Every finding on record at Horizon Health & Subacute Center

Based on observation, interview, and record review, the facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions when one out of two outdoor dumpsters was observed with one lid open. This failure had the potential to attract pests, create offensive odors and negatively impact food safety and the overall sanitary environment of the facility. During a concurrent observation and interview on 7/28/26 at 8:45 a.m. during the initial tour of the kitchen with Dietary Service Supervisor (DSS), the facility was observed with two dumpsters located behind the building. One dumpster for food waste was observed with one lid open. The DSS stated the dumpster's lid should be closed all the time to prevent rodents from getting in the dumpster and could possibly spread disease. During an interview on 7/29/26 at 2:40 p.m. with Dietary [NAME] (DC) 2, DC 2 stated the practice was to ensure the outside dumpster's lid for food waste was to keep closed to prevent rodents from getting in. DC 2 stated the dumpster was dirty and did not want rodents to spread disease and keep the smell contained. During a phone interview on 7/31/26 at 9:25 a.m. with the Registered Dietitian (RD), the RD stated the expectation was to ensure the dumpster's lids for food waste behind the facility were kept closed. The RD stated it was important to keep the dumpster's lid closed to keep unwanted pests away, pests could spread things in the food. During a review of facility's policy and procedure (P&P) titled, Waste Disposal, dated 2026, the P&P indicated, .Waste containers will be emptied as often as necessary throughout the day and at the end of each day. Trash will be deposited into a sealed container outside the premises.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four of 15 sampled residents (Residents 132, 12, 31, and 121) when: 1. Resident 132's nutrition care plan for significant unintended weight loss was not developed. This failure resulted in Resident 132 not being accurately assessed and monitored for significant weight loss by qualified staff which could increase the risk of malnutrition (a state in which a deficiency of nutrients such as energy, protein, vitamins, and minerals causes measurable adverse effects on body composition, function, or clinical outcome), and had the potential for Resident 132 to experience unrecognized negative outcomes including decline in oral intake, worsening of pressure ulcer, and decrease in functional mobility. 2. Resident 12's care plan was not developed to reflect the specific care preferences requested from Resident 12's Responsible Party (RP) 1. This failure had the potential for Resident 12's and Resident 12's Responsible Party's needs and wishes to go unmet. 3. Resident 31 did not have a care plan developed and implemented for the use of oxygen (clear, odorless, and tasteless gas) and insulin (medication used to treat diabetes [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]). 4. Resident 121 did not have a care plan developed and implemented for the use of antibiotics (medication used to treat bacterial infection) since 3/7/26. These failures had the potential to put Resident 31 and Resident 121 at risk of developing complications, side effects, not experiencing relief and not meeting their needs. Findings: 1.During a concurrent observation and interview on 7/28/26 at 9:34 a.m. with Resident 132, in Resident 132's room, Resident 132 was lying in bed, awake, and mumbling. Resident 132 had inability to respond and kept eye contact during conversation. Resident 132 was repeatedly touching the edges of his blanket. During an observation on 7/28/26 at 12:40 p.m. with Resident 132, in Resident 132's room, Resident was lying in bed awake. Resident 132's lunch tray was on top of the bedside table beside Resident 132's right side of bed. Resident 132's lunch tray contained a plate of puree, a carton of milk, and a glass of red juice. During a review of Resident 132's lunch meal ticket dated 7/28/26, the lunch meal ticket indicated, Texture: Puree (solid food that has been blended, mashed, or processed into a smooth, moist, and uniform texture similar to pudding or applesauce), Special Diet: Regular Diet -Thin Liquids.Standing Orders: Fruit juice, Milk 2%. During a concurrent observation and interview on 7/28/26 at 12:46 a.m. with Certified Nursing Assistant (CNA) 5, in Resident 132's room, CNA 5 was placing and setting up Resident 132's lunch tray in front of him. CNA 5 stated Resident 132 does not need assistance with meals, only need set-up. CNA 5 stated Resident 132 had a black lunch tray which indicated Resident 132 does not need assistance with eating. CNA 5 stated residents with red lunch tray require one-on-one assistance with meals. CNA 5 left Resident 132's bedside. During an observation on 7/28/26 at 12:48 p.m. with Resident 132, in Resident 132's room, Resident 132 started eating using the straw (covered with paper) to scoop the puree food. Resident 132 placed the straw in his mouth and started eating the straw and chewing the paper cover of the straw. Resident 132 started putting the spoon (without food) in his mouth. During a concurrent interview and record review on 7/29/2026 at 11:31 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 132's Order Summary Report dated 7/2026 was reviewed. The Order Summary report indicated, Dietary-Diet Regular diet Puree texture, Thin Liquids consistency.Dietary Supplements - [Brand Name] with meals for supplement 8 oz (ounces-) with meals Start Date 7/9/26. LVN 6 stated Resident 132's supplement was provided by the kitchen and included in his tray every meal. LVN 6 stated Resident 132's supplement was administered by the CNAs and CNAs reported to licensed nurses when he refused it. LVN 6 stated she documented Resident 132's supplement was administered for breakfast today (7/29/26) by the CNA and not aware of the amount of consumption. LVN 6 stated Resident 132 had a physician's order of supplement with meals due to Resident 132's oral intake of less than 50% (percent). During a concurrent observation and interview on 7/29/26 at 12:30 p.m. with LVN 6, in the hallway across Resident 132's room, the tray cart containing Resident 132's tray was checked. Resident132's lunch tray does not contain a supplement. LVN 6 stated Resident 132 was assisted by CNA 6 for lunch. LVN 6 stated Resident 132's supplement was given by CNA 6 and Resident 132 refused the supplement. LVN 6 stated CNA 6 could toss the supplement that's why the supplement was not present in Resident 132's lunch meal tray. During a review of Resident 132's lunch meal ticket dated 7/28/26, the lunch meal ticket indicated, Texture: Puree (solid food that has been blended, mashed, or processed into a smooth, moist, and uniform texture similar to pudding or applesauce), Special Diet: Regular Diet- Thin Liquids.Standing Orders: Fruit juice, Milk 2%. During a concurrent observation and interview on 7/29/26 at 12:38 p.m. with LVN 6 and CNA 6, LVN 6 called and validated Resident 132's supplement consumption with CNA 6. CNA 6 stated Resident 132's lunch tray does not contain a supplement. CNA 6 stated supplement was not given to Resident 132 due to being not available in his lunch tray. CNA 6 stated Resident refused his lunch meal including the milk and juice. During a concurrent interview and record review on 7/29/26 at 11:38 a.m. with Unit Manager (UM) 1, Resident 132's Electronic Medical Records (EMR) titled Weights, and Amount Eaten dated 7/2/26 to 7/29/26 were reviewed. The Weights indicated, 7/29/2026 146.0 lbs. (pounds – a unit of weight),7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The Amount Eaten indicated, 0-25% with 41 check marks, 26-50% with 12 check marks, and Resident Refused with 14 check marks. UM 1 stated Resident 132 had triggered a significant unintended seven pounds weight loss from 7/19/26 to 7/26/26. UM 1 stated Resident 132 was at risk for malnutrition due to poor oral intake since admitted to the facility on [DATE] with total check marks (0-25%, 26-50%, and refusals) of 67 out of 84 meals (more than 50%). UM1 stated she communicated with the Registered Dietitian (RD) regarding Resident 132's significant unintended weight loss and poor oral intake and was instructed to reweigh Resident 132. UM 1 stated she did not notify the physician and Resident 132's responsible party about his significant unintended weight loss. UM 1 stated Resident 132's significant weight loss should require a notification from his physician for further evaluation and additional interventions to prevent further weight loss. During a concurrent interview and record review on 7/29/26 at 11:45 a.m. with Unit Manager (UM) 1, Resident 132's nutrition care plan dated 7/2/26 was reviewed. The nutrition care plan indicated, Focus – At risk for altered nutritional status r/t Alzheimer's Disease, dementia, need for assistance with personal care, Parkinsonism. Date Initiated: 07/02/2026. Goal – Will have signs and symptoms of weight changes/malnutrition identified and managed through the review date. Interventions/Tasks – Administer Supplements/Fortified Foods/Snack: N/A. UM 1 stated care plan goal was not objective and should specify signs and symptoms of weight gain and weight loss for accurate assessment. UM 1 stated there was no care plan specific for significant unintended weight loss and should be developed to ensure current interventions related to significant unintended weight loss were being implemented by staff. During a concurrent interview and record review on 7/29/26 at 11:55 a.m. with UM1, Resident 132's electronic medication administration record (EMAR- a daily digital documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/9/26 to 7/29/26 was reviewed. The EMAR indicated, [Brand Name] with meals for supplement 8 oz (ounces- a unit of volume used mostly for liquids) with meals Hours 0900, 1300 (1:00 p.m.), 1700 (5:00 p.m.) showing check marks with Licensed Nurses' initials and X marks for ML (milliliters- metric unit used to measure the volume of a liquid). UM 1 stated check marks in Resident 132's EMAR for supplement indicated it was given and does not mean consumption. UM 1 stated X marks in Resident 132's EMAR for supplement indicated amount of consumption were not documented. UM 1 stated Resident 132's supplement should be included in his food tray for every meal and should be given by the CNAs during meal. UM 1 stated Resident 132's supplement consumption should be documented by the licensed nurses in the EMAR to accurately monitor and evaluate effectiveness of current nutritional intervention to prevent further weight loss. During a review of Resident 132's admission record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/29/26, the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and need for assistance with personal care. During a review of Resident 132's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/8/26, the MDS section C indicated Resident 132's BIMS - was not conducted with a code of 0 indicating No (resident is rarely/never understood). Resident 132's BIMS Summary Score was blank. The MDS Section GG-Functional Abilities-admission indicated, .Safety and Quality of Performance 01-Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity 1. admission Performance: 01 -Eating. The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident . Section K – Swallowing/Nutritional Status. The MDS Section K -Swallowing/Nutritional Status indicated, K 0100. Swallowing Disorder – Signs and symptoms of possible swallowing disorder D. Complaints of difficulty or pain with swallowing. During an interview on 7/30/26 at 9:00 a.m. with CNA 7 stated he was assigned to Resident 132 today (7/30/26) and was familiar with his care. CNA 7 stated Resident 132's oral intake had always been poor for breakfast, about 0-25 percent, and better for lunch. CNA 7 stated that when Resident 132's wife visits, she assisted him with feeding. CNA 7 stated CNA 8 assisted him for breakfast today (7/30/36). During an interview on 7/30/26 at 9:06 a.m. with CNA 8, CNA 8 stated she fed Resident 132 at breakfast today (7/30/26). CNA 8 stated Resident 132 only consumed 2 bites of puree food and refused [Brand Name] supplement. CNA 8 stated Resident 132 started to be combative (ready, eager, or inclined to fight, or resist) and it was her first time assisting him with meals. During a concurrent interview and record review on 7/30/26 at 10:19 a.m. with the RD, Resident 132's weights dated 7/2/26 to 7/29/26 and Nutrition Comprehensive assessment dated [DATE] were reviewed. The Weights indicated, 7/29/2026 146.0 lbs. (pounds – a unit of weight), 7/27/2026 145.0 lbs.,7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The Nutrition Comprehensive Assessment indicated, 10. Medical Nutrition Therapy (MNT) Summary: Parkinsonism, Alzheimer's. dementia, IBW (Ideal Body weight)171 lbs. Skin: [NAME] Tissue Injury (DTI- a severe pressure injury [damage to the skin and soft tissue caused by prolonged pressure, often over a bony part of the body like the heels, hips, or tailbone] where deep underlying soft tissue is damaged) to sacrococcygeal (the area of the body where the sacrum [the large triangular bone at the base of the spine] meets the coccyx [the tailbone] ) . Resident with po (by mouth) intake 35%Regular Puree diet with meal refusals. Recommend adding 8 oz Ensure TID (three times a day). Monitor weight, skin and po. The RD stated Resident 132 had a significant unintended weight loss of more 10% in less than 30 days and the facility treat as severe weight loss. The RD stated Resident 132's nutrition care plan should reflect Resident 132's significant unintended weight loss with current goal of stabilizing his weight with no further significant weight loss. During a concurrent interview and record review on 7/31/26 at 11:40 a.m. with the Director of Nursing (DON), Resident 132' s EMR titled Weights, dated 7/2026 were reviewed. The Weights indicated, 7/29/2026 146.0 lbs.,7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The DON stated Resident 132 triggered a significant unintended weight loss on 7/26/26 and not weighed weekly from 7/2/26 to 7/12/26. The DON stated significant weight changes including loss and gain applies to 5% in 1 month, 7.5% in three months, and 10% in six months. The DON stated the facility also addresses a five pounds weight loss in a week. The DON stated Resident 132 was at risk of malnutrition from admission due to diagnosis of Dementia and require assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The DON stated it was her expectation for all licensed nurses to complete a change in condition evaluation and developed a person-centered care plan on the same day when resident triggered for a significant weight loss to identify and evaluate the root cause of weight losses and prevent a delay in the implementation of new interventions and necessary services to prevent further weight loss. The DON stated it was important to develop a care plan for significant unintended weight loss for Resident 132 to reflect current nutritional interventions in effectively managing Resident 132's significant unintended weight loss. During a review of facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person Centered, dated 3/2022, the P&P 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. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (3) which professional services are responsible for each element of care; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions; 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. During a review of facility's policy and procedures (P&P) titled, Weight Assessment and Intervention, dated 3/2022. The P&P indicated, Weight Assessment and Intervention. Resident weights are monitored for undesirable or unintended weight loss or gain. Weight Assessment – 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team.3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. a. 1 month – 5% weight loss is significant; greater than 5% is severe. b. 3 months – 7.5% weigh loss is significant; greater than 7.5% is severe. c. 6 months – 10% weight loss is significant; greater than 10% is severe. Evaluation – 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: b. the resident's calorie, protein, and other nutrient needs compared with the resident's current intake; c. the relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. whether and to what extent weight stabilization or improvement can be anticipated. 2. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. cognitive or functional decline; b. chewing or swallowing abnormalities; f. increased need for calories and/or protein; i. inadequate availability of food or fluids. Care Planning – 2. Individualized care plans shall address, to the extent possible; the identified causes of weight loss; b. goals and benchmarks for improvement; and c. time frames and parameters for monitoring and reassessment. Interventions – 1. Interventions for undesirable weight loss are based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; e. Chewing and swallowing abnormalities and the need for diet modifications; g. The use of supplementation. During a review of facility's P&P titled, Nutritional Assessment, dated 10/2017, the P&P indicated, As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition should be conducted for each resident. 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the residents at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. 3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: a. Nursing: (3) A description of the resident's usual intake and appetite; (4) A history of reduced appetite or progressive weight loss or gain prior to admission; (5) Current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors; (9) Usual meal and snack patterns. 4. The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition. a. Cognitive or functional decline. b. Chewing or swallowing abnormalities. 7. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences. 8. Individualized care plans shall address to the extent possible: a. the identified causes of impaired nutrition; b. the resident's personal preferences; c. goals and benchmarks for improvement; and d. time frames and parameters for monitoring and reassessment. During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. vital to positive patient outcomes. the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition. 2. During an observation on 7/28/2026 at 9:55 a.m. outside and inside Resident 12'a room, a Contact Precautions (safety measures taken to help prevent the transmission of infectious diseases that can be spread by contact) sign was observed on the wall next to Resident 12's room. Resident 12's room was a single resident room and Resident 12 was observed sitting up, asleep, wearing a gown, with a tracheostomy (a surgical opening in the windpipe to allow air and oxygen reach the lungs) site with oxygen tubing connected. Resident 12 was non-responsive to questions. During a review of Resident 12's AR, dated 7/31/26, the AR indicated Resident 12 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), anoxic brain damage (occurs when the brain receives no oxygen at all), Persistent vegetative state (when a person is awake, but shows no signs of awareness), osteomyelitis (infection [the invasion and growth of germs in the body] in the bone), pressure Ulcer Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) to the sacral [the triangular shaped bone at the base of the back] region and anemia (disease that occurs when the body doesn't have enough red blood cells to carry oxygen). During a review of Resident 12's MDS, dated 4/30/26, the MDS section B indicated, .persistent vegetative state/no discernible consciousness.Yes. During a concurrent observation and interview on 7/29/26 at 11:12 a.m. in Resident 12's room with RP 1, RP 1 stated Resident 12 had been sent to the hospital frequently due to bleeding from his wounds and needing blood transfusions (a procedure in which whole blood or parts of blood are put into a patient's bloodstream through a vein). RP 1 stated Resident 12 was not repositioned enough by staff and when Resident 12 was changed he needed to have his wound dressing replaced, which sometimes his dressing was not put back on. RP 1 stated Resident 12 needed a cloth padding, and not the plastic chucks pad underneath him. Observed a cloth padding underneath Resident 12. During an interview on 7/29/26 at 11:45 a.m. with Registered Nurse (RN)1, RN 1 stated the Respiratory Therapist (RT) was on vacation and all RNs were trained to give respiratory therapy to residents with a tracheostomy or connected to a respiratory ventilator (Vent – a machine or device used medically to support or replace the breathing of a person). RN 1 stated there were usually two staff scheduled on the floor to assist with the residents. RN 1 stated sometimes they had two Certified Nursing Assistants (CNA)s but lately they have had only one CNA to help the nurse with the resident's care and reposition the residents. RN 1 stated staff had to help each other with resident care and repositioning the residents. RN 1 stated as the RN floor nurse residents on vents were checked every four hours and CNAs checked the residents on vents every two hours and helped re-position the residents. RN 1 stated as RT, she checked her vent residents every one hour. During an interview on 7/30/2026 at 9:57 a.m. with LVN 2, LVN 2 stated she was familiar with Resident 12. LVN 2 stated Resident 12's RP wanted Resident 12 positioned in a particular way with padding under his wound and seated in a High-Fowler's (positioning the patient in a semi-sitting posture, with the head of the bed elevated between 60 and 90 degrees) position. LVN 2 stated she had explained to RP 1 about Resident 12's wound cleaning and healing. LVN 2 stated the facility had a Wound Nurse who checked and redressed Resident 12's wound with a CNA every morning. LVN 2 stated Resident 12 had gone to the hospital frequently due to his chronic wound. LVN 2 stated Resident 12 has had his wound since he was admitted to the facility. During a concurrent interview and record review on 7/31/2026 at 9:31 a.m. with Wound Nurse (WN) 1, Resident 12's Order Summary Report (OSR), dated 7/31/26 was reviewed. the OSR indicated, .Stage IV pressure injury site: sacrococcygeal. Cleanse daily with normal saline or Wound Cleanser, pat dry, apply [brand name] cream and Medi-honey.elevate head of bed [HOB] 30-45 degrees at all times during feedings and for 1 hour post-administration of feedings. WN 1 stated Resident 12 had a large area of wound that covered the whole rectum (the end of the large intestine that connects to the anus [opening where stool exits the body]) and sacrococcygeal (pertaining to both the sacrum and coccyx [tailbone] area. WN 1 stated the wound was left open to air (not covered with a dressing) to help with air flow and healing of the wound. WN 1 stated he had spoken with RP 1 about sitting Resident 12 up high and how that affected Resident 12's wound care, but RP 1 wanted Resident 12 sitting up high. WN 1 stated RP 1 was very particular of Resident 12's care. WN 1 stated RP 1's instructions were listed on Resident 12's electronic chart. WN 1 stated he and the Wound Doctor had explained to RP 1 how putting extra pillows, blue padding and cloth padding impaired Resident 12's wound healing. WN 1 stated the reason Resident 12 had an air mattress was to help with air flow and the extra padding impeded the air mattress's function. WN 1 stated Resident 12 had physician ordered cream to be applied to his wound, which became soiled with fecal matter when Resident 12 had a bowel movement, and staff was gentle with removing the cream when changing Resident 12 and cleansing the wound. WN 1 stated RP 1 did not want the cream to be removed, only patted and more cream placed over the old dirty cream. WN 1 stated Resident 12 was on blood thinners (medication that prevented blood clots) for a deep vein thrombosis (DVT - a blood clot that forms in a vein deep in the body). WN 1 stated sometimes Resident 12's wound bled which was the reason for Resident 12's hospitalizations for transfusions. During a concurrent interview and chart review on 7/31/2026 at 10:07 a.m. with UM 2 Resident 12's Care Plan (CP), undated was reviewed. UM 2 stated there was not a CP indicating RP 1's preference on positioning Resident 12 and caring for his wound. UM 2 stated Resident 12 should have had a CP regarding RP 1's preferences. Um 2 stated there was no CP indicating RP 1's requests. UM 2 stated a CP guided staff on how to properly care for residents to optimize their well-being and safety. Um 2 stated the CP directed staff if something in the resident's care needed to be paid more attention to or if the resident had a more specific treatment, the CP made sure it was addressed. UM 2 stated Resident 12's CP should have been resident specific. During an interview on 7/31/26 at 2:29 p.m. with the DON, the DON stated her expectation was for CPs to be resident specific. The DON stated the CP was put in place to be sure the resident's needs were met and had interventions to care for the resident accordingly. The DON stated she and the Administrator (ADM) were responsible for the safe and quality care of residents. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 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.the interdisciplinary team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. During a review of the facility's P&P titled, Wound Care, dated10/2010, the P&P indicated, .the purpose of this procedure is to provide gu[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure food reached the appropriate temperature for all residents' receiving food from the kitchen when the dietary cook did not check and document all food temperatures for the lunch meal served on 7/29/26. This failure had the potential risk to result in all residents receiving food from the kitchen to experienced foodborne illness (an infection from consuming contaminated food) and unappetizing meals which could lead to nutritional decline, unintended weight loss, systemic infection and acute hospitalization. Review of facility document titled, FOOD TEMPERATURE CHART [FTC-food temperature recorded], dated 7/30/26, the FTC indicated, .Noon Meal.Entrees, hot: 208. Entrees, cold: blank, . Salads: blank. Mech Soft: blank. During an observation on 7/29/26 between 11:45 a.m. through 12:58 p.m. in the kitchen during tray line, food trays were already placed in the steam table. DC 1 stated she had already checked the temperatures of the food. DC 1 started with the tray line and placed food on plates without knowing if all food served reached the appropriate temperatures. DC 1 stated she checked the temperatures of mechanical soft food and asked another dietary staff to document. DC 1 stated she should have documented the temperatures herself. DC 1 stated she did not check the temperature of all the foods served. During a concurrent interview and record review on 7/29/26 at 12:30 p.m. with Dietary Services Supervisor (DSS) and DC 1, the DSS reviewed facility document titled FTC and stated, there are so many blank spaces indicating the temperatures were not checked and documented. The DSS stated he was not sure why DC 1 did not check the temperature of all the foods served. The DSS stated the practice was to make sure temperature of all food served was checked and documented prior to serving food to ensure food was safe to serve to residents. The DSS stated food served to residents that did not reach the appropriate temperature could result in growth of bacteria and may lead to illnesses like upset stomach, diarrhea, nausea and vomiting.During an interview on 7/29/26 at 3:20 p.m. with Assistant Dietary Service Supervisor (ADSS), the ADSS stated the practice was to check and document temperature of all food served to residents. The ADSS stated it was a practice to re-check temperatures of food 30 minutes after start of tray line to ensure food temperature did not enter the danger zone (food temperature above 41 degrees Fahrenheit to below 135 degrees Fahrenheit- rapid bacteria growth) and was safe to serve to residents. The ADSS stated she was not sure why DC 1 did not check the temperature during tray line. During a phone interview on 7/31/26 at 9:17 a.m. with the Registered Dietitian (RD), the RD stated her expectation was to check and document food temperature before tray line. The RD stated as good practice, food temperature should be checked again after 30 minutes to ensure food temperature was safe. The RD stated keeping appropriate temperature to ensure safe food, no bacteria growing and resident satisfaction. During a review of facility's policy and procedure (P&P) titled, Food Temperature, dated 3/29/26, the P&P indicated, The temperatures of all food items will be taken and properly recorded prior to service of each meal. 1. All hot food items must be cooked to appropriate internal temperatures. Temperatures should be taken periodically to ensure hot foods stay above 135 degrees Fahrenheit. During a review of facility's P&P titled, Food Preparation and Service, dated 2001, the P&P indicated, .1. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after 4 [four] hours. 2.The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.

