/26, indicated, Moderna COVID-19 Bivalent (a vaccine formulated to protect against two virus strains or variants) Intramuscular (injected into a muscle) Suspension (a liquid medication) 50 MCG/0.5ML (microgram per milliliter - unit of measurement).Inject 0.5 ml intramuscularly one time only for COVID VACCINE until 05/14/2026 23:59 (11:59 PM). A review of Resident 17's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 5/1/26 - 5/31/26, indicated nursing staff did not administer the vaccine to Resident 17 on 5/14/26. A review of Resident 17's clinical record did not identify documentation indicating staff obtained a subsequent physician order for COVID-19 vaccination or made additional attempts to administer the vaccine after 5/28/26. During a concurrent interview and clinical record review on 6/9/26 at 12:23 PM with the DON, the DON confirmed the order was a one-time order that ended on 5/14/26 and the order status was discontinued. The DON stated nursing staff should have removed the vaccine from the medication refrigerator and medication storage area. A review of the facility's policy and procedure titled, Discontinued Medications, dated November 2022, indicated, .Staff shall destroy discontinued medications.

Based on observation, interview, and record review, the facility failed to keep the lids of two of three dumpsters closed which exposed the trash inside.This failure had the potential to attract pests to the premises which could spread disease to residents and staff in the facility.Findings:During a concurrent observation tour and interview on 6/8/26, at 8:53 AM, with the Dietary Supervisor (DS), in the facility's outside garbage area, two of three metal dumpsters were open. Several trash bags were exposed inside one dumpster and trash was observed in the other. The DS confirmed the lids of two metal dumpsters were left open and needed to be closed at all times to prevent harboring of pests. A review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised 10/2017, indicated, 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on interview and record review, the facility failed to implement its abuse prevention policies and procedures (P&P), which were designed to prohibit misappropriation of resident property, for one of three sampled residents (Resident 1) when Certified Nurse Assistant 1 (CNA 1) took Resident 1's credit card out of the facility.This failure resulted in Resident 1 to receive fraudulent charges and violation of resident trust in facility safeguards.Findings: During a review of Resident 1's face sheet (contains demographic and medical information), the face sheet indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included partial intestinal obstruction (partial blockage of the intestines, but food, gas, and fluids can still get through) and muscle wasting (muscles are shrinking and getting weaker over time).During an interview on September 17, 2025, at 1:48 PM, with Resident 1, Resident 1 stated she requested CNA 1 to buy cigarettes from a local store using Resident 1's own personal credit card on two occasions, August 4, 2025, and August 18, 2025. Resident 1 further stated CNA 1 agreed, completed the purchases, and gave the card back to Resident 1 after the last request on August 18, 2025. During an interview on September 17, 2025, at 2:18 PM, with the Social Services (SS), the SS stated the facility does store funds for residents, including cash and occasionally credit cards. The SS explained it was against facility policy for staff to use a resident's credit card or to make purchases on behalf of residents with credit cards or checks. The SS stated only the Social Services or the Activities staff may procure items for residents, and only with cash. The SS further stated the staff were not allowed to pull cash out of residents' accounts using credit cards. During an interview on September 17, 2025, at 2:54 PM, with CNA 1, CNA 1 acknowledged taking Resident 1's credit card on two occasions to buy cigarettes at a nearby gas station after initially refusing. CNA 1 stated the action was against facility policy but still she agreed to do so at the time because of Resident 1's insistence. CNA1 further stated, I don't think I did anything bad. I was helping the resident [Resident 1].During a concurrent interview on September 17, 2025, at 3:01 PM, with the Director of Nursing (DON), the DON stated during an Interdisciplinary Team (IDT - multiple disciplines working together) meeting on September 9, 2025, Resident 1 reported fraudulent charges on her credit card totaling approximately $833, from August 22, 2025, through August 30, 2025. The DON further stated CNA1 did not have possession of Resident 1's card on those dates but did not deny CNA1 taking the card to assist Resident 1 with purchases outside of the facility. The DON stated the Activities and Social Services were the only ones permitted to make purchases for residents, and CNA1 went against facility policy.During a concurrent interview and record review on September 17, 2025, at 3:10 PM, with the DON, the facility's P&P titled, Incidents of Theft and/or Misappropriation of Resident Property, revised April 2021, was reviewed. It indicated, Policy Statement: All reports of exploitation, theft or misappropriation of resident property are promptly and thoroughly investigated.1. Residents have the right to be free from exploitation, theft and/or misappropriation of personal property.2.b. providing measures to safeguard valuables from easy public access. DON stated the facility has physical safeguards, such as controlled access, locked safes available for resident valuables; inventory tracking or personal belongings; signed acknowledgements when residents withdraw cash; and staff education and enforcement on abuse, neglect, and misappropriation. DON further stated facility staff did not follow policy for this matter.A review of the job description titled, Certified Nurse Assistant, indicated, .Essential duties and responsibilities:.Abiding with all facility policies and procedures including not disclosing user ID codes and passwords.