Based on observation, interview, and record review, the facility failed to ensure food were stored, prepared, and served in accordance with professional standards for safety when: 1. Food items stored in the walk-in freezer, walk-in fridge and in the walk-in dry storage room ready for residents' use were not properly labeled with open dates and use-by dates and failed to ensure food was safely dated while thawing. 2. Expired and unlabeled food items ready for residents' used were stored in three of three residents' refrigerators across three nursing stations. These failures had the potential to cause the growth of microorganisms (organisms that are too small to be seen with the naked eye) and spread foodborne illness (disease or period of sickness caused by food contamination) to the residents that were served meals from the kitchen. 1.During the initial tour in the kitchen on 7/28/26 at 8:25 a.m. with the Dietary Service Supervisor (DSS), a whole turkey was thawing in a shelf in the walk-in fridge with no date pulled out and no used by date, one opened bag of lettuce with used a by date of 7/27/26 found in the walk-in fridge, several pieces of fresh lemons with a used by date of 7/27/26 in the walk-in fridge, and an opened bag of dry roasted peanut topping with no open or used by date found in the walk-in dry storage. During an interview on 7/29/26 at 2:40 p.m. with Dietary [NAME] (DC) 2, DC 2 stated it was everyone's responsibility to ensure all food items are labeled. DC 2 stated food items are labeled when it was received, date opened and used by date. DC 2 stated labeling was important to ensure residents are not served food past the used by date. During an interview on 7/29/26 at 3:15 p.m. with Assistant Dietary Service Supervisor (ADSS), the ADSS stated foods are labeled with date received, date opened and used by date. The ADSS stated labeling was important to ensure food served to residents is not expired or not past the used by date. The ADSS stated, residents are very fragile, we do not want them to get sick. Review of facility policy and procedure (P&P) titled, Labeling, Dating, and Use-By Date, dated 2026, the P&P indicated, .1. All prepared, opened, or repackaged food items will be clearly labeled with: .b. Date prepared or date opened (must specify) c. Discard (use-by) date.2. Labeling information must be legible. Refrigerated ready-to-eat time/temperature control for safety (TCS) foods held at 41 degrees Fahrenheit or below will be marked with a discard date not to exceed 7 (seven) days. 10. Refrigerators, freezers, dry storage areas, and nourishment rooms will be monitored routinely to ensure compliance with labeling and dating. 11. Expired, unlabeled, improperly labeled. food items will be discarded immediately. 2. During a concurrent observation and interview on 7/29/26 at 8:15 a.m. with DSS, three Resident refrigerators (fridge) were observed. Resident's refrigerator located in Sequoia Station stored an opened box of opened crusts offs with no date and two opened containers of chocolate milk dated 7/21/26 and 7/27/26 with no name and no used by date. In the Resident's refrigerator located in Vintage Station stored a box of opened ice cream sandwich with no name and date, two containers of opened gelato with no name and date, five containers of unopened gelato with no name and date, one opened container of ice cream with no name and date. Resident's refrigerator in the Special Treatment Program (STP-specialized distinct unit or program for individuals with mental health impairments who also require 24-hour medical and nursing care) station found an opened bottle of ranch dressing with no name and date. During an interview on 7/29/26 at 3:20 p.m. with ADSS, the ADSS stated resident's refrigerators are located at each nursing station. The ADSS stated dietary staff are supposed to check the refrigerators and throw away expired foods. The ADSS stated resident's food are labeled with their name, date it was placed in the refrigerator and used by date. The ADSS stated, food are kept in the refrigerator only for three days then disposed of it. During an interview on 7/30/26 at 8:23 a.m. with the Dietary Service Supervisor (DSS), the DSS stated the expectation was to label every food item received, date opened and used by date. The DSS stated the practice was to, keep food for three days only once opened unless specified otherwise on the food guide to ensure freshness of food. The DSS stated it was important to label food to know when food is no longer safe to use and served to residents to prevent them from getting sick. During an interview on 7/30/26 at 8:58 a.m. with Certified Nurse Assistant (CNA) 12, she stated it was everyone's responsibility to make sure to label resident food with name and date when putting in the resident refrigerator located in every nursing station. CNA 12 stated it was important to label food items to ensure food is not given to another resident. CNA 12 stated food is only kept in the refrigerator for three days then it gets thrown away. During an interview on 7/30/26 at 2:07 p.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated resident food items placed in the resident refrigerator are labeled with their name and date it was placed in the refrigerator. LVN 7 stated labeling is very important for residents' safety, to ensure food is safe for residents to consume and to ensure food is not given to another resident and not knowing could be allergic to the food. LVN 7 stated, We do not want resident to get sick. During a phone interview on 7/31/26 at 9:17 a.m. with Registered Dietitian (RD), the RD stated it is everyone's responsibility to ensure food is labeled with date received, date opened and used by date. The RD stated, we don't want expired food served to resident, expired food could make them sick. The RD stated her expectation is to ensure every food item is labeled and get rid of expired food. The RD stated she was not sure who was responsible in checking resident refrigerator to ensure food items are labeled with the name and date. The RD stated it is important to label food to ensure food is not given to other residents and if safe for residents to consume. During an interview on 7/31/26 at 8:20 a.m. with the Director of Nursing (DON), the DON stated her expectation was to make sure all food items in the resident refrigerators are labeled with name and date. The DON stated it was the responsibility of all nursing staff including unit managers to check resident refrigerators and get rid of expired food items. The DON stated, we want to ensure residents are not eating foods past its used by date which could make them sick. During a review of facility policy and procedure titled, Foods Brought by Family/Visitors, revision date 3/22, the P&P indicated, Foods brought to the facility by visitors and family is permitted.Family members and visitors are asked to inform nursing staff when foods are brought for a resident. Foods brought by family/visitors for individual residents are not shared with or distributed to other residents. Family/visitors are asked to prepare and transport food using safe food handling practices. Review of facility P&P titled, Food Receiving and Storage, dated 2001, the P&P indicated, .1. All food items to be kept at or below 41 degrees Fahrenheit are placed in the refrigerator located at the nurses' station and labeled with a use by date. 2. All foods belonging to residents are labeled with the resident's names, the item and the use by dare. 4. Beverages are dated when opened and discarded after twenty-four (24) hours. 6. Partially eaten food is not kept in the refrigerator.

Based on observation, interview, and record review the facility failed to meet professional standards of practice for 5 of 25 sampled residents (Residents 42, 31, 2, 135, 59) when: 1. The facility did not follow the physician's order to recheck Resident 42's blood glucose (the amount of sugar in the blood) 15 minutes after administering 16 units (a standard measurement used to determine the dose of insulin) of insulin lispro (a rapid-acting insulin medication used to lower blood sugar) for blood glucose results of 451-500 mg/dL (milligrams per deciliter, the unit used to measure the amount of sugar in the blood) and did not establish physician notification parameters for hyperglycemia ( high blood sugar) to guide nursing interventions. This failure had the potential to delay the identification of persistent hyperglycemia and timely physician intervention, increasing the risk of prolonged elevated blood glucose levels and complications associated with uncontrolled Type 1 diabetes mellitus (a lifelong condition in which the body does not make insulin [a hormone that helps control blood sugar]). 2. Resident 31's physician's order for oxygen (an invisible, odorless, and tasteless gas) was not followed when oxygen flow was observed set at 0.5 L (liter- unit of measurement) via nasal cannula (thin plastic tube with two small prongs that rest in the nose to deliver extra oxygen). This failure placed Resident 31 at risk of experiencing respiratory distress. 3. Resident 2 was not weighed monthly per physician order. This failure resulted in Resident 2's weights to go unmonitored. 4. Licensed Vocational Nurse (LVN) 1 did not administer or instruct Resident 135 to chew `the acetylsalicylic acid 81 milligram (mg- a unit of measurement), as ordered, during medication administration. This failure resulted in Resident 135 not receiving prescribed medication as ordered which could result in altered absorption and therapeutic onset. 5. Resident 59 did not receive oxygen therapy as ordered by the physician. This failure placed Resident 59 at potential risk for respiratory distress. 1. During an interview on 7/28/26 at 11:14 a.m. in Resident 42's room, Resident 42 stated she had Type 1 diabetes mellitus and had been diagnosed since childhood. Resident 42 stated she had experienced two diabetic [NAME] in the past. Resident 42 stated she received insulin for diabetes management. Resident 42 stated the highest blood glucose reading she could recall while residing at the facility was 552 mg/dL. During a review of Resident 42's AR, dated 7/30/26, the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses of Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema (an eye condition caused by diabetes that damages the retina [ the layer of tissue at the back of the eye that senses light and sends images to the brain] and causes swelling in the center of the retina that can affect vision), type 1 diabetes mellitus with diabetic polyneuropathy (a condition caused by diabetes that damages multiple nerves, often affecting feeling in the hands and feet), hyperlipidemia (high levels of fats, such as cholesterol and triglycerides, in the blood) and hypertension (high blood pressure-a condition in which the force of blood pushing against the walls of the arteries [blood vessels that carry blood away from the heart] is too high). During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/21/26, the MDS indicated Resident 42 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 42 was cognitively intact. During a review of Resident 42's Order Summary Report, dated 7/30/26, the Order Summary Report indicated a physicians order for insulin lispro to be administered subcutaneously (under the skin) three times daily according to the following sliding scale (a physicians order that adjusts the insulin dose based on the residents blood sugar level): blood glucose 0-149mg/dL= 0 units; 150-199 mg/dL= 2units; 200-249mg/dL =4 units; 250-299mg/dL=6 units; 300-349mg/dL= 10 units; 350-399mg/dL=11 units; 400-450mg/dL =12 units; and 451-500mg/dL, administer 16 units of insulin lispro and recheck the blood glucose in 15 minutes. The physician's order did not include parameters directing staff when to notify the physician of Resident 42's blood glucose results. During a review of Resident 42's Medication Administration Record, dated 7/1/26-7/30/26, the Order Summary Report indicated Resident 42 received 16 units of insulin lispro on ten occasions for blood glucose greater than 450 mg/dL. The record did not document blood glucose recheck 15 minutes after any of these ten blood glucose results. During a review of Resident 42's Care Plan Report, dated 8/30/24, revised 5/7/26, the Care Plan Report indicated the resident focus was hyperglycemia related Type 1 diabetes mellitus with diabetic polyneuropathy. The care plan indicated Resident 42's goals were to remain free from hyperglycemia and have no complications related to hyperglycemia through the review date. The care plan included interventions to monitor vital signs (measurements of the body's basic functions, such as blood pressure, pulse, temperature and breathing) and notify the physician of significant abnormalities, and to monitor, document, and report signs and symptoms of hyperglycemia as needed. The care plan did not identify a specific blood glucose value or range directing staff when to notify the physician of Resident 42's blood glucose results. During a review of Resident 42's SNF H&P WC/OG (History and Physical), dated 7/15/26, the SNF H&P WC/OG indicated Resident 42 blood glucose was critically elevated at 413 mg/dL on 7/15/26 and required close monitoring and sliding scale insulin adjustments. Under the physician's assessment and plan, it indicated to continue insulin lispro three times daily per sliding scale, continue insulin glargine (a long-acting insulin that helps keep blood sugar levels steady throughout the day and night) as ordered, monitor the residents blood glucose every shift per current physician orders, and maintain hyperglycemia and hypoglycemia monitoring protocols. During an interview on 7/29/26 at 2:24 p.m. with Certified Nursing Assistant (CNA) 13, CNA 13 stated Resident 42 had diabetes. CNA 13 stated one of her responsibilities was to ensure Resident 42's blood glucose level was checked by her nurse before meals, ensure the resident received sugar-free snacks and observe for changes from baseline that could indicate sign or symptoms of hypoglycemia (low blood sugar) or hyperglycemia. During a concurrent interview and review of Resident 42's electronic health record on 7/30/26 at 9:29 a.m. with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 42 had type 1 diabetes mellitus and that effective diabetes management was important because uncontrolled blood glucose levels could lead to additional health complications. During the review of Resident 42's physician orders, LVN 9 stated the sliding scale insulin lispro order directed staff to administer 16 units of insulin lispro for blood glucose results of 451-500 mg/dL and recheck the residents blood glucose in 15 minutes. LVN 9 stated the physician's order did not include parameters directing staff when to notify the physician of Resident 42's blood glucose results. Based on her practice, LVN 9 stated if she administered 16 units of insulin lispro for a blood glucose result between 451-500 mg/dL, she would also notify the physician. LVN 9 identified blood glucose results of 478 mg/dL on 7/28/26, 490 mg/dL on 7/27/26, 456 mg/dL on 7/23/26, and 500 mg/dL on 7/10/26. LVN 9 stated she did not observe documentation that the required blood glucose rechecks had been completed following those elevated blood glucose results. LVN 9 further stated there were no progress notes documenting physician notification for those blood glucose results and, without documentation, it could not be determined whether the physician had been notified. LVN 9 stated physician notification was important because Resident 42's blood glucose levels were consistently high, the physician might need to evaluate Resident 42 and adjust treatment, and persistent high blood glucose could increase Resident 42's risk for additional health complications. During a concurrent interview and review of Resident 42's electronic health record on 7/31/26 at 9:37 a.m. with the Director of Nursing (DON), the DON reviewed Resident 42's insulin lispro physician order and stated the physician's order directed staff to administer 16 units of insulin lispro for blood glucose results of 451-500 mg/dL and recheck the resident blood glucose in 15 minutes. The DON stated the 15-minute blood glucose recheck was important to determine whether the resident's blood glucose level had improved following insulin administration or had decreased too rapidly so appropriate interventions could be implemented if needed. The DON stated the physician's order was a specific order nursing staff were expected to follow and the expectation for the 15-minute blood glucose recheck to be completed and documented in the residents electronic health record, including a progress note, each time 16 units of insulin lispro were administered. The DON stated if the resident's blood glucose did not improve after the recheck, staff would need to notify the physician and follow the physician's orders. The DON stated the physician's order did not include a specific blood glucose value directing staff when to notify the physician; however, she would expect the physician to be notified for blood glucose results between 451-500 mg/dL so the physician could evaluate the resident and determine whether additional interventions or changes to treatment were needed. The DON stated persistent hyperglycemia required ongoing monitoring because failure to evaluate the residents response to insulin could delay recognition of persistent hyperglycemia or an excessive decline in blood glucose, increasing the residents risk for additional complications. The DON stated the interdisciplinary team (IDT) was responsible for ensuring physician notification parameters were included in the resident's orders and reviewed during the admission process. When asked about the hyperglycemia monitoring protocol referenced in Resident 42's History and Physical, the DON stated she was unsure whether the facility had a specific hyperglycemia protocol and would look into it. The DON stated she would provide the protocol if one was available. During the survey, the facility provided hypoglycemia protocol; however, no protocol specific to hyperglycemia was provided prior to the conclusion of the survey. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, dated 3/2025, the P&P indicated, the type of insulin, dosage requirements, strength, and method of administration are verified with the order on the medication sheet and the physician's order before administration.insulin therapy is individualized based on prognosis, treatment goals and blood glucose levels.check blood glucose order per physician order or facility protocol.check the order for the amount of insulin.the residents blood glucose result, as ordered. During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes-Clinical Protocol, dated 3/2018, the P&P indicated, the staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems, dated 3/2025, the P&P indicated, the charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management. During a review of the facility's policy and procedure (P&P) titled, Diabetes-Clinical Protocol, dated 3/2025, the P&P indicated, the provider will order desired glucose targets and monitoring regimens, as well as parameters for reporting information related to blood sugar management. During a review of the facility's Charge Nurse Job Description, dated 1/2010, the document indicated prepare and administer medications as ordered by the physician.review medication administration record (MAR) for completeness of information, accuracy in the transcription of the physician's order and adherence to stop orders.consult with the resident's physician in providing the residents care, treatment, rehabilitation, etc., as necessary. During a review of the professional reference, Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association, published 2/2016, the professional reference indicated, patients admitted to long-term care facilities are not seen daily by a practitioner.residents may have uncontrolled blood glucose levels or wide excursions without the practitioner being notified.standing orders for glucose monitoring and practitioner notification approved by the facility and practitioner at the time of admission may be useful. 2. During an observation on 7/28/26 at 10:34 a.m. during the initial tour in Resident 31's room, Resident 31 was observed lying in bed, eyes closed and appropriately dressed. Resident 31 had oxygen via nasal cannula and oxygen flow rate was 0.5 L/min (minute). Resident 31 did not answer questions asked. During a review of Resident 31's AR, dated 7/30/26, the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included anemia (a condition where the body does not have enough healthy red blood cells), unspecified atrial fibrillation (heart condition where the upper chambers of the heart beat fast and in a chaotic, irregular way) and encounter for palliative care (extra medical help that focuses on making you feel better). During a review of Resident 31's Order Summary Report [OSR], dated 7/30/26, the OSR indicated, .Oxygen: Apply PRN [pro re nata meaning as needed] oxygen at 2-3 [two to three] L/min via nasal cannula for hypoxia (body tissues and organs do not get enough oxygen to work the right way)/shortness of breath . Goal: Maintain SPO2(percentage of oxygen in the blood) > 90% (percent) as needed.Order Date 1/22/26 . During a concurrent observation and interview on 7/28/26 at 10:55 a.m. with Licensed Vocational Nurse (LVN) 8 in Resident 31's room, LVN 8 verified oxygen flow rate and stated Resident 31's oxygen was set at 0.5L/min. LVN 8 stated she was not sure of Resident 31's oxygen order. LVN 8 reviewed Resident 31's oxygen order and stated Resident 31's oxygen order was 2-3L/min. as needed to maintain oxygen saturation above 90 percent. LVN 8 stated Resident 31's oxygen saturation was checked at 9:30 and the oxygen saturation was 97 percent. LVN 8 stated Resident 31 did not need her oxygen and should not have been turned on. During an interview on 7/30/26 at 9:24 a.m. with CNA 11, CNA 11 stated she was familiar with Resident 31's care. CNA 11 stated Resident 11 refused to get out of bed and always had her oxygen on when she took care of her. CNA 11 stated Resident 31 needed one person assistance with her activities of daily lining (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 7/30/26 at 10:55 a.m. with LVN 6, Resident 31's clinical record titled OSR, was reviewed. LVN 6 stated Resident 31's oxygen order was as needed. LVN 6 stated, She [Resident 31] is on oxygen, her standing order is 2-3 liters to keep oxygen saturation at a minimum of 90 percent. LVN 6 stated Resident 31's oxygen saturation was checked at 9:38 a.m. and it was 97 percent. LVN 6 stated the nurse who checked the oxygen saturation could have turned off the oxygen, Resident 31 did not need the oxygen. LVN 6 stated Resident 31 could have developed lethargy, difficulty breathing due to over oxygenation. During an interview on 7/31/26 at 10:56 a.m. with the Director of Nursing (DON), the DON stated her expectation was to always follow physician's order for oxygen. The DON stated there was no risk of getting extra oxygen when not needed except the carbon dioxide could go up. The DON stated licensed nurses should have followed up with the physician if Resident 31 wanted her oxygen all the time. During a review of facility's policy and procedure (P&P) titled, Oxygen Administration, revision date 10/19, the P&P indicated, . Verify that there is a physician's order. Review the physician's orders or facility protocol for oxygen administration. Documentation .the following information should be recorded in the resident's medical record: .The rate of oxygen flow, route, and rationale. 3. During an observation on 7/28/2026 at 12:03 p.m. in the dining room, Resident 2 was observed asleep in a Geri-chair with his meal tray on the table in front of him. Staff observed waking and assisting Resident 12 with his meal, encouraging him to take bites, but Resident 12 continued to fall back asleep. During a review of Resident 2's AR, dated 7/31/26, the AR indicated Resident 2 was admitted to the facility from an acute care hospital on 8/23/24 with diagnoses of acquired loss of limb (surgical removal of finger, toe, hand, foot, arm or leg) left great toe, type 2 Diabetes Mellitus, chronic kidney disease (a gradual loss of kidney function where the kidneys cannot filter the blood as they should), end stage heart failure (a condition when the heart muscle is too weak to pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 2's MDS, dated [DATE], the MDS section C indicated Resident 2 had a BIMS score of 14, which indicated Resident 2 was cognitively intact. During an observation on 7/29/2026 at 9:34 a.m. in Resident 12's room, Resident 12 was observed dressed, asleep in his bed, seated up with an empty meal tray in front of him. Resident 12 did not respond when spoken to. Observed catheter bag covered, hanging on the side of the bed, wedge pillow placed on left upper arm, and Resident 2 observed leaning on his left side. During a concurrent interview and record review on 7/30/2026 at 10:19 a.m. with the RD, Resident 2's Electronic Medical Record (EMR) was reviewed. The EMR indicated there was no weight documented for July 2026 for Resident 2 and Resident 2's last weight was on 6/1/26 of 181 pounds and on 5/1/26 Resident 2 weighed 177 pounds which was a weight gain of 4 pounds. On 4/14/26 Resident 2 weighed 166 pounds which was a weight gain of 11 pounds from 4/14/26 to 5/5/26, and a weight gain of 15 pounds from 4/14/26 to 6/1/26. The RD stated she was not aware of Resident 2's weight gain. The RD stated residents will trigger for significant weight loss or weight gain when their weights are entered into the system and the computer will calculate the percentage of weight change. The RD stated when residents trigger for significant weight change, they were put on weekly weights. The RD stated the nurses monitor if the resident was to receive weekly weights. The RD stated nursing communicated with hospice and informed her of residents that needed to be monitored as residents on hospice care were not discussed during the weight meetings. During a concurrent interview and record review on 7/30/2026 at 2:01 p.m. with Restorative Nursing Assistant (RNA) 2, Resident 2's Order Summary Report (OSR), dated 7/30/26 was reviewed. The OSR indicated Resident 2 was to have therapy three times a week which included active Range of Motion (ROM) therapy to his lower extremities, stretching his upper extremities and to use the green band for stretching. RNA 2 stated Resident 2 was compliant with his therapy. RNA 2 stated Resident 2 was not on her list of residents to be weighed. During a concurrent interview and record review on 7/30/2026 at 2:05 p.m. with RNA 1, Resident 2's Weights and Vitals Summary (WVS), undated was reviewed. RNA 1 stated there was no documented weight for July in Resident 2's WVS. Resident 2's Order Summary Report (OSR), undated was reviewed. The OSR indicated, .admission: weekly weight x 4 weeks, then reevaluate.order date 8/23/24.Monthly weights.order status.active.order date 5/13/25. RNA 1 stated Resident 2 was on monthly weights and there was no documentation that Resident 2 had refused being weighed. RNA 1 stated Resident 2 should have been weighed in July to be sure he was not losing or gaining weight rapidly, to be sure Resident 2 was not having any swelling, and to make sure Resident 2 was drinking enough water. RNA 1 stated the system will trigger a flag that would alert staff if a resident had significant weight gain or weight loss of five pounds within a week or within a month. RNA 1 stated the RNAs had a deadline for resident weights to be completed the first week of the month, between days one through the fifth day. RNA 1 stated there was no documented reason why Resident 2 was not weighed for the month of July. RNA 1 stated Resident 2 was not on his list of Residents to be weighed. During an interview and record review on 7/31/26 at 10:22 a.m. with RNA 3, Resident 2's OSR, dated 7/31/26 was reviewed. RNA 3 stated Resident 2 was not on his case load to be weighed. RNA 3 stated he had weighed Resident 2 in the past. RNA 3 stated resident weights were important to see if a resident was losing or gaining weight so staff knew to keep on top of the resident's meals if the resident was overeating, or if staff needed to cut down on the resident's sugar intake. RNA 3 stated there were three RNAs staffed in the facility. During a concurrent interview and record review on 7/31/2026 at 10:30 a.m. with RNA 2, Resident 2's MVS, dated 7/31/26 was reviewed. RNA 2 stated Resident 2 was weighed in June by RNA 1. Resident 2's OSR, dated 7/31/26 was reviewed. RNA 2 stated Resident 2 had orders for monthly weights. RNA 2 stated Resident 2 should have been weighed in July. RNA 2 stated she did not know why Resident 2 was not weighed. RNA 2 stated Resident 2 was not listed on her case load. During an interview on 7/31/2026 at 9:15 a.m. with Unit Manager (UM) 2, UM 2 stated the RNA documented resident weights in the EMR and informed the nurse for the nurse to review and sign-off on the reported weights. UM 2 stated the nurse reviewed the reported weights to see if a progress noted needed to be documented in the resident's record of the weight if there was a weight loss or weight gain that needed to be addressed. UM 2 stated the UM kept a copy of the resident weights that were reported and once a week leadership had a weight meeting to identify any concerns with resident weights and investigate any factors that may be an issue for resident weight loss or weight gain. UM 2 stated Resident 2 should have been weighed in July to monitor for any significant change in Resident 2's status and take action or to be aware to monitor Resident 2. UM 2 stated there was no other way to monitor if residents were being weighed as ordered. During an interview on 7/31/26 at 2:29 p.m. with the DON, the DON stated residents were to be weighed per physician orders. The DON stated if the residents were not weighed as ordered, there was a risk of weight loss or weight gain and staff needed to know to investigate the reason and what to monitor the resident for. The DON stated it was important for physician orders to be followed as it affected the residents' health. The DON stated the DON and ADM were responsible for the safe and quality care of the residents. During a review of the policy and procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss – Clinical Protocol, dated, 9/2012, the P&P indicated, .the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time.the staff and physician will define the individual's current nutritional status [weight, food/fluid intake, and pertinent laboratory values] and identify individuals with anorexia, weight loss or gain and significant risk for impaired nutrition.medications that may be causing weight gain or increasing the risk of anorexia or weight loss.staff will report to the physician significant weight gains or losses.the physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions.for individuals with recent or rapid weight gain or loss [for example, more than a pound a day], the staff will review for possible fluid and electrolyte imbalance as a cause.conditions such as heart failure and renal failure can cause rapid weight gain.the physician will help identify medical conditions.and medications that may be causing weight gain or loss or increasing risk for either gaining or losing weight.the physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions. During a review of the facility job duties document titled, Restorative Nursing Assistant Program Overview, dated 7/22/2020, the document indicated, .the Restorative Nursing Assistants are certified nursing assistants who have received additional rehabilitation/restorative training.the Restorative Nursing Assistants are a part of the nursing department and supervised by license nurses.they are responsible for documenting daily services provided and writing a weekly progress note.monthly, nursing, rehab and RNA will meet to review all residents' orders and care plans.RNA may be responsible for other aspects of nursing care including resident weights. 4. During a medication observation on 7/30/26 at 9:07 a.m. with LVN 1, LVN 1 was observed preparing Resident 135's oral medications. LVN 1 prepared [brand name for acetylsalicylic acid] 81 mg chewable, vitamin D 25 microgram (mcg- a unit of measurement), ezetimibe 10 mg, topiramate 100 mg, and vitamin B12 100 mcg into one medicine cup. The medicine cup was given to Resident 135. Resident 135 swallowed all the medication in the medicine cup at once. During an interview on 7/30/26 at 9:13 a.m. with LVN 1, LVN 1 stated she did not separate Resident 135's [brand name for acetylsalicylic acid] 81 mg chewable medication from all other oral medications. LVN 1 stated she did not instruct Resident 135 to chew [brand name for acetylsalicylic acid] 81 mg chewable. LVN 1 stated Resident 135 swallowed chewable [brand name for acetylsalicylic acid] 81 mg. LVN 1 stated Resident 135 should have chewed [brand name for acetylsalicylic acid] 81 mg and not swallowed it. LVN 1 stated it was important to administer medication as ordered to ensure intended medication effects occurred. LVN 1 stated swallowing [brand name for acetylsalicylic acid] 81 mg was a medication error. During an interview on 7/30/26 at 2:25 p.m. with UM 1, UM 1 stated all licensed nurses were expected, per facility policy and standard of practice, to administer medications as ordered. UM 1 stated chewable medication were expected to be separated from all other medications to ensure it was chewed and not swallowed. UM 1 stated it was important to administer medication as ordered to ensure intended medication effects occurred. UM 1 stated Resident 135 was at risk for not receiving intended medication effects of [brand name for acetylsalicylic acid] 81 mg when she swallowed [brand name for acetylsalicylic acid] 81 mg. During an interview on 7/31/26 at 10:20 a.m. with the DON, the DON stated all licensed nurses were expected, per facility policy and standard of practice, to administer medication as ordered. The DON stated it was a medication error if chewable [brand name for acetylsalicylic acid] 81 mg was swallowed. The DON stated when Resident 135 swallowed [brand name for acetylsalicylic acid] 81 mg she was at risk for not receiving intended medication effects, altered absorption and altered therapeutic onset. The DON stated facility policy and procedure, and nursing standards of practice, were not followed when chewable medication was not separated from all other oral medication and Resident 135 swallowed [brand name for acetylsalicylic acid] 81 mg. During a review of facility policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, .medications are administered in a safe and timely manner, and as prescribed.medications are administered in accordance with prescriber orders.verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the professional reference titled, Nursing Rights of Medication Administration, dated 9/4/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ , the professional reference indicated, .the five traditional rights.right patient.right drug.right route.medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side -effects based on the mode of administration.right time.right dose. 5. During a concurrent observation and interview on 7/28/26 at 10:07 a.m. in Resident 59's room, Resident 59 was observed in bed with a nasal cannula connected to an oxygen source on the wall. The oxygen was set at 1L/min. Resident 59 stated the oxygen should be at 2L/min. During a review of Resident 59's AR, dated 7/30/26, the AR indicated Resident 59 wa

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for two of nine sampled residents (Resident 2 and Resident 146) when: 1. Certified Nursing Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 3 did not donned appropriate Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing care to Resident 2 who was placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant bacteria that requires gown and glove use during high contact resident care activities). 2. Wound Nurses (WN) 1 and WN 2 did not donned appropriate PPE during wound vac (is a medical device that uses suction to help wounds heal faster) dressing change, and failed to ensure evidence-based precaution were initiated upon admission for a resident requiring wound vac. These deficient practices placed Resident 2 and Resident 146 at potential risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and transmission of infection potentially leading to outcomes that could be life-threatening. Findings: 1. During an observation on 7/28/2026 at 11:40 a.m. outside Resident 2's room, a yellow sticker was posted next to Resident 2's name, along with an EBP signage posted on the wall next to the room door to alert staff of required precautions, and a PPE cart (a mobile storage unit to keep PPE) outside Resident 2's room. Resident 2 was not in his room. During a review of Resident 2's admission Record (AR - a summary of information regarding a resident), dated 7/31/26, the AR indicated Resident 2 was admitted to the facility from an acute care hospital on 8/23/24 with diagnoses of acquired loss of limb (surgical removal of finger, toe, hand, foot, arm or leg) left great toe, type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), benign prostatic hyperplasia (the non-cancerous enlargement of the prostate gland [a gland that sits below the bladder and surrounds the urethra] making it difficult to urinate), retention of urine (a condition in which you are unable to empty all the urine from the bladder), chronic kidney disease (a gradual loss of kidney function where the kidneys cannot filter the blood as they should), end stage heart failure (a condition when the heart muscle is too weak to pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [involving the process of thinking, learning and understanding] and physical functional level assessment), dated 5/28/26, the MDS section C indicated Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 2 was cognitively intact. During a review of Resident 2's Order Summary Report (OSR), dated 7/31/26, the OSR indicated, .Enhanced Barrier Precautions [EBP] for high contact resident care activities related to [r/t] wound[s], urinary catheter. Perform hand hygiene and apply personal protective equipment [PPE] gloves, gown and/or goggle/face shield worn if risk of splash/spray during high contact resident care activities. Remove PPE and perform hand hygiene prior to exiting room. Every shift for Prevent Transmission of multi-drug-resistant organisms [MDRO - bacteria that have become resistant to multiple types of antibiotics making them more difficult to treat, can spread rapidly, and threaten patient safety] .remains in place or until resolution of wound or discontinuation of indwelling medical device.order status.active.order date 3/31//26.cleanse shear to sacrococcygeal.order status.active.order date.7/31/26.diabetic ulcer to right 1st toe. Cleanse daily.order status.active.order date.7/31/26. During a review of Resident 2's Care Plan (CP), undated, the CP indicated, .Enhanced Barrier Precautions [EBP] for high contact resident care activities r/t wound[s], indwelling device.at high risk for multidrug-resistant organisms [MDRO] transmission.date initiated: 1/27/25.will be at a decreased risk of MDRO transmission r/t the implementation of enhanced barrier/standard precautions during contact care activities.date initiated: 1/27/25.EBP for high contact resident care activities. Perform hand hygiene & apply personal protective equipment [PPE] & perform hand hygiene prior to exiting room. Date initiated: 1/27/25.wear gown and gloves when performing high-contact care activities.wound care.mobility assistance.date initiated: 1/27/25.EBP will remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical devices.date initiated: 1/27/25. During an observation on 7/29/2026 at 9:34 a.m. in Resident 2's room, Resident 2 was observed dressed, asleep in his bed, seated up with an empty meal tray in front of him. Resident 2 did not respond when spoken to. Observed catheter bag covered, hanging on the side of the bed, wedge pillow placed on left upper arm, and Resident 2 observed leaning on his left side. During a concurrent observation and interview on 7/29/26 at 3:55 p.m. outside Resident 2's room, Resident 2 was observed in bed yelling for a nurse or CNA. Observed CNA 2 and LVN 3 come out of another resident's room, who was also on EBP precautions. CNA 2 and LVN 3 proceeded to perform hand hygiene and apply gloves before entering Resident 2's room and inquired about his needs. Resident 2 complained of lower back pain near his bottom and itching and pain on his right foot. Resident 2 requested the staff to scratch his itching. CNA 2 and LVN 3 proceeded to turn Resident 2 on his side to examine his lower back wound and check his right foot wound. CNA 2 and LVN 3 did not don gowns during Resident 2's repositioning and care. LVN 3 stated for residents on EBP, PPE were only used when providing direct resident care and staff did not wear a gown when repositioning residents. CNA 2 and LVN 3 both stated they should have put on a gown when repositioning Resident 2 to examine his wounds and provide care. LVN 3 stated if appropriate PPE was not worn, there was a risk for Resident 2 to get an infection, and staff could transfer germs and infections to each other and other residents. During an interview on 7/30/2026 at 9:52 a.m. with LVN 2, LVN 2 stated it was not acceptable to reposition a resident on EBP without wearing a gown. LVN 2 stated the EBP sign posted on Resident 2's door indicated to wear a gown during patient care. LVN 2 stated staff did not know what they were touching and could spread germs and infections to the residents. LVN 2 stated appropriate PPE provided protection from infection between staff and the residents from infection. During an interview on 7/30/2026 at 10:03 a.m. with the Infection Preventionist (IP), the IP stated she trained staff on infection prevention practices upon hire, annually, as staff in-services. The IP stated staff should have gowned up and applied gloves before any high-contact care for residents on EBP. The IP stated high contact care included brushing residents' hair, changing briefs, transferring and repositioning residents. The IP stated wearing appropriate PPE helped prevent transmission of germs and infection to and from residents. During an interview on 7/31/26 at 2:29 p.m. with the Director of Nursing (DON), the DON stated her expectation was for staff to wear the appropriate PPE during high contact resident care. The DON stated appropriate PPE was important to prevent resident infections and to stop the spread of infections. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 12/2024, the P&P indicated, .enhanced barrier precautions [EBP] are utilized to prevent the spread of multi-drug resistant organisms [MDROs] to residents.enhanced barrier precautions [EBP] refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms [MDROs] during high contact resident care activities.enhanced barrier precautions apply when.a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained.indwelling medical devices include central lines, urinary catheters.wounds generally include chronic wound.chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.transferring.providing bed mobility.wound care.enhanced barrier precautions are in place for the duration of the resident's stay or until resolution the wound or discontinuation of the indwelling medical device.signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. 2. During a concurrent observation and interview on 7/28/26 at 11:03 a.m. in Resident 146's room, there was no EBP signage or EBP cart with EBP supplies readily available for use outside Resident 146's room. WN 1 and WN 2 were observed at Resident 146's bedside performing a wound VAC dressing change on Resident 146's right lower leg without gowns. WN 1 was observed placing a pad under the resident's right leg and applying a bandage, Kerlix and ace wrap without a PPE gown. WN 2 was similarly observed handing supplies used for the wound dressing change without wearing a gown. Resident 146 stated nobody puts on gowns when performing wound dressing changes and reported her wound dressing had been changed two times; on 7/25/26 and on 07/28/26. Resident 146 stated she arrived at the facility on 07/23/2026 with the wound VAC. During a review of Resident 146's AR, dated 7/30/26, the AR indicated Resident 146 was admitted to the facility on [DATE], and had diagnoses that included Unspecified Open Wound, Right Lower Leg and Unspecified Open Wound of Right Elbow, Heart Failure (a condition in which the heart is unable to pump enough blood to meet the body's needs), Chronic Obstructive Pulmonary Disease (COPD-a progressive lung disease that causes difficulty breathing), Acute Posthemorrhagic Anemia (a decrease in red blood cells following significant blood loss) Essential Hypertension (persistently elevated blood pressure) Hyperlipidemia (abnormally high levels of fats in the blood) History of Falling, Dependence on Supplemental Oxygen, Muscle Weakness, Other Abnormalities of Gait and Mobility (difficulty or irregularity in walking) Presence of Right Artificial Hip Joint, Presence of Artificial Knee Joint, Bilateral, and Other Chronic Pain. The AR indicated Resident 146 was admitted from an acute care hospital with a wound VAC device in place. During a review of Resident 146's MDS, dated 7/24/26, the MDS section C indicated Resident 146 had a BIMS score of 15 out of 15. The BIMS scores indicated Resident 146 had cognitively intact. During a review of Resident 146's OSR, the OSR indicated Wound Vac: Change Dressing Every Tuesdays and Saturdays, with detailed wound VAC care instructions including irrigating the wound, protecting wound margins with adhesive strips, trimming VAC foam, sealing foam, attaching the suction pad, connecting to the wound VAC machine, and monitoring for signs and symptoms of infection (redness, swelling, warmth, increased pain, pus/drainage, fever, chills, sweating, increased fatigue, sudden confusion). The OSR contained no physician order for EBP precautions. During a review of Resident 146's CP, the CP indicated a care plan problem focus of Wound Vac to RLE (Right Lower Extremity), At risk for slow/delayed healing and/or infection, with a date Initiated of 07/23/2026 and date reviewed of 07/24/2026. The care plan listed wound VAC-related interventions including dressing changes, wound evaluation, and monitoring for signs and symptoms of infection. The CP contained no mention of EBP, no EBP goal, and no EBP interventions or tasks identified for Resident 146's care. During a concurrent interview and record review on 07/28/2026 at 11:25 a.m., with WN 1 and WN 2, Resident 146's Electronic Health Record (EHR) was reviewed. WN 1 stated the expectation was to wear a gown because Resident 146 had a wound VAC, but stated he wore the gown and took it off after placing the transparent film on the wound site, and he could apply the kerlix and ace bandage without the gown. When told he was observed without a gown and Resident 146 had stated he did not wear the gown, WN 1 stated he must have confused which resident he wore the gown for. WN 1 and WN 2 stated their understanding was EBP should only be in place if the resident had an infection. WN 1 stated he was unsure if EBP signage and supplies should be in place because no infection was indicated in Resident 146's EHR. The EBP signage was reviewed with WN 2, indicated EBP should be used with wound care, and WN 2 acknowledge the expectations was for wound nurse and staff to wear PPE. During an interview on 07/30/2026 at 11:58 a.m., with the IP, the IP stated EBP applies to any wounds, lines, drains, or a history of MDRO (Multi-Drug-Resistant Organism -a germ that has developed resistance to multiple antibiotics, making it harder to treat) and the admission nurses should initiate EBP for wound vac. The IP acknowledge there was no physician order or care plan for Resident 146, and without these elements, nursing staff lack formal direction, visual prompting, and readily available supplies. The IP stated wound nurses who failed to wear PPE between residents create a risk of cross-contamination, placing multiple residents at potential risk of acquiring infections, with potential outcomes including worsening wounds, new infections, hospitalization, and life-threatening results. During an interview on 07/30/2026 at 2:54 p.m., with the Director of Nursing (DON) the DON stated the expectation was for the wound nurses to wear EBP because they would otherwise pass infection from one resident to another. The DON stated she expected the wound nurses to know Resident 146 had wound VAC and should be placed on EBP. The DON stated without proper PPE, wound nurses risk spreading infection from one resident's wound to the next. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 12/2024, the P&P indicated, .enhanced barrier precautions [EBP] are utilized to prevent the spread of multi-drug resistant organisms [MDROs] to residents.enhanced barrier precautions [EBP] refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms [MDROs] during high contact resident care activities.enhanced barrier precautions apply when.a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained.indwelling medical devices include central lines, urinary catheters.wounds generally include chronic wound.chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.transferring.providing bed mobility.wound care. Outside the resident's room, EBPs are indicated when anticipating close physical contact .enhanced barrier precautions are in place for the duration of the resident's stay or until resolution the wound or discontinuation of the indwelling medical device.signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. Personal Protective Equipment (PPE) is readily available near or outside the resident's room. PPE should be disposed of after use, either before leaving the room or before tending to another resident or cleaning and disinfecting their space who is not on EBP. During a review of the Infection Preventionist Position Description indicated the Infection Preventionist reports to the Director of Nursing and is responsible for directing the entire scope of the facility's infection control program, including planning, developing, organizing, implementing, evaluating, and continuously improving the program in accordance with current rules, regulations, and guidelines. Essential functions included ensuring compliance with current CDC, OSHA, and local regulations concerning infection control or standard/universal precautions; developing, maintaining, and periodically updating infection control precautions and aseptic techniques; and providing ongoing education to facility staff to ensure understanding and compliance with infection control protocols.

Based on interview and record review, the facility failed to maintain accurate and complete medical records in accordance with professional standards and facility policy for one of four sampled residents (Resident 36 ) when Resident 36's Electronic Health Record (EHR) contained incomplete documentation from nursing staff for three orders listed on Resident 36's July 2026 Treatment Administration Record (TAR-a legal digital form used by nurses that tracks special medical care tasks ordered by a doctor; nurses sign the form each time a task is completed).This failure had the potential to result in a disruption of Resident 36's continuity of care by delaying/omitting necessary treatment or interventions, creating gaps in essential services, and resulting in inconsistent care delivery if staff missed critical changes in the resident's condition. During a review of Resident 36's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/29/26, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses of Sepsis-unspecified organism, infection and inflammatory reaction due to indwelling urethral (the tube that carries urine from your bladder to the outside of the body) catheter, type 2 diabetes mellitus with diabetic polyneuropathy ( when long term high blood sugar has caused widespread nerve damage affecting the feet, legs, hands, and arms), neuromuscular dysfunction of bladder (loss of bladder control caused by damage to the nerves or muscles), retention of urine, cirrhosis of liver ( a condition in which the liver is scarred and permanently damaged).During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 5/4/26, the MDS indicated Resident 36's Brief Interview for Mental Status [RM1.1] (BIMS-an evaluation of attention, orientation and memory recall) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 36 had no cognitive impairment. During a review of the facility document titled, .Order Summary Report (OSR), dated 7/29/26, the OSR indicated, .CATHETER: Monitor/record/report to Physician for signs and symptoms of urinary tract infection: acute confusion, urgency.every shift Monitor/record/report to Physician for signs and symptoms of urinary tract infection.Indwelling Urinary Catheter Size.for urinary retention. Monitor placement and functioning every shift. every shift NOTIFY Physician FOR Trial removal of F/C.Indwelling Urinary catheter: Cleanse site with soap and water and Rinse. Then Pat Dry. every shift. During a review of the facility document titled, TREATMENT ADMINISTRATION RECORD, dated 7/2026, the TAR indicated, .CATHETER: Monitor/record/report to Physician for signs and symptoms of urinary tract infection: acute confusion, urgency.every shift Monitor/record/report to Physician for signs and symptoms of urinary tract infection.Indwelling Urinary Catheter Size.for urinary retention. Monitor placement and functioning every shift. every shift NOTIFY Physician FOR Trial removal of F/C.Indwelling Urinary catheter: Cleanse site with soap and water and Rinse. Then Pat Dry. every shift. The TAR contained no documentation from nursing staff for these three orders on 7/7/26-evening shift, 7/11/26-NOC (night) shift, and 7/17/26-evening shift. During a concurrent interview and record review on 7/30/26 at 9:10 a.m. with Unit Manager (UM) 1, Resident 36's TAR, dated 7/2026 was reviewed. UM 1 stated she saw in the evening Tuesday July 7- the TAR was not clicked off, for Noc on July 11th- the TAR was not clicked off, and July 17th evening- the TAR was not clicked off for three orders including Catheter monitoring., Indwelling Urinary Catheter size.and indwelling urinary catheter.UM 1 stated there was missing information in Resident 36's TAR. UM 1 stated information should not be missing on the TAR and the TAR was incomplete. UM 1 stated clicking off/signing indicated that the nurse acknowledged that whatever the order stated was done. UM 1 stated if the task was not signed off, it indicated the order was not acknowledged and was not done. UM 1 stated it was important to have complete documentation in the residents' medical records for resident safety, to ensure quality and proper care, and for ongoing assessment of that resident to catch any changes that would need intervention to avoid a situation that could cause harm to that resident. During a concurrent interview and record review on 7/31/26 at 10:20 a.m. with the Director of Nursing (DON), Resident 36's TAR, dated 7/2026, was reviewed. The DON stated her expectation for documentation from staff in the residents' charts was for staff to document before leaving their shift as well as check the audit binder before leaving their shift. The DON stated audits were binders in each nursing station put together by medical records that informed nurses of any gaps in the documentation so that it could be completed. The DON stated she expected documentation in the residents' medical chart to be completed by the end of the shift. The DON stated it was important for documentation to be complete in the residents' medical chart for continuity of residents' care. The DON stated if there was no documentation from the nurses in the medical record, it indicated that order was not completed and did not happen. After reviewing Resident 36's TAR, the DON stated there were holes in Resident 36's TAR. The DON stated if there were holes and the TAR was not signed off/documented; it meant the activity did not happen. The DON stated continuous monitoring as ordered in Resident 36's TAR was important for continuous resident care and resident safety.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017, the P&P indicated, .All services provided to the resident. any changes in the resident's medical condition, physical, functional or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.Objective observations.Treatments or services performed.Documentation in the medical record will be objective.complete, and accurate .

Based on observation, interview, and record review, the facility failed to ensure residents who received therapeutic diets (a doctor-prescribed meal plan that changes standard foods or nutrients to treat a medical condition) had a current physician's order in place for one of four sampled residents (Resident 6) when Resident 6 was observed with an oral nutritional supplement at bedside without a physician's order. This failure had the potential risk to result in weight and blood sugar fluctuations if the intake was unmonitored, and possible medication interactions.During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/30/26, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses of hemiplegia (total paralysis on one side of the body) and hemiparesis (mild weakness on one side of the body) following unspecified cerebrovascular disease (a group of medical conditions that affect the blood vessels and blood flow in the brain) affecting left non-dominant side, type 2 diabetes mellitus (a long-term health condition where the body does not use insulin properly, leading to too much sugar staying in the blood), anemia (a health condition where the blood does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and long term use of aspirin (a medicine used to lower fever, reduce swelling, relieve minor aches, and in small daily doses used to keep blood from clotting).During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 6/25/26, the MDS indicated Resident 6's Brief Interview for Mental Status [RM1.1] (BIMS-an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 6 had no cognitive impairment.During an observation on 7/28/26 at 10:23 a.m. in Resident 6's room, Resident 6 was lying in bed with an oral nutritional supplement at bedside.During an interview on 7/29/26 at 12:47 p.m. with Resident 6, Resident 6 stated he received his oral nutritional supplement this morning for breakfast and stated he received his oral nutritional supplements with all meals.During a review of the facility document titled, [facility name] Order Summary Report, dated 7/30/26, the Order Summary Report (OSR) indicated, .Dietary-Diet Order Summary Regular diet Easy to Chew texture, Thin Liquids consistency, RED TRAY PROGRAM. The OSR did not indicate any current physician's orders for an oral nutritional supplement.During a review of Resident 6's Physician's order with a start date of 6/12/24 and end date of 6/9/26, the Physician's order indicated the [Brand name] Shake (oral nutritional supplement) give 8ounce (oz-unit of measurement) with meals for weight loss prevention was discontinued.During a review of Resident 6's meal tray ticket for Breakfast, dated 7/30/26, the meal tray ticket indicated Resident 6 had a physician's order for eight oz [brand name] for breakfast, lunch and dinner.During a concurrent interview and record review on 7/30/26 at 8:44 a.m. with Unit Manager (UM) 1, Resident 6's current and discontinued physician's orders were reviewed. UM 1 stated she did not see any current orders for an oral nutritional supplement. UM 1 stated she reviewed Resident 6's discontinued orders and stated the previous nutritional supplement order included [brand name] Shake-Frequency: with meals every day for weight loss prevention additional directions: give 8oz (240ml) or equivalent supplement as available with start date 6/12/24 and end/discontinue date of 6/9/26. UM 1 stated Resident 6 should not be receiving an oral nutritional supplement without a physician's order. UM 1 stated it was important for staff to follow physician's orders and not provide residents' with nutritional supplements without a physician's order to prevent potential harm and medication interactions.During a concurrent interview and record review on 7/30/26 at 10:20 a.m. with the DSS, Resident 6's current physicians orders were reviewed. The DSS stated Resident 6's current diet orders were for regular diet easy to chew thin liquid consistency and red tray program (a program that helped Certified Nursing Assistants [CNA's] identify those residents who needed help with meal consumption). The DSS stated Resident 6 did not have a current doctor's order for a nutritional supplement. During an interview on 7/30/26 at 10:52 a.m. with the RD, the RD stated there should be a physician's order if a resident was receiving an oral nutritional supplement three times a day with meals. The RD stated administering [brand name] oral nutritional supplement to Resident 6 without a physician's order presented a risk of unintended weight gain to Resident 6.During an interview on 7/31/26 at 10:15 a.m. with the Director of Nursing (DON), the DON stated there should be a physician's order for nutritional supplements administered to residents. The DON stated Resident 6 should not be administered nutritional supplements without a physician's order to ensure the nutritional supplements was appropriate for Resident 6's nutritional needs and prevent adverse complications. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, dated 10/2017, the P&P indicated, .A therapeutic diet must be prescribed by the resident's attending physician.A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet.

Based on observation, interview and record review, the facility failed to ensure residents' food preferences were implemented in meeting their needs for one of five sampled residents (Resident 148) when Resident 148 was receiving specific food dislikes such as bananas, tomatoes, potatoes, oranges, milk, bacon, sausage, and ham in his meal tray. Resident 148 had diagnosis of End Stage Renal Disease (ESRD -a condition where the kidneys can no longer function on their own and dialysis [a process of removing excess water, and waste products from the blood] or kidney transplant is required to survive) and was on hemodialysis treatments (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).This failure resulted in delayed implementation of Resident 148's food preferences in meeting his needs and had the potential for Resident 148 to experience unrecognized negative outcomes and complications which could compromise Resident 148's overall health. Findings:Based on concurrent observation and interview on 7/29/26 at 9:20 a.m. with Resident 148, in Resident 148's room, Resident 148 was lying in bed, awake, alert and oriented to names, places, time, and situation. Resident 148 stated he was admitted to the facility about a week from acute care hospital. Resident 148 stated he was on hemodialysis three times a week for two years. Resident 148 stated he was receiving renal diet (a low-sodium, low-phosphorus, and controlled-protein eating plan designed to reduce waste products in the blood and ease the workload on damaged kidneys) at home. Resident 148 stated the facility was serving the same diet for all the residents. Resident 148 stated the dietary staff asked for his food preferences and food dislikes. Resident 148 stated the dietary staff was informed of his food preference and food dislikes such as potatoes, tomatoes, bananas, oranges, milk, bacon, sausage, and ham. Resident 148 stated specific food dislikes had been provided in his meal tray. Resident 148 stated he was served with mashed potatoes in his meal. Resident 148 stated potatoes were not good for dialysis residents due to high content of potassium (an essential mineral and electrolyte regulate fluid balance, nerve signals, and muscle contractions-including the heart). Resident 148 stated he was avoiding food high in potassium and phosphorous (a mineral found in your bones) to keep his blood work within normal limits.During a review of Resident 148's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/31/26, the AR indicated Resident 148 was admitted to the facility on [DATE] with diagnosis of end stage renal disease, dependence on renal dialysis, atherosclerotic heart disease (when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath).During a review of Resident 148's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/23/26, the MDS section C indicated Resident 136 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 148 was cognitively intact.During a concurrent interview and record review on 7/29/26 at 3:44 p.m. with the Dietetic Services Supervisor (DSS), Resident 148's meal ticket was reviewed. Resident 148 meal ticket indicated, . Special Diet: Regular Diet - Thin Liquids.Dislikes: (blank). The DSS stated Resident 148's food dislikes were not added to Resident 148's meal tickets for breakfast, lunch and dinner. The DSS stated Resident 148's food dislikes should be updated and included in Resident 148's meal tickets to ensure Resident 148 will not receive food which could negatively affect his health. The DSS stated it was important to follow Resident 148's food preference and dislikes in managing his medical condition. The DSS stated it was his expectation for Resident 148's food preferences assessment to be completed by the Assistant Dietary Supervisor (ASD) upon admission or within three days from admission to prevent delayed implementation. During an interview on 7/29/26 at 4:18 p.m. with the ADS, the ADS stated Resident 148's food preferences assessment should be conducted within 72 hours from admission to the facility. The ADS stated she completed residents' food preferences assessment which include medical condition, likes, and dislikes. During an interview on 7/30/26 at 12:00 p.m. with the Registered Dietitian (RD), the RD stated Resident 148 was receiving a regular diet and not renal diet. The RD stated Resident 148's recent potassium level was normal when she completed Resident 148's nutritional assessment dated [DATE]. The RD stated Resident 148's laboratory values will be monitored and reassess the need of therapeutic diet (a meal plan prescribed by a doctor or clinical dietitian to treat a medical condition, manage symptoms, or aid recovery). The RD stated residents' food preference assessment should be completed by DSS or assistant within three days from admission to prevent a delay in implementing residents' food preference. The RD stated Resident 148's food preference and specific food dislikes should be specified in his meal tickets and implemented in managing his health and medical condition. During a concurrent interview and record review on 7/30/26 at 4:33 p.m. with the Minimum Data Ser Nurse Coordinator (MDSC), Resident 148's DIET: History and Food Preferences assessment dated [DATE] was reviewed. The DIET: History and Food Preferences indicated, 1. Interview conducted with: a. Resident. 4. Any food dislikes? a. Beverages b. Meats f. Fruits h. Cereals 4a. Specify food dislikes Bananas, Tomatoes, Potatoes, Oranges, Milk, Bacon, Sausage, Ham. The MDSC stated Resident 148's food preferences and dislikes should be followed and implemented in maintaining his potassium and phosphorous level within normal limits. During a review of facility's policy and procedures (P&P) titled, Resident Food Preferences, dated 7/2017, the P&P indicated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the residents' or representative's consent. 1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the residents directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the residents' food and eating preferences in the care plan. 4. The dietitian and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. 5. The dietitian will discuss with the resident or representative the rationale of any prescribed therapeutic diet. The physician and dietitian will communicate the risks and benefits of specialized therapeutic vs. liberalized diets.