Based on interview and record review, the facility failed to ensure proper care was provided to prevent a right heel pressure ulcer (an injury to the skin or underlying tissue that develop from prolonged pressure), for one of three sampled residents (Resident 1).This failure had the potential to place Resident 1, a clinically compromised resident, at risk for further skin breakdown, which could affect his health and safety.Findings:During a review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle wasting and atrophy (a condition with shrinking and loss of muscle), major depressive disorder (a condition with feeling of sadness and hopelessness), fracture of unspecified part of right clavicle ( broken right collarbone where the specific location of the break has not been detailed), fracture of right ilium (a break in the upper largest part of the hip bone), spinal stenosis (narrowing of the spinal canal that puts pressure on spinal cords and nerve), spastic quadriplegic cerebral palsy (affective all four limbs due to abnormal brain development or damage before, during or after birth), cervicalgia ( neck pain), alcohol abuse ( impaired ability to stop or control alcohol use ), and hypertension (high blood pressure, polyp of colon (growth on the inner lining of the large intestine or rectum), dorsalgia (back pain).During an interview on September 25, 2025, at 12:00 PM, with the Wound Treatment Nurse (WTN), WTN stated Resident 1's admission assessment, did not include a pressure sore, injury, or wound on the right heel. WTN further stated that on June 22,2025 while WTN was doing wound care, Resident 1 started complaining of pain on right heel. WTN assessed and noted a darkened area to the right heel, measuring 5.0 cm X 5.0 cm X UTD (unstageable), 100% necrosis (death of body tissue).During an interview on September 25, 2025, at 12:45 PM, with the Physical Therapist (PT), PT stated, Resident 1 was evaluated during admission on [DATE], as totally dependent with maximum assist. Both lower extremities are impaired, and he was unable to move without assistance. PT stated, there should have been a care plan initiated for offloading both feet off the bed to prevent pressure sore on admission.During an interview on September 25, 2025, at 1:00 PM, with the Director of Nursing (DON), DON stated the pressure wound on right heel was identified and assessed on June 22, 2025. Situation, Background, Assessment and Recommendation (SBAR), Change of Condition (COC) were completed that day. Treatment was ordered by the primary physician (PP) and initiated by WTN on the same day on June 22, 20225. DON was asked if there was a care plan initiated on admission to prevent Resident 1's pressure injury by offloading both feet and a daily skin assessment. DON stated, No and was not able to provide documentation. DON further stated they implemented daily skin assessment once a shift for all residents, and care plan was initiated for Resident 1 on June 23, 2025, for offloading and bilateral boots for heel protectors.A review of the following clinical records for Resident 1 indicated:a. Braden Evaluation (a clinical tool to assess a patient's risk of developing pressure ulcers [Severe risk total score: less than 9, High risk total score: 10-12, moderate risk total score: 13-14, Mild risk: total score: 15-18]): .Braden score: 15.0.b. Situation, Background, Assessment and Recommendation (SBAR) communication record dated June 22, 2025, indicated, . complained of pain on right heel, Treatment nurse assessed area and noted darkened area to right heel 100% necrosis measuring 5.0cm X 5.0cm X UTD.c. Physical Therapy Evaluation and Plan of Treatment: May 28,2025: Musculoskeletal System Assessment- Right lower Extremities strength= Impaired, LLE: Left lower extremities = Impaired.During a review of the facility's policy and procedure (P&P), titled, Prevention of Pressure Injuries, revised April 2020, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the intervention designed to reduce or eliminate those considered modifiable. #3. Inspect the skin daily when performing or assisting with personal care or ADL.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to one of three sampled residents (Resident 1) when Resident 1 eloped from the facility without the facility ' s knowledge on March 12, 2025. This failure had the potential to place Resident 1 at increased risk for falls and injuries, heat or cold exposure, dehydration, and/or death. Findings: During a review of Resident 1 ' s clinical record, the face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (brain disorder that causes loss of memory, language, thinking abilities severe enough to interfere with daily life), hypertension (condition where the force of blood pushing against your artery walls is consistently too high), and mood affective disorder (mental health condition that affects your emotional state, causing long periods of extreme happiness or sadness). Further review indicated Resident 1 was in the Memory Care Unit (a unit specifically for residents who have diagnoses such as dementia or Alzheimer ' s [a brain disorder that slowly destroys memory, thinking skills, and the ability to perform everyday tasks]). During a review of Resident 1 ' s nursing notes, dated March 13, 2025, at 7:53 PM, it indicated, At 11:45 PM on 3/12/25, resident attempted to leave facility and was seen wandering outside. Resident was brought in back to the facility. Several minutes later, he was able to get out again. Resident not found in facility premises, so police were called in. Resident was brought back to facility by police. MD was notified. Resident's son was notified. During a concurrent observation and interview with Resident 1, on March 14, 2025, at 3:26 PM, in Resident 5 ' s room, Resident 1 was lying on his bed, resting. He had no visible injuries. Resident 5 stated he does not recall eloping from the facility March 13, 2025. During a concurrent observation and interview with the Maintenance Director (MD), on March 14, 2025, at 3:38 PM, in the Memory Care Unit, the MD demonstrated the alarm activation and how to access the door for the emergency exit door across the hall from Resident 1 ' s room. After the demonstration, the MD reset the alarm, and stated the alarm is checked daily to ensure proper efficiency, and it needs to be reactivated per use. During a telephone interview with Registered Nurse (RN 1), on March 14, 2025, at 4:00 PM, RN 1 stated Resident 1 had two elopement attempts last March 13, 2025, one of which was timely intervened, and the other one required police intervention to bring Resident 1 back to the facility. RN 1 further stated staff did not monitor Resident 1 after he was brought back to the facility after the first elopement attempt. RN 1 stated the alarm was not activated during Resident 1 ' s second attempt, allowing him to successfully elope. During a telephone interview with the Director of Nursing (DON), on March 14, 2025, at 4:15 PM, the DON stated the alarm was not reset in a timely manner after Resident 1 was brought back to the facility following the first elopement attempt. The DON further stated that he was unsure if Resident 1 was monitored by staff following his return to the facility. The DON stated the alarm should have been reset in a timely manner and there should have been staff to monitor Resident 5. During a concurrent telephone interview and record review on March 26, 2025, at 11:26 AM, with the Administrator (Admin), the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2023, was reviewed. The P&P indicated, .Resident supervision is a core component of the systems approach to safety. The type of frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .Resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. The Admin stated the facility staff should have followed the P&P.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen as required by the facility policy when: 1.The floors under equipment had accumulation of food crumbs, trash, and black grime (dirt). The food prep sink drain had residue build-up on the drainpipe and the wall. 2. The dry storage room had food crumbs and trash underneath shelves. The shelves had spill of a powder substance. 3. There were broken tiles, which provided a surface for an accumulation of food crumbs, in the dry storage room and in the main kitchen. 