Based on observation, interview and record review, the facility failed to ensure residents' respiratory services (services that are provided by a qualified professional (respiratory therapists, respiratory nurse) for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function) were provided and documented consistent with the professional standards of practice, and comprehensive person-centered care plan for one of five sampled residents (Resident 10) when Resident 10 diagnosed with pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluids), oxygen therapy (administration of oxygen) was not monitored and assessed, license nurses failed to document the use and administration of oxygen, and did not perform routine oxygen equipment checks, which resulted for Resident 10 being connected to an empty oxygen tank. These failures resulted in Resident 10's oxygen therapy being unmonitored and improperly delivered, which placed Resident 10 at risk for an inaccurate evaluation of oxygen therapy effectiveness which could lead to compromised respiratory function. Findings: During a concurrent observation and interview on 7/28/26 at 12:47 p.m. with Resident 10, in Resident 10's room, Resident 10 was sitting in a wheelchair eating her lunch meal. Resident 10 was on oxygen therapy through nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at 2 lpm/nc (liters per minute per nasal cannula) connected to an emergency oxygen tank behind her wheelchair. Resident 10 was alert and oriented to names, places, and situation. During a concurrent observation and interview on 7/28/26 at 3:36 p.m. with Resident 10, in Resident 10's room, Resident 10 was sitting in her wheelchair and was on oxygen therapy via nasal cannula at 2 lpm/nc connected to an emergency oxygen tank behind her wheelchair. Resident 10 was moving her nasal cannula from her nares and stated she does not feel air coming out from nasal cannula. Resident 10 remained alert and did not complain of shortness of breath. During a concurrent observation and interview on 7/28/26 at 3:42 p.m. with the Infection Preventionist (IP), inside Resident 10's room, the IP checked Resident 10's oxygen tank. The IP stated Resident 10's oxygen tank was empty and informed Resident 10 she will get a new oxygen tank and will replace the empty tank. The IP stated she will notify the licensed nurse to check Resident 10's oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage). The IP stated the length of time when oxygen tank was emptied was unknown. The IP stated Resident 10 should receive the proper flow of oxygen she needed. During a concurrent observation and interview on 7/28/26 at 3:50 p.m. with the IP, in Resident 10's room, the IP was holding a new oxygen tank. The IP connected Resident 10's oxygen tubing into the oxygen wall. Resident 10 had no complaints of shortness of breath. During an observation on 7/29/26 at 12:05 p.m. with Resident 10, in the front lobby, Resident 10 was sitting in her wheelchair. and was on oxygen therapy via nasal cannula with oxygen tubing connected to an emergency oxygen tank behind her wheelchair. Resident 10 was talking to a visitor. During a concurrent interview and record review on 7/29/26 at 12:41 p.m. with the Unit Manager (UM) 1, Resident 10's Change in Condition Evaluation dated 7/20/26 and admission record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), undated were reviewed. The Change in Condition Evaluation indicated, 1. Signs & Symptoms Identified - cough and hypoxemia. 3. Review Findings and Provider Notifications: Assigned CNA reported that the resident had low oxygen 88% -87% RA (Room Air) dry nonproductive. Writer checked the oxygen saturation RA 89%-90%, notified doctor.do chest x-ray now and apply oxygen 2 lpm/nc prn (given as needed or requested) for hypoxemia (a low levels of oxygen in the blood) and SOB (shortness of breath) . The AR indicated, Resident 10 was admitted to the facility on [DATE] with the primary diagnosis of displaced fracture of left femur (a break in the bone of the thigh). UM 1 stated Resident 10 had a change in condition of cough and oxygen desaturation with physician's order of chest x-ray and oxygen at 2-3 lpm/nc prn. UM 1 stated Resident 10 had Pneumonia based on chest x-ray result. UM 1 stated Resident 10's AR does not contain a respiratory diagnosis. UM 1 stated Resident 10's medical diagnosis should be updated to reflect the diagnosis of Pneumonia. During a concurrent interview and record review on 7/30/26 at 4:48 p.m. with Minimum Date Set Coordinator (MDSC), Resident 10's AR, electronic medication administration records (EMAR - a digital daily documentation record used by a licensed nurse to document medications and treatments given to a resident) EMAR dated 7/20/26 to 7/30/26, and care plan for oxygen use dated 7/20/26 were reviewed. The AR indicated Resident 10 had no diagnosis of Pneumonia. The EMAR indicated, Oxygen: Apply PRN oxygen at 2L/min via nasal cannula for hypoxia (decreased perfusion of oxygen to the tissues) /shortness of breath, only after an RN or RT has assessed the resident and made the clinical decision to initiate therapy.Start Date: 07/22/2026. The care plan indicated, Focus: At risk for hypoxemia r/t oxygen desaturation 88% when sleeping and dry nonproductive cough. Date Initiated: 07/20/2026. Goal: Will be free of apnea (a temporary stop in breathing), oxygen desaturation or respiratory distress. Will maintain a patient airway to maintain adequate ventilation. Date Initiated: 07/20/2026. Interventions: Administer oxygen as ordered and observe oxygen precautions. Apply oxygen @ 2-3L/nc for SOB, hypoxemia. The MDSC stated Resident 10 had diagnosis of Pneumonia which should be reflected in her medical records. The MDSC stated she was responsible for updating residents' diagnosis in their medical records and should be updated when diagnosed by the physician. The EMAR for oxygen usage prn from 7/20/26- 7/30/26 were blank which indicated Resident 10 did not receive oxygen therapy. The MDSC stated licensed nurses should follow physician's order for oxygen. The MDSC stated Resident 10's administration of oxygen should be documented in the EMAR by the licensed nurses after RT or RN assessment. The MDSC stated it was important to monitor and document the administration of oxygen to accurately assess Resident 10. The MDSC stated Resident 10 could have respiratory distress, stop breathing, and die when Resident 10 did not receive the oxygen needed. During a concurrent interview and record review on 7/31/26 at 8:48 a.m. with the UM 1, Resident 10's EMAR Administration History dated 7/20/26 to 7/31/26. The EMAR indicated, Oxygen: Apply PRN oxygen at 2L/min via nasal cannula for hypoxia/shortness of breath, only after an RN or RT has assessed the resident and made the clinical decision to initiate therapy.Start Date: 07/22/2026.Administration History: No administration documentation could be found. UM stated Resident 10 had been receiving oxygen therapy, licensed nurses should documented the oxygen was administered to Resident 10. UM 1 stated there was inaccurate documentation of the oxygen administration for Resident 10. UM 1 stated she cannot locate the RT or RN assessment prior to initiating an administration of oxygen for Resident 10. During an observation on 7/31/26 at 1:00 p.m. with Resident 10, in the front lobby, Resident 10 was sitting in her wheelchair, awake with eyeglasses. Resident 10 was on oxygen therapy via nasal cannula with oxygen tubing connected to an oxygen tank behind her wheelchair.During an interview on 7/31/26 at 1:15 p.m. with the Director of Nursing (DON), the DON stated oxygen was considered a medication and it was my expectation for all licensed nurses to administer and document the administration of oxygen according to the physician's order. The DON stated the prescribed order for oxygen prn should be implemented as needed based on resident's oxygen saturation and assessment. The DON stated the oxygen saturation should be checked by licensed nurses on room air to accurately assess the need for oxygen. The DON stated it was my expectation for all licensed nurses to document the administration of oxygen to effectively evaluate if Resident 10 requires prn or routine oxygen. The DON stated the physician should be notified if Resident 10 used oxygen routinely instead of the physician's order as needed. The DON stated it was the licensed nurses' responsibility to check the oxygen tank for functional status including verifying the tank contained adequate oxygen supply to ensure Resident 10 received continuous prescribed respiratory therapy. The DON stated empty oxygen tank does not provide a proper flow of oxygen which placed Resident 10 at increased risk of respiratory distress and respiratory failure. The DON stated the indication of use of oxygen and diagnosis such as Pneumonia should be documented and reflected in Resident 10's' medical diagnosis. During a review of facility's policy and procedures (P&P) titled, Oxygen Administration, dated 2001, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation - 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Guidelines - 1. Oxygen therapy is administered by an oxygen mask, nasal cannula, and/or nasal catheter. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Assessment - Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); 2. Signs of symptoms of oxygen toxicity (i.e., rapid breathing, rapid pulse rate, restlessness, confusion) . Steps in the Procedure - 12. Check the mask, tank. to be sure they are in good working order and are securely fastened. Documentation - After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. Reporting - 2. Report other information in accordance with facility policy and professional standards of practice. During a review of facility's P&P titled, Charting and Documentation, dated 7/2017, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. 7. 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; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. During a review of facility's P&P titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 28. If a resident uses PRN medications frequently, the attending physician and interdisciplinary care team, with support from the consultant pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated.

Based on observation, interview, and record review, the facility failed to implement recommended interventions and monitor effectiveness of nutritional interventions to ensure acceptable parameters of nutritional status for one of five sampled residents (Resident 132) when the facility assessed Resident 132 during admission as a high risk for weight loss. The facility did not monitor Resident 132's weight and did not implement nutritional interventions for significant weight loss. This failure resulted in Resident 132 experiencing significant unintended weight loss of 12 % (percent) for less than 30 days which placed Resident 132 at increased risk for further decline in health. Findings:During a concurrent observation and interview on 7/28/26 at 9:34 a.m. with Resident 132, in Resident 132's room, Resident 132 was lying in bed, awake, and mumbling. Resident 132 had inability to respond and kept eye contact during conversation. Resident 132 was repeatedly touching the edges of his blanket. During an observation on 7/28/26 at 12:40 p.m. with Resident 132, in Resident 132's room, Resident was lying in bed awake. Resident 132's lunch tray was on top of the bedside table beside Resident 132's right side of bed. Resident 132's lunch tray contained a plate of puree, a carton of milk, and a glass of red juice, and does not contain nutritional supplement. During a review of Resident 132's lunch meal ticket dated 7/28/26, the lunch meal ticket indicated, Texture: Puree (solid food has been blended, mashed, or processed into a smooth, moist, and uniform texture similar to pudding or applesauce), Special Diet: Regular Diet -Thin Liquids.Standing Orders: Fruit juice, Milk 2%.During a concurrent observation and interview on 7/28/26 at 12:46 a.m. with Certified Nursing Assistant (CNA) 5, in Resident 132's room, CNA 5 was placing and setting up Resident 132's lunch meal tray in front of him. CNA 5 stated Resident 132 does not need assistance with meals, only need set-up. CNA 5 stated Resident 132 had a black lunch meal tray which indicated Resident 132 does not need assistance with eating. CNA 5 stated residents with red lunch meal tray require one-on-one assistance with meals. CNA 5 left Resident 132's bedside.During an observation on 7/28/26 at 12:48 p.m. with Resident 132, in Resident 132's room, Resident 132's lunch meal tray was in front of him and started eating using the straw (covered with paper) to scoop the puree food. Resident 132 placed the straw in his mouth and started eating the straw and chewing the paper cover of the straw. Resident 132 started putting the spoon (without food) in his mouth.During a concurrent interview and record review on 7/29/2026 at 11:31 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 132's Order Summary Report dated 7/2026 was reviewed. The Order Summary report indicated, Dietary-Diet Regular diet Puree texture, Thin Liquids consistency.Dietary Supplements - [Brand Name] with meals for supplement 8 oz (ounces-) with meals Start Date 7/9/26. LVN 6 stated Resident 132's supplement was provided by the kitchen and included in his tray every meal. LVN 6 stated Resident 132's supplement was administered by the CNAs and CNAs reported to licensed nurses when he refused it. LVN 6 stated she documented Resident 132's supplement was administered for breakfast today (7/29/26) by the CNA and not aware of the amount of consumption. LVN 6 stated Resident 132 had a physician's order of supplement with meals due to Resident 132's oral intake of less than 50% (percent).During a concurrent observation and interview on 7/29/26 at 12:30 p.m. with LVN 6, in the hallway across Resident 132's room, the meal tray containing Resident 132's lunch meal tray was checked. Resident132's lunch meal tray does not contain a supplement. LVN 6 stated Resident 132 was assisted by CNA 6 for lunch. LVN 6 stated Resident 132's supplement was given by CNA 6 and Resident 132 refused the supplement. LVN 6 stated CNA 6 could toss the supplement that's why the supplement was not present in Resident 132's lunch meal tray. During a review of Resident 132's lunch meal ticket dated 7/28/26, the lunch meal ticket indicated, Texture: Puree (solid food has been blended, mashed, or processed into a smooth, moist, and uniform texture similar to pudding or applesauce), Special Diet: Regular Diet- Thin Liquids.Standing Orders: Fruit juice, Milk 2%.During a concurrent interview and record review on 7/29/26 at 11:38 a.m. with Unit Manager (UM) 1, Resident 132's Electronic Medical Records (EMR) titled Weights, and Amount Eaten dated 7/2/26 to 7/29/26 were reviewed. The Weights indicated, 7/29/2026 146.0 lbs. (pounds - a unit of weight),7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The Amount Eaten indicated, 0-25% with 41 check marks, 26-50% with 12 check marks, and Resident Refused with 14 check marks. UM 1 stated Resident 132 had triggered a significant unintended seven pounds weight loss from 7/19/26 to 7/26/26. UM 1 stated Resident 132 was at risk for malnutrition due to poor oral intake since admitted to the facility on [DATE] with total check marks (0-25%, 26-50%, and refusals) of 67 out of 84 meals (more than 50%). UM1 stated she communicated with the Registered Dietitian (RD) regarding Resident 132's significant unintended weight loss and poor oral intake and was instructed to reweigh Resident 132. UM 1 stated she did not notify the physician and Resident 132's responsible party about his significant unintended weight loss. UM 1 stated Resident 132's significant weight loss should require a notification from his physician for further evaluation and additional interventions to prevent further weight loss. UM 1 stated a care plan for Resident 132's significant unintended weight loss should be developed for the staff to implement current interventions.During a concurrent interview and record review on 7/29/26 at 11:41 a.m. with UM 1, Resident 132's Change in Condition Evaluation dated 7/6/26 was reviewed. The Change in Condition Evaluation indicated, 1. Signs and Symptoms Identified Food and/or fluid intake (decreased or unable to eat.) 2. Functional Status Evaluation 2. 5. Swallowing difficulty 2a51 1. Associated with new onset or progressive choking, aspiration (when food or liquid goes into the airway) 2b. resident is having difficulty swallowing food. 3. Provider Notification and Feedback.3. Monitor for 72 hours, Speech evaluation, downgrade to puree. UM 1 stated Resident 132's regular texture diet was downgraded to puree texture per physician's order. UM 1 stated she cannot locate the swallowing evaluation and treatments in his EMR. UM 1 stated Resident 132 should be evaluated by the Speech therapist due to difficulty in swallowing and risk of aspiration.During a concurrent interview and record review on 7/29/26 at 11:45 a.m. with UM1, Resident 132's electronic medication administration record (EMAR- a daily digital documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 7/9/26 to 7/29/26 was reviewed. The EMAR indicated, [Brand Name] with meals for supplement 8 oz (ounces- a unit of volume used mostly for liquids) with meals Hours 0900, 1300 (1:00 p.m.), 1700 (5:00 p.m.) showing check marks with Licensed Nurses' initials and X marks for ML (milliliters- metric unit used to measure the volume of a liquid). UM 1 stated check marks in Resident 132's EMAR for supplement indicated it was given and does not mean consumption. UM 1 stated X marks in Resident 132's EMAR for supplement indicated amount of consumption were not documented. UM 1 stated Resident 132's supplement should be included in his food tray for every meal and should be given by the CNAs during meal. UM 1 stated Resident 132's supplement consumption should be documented by the licensed nurses in the EMAR to accurately evaluate effectiveness of current nutritional intervention to prevent further weight loss.During a review of Resident 132's admission record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/29/26, the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's disease (a brain disorder slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Dementia (loss of memory, language, problem-solving and other thinking abilities are severe enough to interfere with daily life), pressure-induced deep tissue damage of sacral region (a serious pressure ulcer affecting the lower back and tailbone area [the sacrum]) and need for assistance with personal care.During a review of Resident 132's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/8/26, the MDS section C indicated Resident 132's BIMS - was not conducted with a code of 0 indicating No (resident is rarely/never understood). Resident 132's BIMS Summary Score was blank. The MDS Section GG-Functional Abilities-admission indicated, .Safety and Quality of Performance 01-Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity 1. admission Performance: 01 -Eating. The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident . Section K - Swallowing/Nutritional Status. The MDS Section K -Swallowing/Nutritional Status indicated, K 0100. Swallowing Disorder - Signs and symptoms of possible swallowing disorder D. Complaints of difficulty or pain with swallowing.During a concurrent observation and interview on 7/29/26 at 12:38 p.m. with LVN 6 and CNA 6, LVN 6 called and validated Resident 132's supplement consumption with CNA 6. CNA 6 stated Resident 132's lunch tray does not contain a supplement. CNA 6 stated supplement was not given to Resident 132 due to being not available in his lunch tray. CNA 6 stated Resident refused his lunch meal including the milk and juice.During an interview on 7/29/26 at 3:00 p.m. with Resident 132's responsible party (RP) 3, in Resident 132's room, RP 3 stated Resident 132 was transferred to an acute care hospital from home due to decreased in oral intake and weakness. RP 3 stated she was not informed of Resident 132's weight loss since admission to the facility and was not aware of plan of care related to his weight loss.During a concurrent interview and record review on 7/29/26 at 3:44 p.m. with Dietetic Services Supervisor (DSS), Resident 132's tray meal ticket dated 7/29/26, and dietary communication slip dated 7/2026 were reviewed. The tray meal ticket indicated, Texture: Puree, Special Diet: Regular Diet= Thin Liquids.Standing Orders: Fruit juice, Milk 2% .Alerts: Red Tray. The DSS stated Resident 132 [Brand Name] nutritional supplement was not in his tray ticket which indicated Resident 132's nutritional supplement was not provided by the dietary and was not included in his tray. The DSS stated there was no dietary communication slip for Resident 132's [Brand Name] nutritional supplement with meals. The DSS stated the facility process was for nursing to complete a dietary communication slip for nutritional supplement with meals to ensure it will be added in the tray for every meal. The DSS stated Resident 132's red tray just started today (7/29/26) which indicated Resident 132 requires feeding assistance. The DSS stated it was important residents' nutritional interventions should be implemented according to physician's orders and Interdisciplinary Team (IDT) recommendations when the risk of malnutrition (an imbalance between the nutrients your body needs to function with and the nutrients it gets) was identified to prevent delay in implementation which could result in weight loss.During an interview on 7/30/26 at 9:00 a.m. with CNA 7 stated he was assigned to Resident 132 today (7/30/26) and was familiar with his care. CNA 7 stated Resident 132's oral intake had always been poor for breakfast, about 0-25 percent, and better for lunch. CNA 7 stated when Resident 132's wife visits, she assisted him with feeding. CNA 7 stated CNA 8 assisted him for breakfast today (7/30/36).During an interview on 7/30/26 at 9:06 a.m. with CNA 8, CNA 8 stated she fed Resident 132 at breakfast today (7/30/26). CNA 8 stated Resident 132 only consumed 2 bites of puree food and refused [Brand Name] supplement. CNA 8 stated Resident 132 started to be combative (ready, eager, or inclined to fight, or resist) and it was her first time assisting him with meals.During a concurrent interview and record review on 7/30/26 at 10:19 a.m. with the RD, Resident 132's weights dated 7/2/26 to 7/29/26 and Nutrition Comprehensive assessment dated [DATE] were reviewed. The Weights indicated, 7/29/2026 146.0 lbs. (pounds - a unit of weight), 7/27/2026 145.0 lbs.,7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The Nutrition Comprehensive Assessment indicated, 10. Medical Nutrition Therapy (MNT) Summary: Parkinsonism, Alzheimer's. dementia, IBW (Ideal Body weight)171 lbs. Skin: [NAME] Tissue Injury (DTI- a severe pressure injury [damage to the skin and soft tissue caused by prolonged pressure, often over a bony part of the body like the heels, hips, or tailbone] where deep underlying soft tissue is damaged) to sacrococcygeal (the area of the body where the sacrum [the large triangular bone at the base of the spine] meets the coccyx [the tailbone] ) . Resident with po (by mouth) intake 35%Regular Puree diet with meal refusals. Recommend adding 8 oz Ensure TID (three times a day). Monitor weight, skin and po. The RD stated Resident 132 had a significant unintended weight loss of more 10% in less than 30 days and the facility treat as severe weight loss. The RD stated during IDT weight review was identified Resident 132 had missed a weekly weight from 7/2/26 to 7/12/26, resulting in failure to identify a three pounds weight loss and further weight loss continued from 7/19/26 to 7/29/26. The RD stated Resident 132's admission nutritional assessment was completed on 7/8/26 and Resident 132 was assessed at risk for malnutrition due to poor cognition related to diagnosis of Parkinsons, Dementia, and declined in oral intake with recommendation of [Brand Name] nutritional supplement three times a day and monitor weight, skin and oral intake. The RD stated Resident 132 should be receiving [Brand Name] nutritional supplement with meals from 7/9/26 and should be included on his meal tray. The RD stated when the nutritional supplement was not available in his meal tray, Resident 132 had an increased risk of not receiving the nutritional supplement which could result in malnutrition and weight loss. The RD stated new admit residents should be weighed weekly for four weeks. The RD stated weekly weights should be done as scheduled to prevent a delay in implementation of additional interventions (including red tray program [one-on-one assistance with meals) to prevent unavoidable weight loss and risk of malnutrition. The RD stated Resident 132's nutrition care plan should reflect Resident 132's significant unintended weight loss with current goal of stabilizing his weight with no further significant weight loss. The RD stated the IDT will meet today to discuss Resident 132's significant unintended weight loss.During a concurrent interview and record review on 7/31/26 at 11:40 a.m. with the Director of Nursing (DON), Resident 132' s EMR titled Weights, dated 7/2026 were reviewed. The Weights indicated, 7/29/2026 146.0 lbs.,7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The DON stated Resident 132 triggered a significant unintended weight loss on 7/26/26 and not weighed weekly from 7/2/26 to 7/12/26. The DON stated significant weight changes including loss and gain applies to 5% in 1 month, 7.5% in three months, and 10% in six months. The DON stated the facility also addresses a five pounds weight loss in a week. The DON stated residents on weekly weights should be weighed weekly to closely monitor their weights. The DON stated RNAs were responsible in doing weekly weights for the residents. The DON stated it was her responsibility together with the unit nurse managers in overseeing the weights to ensure it was done weekly. The DON stated Resident 132 was identified at risk of malnutrition from admission due to diagnosis of Dementia and require assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The DON stated Resident 132's should be included in the facility's red tray program to provide one-on-one assistance with meals. The DON stated Resident 132's nutritional supplements should be included in his food tray for every meal. The DON validated Resident 132's nutritional consumption was not documented. The DON acknowledged nutritional supplements consumption should be documented to validate effectiveness of nutritional interventions. The DON stated Resident 132's swallowing evaluation and treatment should be conducted to rule out swallowing issues to prevent aspiration. The DON stated it was her expectation for all licensed nurses to complete a change of condition assessment and care plan when resident triggered for a significant weight loss to identify and evaluate the root cause of weight losses and prevent a delay in the implementation of new interventions. The DON stated a person-centered care plan was important because it directs the care of the residents. During a review of facility's policy and procedures (P&P) titled, Weight Assessment and Intervention, dated 3/2022, the P&P indicated, Weight Assessment and Intervention. Resident weights are monitored for undesirable or unintended weight loss or gain. Weight Assessment - 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weigh loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Evaluation - 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes b. the resident's calorie, protein, and other nutrient needs compared with the resident's current intake; c. the relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. whether and to what extent weight stabilization or improvement can be anticipated. 2. The physician and the multidisciplinary team identify conditions and medications may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. cognitive or functional decline; b. chewing or swallowing abnormalities; f. increased need for calories and/or protein; i. inadequate availability of food or fluids. Interventions - 1. Interventions for undesirable weight loss are based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; e. Chewing and swallowing abnormalities and the need for diet modifications; g. The use of supplementation.During a review of facility's P&P titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated 9/2012, the P&P indicated, . 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. 2. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with weight loss or gain, and significant risk for impaired nutrition. 4. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. Cause Identification - 1. The physician will review for medical causes of weight gain, . and weight loss before ordering interventions. 4. The physician will review carefully, and rule out medical causes of, oral or swallowing problems before authorizing other consults or interventions to modify diet consistency. Treatment/Management - 1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. 3. The staff and physician will review and consider existing dietary restrictions and modified consistency diets. Monitoring - 1. Physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss) .During a review of facility's P&P titled, Nutritional Assessment, dated 10/2017, the P&P indicated, As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition should be conducted for each resident. 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the residents at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. 3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: a. Nursing: (3) A description of the resident's usual intake and appetite; (4) A history of reduced appetite or progressive weight loss or gain prior to admission; (5) Current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors; (9) Usual meal and snack patterns. 4. The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition. a. Cognitive or functional decline. b. Chewing or swallowing abnormalities.During a review of facility's P&P titled, Assistance with Meals, dated 2001, the P&P indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 4. Meal consumption: Document how much of the meal the resident consumed: 0% - Resident refused the meal and ate nothing. Offer an alternative meal. 1-25% - Ate 1-2 bites or up to half of one food item. 26-50% - Ate bites of most items, up to half of the entree. Residents Requiring Full Assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.

Based on observation, interview, and record review, the facility failed to ensure indwelling urinary catheters were assessed and maintained in accordance with the facility policy and procedures for one of four sampled residents (Resident 36) when Resident 36 was observed with an indwelling urinary catheter (UC-a common type of indwelling catheter inserted into the bladder, used to drain urine) that had visible sediment (a buildup of minerals, blood cells, bacteria, or mucus that appears as gritty particles, flakes, or cloudiness in the tubing or drainage bag) and increased cloudiness at the bottom of the tubing where the end of the tubing met the drainage bag. Nursing staff did not communicate this change to Resident 36's provider. This failure had the potential to result in a catheter-associated urinary tract infection (CAUTI), catheter blockage from mineral or crystalline biofilm (a sticky layer of tiny living germs like bacteria that join together and glue themselves to wet surfaces) buildup, and hospitalization due to a systemic decline and possible sepsis (a life-threatening reaction to an infection that causes the immune system to harm healthy tissues and organs) if a localized urinary issue went unaddressed.During a review of Resident 36's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/29/26, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses of Sepsis (a life-threatening body wide reaction to an infection)-unspecified organism, infection and inflammatory reaction due to indwelling urethral (the tube that carries urine from your bladder to the outside of the body) catheter, type 2 diabetes mellitus with diabetic polyneuropathy ( when long term high blood sugar has caused widespread nerve damage affecting the feet, legs, hands, and arms), neuromuscular dysfunction of bladder (loss of bladder control caused by damage to the nerves or muscles), retention of urine, cirrhosis of liver ( a condition in which the liver is scarred and permanently damaged).During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 5/4/26, the MDS indicated Resident 36's Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 36 had no cognitive impairment.During an observation on 7/28/26 at 12:45 p.m.in Resident 36's room, Resident 36 was observed with an indwelling UC had visible sediment and increased cloudiness at the bottom of the tubing where the end of the tubing met the drainage bag.During an observation on 7/29/26 at 12:05 p.m.in Resident 36's room, Resident 36 was observed with an indwelling UC had visible sediment and increased cloudiness at the bottom of the tubing where the end of the tubing met the drainage bag.During a concurrent observation and interview on 7/29/26 at 12:11 p.m. with Certified Nursing Assistant (CNA) 4 in Resident 36's room, Resident 36 was observed with an indwelling UC had visible sediment and increased cloudiness at the junction of the tubing and the drainage bag. CNA 4 stated CNA's checked UC to ensure tubing was not folded/bent, off the floor, emptied and documented urine output under activities of daily living (ADL) task. CNA 4 stated CNA's documented urine color, and any observation within the urine. CNA 4 stated the UC line should be clean with no sediment to ensure proper urine flow. CNA 4 stated Resident 36's UC line was not clean, and nursing staff must report UC lines containing significant sediment to the nurse so the nurse could change the UC tubing and drain bag.During a concurrent observation and interview on 7/29/26 at 12:19 p.m. with Licensed Vocational Nurse (LVN) 5 in Resident 36's room, Resident 36 was observed with an indwelling UC with visible sediment and increased cloudiness at the junction of the tubing and drainage bag. LVN 5 stated the UC was not a clean catheter and required changing due to sediment and white mucus in the drainage bag. LVN 5 stated if urine flow remained good, she would keep the UC in place while replacing only the tubing and drainage bag . LVN 5 stated maintaining a clean UC tubing and clean drainage bag was essential for proper urine flow and preventing infection to Resident 36. LVN 5 stated CNAs had not reported the unclean UC tubing to her.During an interview on 7/31/26 at 9:11 a.m. with the Infection Preventionist (IP), the IP stated nursing staff must notice changes in the resident's urine and contact the physician. The IP stated changes in urine should be reported to the physician including increased sediment, color changes , odors, or cloudiness, ensuring the physician stays informed to determine the appropriate interventions. The IP stated increased sediment could cause decreased urine flow or obstruct the flow entirely, making it essential to address sediment accumulation in the UC tubing or bag. The IP stated significant sediment, crystallization or mucus should prompt notification to the physician because these issues could lead to obstruction, infection, or signal underlying health concerns for Resident 36. During an interview on 7/31/26 at 10:05 a.m. with the Director of Nursing (DON), the DON stated her expectations for nursing staff in providing care for residents with indwelling UC was for nursing staff to ensure UC must remain intact, nurses must follow physician's orders and must notify the physician of any changes observed. The DON stated CNAs were expected to communicate noticed changes to the nurses, to ensure nurses performed an assessment, and notified the physician as needed. The DON stated Resident 36 UC should have been free from sediments to avoid infection but was not. During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes-Clinical Protocol, dated March 2018, the P&P indicated, .The physician will help identify individuals with a significant risk for having acute changes of condition during their stay.Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident.and how to communicate these changes to the nurse.Nursing assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse.The staff will monitor and document the resident/patient's progress and response to treatment, and the physician will adjust treatment accordingly.The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized. During a review of the facility's P&P titled, Guidelines for Notifying Physicians of Clinical Problems, dated March 2025, the P&P indicated, .These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record.The charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management.The following are examples of issues that should be reported to the physician.Other.Nursing observations that might require physician action.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers (areas of damaged skin caused by staying in one position for too long) receives necessary treatment to promote wound healing for one of five sampled residents (Resident 132) when Resident 132 did not received necessary medications and wound care treatment as ordered by the wound doctor on 7/8/26 in promoting wound healing and prevent worsening of the pressure injury. Resident 132 had a diagnosis of Pressure-Induced Deep Tissue Damage of Sacral Region (a serious pressure ulcer affecting the lower back and tailbone area [the sacrum]) from admission date of 7/2/26.This failure had the potential for delayed wound healing and worsening of existing pressure ulcer for Resident 132.Findings:During a concurrent observation and interview on 7/28/26 at 9:34 a.m. with Resident 132, in Resident 132's room, Resident 132 was lying in bed, awake, and mumbling. Resident 132 had inability to respond and kept eye contact during conversation. Resident 132 was repeatedly touching the edges of his blanket.During an observation on 7/28/26 at 12:48 p.m. with Resident 132, in Resident 132's room, Resident 132's lunch meal tray was in front of him and started eating using the straw (covered with paper) to scoop the puree food. Resident 132 placed the straw in his mouth and started eating the straw and chewing the paper cover of the straw. Resident 132 started putting the spoon (without food) in his mouth.During an interview on 7/29/26 at 3:00 p.m. with Resident 132's responsible party (RP) 3, in Resident 132's room, RP 3 stated Resident 132 was transferred to an acute care hospital from home due to decreased in oral intake and weakness. RP 3 stated she was not informed of the progress and treatment of Resident 132's wound on his lower back.During a review of Resident 132's admission record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/29/26, the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's disease (a brain disorder slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Dementia (loss of memory, language, problem-solving and other thinking abilities are severe enough to interfere with daily life), pressure-induced deep tissue damage of sacral region and need for assistance with personal care.During a review of Resident 132's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/8/26, the MDS section C indicated Resident 132's BIMS - was not conducted with a code of 0 indicating No (resident is rarely/never understood). Resident 132's BIMS Summary Score was blank.During an interview on 7/30/26 at 9:00 a.m. with CNA 7 stated he was assigned to Resident 132 today (7/30/26) and was familiar with his care. CNA 7 stated Resident 132's oral intake had always been poor for breakfast, about 0-25 percent, and better for lunch. CNA 7 stated when Resident 132's wife visits, she assisted him with feeding. CNA 7 stated Resident 132 was incontinent for bowel and bladder. CNA 7 Resident 132 requires incontinence care every two hours or as needed.During a concurrent interview and record review on 7/30/26 at 1:57 p.m. with Wound Nurse (WN) 1, Resident 132's wound progress note dated 7/8/26, electronic medication administration record (EMAR- a daily digital documentation record used by a licensed nurse to document medications and treatments given to a resident), electronic treatment administration record (ETAR- a daily digital documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 7/2/26 to 7/230/26, and Order Summary Report dated 7/2026 were reviewed. The wound progress note indicated, Chief Complaint: This patient was seen today as a consultation for the evaluation of patient's ulcers.Initial standard orders include Multivitamins (dietary supplements containing multiple essential vitamins and minerals) qd (every day) Vitamin C (builds and stabilizes new collagen for skin strength) qd, Zinc Sulfate (repairs cell membranes, helps new skin grow, and lowers swelling) 320 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) qd 14 days.Active Problem: Pressure-Induced Deep Tissue Damage of Sacral Region. Wound 1 Sacrococcygeal Wound Care Orders: Cleanse wound with ns (normal saline), pat dry, apply barrier cream and leave open to air qd and prn (as needed) The EMAR does not contain an order of Multivitamins qd, Vitamin C qd, Zinc Sulfate 320 mg qd 14 days. The ETAR indicated blank under prn wound treatment for DTI (Deep Tissue Injury-persistent non-blanchable deep red, maroon or purple discoloration) to sacrococcygeal. The Order Summary Report indicated, Pressure Injury Site: DTI to Sacrococcygeal Cleanse daily with NS or Wound Cleanser, pat dry, apply Barrier Cream and leave open to air.every 8 hours as needed for DTI for 14 days Start date 7/7/26. Pressure Injury Site: DTI (Deep Tissue Injury) to Sacrococcygeal Cleanse daily with NS or Wound Cleanser, pat dry, apply Barrier Cream and leave open to air.everyday shift for DTI for 14 days Start Date 7/24/26.WN 1 stated Resident 132 was admitted to the facility on [DATE] with non-blanchable redness on sacrococcygeal area. WN 1 stated the wound doctor classified Resident 132's redness on sacrococcygeal area as deep tissue pressure injury. WN 1 stated wound doctors do wound rounds weekly. WN 1 stated Resident 132 Order Summary Report indicated Resident 132 had no orders for Multivitamins, Vitamin C, Zinc Sulfate 320 mg for 14 days. WN1 stated Resident 132's wound doctor's progress note should be reviewed, and wound doctor's order should be carried out and implemented to promote wound healing. UM 1 stated medications recommended by the wound doctor could help in the healing process. WN 1 stated Resident 132's DTI wound treatment was done by wound nurses during a.m. shift. WN 1 stated Resident 132's DTI to sacrococcygeal treatment every 8 hours as needed in ETAR from 7/2/26 to 7/30/26 were blank which indicated wound care treatments were not done. WN 1 stated it was important to provide wound treatment to Resident 132 every shift or as needed after each incontinence (the loss of bladder or bowel control, causing accidental leaks of urine or stool) care to prevent worsening of the existing pressure injury. WN 1stated it was his expectation for licensed nurses to follow and implement physician's order for Resident 132's DTI sacrococcygeal treatment every 8 hours as needed to prevent pressure injury. During a concurrent interview and record review on 7/30/26 at 2:14 p.m. with WN 1, Resident 132's Braden assessment dated [DATE] was reviewed. The Braden Assessment indicated a score of 15. WN 1 stated Braden Assessment was completed to assess the risk of pressure injury. WN 1 stated it was important to identify the risk for pressure injury. WN 1 stated a score of 15 indicated Resident 132 was at risk for pressure injury due to limitation in physical mobility, incontinence of bowel and bladder, and poor oral intake. WN 1 stated RP3 should be notified about the status of Resident 132's pressure injury and the plan of care.During a concurrent interview and record review on 7/31/26 at 8:23 a.m. with Unit Manager (UM) 1, Resident 132's wound progress note dated 7/8/26, 7/15/26, and 7/22/26 were reviewed. The wound progress note indicated, Chief Complaint: This patient was seen today as a consultation for the evaluation of patient's ulcers.Initial standard orders include Multivitamins qd (every day) Vitamin C qd, Zinc Sulfate 320 mg qd 14 days.Active Problem: Pressure-Induced Deep Tissue Damage of Sacral Region. UM 1 stated it was important for Resident 132 to receive Multivitamins, Vitamin, Zinc Sulfate 320 mg to promote wound healing of DTI. UM 1 stated wound progress notes should be reviewed by licensed nurses to ensure all recommendations will be implemented. UM 1 stated the facility needed to change the wound care process to prevent the risk of improper wound healing and decline in health.During an interview on 7/31/26 at 11:40 a.m. with the Director of Nursing (DON), the DON stated it was her responsibility to oversee wound care. The DON stated Resident 132's wound progress notes were not reviewed, no one catch it. The DON stated the facility process was the Medical Records Director (MRD) will print the wound progress notes and directly scanned to the residents' electronic medical records. The DON stated the facility's wound care process should be changed to ensure wound doctor's orders will be implemented to prevent delayed wound healing. The DON stated Resident 132 had DTI and could benefit from receiving Multivitamins, Vitamin C, and Zinc Sulfate to promote wound healing.During a review of Resident 132's care plan dated 7/2/26, the care plan indicated, Focus - admitted with actual impairment to skin integrity: DTI to Sacrococcygeal. Date Initiated: 07/02/2026. Goal - Will develop clean and intact skin by the review date. Revision on: 07/17/2026. Interventions - Administer medications and treatments as ordered by Physician. Monitor side/effects and effectiveness.During a review of facility's policy and procedures (P&P) titled, Pressure Injuries/Skin Breakdown - Clinical Protocol, dated 4/2018, the P&P indicated, To ensure skin issues are identified promptly, properly classified, treated and monitored appropriately to facilitate healing and to identify potential declines and barriers to healing. Treatment/Management - 1. Physicians will order pertinent wound treatments. 3. Licensed nurses will carry out ordered treatments and notify attending physician and resident/RR as needed for any significant changes in wounds or ineffectiveness of ordered treatments . Documentation and Care plan Integration. 3. Nursing and interdisciplinary notes must reflect: b. Implementation of physician orders.During a review of facility's P&P titled, Wound Care, dated 10/2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Verify that there is a physician's order for this procedure. Documentation - The following information should be recorded in the resident's medical record: 4. The name and title of the individual performing the wound care. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Reporting - 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and assistive devices to maintain hearing abilities and attain or maintain residents' highest practicable physical, mental, and psychosocial well-being for one of five sampled residents (Resident 17) when Resident 17's physician's order and care plan for audiology referral was not implemented. Resident 17 was assessed with highly impaired hearing.This failure had the potential for Resident 17 not to receive necessary services and appropriate hearing devices to effectively communicate Resident 17's needs to staff and family. Findings:During a concurrent observation and interview on 7/28/26 at 10:22 a.m. with Resident 17, in Resident 17's room, Resident 17 was lying in bed in upright position, awake wearing eyeglasses. Resident 17 had family visitor at bedside. Resident 17 was alert oriented to familiar names, places, time, and situation. Resident 17 had difficulty hearing during conversation. Resident 17's family spoke in a loud tone close to her left ear to appropriately respond during conversation. Resident 17 stated she had impaired hearing on both ears and had no hearing aids.During a review of Resident 17's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 6/25/26, the AR indicated Resident 17 was admitted to the facility on [DATE] with diagnosis of intracranial injury (an injury to the brain caused by an external force), history of falling, need for assistance with personal care, and muscle weakness. During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/1/26, the MDS section C indicated Resident 17 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 12 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 17's cognition was moderately impaired.During a concurrent interview and record review on 7/30/26 at 5:02 p.m. with the Minimum Date Set Coordinator (MDSC), Resident 17's MDS Section B and care plan for impaired hearing were reviewed. The MDS Section B indicated, Hearing, Speech, and Vision.B0200 Hearing: 3. Highly impaired - absence of useful hearing; B0300 Hearing Aid: No. The care plan indicated, Actual impaired hearing related to hearing deficit Date initiated: 7/17/26 Goal: Will be able to communicate with staff to make basic needs known on daily basis.Interventions: Refer to audiology for hearing consult as indicated. The MDSC stated Resident 17 was assessed with highly impaired hearing and would benefit for a hearing consult for further evaluation. The MDSC stated Resident 17's care plan for impaired hearing should be implemented to assist Resident 17 for hearing services she needed. The MDSC stated Resident 17's care plan for impaired hearing should have additional interventions like communication board for Resident 17 to effectively communicate with the staff. The MDSC stated care plan was important to direct residents' care.During a concurrent interview and record review on 7/31/26 at 9:06 a.m. with Unit Manager (UM) 1, Resident 17's Order Summary Report dated 7/2026 was reviewed. The Order Summary Report indicated, .Consults: Refer to Audiology, . ENT (ear Nose and Throat) as needed. UM1stated Resident 17's physician order for audiology consult should be followed and implemented to evaluate and manage Resident 17's hearing impairment.During a concurrent interview and record review on 7/31/26 at 10:00 a.m. with the Social Services Supervisor (SSS), Resident 17's ENT Referral form, undated, was reviewed. The SSS indicated there was no ENT referral form completed by licensed nurses. The SSS stated the facility process was for nursing department to coordinate with social services department by completing an ENT Referral form. The SSS stated he was responsible for scheduling an audiology and ENT consult. The SSS stated when Resident 17 was identified with highly impaired hearing based on comprehensive assessment, Resident 17's physician's order and care plan for audiology consult should be implemented to address Resident 17's hearing impairment. The SSS stated it was important for Resident 17 to receive necessary services including hearing devices such as hearing aids to communicate better with her family and staff.During an interview on 7/31/26 at 1:24 p.m. with the Director of Nursing (DON), the DON stated it was her expectation for licensed nurses to communicate with the social services about referral for audiology/ENT. The DON stated it was important for Resident 17's physician's order and care plan for audiology consult should be followed and implemented. The DON stated it was important for Resident 17 to be evaluated by the audiologist/ENT to properly manage Resident 17's hearing impairment and effectively communicate Resident 17's needs.During a review of facility's review of policy and procedures titled, Referrals, Social Services, dated 12/2008, the P&P indicated, Social Services personnel shall coordinate most resident referrals with outside agencies. 3. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 4. Social services will document the referral in the residents' medical record. 6. Social services will help arrange transportation to outside agencies, clinic appointments, etc., as appropriate.During a review of facility's P&P titled, Sensory Impairments - Clinical Protocol. Assessment and Recognition, dated 3/2018, the P&P indicated, Assessment and Recognition -1. As part of the initial assessment, the staff and physicians will help identify individuals with sensory impairments, including hearing. 2. The staff and physician will identify risk factors for sensory deficits or complications of sensory deficits. Cause Identification - 2. The physician will order appropriate consultations. to help define causes and complications of sensory impairments. Treatment/Management - 4. The physician will identify and order appropriate consultations to help manage the causes, complications, and risks of sensory impairment. Monitoring - 1. The staff and physicians will monitor the function and symptoms of individuals with sensory impairments, and the status of any underlying causes and complications. 2. The physician and staff will adjust interventions based on the results of these interventions and on subsequent change in the resident's condition, prognosis, and function.