4. Food equipment (food processor, plate warmer, blender, and can opener) were stored with food crumbs and build up. 5. The clean utensil bins had food splash and crumbs. 6. The ice machine had black spots in the ice bin ceiling and yellow discoloration (change of natural color) in the ice chute (the part of the ice machine where ice drops into the ice bin). These failures have the potential to compromise food safety and increase the risk of foodborne illness (caused by the ingestion of contaminated food or bevergaes) for 64 high vulnerable residents who receives food from the the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Services Supervisor (DSS), on February 18, 2025, at 8:10 AM, in the kitchen, the floors under equipment had accumulation of food crumbs, trash, and black grime (dirt). The food prep sink drain had residue build-up on the drainpipe and the wall adjacent to it. The DSS stated the floors and food prep sink should be kept clean. During an interview with the Registered Dietician (RD), on February 20, 2025, at 10:58 AM, the RD stated her expectation was for the floors to be kept clean. The RD further stated the food prep sink drain should be kept clean and that it needed some kind of splash guard. During a review of the facility's policy and procedure (P&P) titled, Section F: Safety and Sanitation, revised 2017, it indicated Floors are kept clean, dry, and uncluttered . During a review of the U.S. Food and Drug Administration Food Code 2022, 4-602.13, it indicated, (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and debris. Annex 3 titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicates the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 2. During a concurrent observation and interview with the DSS, on February 18, 2025, at 8:45 AM, in the kitchen, the dry storage room had food crumbs and trash underneath the shelves. The shelves had spill of powder substance. During an interview on February 20, 2025, at 10:58 AM, the RD stated the storage room should be kept clean and free of spills. During a review of the facility's P&P titled, Sanitization, revised November 2022, it indicated All kitchens, kitchen areas, and dining areas are kept clean, free from garbage, debris, and protected from rodents and insects. During a review of the U.S. Food and Drug Administration Food Code 2022, 4-602.13, it indicated, (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and debris. Annex 3 titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicates the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During a concurrent observation and interview with the DSS, on February 18, 2025, at 8:45 AM, an inspection of the kitchen was conducted. There were broken tiles in the dry storage room and in the main kitchen. During an interview on February 20, 2025, at 10:58 AM, the RD stated there should not be any broken tiles and it should be fixed. During a review of the facility's P&P titled, Section F: Safety and Sanitation, revised 2017, it indicated, Floors are to be kept clean, dry, uncluttered and free of broken tiles or defective boards. During a review of the FDA Federal Food Code, date 2022, 4-202.16, it indicated, Nonfood-Contact Surfaces. shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. In addition, annex 3 indicated, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. Well-designed equipment enhances the ability to keep nonfood-contact surfaces clean. 4. During a concurrent observation and interview with the DSS, on February 18, 2025, at 8:10 AM, in the kitchen, the food processor and blender had old, crusted food splash in the crevices of the equipment. The plate warmer had food crumbs and splash on the handle. The can opener was sticky and dirty. The DSS stated all equipment should be kept clean. During an interview on February 20, 2025, at 10:58 AM, the RD stated she started working for the facility a month ago and the DSS started a couple weeks ago. The RD further stated the kitchen was in a terrible condition and the kitchen staff had no supervisor when she started. The RD stated she made a lot of changes and improvements, however, she expects the equipment to be kept clean and staff need a strict cleaning schedule. During a review of the facility's P&P titled, Section F: Safety and Sanitation, revised 2017, it indicated, Food & Nutrition Services employees will practice safe handling practices for themselves and the equipment by . 11. Wash can opener daily. During a review of the facility's P&P titled, Sanitation, dated November 2022, it indicated, The food service area is maintained in a clean and sanitary manner - 2. All utensils, counters, shelves and equipment are kept clean . 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions . 5. During a concurrent observation and interview with the DSS, on February 18, 2025, at 8:24 AM, in the kitchen, the clean utensil bins (3 metals and 1 plastic bins with lids) had food splash and crumbs inside. The DSS stated it should be kept clean. During an interview on February 20, 2025, at 10:58 AM, the RD stated utensils should be kept clean and run in the dish washer after every meal. During a review of the facility's P&P titled, Sanitation dated November 2022, it indicated, The food service area is maintained in a clean and sanitary manner - 2. All utensils, counters, shelves and equipment are kept clean . 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions . 6. During a concurrent observation and interview with the Maintenance Supervisor (MS), on February 18, 2025, at 10:02 AM, the ice machine was inspected. The ice machine had a black build-up in the bin of the ice machine ceiling. The black spots were wipeable with a paper and there was yellow discoloration in the ice chute. The MS stated he oversees cleaning the ice machine monthly however the facility has a contracted company, who cleaned it for the month of February 2025. The MS stated he expects the ice machine to be clean. During an interview on February 20, 2025, at 10:58 AM, the RD stated the ice machine should always be kept clean. During a review of the facility's P&P titled, Sanitation, dated November 2022, it indicated, Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for two of eleven residents (Residents 40 and 475) reviewed for dining observation when: 1. Licensed Vocational Nurse (LVN 2) was standing over Resident 40 while feeding her lunch on February 18, 2025. 2. Certified Nursing Assistant (CNA 4) pulled Resident 475 while he was on his wheelchair into the dining room, with his feet dragging on the floor, on February 18, 2025. These failures resulted in staff not maintaining and enhancing Residents 40 and 475's individuality and dignity, and had the potential to devalue and dishonor their self-esteem and self-worth. Findings: 1. During an observation on February 18, 2025, at 12:54 PM, in the Memory Care Unit's dining room, LVN 2 was standing over Resident 40 while feeding her lunch. During an interview on February 19, 2025, at 4:45 PM, CNA 5 stated the job expectation when feeding residents was to perform hand hygiene before, sit down beside residents hand hygiene after. During an interview with the Registered Dietician (RD), on February 20, 2025, at 10:58 AM, the RD stated LVN 2 should be at the same level as Resident 40. During a review of the facility's policy and procedure (P&P) titled Assistance with Meals, revised March 2022, it indicated . 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: A. not standing over residents while assisting them with meals . During a review of the facility's P&P titled Dignity, revised February 2021, it indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . 1. Residents are treated with dignity and respect at all times. 2. During an observation on February 18, 2025, at 1:11 PM, in the hallway, CNA 4 was pulling Resident 475 into the dining room while he was in his wheelchair. Both of his feet was dragging on the floor. During an interview on February 20, 2025, at 4:04 PM, with CNA 6, CNA 6 stated staff were expected to lock wheelchairs first when parked, elevate resident's feet and place on footrest (part of wheelchair where legs are off the floor), and make sure residents are secured before wheeling. During a review of the facility's P&P titled Dignity, revised February 2021, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . 1. Residents are treated with dignity and respect at all times.