Based on observation, interview, and record review, the facility failed to review and revise a comprehensive person-centered care plan to reflect assessments and interventions to address a significant weight change for one of five sampled residents (Resident 132) when Resident 132's nutritional care plan was not revised to reflect Resident's 132's significant unintended weight loss risk factors and nutritional interventions.These failures had the potential for Resident 132 not to receive the necessary care and services and put Resident 1 at an increased risk of unintended weight loss.Findings:During a concurrent observation and interview on 7/28/26 at 9:34 a.m. with Resident 132, in Resident 132's room, Resident 132 was lying in bed, awake, and mumbling. Resident 132 had inability to respond and kept eye contact during conversation. Resident 132 was repeatedly touching the edges of his blanket. During an observation on 7/28/26 at 12:40 p.m. with Resident 132, in Resident 132's room, Resident was lying in bed awake. Resident 132's lunch meal tray was on top of the bedside table beside Resident 132's right side of bed. Resident 132's lunch meal tray contained a plate of puree, a carton of milk, and a glass of red juice. Resident 132's lunch meal tray does not contain a nutritional supplement.During a review of Resident 132's lunch meal ticket dated 7/28/26, the lunch meal ticket indicated, Texture: Puree (solid food that has been blended, mashed, or processed into a smooth, moist, and uniform texture similar to pudding or applesauce), Special Diet: Regular Diet -Thin Liquids.Standing Orders: Fruit juice, Milk 2%.During a concurrent observation and interview on 7/28/26 at 12:46 a.m. with Certified Nursing Assistant (CNA) 5, in Resident 132's room, CNA 5 was placing and setting up Resident 132's lunch meal tray in front of him. CNA 5 stated Resident 132 does not need assistance with meals, only need set-up. CNA 5 stated Resident 132 had a black lunch meal tray which indicated Resident 132 does not need assistance with eating. CNA 5 stated residents with red lunch tray require one-on-one assistance with meals. CNA 5 left Resident 132's bedside.During an observation on 7/28/26 at 12:48 p.m. with Resident 132, in Resident 132's room, Resident 132's lunch meal tray was in front of him and started eating using the straw (covered with paper) to scoop the puree food. Resident 132 placed the straw in his mouth and started eating the straw and chewing the paper cover of the straw. Resident 132 started putting the spoon (without food) in his mouth.During a concurrent interview and record review on 7/29/2026 at 11:31 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 132's Order Summary Report dated 7/2026 was reviewed. The Order Summary report indicated, Dietary-Diet Regular diet Puree texture, Thin Liquids consistency.Dietary Supplements - [Brand Name] with meals for supplement 8 oz (ounces-) with meals Start Date 7/9/26. LVN 6 stated Resident 132's supplement was provided by the kitchen and included in his tray every meal. LVN 6 stated Resident 132's supplement was administered by the CNAs and CNAs reported to licensed nurses when he refused it. LVN 6 stated she documented Resident 132's supplement was administered for breakfast today (7/29/26) by the CNA and not aware of the amount of consumption. LVN 6 stated Resident 132 had a physician's order of supplement with meals due to Resident 132's oral intake of less than 50% (percent).During a concurrent observation and interview on 7/29/26 at 12:30 p.m. with LVN 6, in the hallway across Resident 132's room, the tray meal cart containing Resident 132's lunch meal tray was checked. Resident132's lunch meal tray does not contain a supplement. LVN 6 stated Resident 132 was assisted by CNA 6 for lunch. LVN 6 stated Resident 132's supplement was given by CNA 6 and Resident 132 refused the supplement. LVN 6 stated CNA 6 could toss the supplement that's why the supplement was not present in Resident 132's lunch meal tray. During a review of Resident 132's lunch meal ticket dated 7/28/26, the lunch meal ticket indicated, Texture: Puree (solid food that has been blended, mashed, or processed into a smooth, moist, and uniform texture similar to pudding or applesauce), Special Diet: Regular Diet- Thin Liquids.Standing Orders: Fruit juice, Milk 2%.During a concurrent observation and interview on 7/29/26 at 12:38 p.m. with LVN 6 and CNA 6, LVN 6 called and validated Resident 132's supplement consumption with CNA 6. CNA 6 stated Resident 132's lunch meal tray does not contain a supplement. CNA 6 stated supplement was not given to Resident 132 due to being not available in his lunch tray. CNA 6 stated Resident refused his lunch meal including the milk and juice.During a concurrent interview and record review on 7/29/26 at 11:38 a.m. with Unit Manager (UM) 1, Resident 132's Electronic Medical Records (EMR) titled Weights, and Amount Eaten dated 7/2/26 to 7/29/26 were reviewed. The Weights indicated, 7/29/2026 146.0 lbs. (pounds - a unit of weight),7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The Amount Eaten indicated, 0-25% with 41 check marks, 26-50% with 12 check marks, and Resident Refused with 14 check marks. UM 1 stated Resident 132 had triggered a significant unintended seven pounds weight loss from 7/19/26 to 7/26/26. UM 1 stated Resident 132 was at risk for malnutrition due to poor oral intake since admitted to the facility on [DATE] with total check marks (0-25%, 26-50%, and refusals) of 67 out of 84 meals (more than 50%). UM1 stated she communicated with the Registered Dietitian (RD) regarding Resident 132's significant unintended weight loss and poor oral intake and was instructed to reweigh Resident 132. UM 1 stated she did not notify the physician and Resident 132's responsible party about his significant unintended weight loss. UM 1 stated Resident 132's significant weight loss should require a notification from his physician for further evaluation and additional interventions to prevent further weight loss.During a concurrent interview and record review on 7/29/26 at 11:41 a.m. with UM 1, Resident 132's Change in Condition Evaluation dated 7/6/26 was reviewed. The Change in Condition Evaluation indicated, 1. Signs and Symptoms Identified Food and/or fluid intake (decreased or unable to eat.) 2. Functional Status Evaluation 2. 5. Swallowing difficulty 2a51 1. Associated with new onset or progressive choking, aspiration (when food or liquid goes into the airway) 2b. resident is having difficulty swallowing food. 3. Provider Notification and Feedback.3. Monitor for 72 hours, Speech evaluation, downgrade to puree. UM 1 stated Resident 132's regular texture diet was downgraded to puree texture per physician's order. UM 1 stated she cannot locate the swallowing evaluation and treatments in his EMR. UM 1 stated Resident 132 should be evaluated by the Speech therapist due to difficulty in swallowing and risk of aspiration.During a concurrent interview and record review on 7/29/26 at 11:45 a.m. with Unit Manager (UM) 1, Resident 132's nutrition care plan dated 7/2/26 was reviewed. The nutrition care plan indicated, Focus - At risk for altered nutritional status r/t Alzheimer's Disease, dementia, need for assistance with personal care, Parkinsonism. Date Initiated: 07/02/2026. Goal - Will have signs and symptoms of weight changes/malnutrition identified and managed through the review date. Interventions/Tasks - Administer Supplements/Fortified Foods/Snack: N/A (Not applicable). UM 1 stated care plan goal was not objective and should specify signs and symptoms of weight gain and weight loss for accurate assessment. UM 1 stated Resident 132's difficulty in swallowing, declined in oral intake, [Brand Name] nutritional supplement with meals, and swallowing evaluation should be added in Resident 132's nutrition care plan. UM 1 stated licensed nurses should update residents' care plan upon completion of change in condition assessment. UM 1 stated Resident 132's care plan for at risk for altered nutritional status should be reviewed and revised by the licensed nurses and Interdisciplinary team (IDT) for significant unintended weight loss to ensure current interventions related to significant unintended weight loss were implemented by staff. During a review of Resident 132's admission record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/29/26, the AR indicated Resident 132 was admitted to the facility on [DATE] with diagnoses Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and need for assistance with personal care.During a review of Resident 132's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/8/26, the MDS section C indicated Resident 132's BIMS - was not conducted with a code of 0 indicating No (resident is rarely/never understood). Resident 132's BIMS Summary Score was blank. The MDS Section GG-Functional Abilities-admission indicated, .Safety and Quality of Performance 01-Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity 1. admission Performance: 01 -Eating. The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident . Section K - Swallowing/Nutritional Status. The MDS Section K -Swallowing/Nutritional Status indicated, K 0100. Swallowing Disorder - Signs and symptoms of possible swallowing disorder D. Complaints of difficulty or pain with swallowing.During an interview on 7/29/26 at 3:00 p.m. with Resident 132's responsible party (RP) 3, in Resident 132's room, RP 3 stated Resident 132 was transferred to an acute care hospital from home due to decreased in oral intake and weakness. RP 3 stated she was not informed of Resident 132's weight loss since admission to the facility and was not aware of plan of care related to his weight loss.During an interview on 7/30/26 at 9:00 a.m. with CNA 7 stated he was assigned to Resident 132 today (7/30/26) and was familiar with his care. CNA 7 stated Resident 132's oral intake had always been poor for breakfast, about 0-25 percent, and better for lunch. CNA 7 stated that when Resident 132's wife visits, she assisted him with feeding. CNA 7 stated CNA 8 assisted him for breakfast today (7/30/36).During an interview on 7/30/26 at 9:06 a.m. with CNA 8, CNA 8 stated she fed Resident 132 at breakfast today (7/30/26). CNA 8 stated Resident 132 only consumed 2 bites of puree food and refused [Brand Name] supplement. CNA 8 stated Resident 132 started to be combative (ready, eager, or inclined to fight, or resist) and it was her first time assisting him with meals.During a concurrent interview and record review on 7/30/26 at 10:19 a.m. with the RD, Resident 132's weights dated 7/2/26 to 7/29/26 and Nutrition Comprehensive assessment dated [DATE] were reviewed. The Weights indicated, 7/29/2026 146.0 lbs. (pounds - a unit of weight), 7/27/2026 145.0 lbs.,7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The Nutrition Comprehensive Assessment indicated, 10. Medical Nutrition Therapy (MNT) Summary: Parkinsonism, Alzheimer's. dementia, IBW (Ideal Body weight)171 lbs. Skin: [NAME] Tissue Injury (DTI- a severe pressure injury [damage to the skin and soft tissue caused by prolonged pressure, often over a bony part of the body like the heels, hips, or tailbone] where deep underlying soft tissue is damaged) to sacrococcygeal (the area of the body where the sacrum [the large triangular bone at the base of the spine] meets the coccyx [the tailbone] ) . Resident with po (by mouth) intake 35%Regular Puree diet with meal refusals. Recommend adding 8 oz Ensure TID (three times a day). Monitor weight, skin and po. The RD stated Resident 132 had a significant unintended weight loss of more 10% in less than 30 days and the facility treat as severe weight loss. The RD stated Resident 132's nutrition care plan should be reviewed and revised by IDT to reflect Resident 132's significant unintended weight loss with current goal of stabilizing his weight with no further significant weight loss, and current nutritional interventions.During a concurrent interview and record review on 7/31/26 at 11:40 a.m. with the Director of Nursing (DON), Resident 132' s EMR titled Weights, dated 7/2026 were reviewed. The Weights indicated, 7/29/2026 146.0 lbs.,7/26/2026 158.0 lbs.,7/19/2026 165.0 lbs., 7/12/2026 163.0 lbs., 7/2/2026 166.0 lbs. The DON stated Resident 132 triggered a significant unintended weight loss on 7/26/26 and not weighed weekly from 7/2/26 to 7/12/26. The DON stated significant weight changes including loss and gain applies to 5% in 1 month, 7.5% in three months, and 10% in six months. The DON stated the facility also addresses a five pounds weight loss in a week. The DON stated Resident 132 was at risk of malnutrition from admission due to diagnosis of Dementia and require assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The DON stated Resident 132's care plan should reflect current nutritional interventions to effectively manage Resident 132's significant unintended weight loss. The DON stated it was her expectation for all licensed nurses to review, update and revise long term care plan based on residents' assessment and change in condition to ensure necessary treatment and services (including swallowing evaluation and treatment) to prevent the risk of aspiration and further weight loss. The DON stated a person-centered care plan is important because it directs the care of the residents. During a review of facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person Centered, dated 3/2022, the P&P 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. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (3) which professional services are responsible for each element of care; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions; 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.During a review of facility's policy and procedures (P&P) titled, Weight Assessment and Intervention, dated 3/2022, the P&P indicated, Weight Assessment and Intervention. Resident weights are monitored for undesirable or unintended weight loss or gain. Weight Assessment - 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria. a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weigh loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Evaluation - 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: b. the resident's calorie, protein, and other nutrient needs compared with the resident's current intake; c. the relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. whether and to what extent weight stabilization or improvement can be anticipated. 2. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. cognitive or functional decline; b. chewing or swallowing abnormalities; f. increased need for calories and/or protein; i. inadequate availability of food or fluids. Interventions - 1. Interventions for undesirable weight loss are based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; e. Chewing and swallowing abnormalities and the need for diet modifications; g. The use of supplementation.During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. vital to positive patient outcomes. the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for two of nine sampled Residents (Resident 121 and Resident 59) when: 1.Resident 121's upper and lower extremities were coded inaccurately in the MDS assessment. This failure had the potential to result in Resident 121's care needs not met. 2. Resident 59's use of oxygen was not coded in the MDS assessment dated [DATE].This failure had the potential to result in Resident 59 not experiencing respiratory relief.1. During a concurrent observation and interview on 7/28/26 at 10:42 a.m. during the initial tour in Resident 121'a room, Resident 21 was observed lying in bed and able to answer questions appropriately. Resident 121 stated she could only move her right upper extremity (arm, including everything from shoulder down to the fingertips) from the elbow and not able to raise her right arm from the shoulder. Resident 121 stated she could not lift both her lower extremities (entire leg, starting from the hip down to the toes). Resident 121 stated her right leg was stronger than her left leg. Resident 121 was able to move her foot from the ankle but not able to lift off the mattress/bed. During a review of Resident 121's admission Record [AR- a document containing resident profile information], dated 7/30/26, the AR indicated, Resident 121 was admitted to the facility on [DATE] with diagnoses which included varicose veins (swollen, twisted, and bulging blood vessels) of left lower extremity with ulcer (open sore or break in the skin), peripheral vascular disease (poor circulation problem) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During an interview on 7/30/26 at 10:30 a.m. with Certified Nurse Assistant (CNA) 10, CNA 10 stated she was familiar with Resident 121's care. CNA 10 stated Resident 121 was alert and able to verbalize her needs. CNA 10 stated Resident 121 did not like to get out of bed and needed assistance with her activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting; a person performs daily to care for themselves). CNA 10 stated Resident 121 could not move her lower extremities without staff assistance. CNA 10 stated staff had to lift her (Resident 121) lower extremities when providing care. During a concurrent interview and record review on 7/30/26 at 11:15 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 121'a clinical record was reviewed and stated Resident 121 had no mobility on her lower extremities and can only move her right upper extremity from the elbow down. LVN 6 stated Resident 121 needed two person extensive (hands-on physical assist) to total assistance (needing 100 percent help) with bed mobility and turning. During a concurrent observation, interview and record review on 7/30/26 at 4:17 p.m. with Minimum Data Set Nurse (MDSN) and Resident 121, MDSN stated she was responsible in completing MDS assessments for the long-term residents. The MDSN reviewed Resident 121's quarterly MDS assessment dated [DATE] Section GG (Functional Abilities). The MDSN stated she coded Resident 121 as not having impairment of upper and lower extremities. The MDSN stated she based her assessments on documentations of Rehabilitative Nurse Assistants (RNA-a certified nursing assistant who takes extra training to help patients rebuild their strength, movement, and daily living skills). MDSN stated, I think I went to assess her [Resident 121] in person, but I relied more on staff documentations. The MDSN at bedside asked Resident 121 to lift her lower extremities and Resident 121 stated, I can't. Resident 121 stated RNAs' and other staff had to lift her lower extremities when they worked with her. The MDSN stated she should have coded Resident 121 as having impairment to bilateral lower extremities and right upper extremity. During an interview on 7/31/26 at 9:05 a.m. with Wound Nurse (WN) 1, WN 1 stated he was familiar with Resident 121, he does the treatment on Resident 121's left lower leg. WN 1 stated Resident 121 cannot lift both her lower extremities. WN 1 stated he had to pick up Resident 121's leg when he did the treatment on her left lower leg. During an interview on 7/31/26 at 11:10 a.m. with the Director of Nursing (DON), the DON stated her expectation was for the MDS assessments completed timely and accurately. The DON stated each person completing a portion of the MDS is responsible in ensuring their assessments are accurate and complete. During a review of facility policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, revision date 10/26, the P&P indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The assessment coordinator or designee is responsible for ensuring resident assessments are submitted .in accordance with current federal and state guidelines. 2. During a concurrent observation and interview on 7/28/26 at 10:07 a.m. in Resident 59's room, Resident 59 was observed in bed with a nasal cannula (lightweight plastic tube, which fits into the person's nostrils to provided supplemental oxygen) connected to an oxygen source on the wall. The oxygen was noted to be set at 1L. Resident 59 stated the oxygen should be at 2L. During a review of Resident 59's AR, dated 7/30/26, the AR indicated Resident 59 was admitted to the facility on [DATE], with diagnoses which included Hypo-Osmolality and hyponatremia (abnormally low sodium levels in the blood), weakness, history of Falling, hypertension (high blood pressure), and Personal History of Other Malignant Neoplasm of Bronchus and Lung (a documented history of lung cancer) . During a review of Resident 59's MDS, dated [DATE], the MDS section C indicated Resident 59 had a Brief Interview for Mental Status (BIMS-an evaluation of attention, orientation and memory recall) score of 12 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS scores indicated Resident 59 was moderately impaired. During a review of Resident 59's Order Summary Report (OSR), the OSR indicated Order Date 12/03/2025, Oxygen: At 3 Liters/Min via Nasal Cannula Every Shift for hypoxia/shortness of breath. Goal is to maintain oxygen saturations above 90%, every shift. The OSR reflected this order was marked as Other Active 12/3/2025 with every shift frequency; confirming the oxygen order was an active, continuous standing order at the time the MDS quarterly assessment was completed with ARD 07/09/2026. During a review of Resident 146's Care Plan (CP), the CP indicated a care plan problem focus of Shortness of breath as evidenced by wheezing, hypoxemia, cyanosis, air hunger, difficulty breathing while lying flat, breathlessness, CHF, COPD, Date Initiated: 07/04/2026, Revision on: 07/04/2026. The care plan goal stated: Pulse Oximetry will remain above 90% on room air through the review date, with a Revision Date of 07/17/2026 and Target Date of 10/14/2026. Interventions listed included: Administer oxygen therapy as ordered by Physician, Date Initiated: 07/04/2026; and Administer/monitor effectiveness of medications and breathing treatments as ordered by Physician, Date Initiated: 07/04/2026. The CP confirmed Resident 59 was receiving continuous oxygen therapy during the MDS assessment reference period. During a review of Resident 59's MDS Section O: Special Treatments, Procedures, and Programs, the MDS section O with ARD: 7/9/2026, indicated under Item O0100- Special Treatments, Procedures, and Programs - Section O0100 Oxygen Therapy (C1 Continuous and C2 Intermittent) was not checked under column (b) While a Resident (performed within the last 14 days). Instead, Item Z1 None of the Above was checked under column (b), indicating the Minimum Data Set Nurse (MDSN) coded Resident 59 as not receiving any of the listed special treatments or procedures; including oxygen therapy; during the assessment period, despite the active continuous physician's order for oxygen at 3 L/Min via Nasal Cannula Every Shift that had been in place since 12/03/2025. During a concurrent interview and record review on 7/30/2026 at 1:59 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 59's MDS Section O was reviewed. The MDSC stated Section O of the MDS reflects documents on what therapy residents were receiving, which would reflect whether Resident 59 was on oxygen. The MDSC stated Resident 59's oxygen order at 3L was dated 12/3/25, and Section O was completed on 7/9/26 and signed on 7/14/26. The MDSC stated the importance of accurate documentation was that since Resident 59 was still on O2 during the timeframe of the assessment, the MDSN should have accurately documented her therapy because the MDS directs Resident 59's plan of care. The MDSC stated Resident 59 would not get the appropriate care she needed if the MDS was coded inaccurately. During a concurrent interview and record review on 7/30/2026 at 2:33 p.m. with MDSN, Resident 59's Electronic Health Record (EHR) was reviewed. MDSN stated Resident 59's oxygen order at 3L was dated 12/3/25 and the order was still active. The MDSN stated the current order of oxygen was dated 6/27/26. The MDSN confirmed the ARD was 7/9/26, signed 7/14/26, Section O indicated no oxygen and stated the assessment was inaccurate. The MDSN stated it was important to document accurate assessment, and the care provided to Resident 59 should be what was documented. MDSN stated the potential outcome could be harm to Resident 59 if resident needed oxygen. During an interview on 07/30/2026 at 4:13 p.m. with the Director of Nursing (DON), the DON stated MDSN was expected to assess Resident 59 accurately and input correct and accurate information into the assessment. The DON stated accurate and complete assessment was important to create individualized care plan for Resident 59's care. During a review of the facility's P&P titled, Resident Assessments dated 10/2023, the P&P indicated, . A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the Minimum Data Set (MDS) is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. 6 The resident assessment coordinator is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments. During a review of the facility's document titled, PointClickCare User Roles and Accountabilities with effective date: June 2019, revision date: July 2024, Electronic Medical Record Policy & Procedure, indicated the following relevant provisions applicable to MDS accuracy.MDS Coordinator. MDS Coordinator is responsible to: (1a) ensure that Minimum Data Set (MDS) assessments are completed accurately and within the required timeframes; (1b) collaborate with nursing staff, therapists, social workers, and other interdisciplinary team members to gather and validate information for the MDS; (1d) verify/scrub MDS assessments prior to submission; (2a) enter MDS data into the PointClickCare (PCC) system accurately and timely. participate in audits to ensure the facility's compliance with MDS documentation and reporting requirements; and (4a) ensure that PCC documentation for MDS assessments meets federal, state, and facility regulations.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for self-administration of medications by the Interdisciplinary Team (IDT) for two of five sampled residents (Resident 136 and Resident 148) when: Resident 132 stored an expired [Brand Name] Triamcinolone Acetonide nasal spray (used to treat seasonal and year-round allergy symptoms like sneezing, runny nose, and nasal congestion) at bedside without physician's order and was available for use. The [Brand Name] nasal spray had an expiration date 7/2004 and was available for use. Resident 132 had no assessment, physician's order and care plan for self-administration of medications stored at her bedside.Resident 148 stored a container of [Brand Name] Acetaminophen (used to relieve mild to moderate pain) 500 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) at bedside dresser without a physician's order and was available for use. Resident 148 had no assessment, physician's order and care plan for self-administration of medications stored at her bedside; and was available for use. These failures placed Resident 136 and Resident 148 at an increased risk of improper self-administration of medications which could result in medication errors (any preventable event causing inappropriate medication used or patient harm) and side effects (undesirable effects of drugs), and had the potential for other residents, staff and visitors accessing medications stored at bedside.Findings:1.During a concurrent observation and interview on [DATE] at 9:08 a.m. with Resident 136, in Resident 136's room, Resident 136 was sitting in her wheelchair, awake, wearing eyeglasses. Resident 136 was on oxygen therapy (the administration of oxygen with the intent of treating or preventing the symptoms and manifestations of hypoxia [decreased perfusion of oxygen to the tissues] via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at three lpm/nc (liters per minute per nasal cannula). Resident 136 's nasal spray was stored at bedside. Resident 136 checked, opened and sprayed the nasal spray in her hand. Resident 136 stated the nasal spray won't spray, not working. Resident 136 stated the nasal spray came from home and she still have two more bottles at home.During a concurrent observation and interview on [DATE] at 9:15 a.m. with the Director of Staff Development (DSD), in Resident 136's room, the DSD checked Resident 136's [Brand Name] nasal spray and stated the expiration date was on 7/2004. The DSD Resident 136's nasal spray should not be stored at bedside. The DSD stated medications should not be stored at bedside to prevent access to medication by other residents.During a concurrent interview and record review on [DATE] at 9:01 a.m. with tUnit Manager (UM) 1, Resident 136's electronic medication administration records (EMAR - a digital daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and Order Summary Report dated 7/2026 were reviewed. UM 1 stated Resident 136's EMAR and Order Summary Report does not contain an order for [Brand Name] Triamcinolone Acetonide nasal spray. UM 1 stated Resident 136 had no physician's order for nasal spray medication. UM 1 stated medications should not be stored at bedside because other residents can access the medications without a physician's orders which could cause harm and medication errors. UM 1 stated expired medication was contaminated, deteriorated and ineffective. UM 1 stated Resident 136 had no assessment, physician's order, and care plan for self-administration. UM 1 stated Resident 136's should be assessed if she was capable of administering her medications safely. During a review of Resident 136's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 136 was admitted to the facility on [DATE] with diagnosis of acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood) with hypoxia.During a review of Resident 136's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS section C indicated Resident 136 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 136 was cognitively intact.During an interview on [DATE] at 1:16 p.m. with the Director of Nursing (DON), the DON stated medications should not be stored at bedside for the safety of all residents. The DON stated medication stored at bedside can be accessed by other residents and were available for use which could result in drug overdose and medication errors. The DON stated expired medication would not be effective and contaminated. The DON stated residents should be assessed by the licensed nurses and IDT for self-administration of medication to ensure residents can safely administer and store their medications. The DON stated Resident 136 should be asked by IDT for her wishes to self-administer her medication and assessed for her safety. The DON stated self -administration of medications requires an IDT assessment, physician's order and care plan. During a review of facility's policy and procedures (P&P) title, Self-Administration of Medications, dated 2/2021, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident. 5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family. 2. During an observation on [DATE] at 9:38 a.m. in Resident 148's room, a container of [Brand Name] Acetaminophen 500 mg was on top of bedside table. Resident 148 was not in the room.During an observation on [DATE] at 12:42 p.m. in Resident 148's room, a container of [Brand Name] Acetaminophen 500 mg was on top of bedside table. Resident 148 was not in the room. During a concurrent observation and interview on [DATE] at 9:20 a.m. with Resident 148, in Resident 148's room, Resident 148 was lying in bed, awake, alert and oriented to names, places, time, and situation. Resident 148 stated he was admitted to the facility about a week from acute care hospital. Resident 148 stated he had nerve pain on his right hip. Resident 148 stated he had [Brand Name] Acetaminophen at bedside available for use, just in case I need it. Resident 148 stated the [Brand Name] Acetaminophen was new and was not open. Resident 148 stated the [Brand Name] Acetaminophen had been there (pointing at bedside dresser) for days, and staff did not ask him about the medication.During a concurrent interview and record review on [DATE] at 1:33 p.m. with Licensed Vocational Nurse (LVN) 7, Resident 148's EMAR and Order Summary Report dated 7/2026 were reviewed. The EMAR and Order Summary Report indicated, Acetaminophen Tablet 325 mg Give 2 tablet by mouth every 4 hours as needed for mild to moderate pain.Start Date -[DATE]. LVN 7 stated Resident 148 had a physician's order for Acetaminophen 325 mg as needed and had no physician's order for Acetaminophen 500 mg. LVN 7 stated licensed nurses were responsible in administering Resident 148's medications. LVN 7 stated Resident 148 was not assessed for self-administration of his medications. During a concurrent observation and interview on [DATE] at 1:42 p.m. with LVN 7, in Resident 148's room, LVN 7 removed the container of [Brand Name] Acetaminophen at bedside dresser. LVN 7 stated Resident 148 had the potential to self-administer [Brand Name] Acetaminophen 500 mg which could result in drug overdose which is a medication error. LVN 7 stated Resident 148's [Brand Name] Acetaminophen should not be stored at bedside to prevent accessing the medication by other residents which could cause allergies and side effects. LVN 7 stated she will call Resident 136's family to pick up the container of [Brand Name] Acetaminophen. During a review of Resident 148's AR, dated [DATE], the AR indicated Resident 148 was admitted to the facility on [DATE] with diagnosis of Spinal Stenosis (a narrowing of the spaces within your spine that puts pressure on your spinal cord and nerves).During a review of Resident 148's MDS, dated [DATE], the MDS section C indicated Resident 148 had a BIMS score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 148 was cognitively intact.During an interview on [DATE] at 8:32 a.m. with UM 1, UM 1 stated medications should not be stored at bedside because other residents can access the medications without a physician's orders which could cause medication errors and harm. UM 1 stated residents should have a self-administration assessment, physician's order, and care plan prior to self-administration of medications.During an interview on [DATE] at 1:16 p.m. with the DON, the DON stated medications should not be stored at bedside for the safety of all residents. The DON stated medication stored at bedside can be accessed by other residents and were available for use which could result in drug overdose and medication errors. The DON stated residents should be assessed by the licensed nurses and IDT for self-administration of medication to ensure residents can safely administer and store their medications. The DON stated Resident 136 should be asked by IDT for his wishes to self-administer his medication and assessed for his safety. The DON stated self -administration of medications requires an IDT assessment, physician's order and care plan.During a review of facility's policy and procedures (P&P) title, Self-Administration of Medications, dated 2/2021, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident. 5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family.

Based on observation, interview, and record review, the facility failed to ensure residents' was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for one of three sampled residents (Resident 68) when Resident 68 diagnosed with attention deficit hyperactivity disorder (ADHD-difficulty focusing, sit still, and control sudden actions) was administered lisdexamfetamine dimesylate (a drug that stimulates the central nervous system to help the brain focus and control impulses) without a written informed consent (a signed document indicated the physician fully explained the medical treatment to the resident or their legal guardian, and they agreed to the treatment). This failure placed Resident 68 at risk for experiencing adverse effects from receiving psychotropic medication without giving explanation of potential risk and benefits and the opportunity to exercise a choice regarding their medical treatment to receive medication. During a concurrent observation and interview on 7/28/26 at 10:22 a.m. during the initial tour in Resident 68's room, Resident 68 was sitting up in her wheelchair at bedside. Resident 68 stated she had been in the facility for eight years and stated, too long. Resident 68 stated she wants to go home in the coast eventually. During a review of Resident 68's admission Record [AR-document containing resident profile information], the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included ADHD, anxiety (feeling of worry, nervousness, or unease about something with an uncertain outcome), rheumatoid arthritis (autoimmune disease where the body's immune system attacks the healthy lining of the joint, causing pain, swelling, and stiffness), and depression (constant feeling of sadness and loss of interest, which stops you from doing your normal activities). During a review of Resident 68's Order Summary Report [OSR], dated 7/30/26, the OSR indicated, . [brand name] Oral Capsule 70 MG [milligram-unit of measurement] (Lisdexamfetamine Dimesylate) Give 70 mg by mouth one time a day for attention deficit hyperactivity disorder. Order Date 11/22/24. Start Date 11/23/24. During an interview on 7/30/26 at 8:54 a.m. with Certified Nurse Assistant (CNA) 12, CNA 12 stated she was familiar with Resident 68's care. CNA 12 stated Resident 68 wasis alert and oriented and able to verbalize her needs. CNA 12 stated Resident 68 sometimes gets upset when her call light was not answered right away. CNAAN 12 stated, She [Resident 68] thinks I am taking a long-time taking care of other residents. During a concurrent interview and record review on 7/30/26 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 68's medication orders were reviewed. LVN 6 stated Resident 68 was on psychotropic medications including [brand name]Vyvanse. LVN 6 stated she did not find a signed informed consent. LVN 6 stated there should have been a signed informed consent prior to administering medication. LVN 6 stated the nurse receiving the medication order was responsible in obtaining informed consent. LVN 6 stated, Licensed nurses cannot administer the medication without a signed informed consent During an interview on 7/31/26 at 8:45 a.m. with the Director of Nursing (DON), the DON stated she was not sure how Resident 68's informed consent was overlooked. The DON stated there should have been a signed informed consent for Resident 68's [brand name] psychotropic medication because it wasis considered a chemical restraint. The DON stated her expectation was for licensed nurses to get an informed consent signed as soon as order was received. During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, Revised date 2/25, the P&P indicated, .Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendations; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warning); and d. the resident's/representative's rights to accept or decline the treatment. During a review of facility's P&P titled, Resident Rights, version 2/21, the P&P indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility, These rights include the resident's right to: .d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms; . j. be informed about his or her rights and responsibilities; .p. be informed of, and participate in, his or her care planning and treatment; .

Based on observation, interview, and record review the facility failed to ensure legally appointed conservator's authority were upheld for one of four sampled residents (Resident 141) when Resident 141 had an acute trouble managing behaviors earlier in the day and was allowed to leave the facility on 7/14/26, for a family community outing, without conservator's (court-appointed person who makes healthcare and medical treatment choices for a resident) consent. This failure resulted in Resident 141's conservator legal rights and safeguards not being upheld by the facility which could place Resident 141 at risk for compromised safety, elopement, and increased emotional distress outside the facility. Findings: During a concurrent interview and record review on 7/29/26 at 3:24 p.m. with Licensed Vocational Nurse (LVN) 10, Resident 141's Electronic Medical Record, dated 7/29/26, was reviewed. LVN 10 stated Resident 141 was re-admitted to the facility's special treatment program (STP-specialized treatment unit for residents with psychiatric or mental health diagnosis) on 9/7/25 with diagnosis of schizoaffective disorder bipolar type (mental health condition resulting in extreme mood swings) and manic episodes (mood, behavior and energy become higher or more intense than usual). LVN 10 stated Resident 141 had a conservator. LVN 10 stated Resident 141 was a level 3 in the STP, which meant she had special privileges, such as community outings, with conservator consent and provider orders. LVN 10 stated Resident 141's mood and behavior changed frequently due to her diagnosis. LVN 10 stated singular behavioral events, such as verbal aggression, was enough to revoke privileges on level 3 in the STP, such as community outings. LVN 10 stated on 7/14/26 he observed Resident 141 approach Unit Manager (UM) 3 at the nursing station upset her conservatorship court hearing had been rescheduled. LVN 10 stated Resident 141 became verbally aggressive, using profanity, with UM 3 and was not re-directable. LVN 10 stated Resident 141's verbal aggression continued to escalate. LVN 10 stated Resident 141's family arrived and requested to take Resident 141 out on a community outing. LVN 10 stated, UM 3 explained to Resident 141's family, Resident 141 was experiencing aggressive verbal behaviors, and the behavior had been discussed with the conservator, in which the decision was made Resident 141 would not be able to participate in a community outing with family. LVN 10 stated Resident 141's family became upset and UM 3 contacted the Administrator (ADM) to assist. LVN 10 stated the ADM allowed Resident 141 to leave on a community outing with family because there was no documentation of reported behaviors. LVN 10 stated Resident 141's Electronic Medical Record did not contain a provider order or documentation of provider notification or approval for a community outing with family for 7/14/26. LVN 10 stated Resident 141's Electronic Medical Record indicated Resident 141's conservator did not consent to Resident 141 to participate in a community outing with family on 7/14/26 due to her inability to regulate her behavior. LVN 10 stated Resident 141's Electronic Medical Record indicated Resident 141 left the facility with her family on 7/14/26 at 1:45 p.m. and returned at 4:53 p.m. LVN 10 stated Resident 141 was placed at risk for accidents when she left for a community outing with family on 7/14/26 without conservator consent or provider order. During a concurrent interview and record review on 7/29/26 at 3:51 p.m. with the ADM, the Director of Nursing (DON), and the Minimum Data Set Coordinator (MDSC), Resident 141's Electronic Medical Record, dated 7/29/26, was reviewed. The ADM stated Resident 141 was located on the STP, a locked unit within the facility, due to her diagnosis and behaviors. The ADM stated Resident 141 had a conservator, who was responsible for providing all consents. The ADM stated Resident 141 was a level 3 on the STP, which meant she had special privileges, such as community outings, with conservator consent and provider orders. The ADM stated for a resident within the STP to participate in a community outing, per policy, they were required to be a level 3, have documented conservator consent and provider orders, to ensure a safe community outing for the resident. The ADM stated if something was not documented, it did not happen. The ADM stated on 7/14/26 she responded to the STP because Resident 141's family was upset Resident 141 could not participate in a community outing with them. The ADM stated, UM 3 reported, Resident 141 would not be participating in a community outing with family due to her behavior and inability to obtain consent, orders and evaluations prior to the outing. The ADM stated UM 3 explained Resident 141 needed conservator approval and a provider order to participate in a community outing. The ADM stated UM 3 could not provide documentation of Resident 141's reported behavior. The ADM stated she instructed Resident 141's assigned nurse, LVN 11, to contact the provider. The ADM stated the provider gave LVN 11 a verbal order for Resident 141 to participate in a community outing with family on 7/14/26, based on the previous week's report of documented behavior. The ADM stated she believed a community outing on 7/14/26 would be beneficial to Resident 141 because she had recently had a family member pass away. The ADM stated she did not speak to the provider or conservator. The ADM and the MDSC stated there was no documentation LVN 11 contacted the provider on 7/14/26 and received a verbal order for Resident 141 to participate in a community outing with family. The ADM and the MDSC stated there was no provider order for Resident 141 to participate in a community outing with family on 7/14/26. The ADM and the MDSC stated, documentation indicated on 7/14/26, UM 3 spoke with Resident 141's conservator regarding her behavior and the request for a community outing with family. The ADM and the MDSC stated it was documented Resident 141's conservator did not give consent for Resident 141 to participate in a community outing with family on 7/14/26. The ADM and DON stated facility policy and procedure were expected to be followed for community outings. The ADM stated Resident 141 was placed at risk for accidents when she was allowed to participate in a family community outing on 7/14/26 against conservator approval and without documented provider orders. The ADM stated UM 3 no longer worked for the facility. During a concurrent interview and record review on 7/30/26 at 9:37 a.m. with LVN 11, Resident 141's Electronic Medical Record, dated 7/30/36, was reviewed. LVN 11 stated he was Resident 141's assigned nurse on 7/14/26. LVN 11 stated on 7/14/26 Resident 141 approached UM 3 and was upset and verbally aggressive because her conservatorship court hearing had been rescheduled. LVN 11 stated Resident 141's family arrived to STP and he contacted the provider for a community pass outing order. LVN 11 stated he reported Resident 141's behavior to the provider. LVN 11 stated the provider did not give approval for Resident 141 to participate in a community outing with family on 7/14/26 due to reported behaviors. LVN 11 stated the ADM instructed him to contact the provider again and report Resident 141's behaviors had not been documented. LVN 11 stated he contacted the provider again, in which, the provider gave LVN 11 a verbal order to allow Resident 141 to participate in a community outing with family on 7/14/26. LVN 11 stated he did not document the conversation with the provider or place an order for the community outing on 7/14/26. LVN 11 stated the ADM made the decision to allow Resident 141 to participate in a community outing with family on 7/14/26. LVN 11 stated the facility did not communicate effectively or follow facility policy to ensure a safe community outing for Resident 141. LVN 11 stated Resident 141 was placed at risk for accidents when she was allowed to participate in a family community outing on 7/14/26 against conservator approval and without documented provider orders. During a concurrent interview and record review on 7/30/26 at 10:12 a.m. with Mental Health Worker (MHW) 1, Resident 141's Electronic Health Record, dated 7/30/26, was reviewed. MHW 1 stated residents on STP were categorized into 3 levels. MHW 1 stated residents on level 3 were granted special privileges, such as community outings. MHW 1 stated singular behavioral events were enough to revoke privileges within level 3, including verbal aggression. MHW stated on 7/14/26 Resident 141 had documentation of initial refusal of labs, profanity and verbal aggression. During an interview on 7/30/26 at 1:24 p.m. with Resident 141's Conservator (CV) 1, CV 1 stated Resident 141 had been conserved since 3/2024, before admission to the facility. CV 1 stated on 7/14/26 Resident 141's family contacted her to request a community outing. CV 1 stated family request for community outings required a two day advance notice, but she would contact the facility and see how Resident 141 was doing. CV 1 stated she contacted the facility and UM 3 reported Resident 141 was upset and her emotions were elevated because her conservatorship court hearing had been rescheduled. CV 1 stated UM 3 reported Resident 141 expressed wanting to go home and wanting to leave the facility. CV 1 stated, based on Resident 141's reported behaviors, CV 1 and UM 3 agreed it would not be safe for Resident 141 to participate in a community outing on 7/14/26 with family. CV 1 stated she did not give consent for Resident 141 to participate in a community outing on 7/14/26. CV 1 stated she contacted Resident 141's family and relayed Resident 141's reported behaviors. CV 1 stated she notified Resident 141's family they were still welcome to visit Resident 141, but she would not be able to leave the facility on 7/14/26 for a community outing. CV 1 stated family arrived to the facility on 7/14/26 and were upset they could not take Resident out for a community outing and the situation escalated. CV 1 stated the ADM responded to the situation and Resident 141 was allowed to leave for a community outing with family on 7/14/26, despite not having conservator consent to do so. CV 1 stated Resident 141 returned to the facility after the outing. CV 1 stated facility policy indicated conservator approval was required for all community outings, and consent was not given on 7/14/26. CV 1 stated Resident 141's safety was placed at risk when she was allowed to leave against conservator approval. During an interview on 7/3/26 at 10:20 a.m. with the DON, the DON stated per facility policy and procedure residents on the STP unit were required to be a level 3, have conservator consent, and provider orders to participate in community outings. The DON stated if something was not documented, it did not happen. The DON stated facility policy was not followed when Resident 141 was allowed on a community outing with family on 7/14/26 with no documented provider orders and against conservator approval. The DON stated Resident 141's safety was placed at risk. During a review of Resident 141's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 7/30/26, the AR indicated Resident 141 was re-admitted to the facility on [DATE]. The AR indicated CV 1 was Resident 141's guarantor, responsible party, emergency contact #1, disclosure and conservator. The AR indicated Resident 141 had diagnosis which included schizoaffective disorder bipolar type, restlessness and agitation, and manic episode. During a review of Resident 141's progress note titled, Health Status Note, dated 7/14/26, the progress indicated Resident 141 refused morning labs and used profanity toward the nurse, after education Resident 141 agreed to labs. During a review of Resident 141's progress note titled, Behavioral Health Note, dated 7/14/26 at 11:00 a.m., the progress note indicated, . approximately 10:00, the resident approached the writer at the nurses station visibly upset after learning that her conservatorship court hearing had been rescheduled. The resident became verbally agitated, calling the writer derogatory names and stating that she was tired of being at the facility and believed staff were preventing her from retuning home. This writer utilized verbal de escalation techniques, including active listening, providing reassurance, and reminding the resident that she is currently on level three and that respectful behavior is expected. Despite these interventions, the resident continued to direct derogatory remarks toward the writer before walking away from the nurses station. The writer notified [CV 1] and discussed the resident's presentation and behavior. The conservator and writer discussed resident's daughter called 7/14/26 [approximately] 1030 and asked to take her on an outing later that day. Following the discussion of the residents verbal aggression and inability to regulate her behavior that morning, it was agreed that the outing would not occur for today. Resident placed on alert charting [for] 72 hours. Care plan updated. During a review of Resident 141's progress note titled, Health Status Note, dated 7/14/26 at 1:45 p.m., the progress note indicated, .resident is on outing with daughter. Resident will be at [address of resident's location] for outing. Resident expected to on outing for 2-4 hours. During a review of Resident 141's progress note titled, Health Status Note, dated 7/14/26 at 4:53 p.m., the progress note indicated, .resident retuned from [leave of absence] with daughter. Alert and oriented x4. [Vital Signs] within normal limits. Skin warm, dry and intact. No [complaints] pain/discomfort noted. During a review of Resident 141's progress note titled, Behavioral Health Note, dated 7/14/26 at 6:31 p.m., the progress note indicated, .resident is in good spirits and happy to have been on visit with daughter. During a review of the facility's document titled, [facility name] Level System, undated, the document indicated level 3 requirements required, .no aggressive/assaultive [behavior]. The document indicated level 3 benefits included, .outings with staff.outings [with] approved family/friends. During a review of the facility's policy and procedure (P&P) titled, Behavioral Health Community Passes, dated 6/4/26, the P&P indicated, .while community passes are an important aspect of treatment, they are not automatically granted. Each resident will be evaluated individually, and passes will be issued only with the approval of the conservator .The conservator.will determine the duration of the pass and specify who may accompany the resident. Additionally, an order for the community pass must be obtained from the resident's attending physician.residents must achieve level 3 status before being considered for a pass.all licensed nurses have the authority and responsibility to deny a pass if inappropriate behavior is exhibited. They must notify the conservator. During a review of the facility's P&P titled, Behavioral Health Outdoor Activities: Resident Safety and Supervision, dated 6/2026, the P&P indicated, .on the day of the activity, the licensed nurse shall review each participating resident to ensure the resident.is medically stable for participation. demonstrates behavior consistent with safe participation based on current mental status, behavioral presentation, and individualized treatment plan.does not have physician, court, nursing, or treatment plan restrictions that prohibit participation. During a review of the facility's P&P titled, Telephone Orders, dated 2/2014, the P&P indicated, .verbal telephone orders may only be received by licensed personnel . orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record .the entry must contain the instructions from the physician, date, time and the signature and title of the person transcribing the information .