Based on observation, interview, and record review, the facility failed to ensure their policy for assistive device and equipment (tool that helps a person with disability perform daily tasks) was being implemented for one of four residents (Resident 8) reviewed for range of motion (ROM - full movement potential of a joint) when Resident 8's hand splint (device applied to prevent or reduce contractures) was not applied as ordered. This failure had the potential to cause further contractures (when muscles, tendons or skin around a joint become permanently tight and shortened) discomfort and loss functional mobility negatively impacting Resident 8's quality of life and increasing the risk for preventable physical deterioration and pain. Findings: During a review of Resident 8's Admission Record (contains demographic and medical information), it indicated Resident 8 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis or weakness on one side of the body), and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (occurs when blood flow to the brain is block) affecting left non-dominant side. During a review of Resident 8's Physician Orders dated May 10, 2024, it indicated, RNA (restorative nurse assistant - person who helps patients regain mobility and independence in nursing home) order: Pt (patient) to have resting hand splint to LUE (left upper extremity) hand in order to decrease risk of contracture 7 (seven) x (times) week. During a review of Resident 8's Care Plan for Risk for decline in ROM, dated November 9, 2020, it indicated, The resident has limited physical mobility r/t (related to) quadriplegia (one affected side with partial or complete paralysis of both arms and hands), Risk for decline in ROM (range of motion - extent to which muscle or joint can be stretched or move without causing pain) or joint mobility of BLE (bilateral lower extremities- legs) .Interventions, RNA to have resting hand splint to LUE (left upper extremity - left hand) in order to decrease risk of contracture. During an observation on February 18, 2025, at 10:04 AM, in Resident 8's room, Resident 8 was lying in bed awake, alert and oriented. His left hand was contracted. A hand splint was found inside the first drawer of his nightstand. During an interview on February 18, 2025, at 10:12 AM, with Resident 8, Resident 8 stated the staff do not ask him if he wants to wear the hand splint. During a virtual interview on February 18, 2025, at 10:16 AM, with Resident 8's mother, in the presence of Resident 8, Resident 8's mother stated that she rarely sees Resident 8 wearing the hand splint. During a concurrent observation and interview on February 18, 2025, at 10:28 AM, with RNA 1, in Resident 8's room, RNA 1 stated Resident 8 was not wearing the hand splint. RNA 1 stated the hand splint should be applied. During a concurrent observation and interview on February 18, 2025, at 10:45 AM, with the Physical Therapist (PT), in Resident 8's room, the PT stated Resident 8's hand splint was not applied and emphasized its importance in preventing further contractures. The PT further stated nursing staff was responsible for ensuring it was applied as ordered. During another observation and concurrent interview, with a Certified Nursing Assistant (CNA 7), on February 19, 2025, at 8:36 AM, in Resident 8's room, Resident 8's hand splint was inside the drawer of the nightstand. CNA 7 acknowledged Resident 8 was not wearing the hand splint and stated when the resident's mother visits, she applies it for him. During a follow up observation on February 20, 2025, at 10:40 AM, inside Resident 8's room, Resident 8 was lying in bed. He was not wearing his hand splint. The hand splint was on top of the nightstand. During an interview on February 21, 2025, at 2:00 PM, with a Licensed Vocational Nurse (LVN 4), LVN 4 stated staff should follow the doctor's order for splint application. During a concurrent interview and record review on February 21, 2025, at 10:45 AM, with the Director of Nursing (DON), the facility's policy and procedure titled Assistive Device and Equipment dated January 2020, was reviewed. The P&P indicated, Policy Statement, our facility maintains and supervises the use of assistive devices and equipment for residents .3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan .6. c. Device condition - devices and equipment are maintained on scheduled and according to manufacturer's instructions. Defective or worn devices are discarded or repaired. d. Staff practices - staff are required to demonstrate competency on the use of devices and equipment and are available to assist and supervise residents as needed . The DON agreed the facility staff failed to follow the policy.

Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 16) reviewed for respiratory received proper respiratory care in accordance with physicians' orders and professional standards of practice. Resident 16's oxygen tubing was found disconnected from the oxygen concentrator (medical device that provides extra oxygen) for approximately 15 minutes on February 18, 2025. This failure had the potential to cause respiratory distress, oxygen deprivation and other health complications due to insufficient oxygen supply, placing Resident 16's health at risk. Findings: During a review of Resident 16's Admission Record (contains demographic and medical information), it indicated Resident 16 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (a long-term condition that make it hard to breath), dysphagia (difficulty of swallowing) and hypertension (elevated blood pressure). During a review of Resident 16's Physician Orders dated February 19, 2025, it indicated Resident 16 has an order to receive oxygen at 2-5 liter / min (liters per minute) via nasal cannula (plastic clear tube use to delivered oxygen into the body) continuously every shift. During a review of Resident 16's Care Plan for Risk for Respiratory Distress COPD dated December 11, 2024, it indicated Interventions, Monitor and report increases s/s [signs and symptoms] of SOB [shortness of breath or respiratory distress] .Oxygen available .as ordered . During an observation on February 18, 2025, from 12:59 PM through 1:14 PM, Resident 16's oxygen tubing was disconnected from the oxygen concentrator for approximately 15 minutes during lunch time. During an interview on February 18, 2025, at 1:03 PM, with Resident 16, Resident 16 stated I did not feel my oxygen was running. Resident 16 further stated that she was feeling very tired. During a concurrent interview and record review on February 21, 2025, at 1:14 PM, in Resident 16's room, with the Director of Nursing (DON), the DON verified Resident 16's oxygen tubing was disconnected from the oxygen concentrator, and stated Resident 16's oxygen tubing should always be connected to ensure she is receiving the prescribed oxygen therapy. During a concurrent interview and record review on February 21, 2025, at 10:45 AM, with the DON, the facility's policy and procedure (P&P) titled, Oxygen Administration dated February 2024, was reviewed. The P&P indicated, Assessment, Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restless, confusion); 4. Vital signs; .6. Oxygen saturation, if applicable and ., Steps in the procedure .7. Check the tubing connected to the oxygen .to assure that is free of kinks, 8. Turn on the oxygen, unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and / or nasal catheter) . The DON acknowledged the policy was not followed because Resident 16's oxygen tubing was found disconnected which could lead to serious health risk including desaturation (low oxygen levels).

Based on observation, interview, and record review, the facility failed to provide supervision to one of three sampled resident (Resident 1), when Resident 1 was left unattended and unsupervised by staff while in the Memory Care Unit patio on a hot day. This failure potentially contributed to the death of Resident 1, a clinically compromised resident with dementia (memory loss), on [DATE]. Findings: An unannounced visit was conducted on [DATE], at 12:20 PM, to investigate a complaint regarding death of a resident (Resident 1). During the tour and observation of the facility's Memory Care Unit patio, with the Director of Nursing (DON), on [DATE], at 1:50 PM, the DON stated there was no door alarm to alert the staff that someone is going out to the patio. She stated, the facility recently installed a door alarm in Memory Care Unit double exit doors on [DATE]. During an interview with the DON, on [DATE], at 2:00 PM, the DON stated Resident 1 was found unresponsive, not breathing, with skin pale, and warm to touch by Certified Nursing Assistant (CNA 1) in Memory Care Unit patio on [DATE], at 4:30 PM. During a review of Resident 1's Admission Record (contains demographic data), it indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses of Alzheimer's disease (memory loss), heart failure (a heart does not pump enough blood), and hemiplegia (caused by a brain injury resulting in varying degree of weakness on one side of the body). During a review of Resident 1's clinical notes Progress Notes , documented by Licensed Vocational Nurse (LVN), on [DATE], at 5:15 PM, it indicated, .at 4:15 PM during rounds, resident was not seen in his room or dining room. Upon checking patio, where resident goes at times, resident was seen sitting in patio bench. Upon approaching, resident was unresponsive and had no pulse. A code blue was called and simultaneously checked POLST (Physician Orders for Life-Sustaining Treatment), resident is a DNR (Do Not Resuscitate, a medical order written by a doctor to instruct health care providers not to do CPR (Cardio- Pulmonary Resuscitation an emergency life-saving procedure that is done when someone's breathing, or heartbeat stops) with comfort measures, CPR was not initiated. Resident was transferred from patio bench and hydroplaned (sliding over) using sheets back to bed. Time of death called at 5:10 PM by the DON. During an interview, on [DATE], at 1:20 PM, with Certified Nurse Assistant, (CNA 1), stated she was assigned to Resident 1 on [DATE], during the morning shift. CNA 1 stated, she started her shift from 7:00 AM to 3:00 PM. CNA 1 stated she last saw Resident 1 on the wheelchair, around 3:00 PM. She further stated she was clocking out to leave the unit, when she saw Resident 1 in the hallway, scooting in his wheelchair. CNA 1 stated Resident 1 was able to wheel himself alone, however she did not see Resident 1 going to the patio. She stated, she did not bring him in patio because Resident 1 was confused, and it was hot on [DATE]. During an interview, with the DON, on [DATE], at 2:00 PM, the DON checked the weather in Redlands (city where the facility was located) using a mobile phone. The DON stated the weather on [DATE], was at 94 Fahrenheit (F unit of measure) to 97 F from 3:00 PM to 6:00 PM. During a telephone interview, on [DATE], at 2:45 PM, with Certified Nurse Assistant, (CNA 2), she stated, she starts her shift from 3:00 PM to 11:00 PM. She further stated she was assigned to Resident 1 during the afternoon shift. CNA 2 stated it was a change of shift, and she did not do her afternoon rounds with CNA 1 (outgoing staff). She further stated she did not see Resident 1 since the start of her PM shift. CNA stated she was ready to prepare him for dinner around 4:15 PM and was unable to find him, so she went to the Memory Care Unit patio at 4:30 PM, and found Resident 1 sitting on the bench by himself, unresponsive and immediately notified the Charge Nurse. During a review of Resident 1's Care Plan , on [DATE], at 3:00 PM, it indicated, Resident 1 had a communication problem related to poor condition .Resident 1 is dependent on staff for activities, cognitive (relating to the mental process involved in knowing, learning, and understanding things) stimulation, social interactions related to cognitive deficient . During a review of Resident 1's MDS (Minimum Data Set, a standardized assessment tool that measures health status in nursing home residents) 3.0 Section C-Cognitive Patterns , on [DATE], at 3:00 PM, it indicated, Resident 1 has BIMS (Brief Interview for Mental Status, an initial tool to identify a resident's cognitive function changes) score of 4 as severely impaired (significantly limits the resident's physical or mental abilities to do basic work activities . During an interview, on [DATE], at 2:15 PM, with the Minimum Data Set Coordinator, he stated Resident 1 was confused, wanders, wheelchair bound but able to scoot himself with his wheelchair around the facility and needs to be re-directed. He further stated Resident 1 needed minimal assist in transfers from wheelchair to bed, bed to wheelchair. During a follow up interview with the DON, on [DATE], at 9:10 AM, the DON stated she did not call 911 for Resident 1 because the POLST was Do Not Resuscitate. She further stated she cannot remember if she saw Resident 1 in the patio. She stated they did not call the police, but able to call and notify Resident 1's physician and family member. During an interview with Activity Director Assistant, on [DATE], at 9:50 AM, she stated, she had seen Resident 1 trying to open the patio door, but she has not seen Resident 1 able to make it outside. She stated Resident 1 should not be left alone, unassisted, and unsupervised. She further stated Resident 1 had memory problems and needed to have constant re-direction. She stated resident's safety was the facility's concern and the facility cannot leave confused residents by themselves. She further stated they should have checked him more often and kept their eyes on him. She stated Resident 1's passing could have been avoided if there was adequate supervision. A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents , dated [DATE], indicated, 2. Safety risks and environmental hazards are identified on an ongoing through a combination of employees training, employee monitoring, and reporting process .4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents .2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents .3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices .2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment . During an interview, on [DATE], at 10:30 AM, with the Director of Nursing (DON), the DON further stated all residents in the Memory Care Unit were vulnerable for accident or harm and it was possible the death of Resident 1 might have been prevented or avoided if Resident 1 was seen earlier. An immediate jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 