Based on interviews, observations, and record review, the facility failed to follow their Policy and Procedure (P&P) and provide professional standards of care when:1. The facility did not provide behavioral health training for Activity Aides per policy.2. The facility did not review and update 1 of 4 sampled P&Ps at least annually per policy.3. The facility did not create a multidisciplinary plan for ventilator (respiratory ventilator (a machine that helps a person breathe when they cannot breathe well enough on their own) weaning for one of one sampled resident (Resident 1) per policy. This had the potential to result in poor care, unsafe conditions, and injury to residents and staff. 1. During a phone interview on 3/18/26 at 11:02 am with Complainant 1, Complainant 1 stated the Activity Assistants were being sent into the behavioral health Special Treatment Program (STP) to assess the resident's activity needs without the required behavioral health training.During an interview on 3/20/26 At 9:20 AM with Special Treatment Program (STP) Director (STPD), the STPD stated all employees working in the STP are required to have behavioral health training for their safety and the safety of their residents.During a concurrent interview and record review on 3/20/26 at 11:31 am with Director Staff Development (DSD), the facility record of employee behavioral health training was reviewed. DSD stated activity assistant (AA) 1 and 3 we're not on the list. DSD stated this indicated AA 1 and AA 3 had not received the facility behavioral health training. DSD stated he was not sure if the activity assistants were required to have the training.During an interview on 3/20/26 at 1:35 pm with AA1, 2, and 3, behavioral health training was discussed. AA 1 stated she had been working at the facility for about one year. AA 2 stated she had been working at the facility for 5 months. AA 3 stated she had been working at the facility for over 2 years. AA 1, AA 2, and AA 3 stated they had all been required to go into the STP unit to do activity assessments and revise resident's activity plan of care. AA 1 and AA 3 stated they had both requested behavioral health training because they were afraid for their safety in the STP but they had not been provided with the training.During a concurrent interview and record review on 3/20/26 at 3:10 PM with Director of Nursing (DON) and Administrator (ADM), the facility behavioral health training log, undated, was reviewed. ADM stated all staff in the behavioral health unit were required to have the facility behavioral health training. Neither DON or ADM could state if the AAs were required to have the behavioral health training. ADM confirmed only AA 2 was listed on the log as having any of the behavioral health training.During a concurrent interview and record review on 3/24/26, at 2 pm, certificates of completion for the facility's behavioral health training documentation provided by the facility were reviewed. The document indicated AA 1 and AA 2 had completed day 1 (of 2) of the behavioral health training. ADM confirmed that the facility had no documentation of training completion for day 2 for AA 1 and AA 2 and no documentation of any behavioral health training for AA 3 and AA 4. 2. During a concurrent interview and record review on 3/20/26 at 3:10 PM with DON and ADM, the facility policy and procedure (P&P) titled Ventilation, Weaning a Patient from Mechanical, dated 7/31/2017, was reviewed. ADM confirmed last date of review documented on the P&P was 7/31/2017. ADM stated P&Ps should be reviewed annually. Review of the Facility P&P titled Facility Policy and Procedures - Annual Reviews, dated (last revision) 10/2018, indicated .Policies and procedures are reviewed as needed and at least annually. Revisions to policies and procedures are made as necessary to reflect current facility operations, regulatory requirements and accepted standards of care. The quality assurance and performance improvement committee reviews policies and procedures and makes revisions as necessary. c. at least annually. Final revisions are posted for staff with a summary of changes and effective date. 3. During a phone interview on 3/19/26 at 4:24 pm with Complainant 2, Complainant 2 reported that Resident 1 was admitted to the facility nine months ago for ventilator weaning but has not been weaned. He expressed concern that weaning trials have stopped and stated that neither he nor Resident 1 could obtain information on the facility's ventilator weaning policy from any Respiratory Therapists (RT). During a record review of Resident 1's physician order for vent weaning, dated 10/2/25 and respiratory therapy notes dated 9/30/2025, 10/3/25, 2/11/26, 2/14/26, and 2/15/26, were reviewed. the physician ordered ventilator weaning as Wean Orders: May start mode:. Document Tolerance: TOL: 1 = Tolerated; 0 = Not Tolerated. Document number of hours (HRS); use 0 if tolerated less than one hour. RT must stay with resident when weaning on this mode. every shift for Shortness of Breath until 10/06/2025 09:53 Start of Wean as tolerated. Physician order dated 10/2/25 indicated Please continue weaning with.try not to change it. In knowing that he will be harder to wean off due to Guillain Barre Syndrome, we should be very patient. During a concurrent interview and record review with RT 1, Resident 1's RT notes dated 2/11/26 were reviewed. The notes indicated .Pause cool mist to wean off ventilator until next week to reevaluate. RT 1 stated he could not find the reassessment that was supposed to be completed the following week. RT 1 could not locate the follow-up assessment for Resident 1. RT 1 could not state the facility's current ventilator weaning policy and did not know how to access it. RT 1 reported that he relied on his own experience for ventilator weaning procedures. During a concurrent interview and record review on 3/25/26 at 11:05 am with RT 2, the facility Policy and Procedure titled, Ventilation, Weaning a Patient from Mechanical, dated 7/31/2017, was reviewed. The P&P indicated . It is the policy of this facility to wean patients from the mechanical ventilator when ordered by the physician . Assessment findings should be reviewed by the physician and respiratory therapist to determine the patient's suitability to wean. Develop a multidisciplinary weaning plan that includes: a. Time to start weaning during the day shift, b. The mode, (SIMV) C. Duration of a weaning trial (off ventilator 5, 10 and 15 minutes to 1/2 hour, then double the time if tolerated well, and d. Method of monitoring the patient and periods of rest.RT 2 stated she was unfamiliar with the multidisciplinary plan was and had not used one. RT 2 stated the RTs entered the weaning parameters as an order. orders after consulting other staff but did not document participants. RT 2 provided Resident 1's multidiscipline order for ventilator weaning dated 1/2/26, the order indicated, weaning trial per [MD].daily as tolerated up to 12 hours. The order was entered by RT 1. There were no details listed for time to start weaning during the day shift, day to start weaning, the duration of the weaning trial, or the method of monitoring the patient and periods of rest.and it did not include time to start weaning during the day shift or the method of monitoring the patient and periods of rest.