Free of Accident Hazards/Supervision/Devices S483.25(d) Accidents. The facility must ensure that - S483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on [DATE], at 11:55 AM, in the presence of the Administrator and the Director of Nursing when Resident 1 was left unattended and unsupervised by staff while in the Memory Care Unit patio on a hot day and contributed to the death of Resident 1 on [DATE]. A corrective action plan was requested on [DATE], at 11:55 AM. A corrective action plan was provided by facility on [DATE], at 12:45 PM included: * Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator identified 31 wheelchair bound residents as clinically compromised, wheelchair bound residents including 15 residents located in the Memory Care Unit. *All identified residents have been assessed on their ability to sit on either patio, safely with supervision. Only 7 residents can safely sit on the patio with the line-of-sight supervision based on cognitive status and functional ability. The 7 residents identified are located on Station A. All 15 residents in Station B-Memory Care Unit require direct supervision if on the patio. * All 31 resident's person-centered care plans have been revised and updated. *Administrator and DON and other staff members conducted random rounds checking the outside patio on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], and at this time, there have been no other residents affected. * Maintenance Supervisor installed security alarm on Memory Care Unit double doors heading toward the outside patio on [DATE] to alert the staff when the double doors open, and it indicates that someone is going outside to the patio in Station B. *Maintenance Supervisor and/or Designee will check the door alarm once a day Monday through Friday and the Manager of the Day will check the door alarm once a day on Saturday and Sunday. *License Nurse assigned to Station B will check the door alarm function every 2 hours and the outside patio. At the change of shift, the License Nurses will check the outside patio and the door alarm to ensure it's alarmed, functioning, and will be endorsed to the next shift. The License Nurse will use the form, Door Alarm & Patio Check (every 2 hours and change of shift) . *CNA (Certified Nursing Assistant) will conduct safety rounds every hour during their shift to ensure every resident assigned to them is accounted for. The CNA's will document on Resident Safety Log . *DON and DSD (Director of Staff Development) in-serviced and re-educated the staff on [DATE], [DATE], and [DATE] on the door alarm and on the policy and procedure titled, Safety and Supervision of Residents , emphasizing that if the door alarm goes off to immediately check who is outside, ensure the resident is safe, and redirect them back inside especially on hot days. The staff were informed that no resident should be left outside unsupervised. *Any staff that is scheduled off, on vacation time, or on a leave of absence will be in-serviced before assigned to the floor by the Director of Nursing and/or the Director of Staff Development. *All new admissions and readmissions will be assessed during the Clinical Meeting (Monday through Friday), to assess potential risk and hazards and ensure that their person center care plan is revised and updated as needed. Friday Admission/Readmission will be reviewed on Saturday by the MDS Assistant. Saturday Admission will be reviewed on Sunday by DON. *The Department Heads and the Manager of the Day will conduct hourly rounds Monday through Friday including weekends to ensure that no residents are outside in the patio unsupervised. Any residents found outside will be supervised and/or re-directed inside. Any findings will be documented in the Angel Rounds Report and reported to the Administrator and the Director of Nursing immediately. *The QAPI Committee will evaluate the intervention and determine if identified goals re met or if new interventions are needed. The report will be reviewed monthly by the QAPI Committee for three months and quarterly thereafter. The immediate jeopardy was removed after the Corrective Action Plan was verified to be implemented through observations, interviews, and record reviews on [DATE], at 2:58 PM in the presence of the Administrator and the Director of Nursing.

Based on observation, interview, and record review, the facility failed to ensure staff provided care according to facility's policy and procedure and acceptable standards of clinical practice for one of three residents (Resident 1) when Resident 1 received blisters to the bottom of both feet and no wound care was provided for three days. This failure potentially jeopardized Resident 1's highest practicable level of health and well-being. Findings: A review of Resident 1's clinical records, indicated Resident 1 was readmitted to the facility on [DATE], and originally admitted [DATE] with [DIAGNOSES REDACTED]. During an observation of Resident 1 with Licensed Vocational Nurse 1 (LVN 1) on August 29, 2019 at 2:35 PM, Resident 1 was awake in bed, lying on her back and had Prevalon heel protector (designed to lift the heel off the mattress, minimizing pressure on the heel) covering her right foot. LVN 1 picked up Resident 1's right foot and Resident 1 grimaced and pushed LVN 1's arm away. A review of the nurse's progress note dated July 26, 2019 at 9:21 PM, Certified Nursing Assistant (CNA) providing cooling measures to Resident 1. A review of the nurse's progress note dated July 31, 2019 at 3:02 PM, revealed the following: CNA found Resident 1 on July 26, 2019 around 2:30 PM, walking in the walkway with non-skid socks on. Assisted back in, given water and sat on the porch. At around 4:00 PM, the Charge Nurse (CN) noticed Resident 1 looked warm, temperature was 99.6 Fahrenheit (F), cooling measures and [MED] (Pain medication and fever reducer) were provided. While the CNA was changing Resident 1's clothes, she noticed blisters to the bottoms of both feet. Reported to Responsible Party (RP) and physician. New orders received for Complete Blood Count to be drawn on Monday and wound care physician to look at blisters. A review of the nurse's progress notes revealed the incident of Resident 1 being found on July 26, 2019 around 2:30 PM with blisters on the bottom of Resident 1's feet, was not documented by a skilled nurse until five days after it occurred. A review of the Change in Condition (CIC) Evaluation for Resident 1, dated July 26, 2019 at 9:04 PM, indicated it was completed for fluid blisters to Resident 1's feet on July 26, 2019 in the afternoon. Describe skin changes: Blister. Describe the blister: New onset large tense blisters with fever no size, color or if skin is intact. Under pain evaluation it indicates: Resident has no pain. Under date and time primary care physician notification: July 26, 2019 at 9:00 PM and Responsible Party (RP) notification was 9:20 PM. Recommendation of physician is Complete Blood Count (CBC-is the calculation of the formed elements of blood). During an interview with LVN 1 on August 29, 2019 at 2:24 PM, LVN 1 confirmed she heard that Resident 1 was found outside on July 26, 2019 with barefoot and received blisters to the bottom of both feet. LVN 1 stated it was very hot outside that day and Resident 1 is always supposed to have socks and shoes on. LVN 1 stated because Resident 1 has [MEDICAL CONDITION], Resident 1 is unable to notify the nurses how she received the blisters to the bottom of both of feet. LVN 1 has acknowledged this has changed Resident 1's quality of life because Resident 1 was able to ambulate, smiled a lot and now depends on staff to get her up and transfer her to a geri-chair (a large reclining chair). LVN 1 further stated Resident 1 had no treatment ordered for wound care for her blisters on her feet prior to the wound care physician that assessed her blisters, drained them, and ordered daily wound care to be completed by our treatment nurse on July 29, 2019. A review of Resident 1's physician's order summary report dated July 30, 2019, revealed an order dated on July 29, 2019 and a start date of July 30, 2019 for the following: a. Cleanse blister to left heel with normal saline (NS), pat dry, apply xeroform (sterile wound dressing that will not stick), apply antibiotic disinfectant (ABD- help prevent infection) pad, secure with [MED] (woven gauge dressing) every shift for blister for 14 days. b. Cleanse blister to left plantar (thick band of tissue that connects the heel bone to toes) foot with NS, pat dry, apply xeroform, apply ABD pad, secure with [MED] every shift for blister for 14 days. c. Cleanse blister to right heel with NS, pat dry, apply xeroform, apply ABD pad, secure with [MED] every shift for blister for 14 days. d. Cleanse blister to right plantar foot with NS, pat dry, apply xeroform, apply ABD pad, secure with [MED] every shift for blister for 14 days. e. Wound consult with (Name of physician) order date of July 29, 2019. f. Monitor fluid filled blisters to bilateral (both) plantar feet for skin breakdown, notify physician if occurs every shift for 14 days. Order date of July 27, 2019 There was no documented evidence on Resident 1's Medication Administration Record [REDACTED]. Reviewed TX log for Resident 3 with LVN/CN 1 for the months 8/19 through 1/20 and it revealed the following: For August 2019 the following dates reflected no documentation for wound Care-Cleanse Blister to left heel with NS, dry apply triple antibiotic ointment, apply Xeroform, apply ABD pad, secure with [MED] every day shift for blister for 14 days for August 3,8,10, 2019. Cleanse Blister to left plantar foot with NS, dry apply triple antibiotic ointment, apply Xeroform, apply ABD pad, secure with [MED] every day shift for blister for 14 days for August 3, 2019. Cleanse Blister to right heel with NS, dry apply triple antibiotic ointment, apply Xeroform, apply ABD pad, secure with [MED] every day shift for blister for 14 days for August 3,8.10, 2019. Cleanse Blister to right plantar foot with NS, dry apply triple antibiotic ointment, apply Xeroform, apply ABD pad, secure with [MED] every day shift for blister for 14 days for August 3, 2019. Monitor fluid filled blisters to bilateral plantar feet for skin breakdown. Notified MD if occurs every shift fluid filled blisters for 14 days revealed missing documentation for 7-3 for August 3 2019, and 3-11 August 4 2019. For September 2019 the following dates reflected no documentation for wound care for Cleanse Blister to right plantar foot with NS, dry apply triple antibiotic ointment, apply Xeroform, apply ABD pad, secure with [MED] every day shift for blister for 14 days: September 4,8, 2019. For October 2019 the following dates reflected no documentation for wound care for Cleanse Blister to right plantar foot with NS, dry apply Iodine, cover with ABD pad, secure with [MED] every day shift for blister for 14 days: October 13, 2019. For November 2019 Clean solution apply to RT heel topically every day for blister for 14 days Cleanse Blister to right heel with NS, dry apply Iodine swab cover with dry dressing. Missing documentation for 11/17,18,19, 23, 27/19 For November 2019 Boost BID 1 box for supplement missing documentation for November 17,18x2,19x2, 22x2, 23x2, 24x2, 25x2, 26x2, 27x2, 28x2, 29x2, and 30x2. For November 2019 Resource BID for supplement missing documentation for November 17,18x2,19 x1, 22x2, 23x2, 24x2, 25x2, 26x2, 27x2, 28x2, 29x2, and 30x2. On January 15, 2020 reviewed TX log for Resident 3 with LVN/CN 1 and she confirmed the missing documentation and that could have jeopardized her wound care by if those TX's had been missed and the supplements were not given. During interview with Treatment Nurse/LVN 2 (TX/LVN 2) on August 28, 2019, at 2:50 PM, TX/LVN 2 stated Resident 1 has blister's on both her feet and TX/LVN 2 does wound care everyday on both feet. TX/LVN 2 stated Resident 1 had no wound care provided until July 29, 2019 when the wound care physician assessed her wounds. TX/LVN 2 stated the wound care physician ordered Prevalon heel protectors bilaterally to protect her feet. TX/LVN 2 further stated she not know how Resident 1 acquired the blisters to both feet. A review of Resident 1's multi wound chart details, completed in the facility, dated July 29, 2019 by wound care physician with instructions for non-weight bearing bilateral lower extremities (BLE) revealed the following: a. Right Plantar Foot- Blister measures four by (x) 2.8 centimeters (cm-unit of measure) with [MEDICAL CONDITION]- debridement done. Treatment Xeroform (is an occlusive dressing that keeps air out, which can help to protect the area while also promoting a moist environment for healing), ABO, and [MED]. b. Right Heel-Blister- measures 14. 5 cm x 17 cm with [MEDICAL CONDITION]- debridement done. Treatment Xeroform, ABO, and [MEDEQUIP]. c. Left Plantar Foot- Blister- measures two cm x 1.5 cm with [MEDICAL CONDITION]-debridement done. Treatment Xeroform, ABO, and [MEDEQUIP]. d. Left Heel-Blister-measures 14 cm x 15.2 cm with [MEDICAL CONDITION]- debridement done. Treatment Xeroform, ABO, and [MEDEQUIP]. A review of multi wound chart details, completed in the facility, dated July 31, 2019 by wound care physician revealed the following: a. Right Plantar Foot- Blister measures eight cm x 14 cm x 0. 1 cm with moderate amount of drainage. Treatment Triple antibiotic ointment (TAO), Xeroform, and dry dressing. b. Right Heel-Blister- measures 1.3 cm x 1.2 cm with moderate amount of drainage. Treatment TAO, Xeroform, and dry dressing. c. Left Plantar Foot- Blister- measures 12 cm x 14 cmx 0.1 cm with moderate amount of drainage. Treatment TAB, Xeroform, and dry dressing. d. Left Heel-Blister-measures 3.3 cm x 2.3 cm with moderate amount of drainage. Treatment TAO, Xeroform, and dry dressing. A review of multi wound chart details, completed in the facility, dated [DATE] by wound care physician revealed the following: a. Left Heel- Blister measures 0.5 cm x 2 cm with scant amount of drainage. b. Right Heel-Blister- measures 5.3 cm x 4.5 cm with no drainage. During an interview with the Director of Nursing (DON) and Administrator on August 29, 2019 at 3:00 PM, the Administrator was asked if he knew how Resident 1 obtained the blisters on the bottom of both feet, the Administrator stated, Did you ask my staff. The Administrator further stated he would need to review Resident 1's clinical record. When asked the DON/ADM, if the facility followed their policy and procedure for CIC and wound care and they both stated they would have to review the policy's. A review of Resident 1's care plans (C/P's) indicated one was written for a blister to her right plantar foot with date initiated July 26,2019. Interventions: CBC, wound consults, monitor for [AGE] hours, notify physician if any changes. Offloading of bilateral feet, Prevalon boots on at all times with date initiated August 7, 2019. During a telephone interview with Resident 1's RP on September 3, 2019 at 11:30 AM, Resident 1's RP stated (Name of Facility) called him on July 26, 2019 at 9:00 PM and informed him Resident 1 had received some bruises on her feet but, they did not know how it happened. Resident 1's RP stated he visited his mom on July 27, 2019 around 10:00 AM and found Resident 1 had fluid filled blisters to both feet. When requested to have Resident 1 sent to the hospital, the facility responded they would need to get an order from Resident 1's physician. Resident 1's RP asked about wound care and treating his mom's pain, he was informed a wound care specialized would see her on July 29, 2019 and they were administering [MED] for the pain. Wound care physician did treat Resident 1 on July 29, 2019, but, Resident 1's RP stated the physician debrided (to remove damaged tissue) the blisters right there in the facility Resident 1' RP stated a Registered Nurse (RN) informed him, the physician ordered no wound care treatment until July 29, 2019 when the wound specialized comes. He was very concerned about his mom getting a delay of care from (Name of Facility} and how they could treat Resident 1 like that. A review of the facility's policy and procedure titled, Acute Condition Changes-Clinical Protocol, Revised December 2012, indicated .In addition the nurse shall assess and document /report the following baseline information a. vital sign b. neuro status c. current level of pain d. level of consciousness e. cognitive and emotional status f. resident's age and sex g. onset, duration and severity h. recent labs I. history of mental illness j. all active [DIAGNOSES REDACTED]. The nursing staff will contact the physician based on the urgency of the situation. The attending will respond in a timely manner. The staff will notify the Medical Director for additional guidance and consultation if they do not receive or appropriate response. Review of the job description for the Charge Nurse, dated October 3, 2003, indicated . The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day- to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times. A review of the facility's policy and procedure titled, Wound Care, revised October 2010, indicated . The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident.

Based on observation and record review the facility failed to : 1. Ensure that one of 10 sampled residents (Resident 8) received a sufficient fluids as recommended by the registered dietitian (RD) of 1626- 1788 ml (milliliters) per day for hydration. 2. Ensure that the fluid intake for 2 of 10 sampled residents (Residents 4, and 5 ) were completed and recorded to accurately track the residents hydration status. These failures had the potential to result in over-hydration (too much fluid) or dehydration (not enough fluid) for the residents. Findings: 1. A record review for Resident 8 conducted on 10/10/11, showed Resident 8 was admitted to the facility with [MEDICAL CONDITION] (a chronic, progressive brain disease that causes loss of memory) , Acute Kidney Failure and other medical conditions. A review of the Total Intake and Output Record dated 9/22/11 showed: Day - 900 ml PM - 540 ml NOC- 60 ml Total intake= 1,500 ml for 24 hours Total output= x 7 (The resident had wet diapers 7 times) A review of the RD (Registered Dietician) notes, dated 9/8/11, indicated that fluid requirement for Resident 8 was 1628- 1788 cc per 24 hours. Care plan interventions for Resident 8 included monitoring the resident's fluid intake and output every shift, 24 hours to ensure that Resident 8 meet the amount of fluid recommended by the RD. In an interview with the DON on 10/11/11 at 8:45 AM, the DON stated that residents on intake and output are being monitored closely, " I don't know what happened that day." 2. At 9 AM, on the same day, 10/11/11, a tour of the Alzheimer's Unit with the DON was conducted in relation to monitoring of fluids and to observe how the hydration program was being implemented. It was noted that there was no water pitcher by the bedside. In an interview with the DON during the observation, she explained that, " For safety reasons, no water pitcher is left by the bedside. Fluids, water and juice are available in the dining room". Hydration records were requested for review. Samples of Fluid Consumed records for the month of October were presented with the list of all the residents and the amount of fluid consumed by each resident.. The Fluid Consumed records revealed that Resident 4 had no documentation to indicate that the resident's fluid intake had been monitored from 10/2/11 to 10/5/11 and 10/9/11. The Fluid Consumed record for Resident 5 was left blank on 10/7/11 for the 7 AM - 3 PM shift. The daily Nursing Report under the section "Important Information You Must Know" indicated, "ENCOURAGE FLUIDS". The DON acknowledged the findings at the time of the hydration record review. During an interview with the RN on 10/11/11, at 9:15 AM, she stated that the CNAs ( Certified Nursing Assistant) were made aware of the signs and symptoms of dehydration. She further stated that the LVN in charge, records the daily total amount of fluid intake and output. On 10/12/11 at 9:50 AM an interview with the LVN ( Licensed Vocational Nurse) charge nurse was conducted. She stated that CNAs were educated that it was important to keep an accurate Intake and Output to prevent dehydration or over-hydration. They were taught to recognize the warning signs of dehydration and were provided with "Early Warning Tool, STOP AND WATCH" to alert the charge nurse. The Charge nurse then upon assessment will initiate a change of condition and notify the attending physician. In a subsequent interview with the CNA, she expressed her understanding of the importance of recording the Intake and Output. The CNA also was able to state the process to follow once an early warning sign of dehydration was recognized.