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to: 1) ensure staff monitored urinary output in accordance with the physician's order, and the facility policy; 2) immediately address Resident #1's complaint of severe pain; and 3) ensure the resident's stage four pressure ulcers were treated as ordered by the physician. On 02/26/2024 at 11:12 AM, Resident #1 notified Certified Nursing Assistant (CNA) #1 of their pain; however, staff did not intervene and address the resident's complaint of pain until 1:10 PM. Resident #1 experienced severe pain for greater than two hours, suffered bladder distension due to a malfunctioning catheter and had an infected pressure ulcer that was left uncovered. Once the malfunctioning catheter was removed, Resident #1 expelled a copious (large in quantity) amount of urine. The copious amount of urine expelled by the resident leaked onto the resident's uncovered, infected stage four pressure ulcers on their buttocks and sacrum. High volumes of urine removed at once could cause serious clinical complications for 1 (Resident #1) of 6 sampled residents reviewed for urinary catheter. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 02/26/2024 at 11:00 AM, when Resident #1 verbalized pain and was observed writhe in pain from bladder distention due to a lack of urinary output since. The last time staff indicated the resident had urinary output was during the 3:00 PM to 11:00 PM shift on 02/25/2024. The Administrator and Director of Nursing (DON) were notified of the IJ and provided with the IJ Template on 02/27/2024 at 9:00 AM. A Removal Plan was requested. The Removal Plan was accepted by the state survey agency on 03/01/2024 at 1:17 PM. The IJ was removed on 03/01/2024 at 5:00 PM, after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F684 remained at the lower scope and severity of G. Furthermore, the facility failed to follow the physician's order for 1 (Resident #105) of 2 sampled residents reviewed for non-pressure related skin concerns. Specifically, the facility failed to ensure staff changed the resident's bilateral lower leg compression dressings as ordered by the physician. Findings included: 1. A review of the facility policy titled, Wound Care, revised on 09/19/2022, revealed The purpose of this procedure is to provide guidelines for the care of wounds to promote healing and prevent infection. The policy specified, 7. Apply treatments as ordered by the physician. A review of the facility policy titled, Catheter Care - Urinary, revised on 07/01/2023, revealed The purpose of this procedure is to prevent catheter-associated urinary tract infections. Per the policy, 3. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. The policy revealed, Complications 1. Observed the resident for complications associated with urinary catheter. a. If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify the physician or supervisor. b. Check the urine for unusual appearance. c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed, d. Report any complaints the resident may have of burning tenderness, or pain in the urethral area. e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. A review of Resident #1's Admission Record revealed the facility admitted the resident on 04/11/2023, with diagnoses that included quadriplegia, hypertension, constipation, stage four pressure ulcer of the sacral regional and left buttock, muscle spasm, and neuromuscular dysfunction of the bladder. A review of Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/2024, revealed the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. The MDS revealed the resident was dependent on staff for toileting and personal hygiene. Per the MDS, the resident had an indwelling catheter and was always incontinent of bowel. The MDS revealed the resident had occasional pain and received a scheduled pain medication regimen, as needed pain medication, and non-medication interventions for pain. Per the MDS, the resident had a stage four pressure ulcer that was present on admission and other opened lesion(s) other than ulcers, rashes, or cuts. A review of Resident #1's care plan, revised on 03/02/2022, revealed the resident had an indwelling urinary catheter related to diagnoses of neuromuscular dysfunction of the bladder and quadriplegia. Interventions directed staff to monitor/record/report to the physician signs and symptoms of urinary tract infection to include pain, blood-tinged urine, and no urinary output, deepening of urine color. A review of Resident #1's care plan, revised on 02/05/2024, revealed the resident had actual skin impairment of a stage four pressure ulcer to their left buttocks. Interventions directed staff to provide treatment as ordered by the MD. A review of Resident #1's Order Summary Report, with active orders as of 02/29/2024, revealed an order dated 04/11/2023, for indwelling catheter output every shift. If no output, assess the resident's bladder for distention, check for malfunction, and notify the MD as needed. The order dated 02/13/2024, directed staff to cleanse the resident's stage four pressure ulcer to the left buttocks with wound cleanser, pat dry, apply skin prep to the periwound (tissue that surrounded a wound), and apply a topical antiseptic solution with a soaked gauze sprinkled with Flagyl (an antibiotic) 500 milligrams crushed to wound bed, then cover with a foam dressing every day shift for 28 days. The order dated 02/21/2024, directed staff to cleanse the resident's stage four pressure ulcer to the right buttocks with a topical antiseptic solution, pat dry, apply medical honey to the wound bed, cover with an abdominal pad, and secure with paper tape every day shift. The order dated 02/21/2024, directed staff to cleanse the resident's stage four pressure ulcer to the sacrum with a topical antiseptic solution, pat dry, apply medical honey to the wound bed, cover with abdominal pad, and secure with paper tape every day shift. On 02/26/2024 at 11:00 AM, Resident #1 stated their catheter leaked and their bladder hurt. The surveyor noted the resident writhed (to move or proceed with twists and turns) in pain and hit their bed with their hands/fists. At 11:10 AM, the resident pressed their call light for assistance. At 11:12 AM, CNA #1 entered the resident's room to answer the resident's call light and stated she would notify Licensed Vocational Nurse (LVN) #2 of the resident's complaints. At 11:30 AM, the resident used a telephone to call the front desk of the facility to request their nurse. Resident #1 complained of bladder pain and was noted to writhe in bed. At 11:32 AM, a staff member (later identified as the unit clerk) approached the bedside of Resident #1 and stated their nurse (LVN #2) was at lunch and that another nurse had been made aware of the resident's complaint. At 11:39 AM, CNA #1 returned to Resident #1's bedside and asked the resident if they had been assisted yet. Resident #1 asked CNA #1 to reposition them in bed. As CNA #1 performed perineal care on Resident #1, the surveyor noted the resident had numerous uncovered pressured ulcers on their buttocks. The numerous uncovered pressure ulcers had bled/wept onto the disposable bed pad that was underneath the resident. The disposable bed pad was wet with moisture and CNA #1 stated she did not know if the disposable bed pad was wet from the resident's catheter that leaked or the resident's pressure ulcers. CNA #1 also reported that she was unaware of how long the resident's pressure ulcers had been uncovered. According to Resident #1, the wound care nurse (WCN) would perform wound care after the resident had a shower. At 11:50 AM, the surveyor noted there was no urine in Resident #1's catheter drainage bag. At 11:59 AM, LVN #2 entered the resident's room to administer the resident their medication(s) to include pain medication. According to LVN #2, she did not do anything with the resident's catheter. Per LVN #2, the resident's catheter and pressure ulcers were managed by the WCN. LVN #2 acknowledged Resident #1 had no urine in their catheter drainage bag and stated the WCN would complete the dressing change for the resident's pressure ulcers once the resident had a shower. At 12:03 PM, the resident acknowledged they were in pain. LVN #2 stated the facility was in the process of getting an urology consultation for the resident as staff did not want to keep having to change the resident's urinary catheter. On 02/26/2024 at 1:10 PM, the surveyor entered Resident #1's room just as the WCN removed the resident's catheter. LVN #2 stated since the resident was in so much pain, she decided to handle the resident's urinary catheter. Once the urinary catheter was removed from the resident, the resident began to urinate a copious amount of urine. The WCN stated she did not know how long it had been since the resident last had urine in their catheter drainage bag. The resident's mattress and two disposable bed pads were saturated, and the two disposable bed pads dripped of fluid as they were placed in a trash bag. The resident was noted to have an additional 300 cubic centimeters of dark yellow, blood-tinged urine that drained into the catheter drainage bag once a new catheter was inserted by LVN #2, who was under the direction of the WCN. Resident #1 stated they felt better now that their bladder had been emptied. As the resident was turned so the staff could remove the soiled bedding, Resident #1 began to have a bowel movement. While staff cleaned the resident of bowel, the WCN noticed the resident's lunch meal tray had arrived. In a hurried manner, the WCN placed a dressing on the resident's pressure ulcers to cover the areas and stated she would be back after lunch to place a fresh dressing on the resident's pressure ulcers. A review of Resident #1' catheter output document, revealed on 02/25/2024, staff documented the resident had 400 cc of output for the 3:00 PM to 11:00 PM shift. Per the document, there was no documentation of urinary output during the 11:00 PM to 7:00 AM shift that began on 02/25/2024 and ended on 02/26/2024 until the 3:00 PM to 11:00 shift on 02/26/2024. A review of facility Removal Plan, signed by the Administrator revealed in the early hours of 02/26/2024 at 2:44 AM, a CNA inadvertently removed the dressings from Resident #1's pressure ulcers. Per the Removal Plan, the CNA failed to inform the nurse of the need to replace the resident's pressure ulcer dressings. The Removal Plan revealed Resident #1's pressure ulcer dressings were replaced on 02/26/2024 at 1:24 PM. A review of Resident #1's Progress Notes, dated 02/26/2024 at 12:00 PM, revealed the resident complained of pressure in their bladder. The Progress Note indicated the resident's bladder was palpated (examine by touch) and noted to be slightly distended. Per the Progress Note, once the resident's indwelling urinary catheter was removed, the resident urinated on their bed. A review of Resident #1's Progress Notes, dated 02/26/2024 at 12:10 PM, revealed the resident's indwelling urinary catheter was changed and the resident had 300 cc of blood-tinged urine output. During an interview on 02/26/2024 at 1:47 PM with the DON and Regional Nurse Consultant, they stated the resident's pressure ulcers should be covered per the physician's order and they were unsure how long the pressure ulcers had not been covered. It was reported they would follow up with the night shift to figure out why the resident's pressure ulcers were not covered. During an interview on 02/27/2024 at 9:39 with the DON and WCN, the WCN stated she was not responsible for the care of the resident's catheter, but if she did see a problem, she would address it. The WCN stated she adjusted the resident's catheter and noticed it was clogged. Per the WCN, once the resident's catheter was adjusted, urine started to flow. According to the WCN, someone approached her and told her that Resident #1's bandages needed to be changed. The WCN states she was unsure how long the resident's pressure ulcers had been uncovered. The WCN stated from her observation of Resident #1, the resident only received pain relief once they were able to expel urine from their bladder. During an interview on 02/28/2024 at 3:30 PM, LVN #2 acknowledged it was around 11:10 AM on 02/26/2024 that CNA #1 notified her that Resident #1 was in pain. LVN #2 stated she then checked on a different resident and took a lunch break. LVN #2 stated once she returned from her lunch break, she went to Resident #1's room to address the resident's concerns. LVN #2 stated she did not know when the resident's pressure ulcer bandages were removed. LVN #2 acknowledged it would her responsibility to place a new pressure ulcer dressing in the event the WCN was unavailable. During a telephone interview on 02/29/2024 at 5:10 PM, the Medial Director (MD) stated staff informed him that Resident #1's indwelling urinary catheter was obstructed, and the resident had bladder distention. The MD stated he was not aware Resident #1 had no urine output for 12 hours. During an interview on 03/01/24 at 11:00 AM, the Administrator stated he expected the staff to acknowledge a resident's complaint of pain and address it immediately. The Administrator stated the nurse and CNA should monitor to ensure the resident had urinary output in order to determine what further needed to be done to treat the resident. The Administrator stated a resident's pressure ulcer should be covered and staff should replace the dressing as ordered by the physician. According to the Administrator, he would have wanted the concern with Resident #1 to be addressed with a greater sense of urgency. On 03/01/2024 at 1:17 PM, a Removal Plan was submitted by the facility and accepted by the state survey agency. It read as follows: Removal Plan F684 Failure to provide care to indwelling catheter and to measure output in accordance with professional standard and facility policy and procedure: 1. Resident #1's catheter was checked by nursing staff who were unable to get urine to flow. The catheter was changed by nursing staff on 02/26/2024, completed by 1:24 PM. Root cause analysis determined the catheter was non-functioning. 2. On February 26th, 2024, Resident #1 was scheduled for hourly checks to ensure the proper functioning and care of the catheter. Licensed nurses will verify the catheter's proper function every hour, with documentation to be recorded in the electronic medication administration record (EMAR) system. 3. Urology consult was in process with the insurance company. Authorization was given by the facility to proceed with scheduling without insurance authorization. A urology office was found on 02/27/2024 that will see private pay (by the facility) and their scheduling department is arranging the date. 4. Resident #1's primary care physician was made aware of concerns and came to review the resident on 02/27/2024. The physician left a report detailing his visit. 5. On 02/27/2024, the Assistant Director of Nursing (ADON) conducted an audit of all residents with urinary catheters to confirm the presence of orders, care plans, and documentation of urinary intake and/or output. The purpose was to ensure compliance and identify any potential issues. The audit revealed no other issues or discrepancies. 6. On 02/27/2024, the Director of Nursing (DON) in-serviced the AM [ante meridiem, translated as before midday] and PM [post meridiem, translated as the time after noon] licensed nurses and CNAs [certified nursing assistants] regarding Urinary Catheter Care. Topics covered under Catheter Care, Urinary: Preparation, General Guidelines, Catheter Evaluation, Perineal Care, Infection Control, Input/Output, Maintaining Unobstructed Urine Flow, Changing Catheters, Complications, Cleaning and Disinfecting Drainage Bags, Equipment and Supplies, Proper Procedures, Documentation. The ADON or designee will in-service the remaining employees before start of the staff's next scheduled shift. Additionally, all in-service material will be placed at each station available for staff review prior to starting their shift. 7. Because the issue of taking a break without checking on a resident was isolated to the resident's assigned licensed nurse, on 02/28/2024 the DON educated the licensed nurse, who took the lunch break before checking with the resident, that it is her responsibility to make sure any concerns shared with the nurse are addressed or delegated prior to taking their break. The MDS [minimum data set] nurse mentioned was determined to be a unit clerk. 8. On 02/28/2024, the ADON in-serviced all PM and NOC [nocturnal, night shift] licensed nurses and CNAs regarding not leaving for breaks with unresolved resident care needs and/or without proper delegation to another licensed nurse. On 02/29/2024, the DON in-serviced all AM licensed nurses and CNAs on the same topics. The ADON or designee will in-service the remaining employees, including the unit clerk, before the start of their next scheduled shift. Additionally, all in-service material will be placed at each station available for staff review prior to starting their shift. 9. Certified Nursing Assistants (CNAs) and licensed nurses are required to check the proper function of catheters during each shift. Over the next 90 days, until 05/31/2024, the Director of Nursing (DON) or assigned representative will conduct weekly audits of all residents with urinary catheters. These audits will verify the presence of necessary documentation, including care orders, removal/change procedures, care plans, and documentation of urinary intake and/or output. 10. An impromptu meeting of the Quality Assurance Committee was held on 02/28/2024, which included the Administrator, Medical Director, DON, RN [registered nurse] ADON [assistant director of nursing], Activity Director, Director of Staff Development, Minimum Data Set Nurse, and Wound Licensed Vocational Nurse to review the above findings and corrective actions. Topics discussed were those identified above: failure to provide care to indwelling catheter, failure to immediately address severe pain, and failure to provide care to a diagnosed pressure ulcer. Also discussed were the root causes identified, the training given, the audits to be completed, and the reports to be given to the Quality Assurance Committee. Any issues found during the performance of the items above will be shared with the Quality Assurance Committee for review and action as necessary. Failed to immediately address severe pain of Resident #1, after notifying the CNA and nursing staff, for over 2 hours. 1. Upon the return from her break at 12:00 PM, Resident #1's licensed nurse administered the resident's scheduled hydrocodone [a medication used to treat moderate to severe pain]. On 02/26/2024 when the catheter was adjusted and ultimately removed, the resident's bladder emptied, and the discomfort was relieved. It was determined that the root cause of the resident's pain was the non-functioning catheter. 2. The DON educated Resident #1's assigned licensed nurse that it is her responsibility to make sure that any concerns shared with her are addressed or delegated prior to taking her break on 02/28/2024. 3. On 02/27/2024, the resident was interviewed and felt comfortable with the current measures for pain management. 4. Licensed nurses will assess pain every shift and as needed and document in the EMAR system. 5. On 02/27/2024, all other residents with recorded pain were audited by the DON for any un-addressed pain, including residents with catheters. No other issues were found. 6. On 02/27/2024, The DON in-serviced licensed nurses and CNAs regarding Pain Assessment and Management, including how to recognize and report pain. Topics on Pain Assessment and Management covered: General Guidelines, Equipment and Supplies, Recognizing Pain, Assessing Pain, Identifying the Causes of Pain, Defining Goals and Appropriate Interventions, Implementing Pain Management Strategies, Monitoring and Modifying Approaches, Promptly Addressing Resident's Complaints of Pain, Documentation, Reporting. The ADON or designee will in-service remaining employees before the start of their next scheduled shift. Additionally, all in-service material will be placed at each station available for staff review prior to starting their shift. 7. For the next 90 days, until 05/31/2024, on a weekly basis, the DON or designee will audit resident pain scores to ensure proper pain management, including resident interviews to ensure timely responses. 8. An impromptu meeting of the Quality Assurance Committee was held on 02/28/2024, which included the Administrator, Medical Director, DON, RN ADON, Activity Director, Director of Staff Development, Minimum Data Set Nurse, and Wound Licensed Vocational Nurse to review the above findings and corrective actions. Topics discussed were those identified above: failure to provide care to indwelling catheter, failure to immediately address severe pain, and failure to provide care to a diagnosed pressure ulcer. Also discussed were the root causes identified, the training given, the audits to be completed, and the reports to be given to the Quality Assurance Committee. Any issues found during the performance of the items above will be shared with the Quality Assurance Committee for review and action as necessary. Failed to provide care to diagnosed pressure ulcer and follow physician's orders on wound care for Resident #1. 1. The root cause analysis revealed the following: According to the physician's orders, dressings on each wound were to be changed during every AM shift and as needed. In the early hours of February 26, 2024, at 2:44 am, while receiving peri-care administered by the NOC CNA, the dressings were inadvertently removed. The CNA did not inform the floor nurse about the need to replace the dressings. Around 8 am, during peri-care performed by the AM CNA, the absence of dressings was observed, prompting immediate notification of the treatment nurse. Assuming the resident's shower was imminent, the treatment nurse planned to reapply the dressings afterward. However, the treatment nurse was mistaken, and it was scheduled for a later time. 2. On 02/26/2024, following the catheter change completed by 1:24 PM, new dressings were placed on the pressure ulcers by the treatment nurse. A shower was given to the resident at 2:00 PM, and new dressings were placed immediately afterward and again the next morning on 02/27/2024. 3. Resident #1's has an order in place, dated 02/21/2024, for daily treatment and dressing changes for pressure ulcers and/or PRN due to soiling or dislodged. Floor staff nurses to date and initial all dressings and report any issues to a nurse supervisor when performing daily dressing changes. 4. On 02/27/2024, all other residents with pressure ulcers were audited by Assistant Directors of Nursing and Unit Supervisors to ensure that orders were in place, being followed, and dressings were in place accordingly. No other issues were found. 5. On 02/27/2024, the DON in-serviced AM and PM licensed nurses and CNAs regarding wound care. Wound Care topics covered: Preparation, Equipment and Supplies, Proper Procedures, Infection Control, Dating with Time and Initials, Timely Changing of Dressings (including promptly responding when dislodged dressings are reported), Appropriate Coordination of Dressing Changes with Regards to Showers, Monitoring for Signs and Symptoms of Infection, Medication use when appropriate, Documentation, Reporting. The ADON or designee will in-service remaining employees before the start of their next shift. Additionally, all in-service material will be placed at each station available for staff review prior to starting their shift. 6. On 02/28/2024, all PM and NOC shift CNAs were in-serviced by the ADON, and on 02/29/2024 all CNAs were in-serviced by the DON regarding the requirement to notify nursing in the event of detached dressings and/or uncovered pressure ulcers/wounds. The ADON or designee will in-service the remaining employees before the start of their next scheduled shift.) 7. For the next 90 days, ending on 05/31/2024, on a weekly basis, the Director of Nursing or designee will audit all pressure ulcers to ensure that orders are in place, being followed, and dressings are in place according to physician's orders, including the dressing having the appropriate date and initials. 8. An impromptu meeting of the Quality Assurance Committee was held on 02/28/2024, which included the Administrator, Medical Director, DON, RN ADON, Activity Director, Director of Staff Development, Minimum Data Set Nurse, and Wound Licensed Vocational Nurse to review the above findings and corrective actions. Topics discussed were those identified above: failure to provide care to indwelling catheter, failure to immediately address severe pain, and failure to provide care to a diagnosed pressure ulcer. Also discussed were the root causes identified, the training given, the audits to be completed, and the reports to be given to the Quality Assurance Committee. Any issues found during the performance of the items above will be shared with the Quality Assurance Committee for review and action as necessary. All corrections were completed on 02/29/2024. The immediacy of the IJ was removed on 02/29/2024. Onsite Verification: The IJ was removed on 03/01/2024 at 5:00PM, after the survey team verified the implementation of the Removal Plan as follows: Failure to provide care to indwelling catheter and to measure output in accordance with professional standard and facility policy and procedure: 1. Verified through interview and review of the quality assurance and performance improvement (QAPI) minutes with the Administrator on 03/01/2024. An impromptu QAPI meeting was held with the facility MD, DON, Administrator, and ADON on 02/28/2024. In this meeting, the resident was discussed, and a root cause was determined to be the resident's non-functioning catheter. 2. Verified through audit review and interview with LVNs on 03/01/2024. Verified through record review on 03/01/2024. 3. Verified through resident record review and interview with DON on 03/01/2024 at 3:30 PM. He stated the urology consultation was being sought in the community. The facility called the hospital where the resident was sent and asked the nurse to include a urology consultation at the hospital. Review of progress notes revealed the hospital staff documented the request. 4. Verified through resident record review and interview on 02/29/2024 at 5:15 PM with the physician. The physician's note was included in the chart and revealed the resident's condition of suprapubic abdominal distention and urinary obstruction. 5. Verified through interview and audit record review on 03/01/2024 with the ADON. No other issues were found during the audits. Audits reviewed residents with catheters for pain, input and output and proper placement. 6. Verified through interviews on 03/01/2024 with dayshift and nightshift CNAs, LVNs, ad RNs. No concerns were identified. 7. Verified through interview with LVN #2 on 03/01/2024 at 2:24 PM. Verified through in-service document review on 03/01/2024. 8. Verified through interviews on 03/01/2024 with the DON. He stated output and input would be monitored, any pain, discoloration, odor, signs and symptoms of infection, and catheter functioning. Audit will be conducted weekly, residents who have catheter will be interviewed and functionality checked. Verified through record review on 03/01/2024. Failed to immediately address severe pain of Resident #1, after notifying the CNA and nursing staff, for over two hours. 1. Verified through interview and review of the QAP) minutes with the Administrator on 03/01/2024. An impromptu QAPI meeting was held with the facility MD, DON, Administrator, and ADON on 02/28/2024. In this meeting, the resident was discussed, and a root cause was determined to be the resident's non-functioning catheter. 2. Verified through interview with LVN #2 on 03/01/2024 at 2:24 PM. Training provided to LVN #2 verified through in-service review on 03/01/2024 at 2:18 PM. 3. Validated through interview and observation with the resident on 02/26/2024 and 02/27/2024 after the issues were addressed. The resident reported their pain was controlled, and they were not in pain. 4. Verified through interviews on 03/01/2024 with dayshift and nightshift CNAs, LVNs, ad RNs. No concerns were identified. 5. Verified through interview on 03/01/2024 with the DON. He stated pain audits would be completed for any resident who has a pain level of five or greater, and the staff would meet with the residents weekly to cover pain and pain management. Per the DON, the staff would review resident charts for documented pain levels. Any residents who reported a pain level of five or greater would be reviewed that week. Verified through audit review on 03/01/2024. All residents who had pain scores greater than one for multiple days through February 2024 reviewed and interviewed regarding pain control. No issues found. Failed to provide care to diagnosed pressure ulcers and follow physician's orders on wound care for Resident #1. 1. Verified through interview and review of the QAPI minutes with the Administrator on 03/01/2024. An impromptu QAPI meeting was held with the facility MD, DON, Administrator, and ADON on 02/28/2024. In this meeting, the resident was discussed, and a root cause was determined to be a miscommunication between the resident, CNA, and the wound treatment nurse. 2. Verified through record review on 03/01/2024. Documentation of wound care present in medication administration record/treatment administration record. 3. Verified through interviews with licensed nursing staff on 03/01/2024. 4. Verified through interviews on 03/01/2024 with both ADONs and unit managers. No other issues arose from the audits. 5. Verified through interviews on 03/01/2024 with dayshift and nightshift CNAs, LVNs, ad RNs. No concerns were identified. 6. Verified through interview on 03/01/2024 with the DON. He stated pressure ulcer audits would be reviewed weekly and staff would check for injuries and that dressings were intact and accurate per the physician's order. 42192 2. A review of Resident #105's Admission Record, revealed the facility admitted the resident on 04/20/2023 with diagnoses that included type 2 diabetes mellitus, congestive heart failure, morbid obesity, localized edema. Per the Admission Record, the resident received a diagnosis of non-pressure chronic ulcer of the left lower leg on 04/28/2023. A review of Resident #105's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/27/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #105's care plan, revised on 08/30/2023, revealed the resident had a venous/stasis ulcer of the left and right lower leg. Interventions directed staff to administer treatment as ordered by the physician. A review of Resident #105's Order Summary Report with active orders as of 02/29/2024, revealed an order dated 0[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 62) with known risk for injuries due to the [DIAGNOSES REDACTED]. repositioning every two hours as prescribed by the physician. This failure resulted in Resident 62's hospitalization with a [DIAGNOSES REDACTED]. Findings: During an interview with Licensed Vocational Nurse (LVN) 5, on 1/30/19, at 7:22 a.m., LVN 5 stated she worked on 1/15/19, during the 3:00 p.m., to 11:00 p.m., shift and did not notice any problems with Resident 62's left arm during her eight-hour shift. LVN 5 stated Resident 62's left arm was contracted as usual. During an interview with CNA 3, on 1/30/19, at 8:12 a.m., he stated, I work from 2:45 (p.m.) to 11:45 p.m., on (1/15/19) and (Resident 62) was one of my residents to care for during my shift. CNA 3 stated, I did not notice any problems with (Resident 62's) left arm during my shift. During an interview with Registered Nurse (RN) 1, on 1/30/19, at 1:40 p.m., he stated, (Resident 62) needs total care for all of his needs. RN 1 stated Resident 62 required two-person assistance for repositioning (turning). During an interview with LVN 2, on 1/30/19, at 2:15 p.m., she stated during report on 1/16/19 (morning shift report) she was informed Resident 62 was found in his bed by CNA 4 with swelling and redness to his left arm. LVN 2 stated CNA 4 reported Resident 62's left arm was limp, looked abnormal and not contracted as was his usual physical condition. During an interview with CNA 4, on 1/30/19, at 3:15 p.m., she stated Resident 62 required complete assistance with all of his care and repositioning movements. CNA 4 stated, We should have two persons to change (Resident 62's) briefs, but sometimes we are short staffed. CNA 4 stated it was not safe to provide care for Resident 62 using one person because of Resident 62's contractures, stiffness and it was, Hard to provide care with one person. During a review of Resident 62's clinical record, the face sheet (a document with personal identifiable and medical information) undated, indicated Resident 62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with LVN 6, on 4/24/19, at 7:25 a.m., LVN 6 stated he worked night shift on 1/16/19 and was assigned to Resident 62. LVN 6 stated at 4:10 a.m., CNA 4 called him to Resident 62's room and notified him that Resident 62's left arm was limp, swollen and not in its usual condition (contracted). LVN 6 stated, I went into (Resident 62's room) and noticed Resident 62's left arm was above the covers and turned in an awkward position (not his usual position). LVN 6 stated, I went to get the registered nurse on duty. LVN 6 stated, I did not help (CNA 4) throughout the entire shift to reposition or change (Resident 62's) brief. LVN 6 stated, I offered to help (CNA 4), but she refused help. During an interview with CNA 4, on 4/24/19, at 7:40 a.m., CNA 4 stated she was assigned to provide care to Resident 62 on 1/15/19 to 1/16/19 from 11 p.m. to 7 a.m. CNA 4 stated on 1/15/19 at 11 p.m., she conducted resident rounds (checking each resident and receiving a report of care and any changes of condition from the PM (3-11 p.m.) shift staff). CNA 4 stated, PM CNA did not report any unusual occurrences with Resident 62 during the shift. CNA 4 stated she returned to Resident 62's room at around 12:30 a.m., on 1/16/19 to perform care, turned and repositioned Resident 62 in his bed. CNA 4 stated Resident 62's left arm was positioned with a pillow under his arm due to his contracture. CNA 4 stated the left arm was unchanged from Resident 62's normal condition. CNA 4 stated she turned Resident 62 onto his left side to reposition and check his brief to determine if it needed to be changed. CNA 4 stated at approximately 4 a.m., she returned to Resident 62's room to again reposition him and provide care. CNA 4 stated she removed the pillows from underneath Resident 62's left arm, To get them out of the way to change Resident 62's soiled brief. CNA 4 stated she placed a pillow between the resident and the bed rail to, Keep him from rolling further onto the rail or onto his left arm. CNA 4 stated she provided incontinent care (a change of a wet or soiled brief and cleansing of the skin) using one hand while she held resident on his left side with the other hand. CNA 4 stated she changed the soiled brief by herself and when she moved Resident 62 back onto his back and moved his left arm she noticed it was flaccid (hanging loosely or limply) and not contracted like it usually was. CNA 4 stated she called LVN 6 into Resident 62's room to report the condition of the left arm. CNA 4 stated, (LVN 6) and myself were the only people who went into his room all night. During a concurrent interview and record review with LVN 6, on 4/24/19 at 7:50 a.m., LVN 6 stated Resident 62's Nurse Progress Note dated 1/16/19 at 4:30 a.m., indicated, CNA 4 asked LVN 6 to go into Resident 62's room. CNA 4 reported to LVN 6 that Resident 62's left arm was not in its usual position. LVN 6 performed an assessment on Resident 62's left arm and found a small indentation on the upper area of the left arm near the bicep (a large muscle in the upper arm which turns the hand to face palm uppermost and flexes the arm and forearm). The Nurse Progress Note dated 1/16/19 at 4:30 a.m., indicated, The indentation looked suspicious. LVN 6 stated, I was also not present (to assist and monitor body repositioning during care) and may be partly to blame for not helping my CNA (4). During a concurrent observation and interview with CNA 4, on 4/24/19, at 8:05 a.m., Resident 62 was lying on his bed, had a [MEDICAL CONDITION] (a surgically created hole through the front of the neck and into the windpipe to provide an air passage to help in breathing) tube in place and was wearing a sling on his left arm. Resident 62 was unable to speak and unable to move on his own. CNA 4 stated Resident 62 was wearing the sling because he broke his left arm. CNA 4 stated Resident 62 was unable to speak and did not have the ability to move on his own, and required staff to perform all of his body repositioning movements. During a review of the clinical record for Resident 62, the Minimum Data Sheet (MDS) assessment (assessment of healthcare and functional needs) dated 1/14/19, indicated Resident 62 required total dependence with two-person physical assistance for his bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of the clinical record for Resident 62, the Nurse Progress Note dated 1/16/19 at 7:30 a.m., indicated, (Doctor) notified regarding swelling to LUE (left upper extremity) .order received for STAT (urgent or rushed) x-ray to LUE (due to) swelling . (at 11:21 a.m., Doctor) reviewed (x-ray) results and ordered to transfer resident to (hospital) .(at 9:58 p.m.,) spoke with (Doctor) at (hospital). She stated resident will be admitted for fracture .waiting surgery consultation . During a review of the clinical record for Resident 62, the Physician order [REDACTED]. During a review of the clinical record for Resident 62 the bone (left arm) x-ray results dated 1/17/19, indicated, There is a spiral, displaced fracture (break) of the proximal (situated closest to the center of the body or the point of attachment) shaft of the left humerus (long bone in the left arm) with one shaft width medial (middle) displacement of the distal (end of the bone) fracture fragment. During a concurrent interview and record review with LVN 5, on 6/20/19, at 4:53 p.m., LVN 5 reviewed Resident 62's physician orders [REDACTED]. Licensed Nurse (LN) to assist and monitor repositioning every 2 hours and document every time you reposition . every 2 hours .do not turn onto (left) side . LVN 5 stated she was aware of the physician's orders [REDACTED]. LVN 5 stated, .We do not turn (Resident 62) on the left side because of the [MEDICAL CONDITION] arm (sustained on 1/16/19). Prior to (the fracture), we did turn him on the left and right side . LVN 5 stated she signed the physicians order that indicated she assisted and monitored Resident 2 every two hours during repositioning but had not actually implemented the physicians order. During an interview with CNA 3, on 6/21/19, at 8 a.m., CNA 3 stated he was familiar with Resident 62's care needs and was frequently assigned to care for Resident 62. CNA 3 stated Resident 62 always received a one person assist with ADL's. CNA 3 stated, The nurses don't help all the time with the repositioning (of residents). CNA 3 stated he was not aware there was a physician's orders [REDACTED]. CNA 3 stated LN's should inform CNA's if there was a physician's orders [REDACTED]. During a concurrent interview and record review with LVN 6, on 6/21/19, at 8:01 a.m., LVN 6 reviewed Resident 62's Medication Administration Record [REDACTED]. Licensed Nurse to assist and monitor repositioning every 2 hours and document every time you reposition . Do not turn onto (left) side . LVN 6 stated, That order was not there before . Oh it (order) is dated 1/4/19, I guess it was there. I should have checked the physician's orders [REDACTED]. I signed it (initialed the doctors order indicating he performed the task ordered) but I didn't think it was a doctor's order. I didn't even know there was a doctor's order. When I signed it (Initialing the order) means I did it, but I didn't (follow the physician order [REDACTED]. I just asked (CNA 4) if she needed help and she told me she was fine, she got it, so I didn't help her . LVN 6 reviewed Resident 62's care plan dated 7/11/18 which indicated, . (Resident 62) has an ADL Self Care Performance Deficit (related to) immobility secondary to [MEDICAL CONDITION] .admitted with contractures. At risk for unavoidable . increase contractures . LVN 6 stated he was not aware Resident 62 was a high risk for injury. LVN 6 stated, All I knew is (Resident 62) was contracted. LVN 6 stated it was important to follow physician's orders [REDACTED]. LVN 6 stated he signed the physician's orders [REDACTED]. LVN 6 stated he signed without implementing the physicians order. The facility policy and procedure titled, Documentation Standards dated 12/1/15, indicated . It is the policy of this facility to observe all legal and regulatory requirements and standards representing good professional practice relative to documentation in medical records by all health care professionals . Standards . 9. Documentation should be factual, concise, truthful, and accurate . Review of the facility document titled, Job Description Licensed Nurse (RN or LVN) undated, 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 the nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility . to ensure that the highest degree of quality care is maintained at all times . Chart and ensure that care plans are complete on all accidents/incidents involving the resident. Follow established procedures . Make periodic checks to assure that prescribed treatments are being properly administered by the nursing assistants and to evaluate the resident's physical .status .Review the resident's chart for specific treatments, medication order . Write any changes that need to be made on the care plan. Review care plans daily to ensure that appropriate care is being rendered. Ensure that your nurses' notes reflect that the care plan is being followed. Review resident care plans for appropriate resident goals, problems, approaches and revisions based on nursing needs. Ensure that your assigned nursing assistants are aware of the resident care plans and that they are used in administering daily care to the resident . During a concurrent interview and record review with the Director of Nursing (DON), on 6/21/19, at 10 a.m., the DON reviewed Resident 62's physician orders [REDACTED]. The DON stated it was Unit Manager (UM) 1 who documented the physician's orders [REDACTED]. repositioning. The DON stated it was important to communicate to the staff when there was a new physician's orders [REDACTED]. The DON stated LNs should have read the physician's orders [REDACTED]. The DON stated LNs and CNA's should have followed the physician's orders [REDACTED]. During a telephone interview with CNA 4, on 6/21/19 at 10:49 a.m., CNA 4 stated Resident 62 required the assistance of two staff members to turn and reposition after the fracture. CNA 4 stated, I was not aware (Resident 62) was a two person assist (with ADL's). I do turn him by myself because sometimes there is no help available. We are supposed to turn him every 2 hours and document it right away but it does not happen because we get busy and there's other tasks that become a priority. The nurses don't help us all the time and I have been turning and repositioning the resident all by myself for a long time now. There have only been a few times the nurses helped me reposition (Resident 62). The facility policy and procedure titled Nursing Responsibilities dated 11/24/17, indicated .Policy: It is the policy of this facility to provide person centered care to meet the needs and preferences of each resident, following current nursing standards of care, state and federal regulations . Procedures . 2. Nursing services, but not be limited to . b .11. Nursing is to assure that the environment is free of hazards and implement measures to prevent resident . injuries .7. Licensed Nurses are responsible for administering .treatment as follows . b .treatment are to be administered as prescribed .

Based on interview and record review, the facility failed to provide physician ordered care and treatment in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1's right and left hand mittens (device used to cover the hands in an effort to prevent movement of the hands and fingers) were not applied on [DATE] as ordered by the physician. The physician order written [REDACTED]. This failure resulted in Resident 1 removing the [MEDICAL CONDITION] device and was found not breathing and without a pulse. Resident 1 was declared dead on [DATE] at 11:30 p.m., 35 minutes after being observed alive, with [MEDICAL CONDITION] in place and in her usual condition. Findings: During a review of the clinical record for Resident 1, the Admission Record (document containing resident personal information), undated, indicated Resident 1 was a [AGE] year-old female admitted to the Skilled Nursing Facility (SNF) on [DATE] for [DIAGNOSES REDACTED]. On [DATE], Resident 1 was diagnosed with [REDACTED]. During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 11:55 p.m., indicated, (11:30 p.m.) made walking rounds with (night shift) nurse. Resident was found in her bed unresponsive. Resident had removed ([MEDICAL CONDITION]) and mitten. Resident appeared cyanotic (skin and lips were bluish color) with pupils fixed (not responsive). No pulse or respirations were noted. Three RN's (registered nurses) and one LVN (licensed vocational nurse) at bedside aided to assess vitals and resident status. Resident reintubated (tube placed back into the lungs to artificially provide breaths for the patient), suctioned and was provided with 100% oxygen. Interventions were ineffective . Orders received to . release body to mortuary. During a review of the clinical record for Resident 1, the Physician Order dated [DATE], at 11:14 a.m., indicated, Monitor R/L (right/left) soft hand mitten restraint. Remove (every) 2 hours for 15 minutes. Wash hands and dry thoroughly before re-applying mitten, assess skin every 2 hours for 30 days (related to) repetitive behaviors of pulling [MEDICAL CONDITION], blow by mask (provides oxygen), and Posey (type of restraint) resulting in multiple episodes of self-extubation. During a telephone interview with Certified Nursing Assistant (CNA) 1, on [DATE], at 4:19 p.m., he stated Resident 1 had history of restlessness on a daily basis and during her restless periods she would pull out her medical devices (feeding tubes, [MEDICAL CONDITION], nephrostomy tubes (inserted into the kidneys)). CNA 1 stated he observed Resident 1 around 8 p.m. and noted her arms and hands were covered with a bed sheet. CNA 1 stated he had not checked Resident 1's hands to make sure she was wearing her mittens. CNA 1 stated on [DATE] before his shift ended at 10:30 p.m., he provided Resident 1 with care and did not observe hand mittens on Resident 1. During a telephone interview with RN 1, on [DATE], at 3:31 p.m., RN 1 stated she was assigned to care for Resident 1 on [DATE] and was not familiar with Resident 1's care. RN 1 stated [DATE] was the second time she was assigned to care for Resident 1. RN 1 stated she was unaware of the physician order written [REDACTED]. RN 1 stated the day shift nurse notified her on [DATE] Resident 1 had one hand mitten on and not two hand mittens. RN 1 stated she did not review Resident 1's clinical record before initiating care and was unaware why Resident 1 required hand mittens. RN 1 stated she became aware of the physician orders for Resident 1 to wear left and right hand mittens after Resident 1 had died on [DATE]. RN 1 stated she did not apply or remove Resident 1's hand mitten on [DATE]. During a telephone interview with RN 1, on [DATE], at 3:27 p.m., she stated on [DATE] at 10 p.m. she observed one hand mitten on Resident 1's left hand and the right hand without a hand mitten. RN 1 stated at 11:30 p.m. she performed resident rounds (exchange of shift communication of resident information from one nurse to another) with the night shift nurse and found Resident 1 in her bed with her [MEDICAL CONDITION] device pulled out, pupils fixed, and without a pulse. RN 1 stated she initialed the physician's order documenting that she provided the ordered treatment. RN 1 stated she did not read the physicians order to apply and remove the bilateral hand mittens. RN 1 stated she did not follow the physician's order for hand mittens. RN 1 stated she should have read the physicians order to ensure Resident 1's bilateral hand mittens were on Resident 1's left and right hands. RN 1 stated she was responsible for following Resident 1's care plan interventions for hand mittens. RN 1 stated she did not follow the care plan interventions to apply and remove Resident 1's bilateral hand mittens. During an interview with LVN 1, on [DATE], at 3:05 p.m., she stated Resident 1 had a history of [REDACTED]. LVN 1 stated the Attending Physician (AP) ordered bilateral hand mittens on [DATE] to ensure Resident 1 did not pull out her [MEDICAL CONDITION] device. LVN 1 stated Resident 1 had a history of [REDACTED]. LVN 1 stated when Resident 1 would pull out her [MEDICAL CONDITION] nurses would immediately reinsert the [MEDICAL CONDITION] device in order for her to breathe. During a concurrent interview and clinical record review with the Director of Nurses (DON), on [DATE], at 1:38 p.m., the DON reviewed the Progress Notes and stated the Nursing Notes indicated Resident 1 pulled out her [MEDICAL CONDITION] device completely on different occasions dating from [DATE] to [DATE] for a total of five times. The DON reviewed the Progress Note dated [DATE] at 10 a.m. and stated the Nursing Note indicated Resident 1 was having increased restlessness, pulling out the [MEDICAL CONDITION] device, and was throwing her legs over the bed. The DON stated Resident 1's behaviors were increasing so the bilateral hand mittens were ordered on [DATE] to prevent Resident 1 from pulling out her [MEDICAL CONDITION] device. The DON stated the expectation was for the CNA or Licensed Nurse (LN) to apply the bilateral hand mittens if they were not on Resident 1. The DON stated Resident 1 was supervised by the CNA, LN and RT at different times. The DON stated staff were able to go to the linen closet, central supply or laundry to obtain the hand mittens when they were not observed on Resident 1. During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 10:10 p.m., indicated, Entered residents room, resident is agitated pulling [MEDICAL CONDITION] Posey (one-piece collar helps secure [MEDICAL CONDITION] around the neck to help prevent removal, extubation of [MEDICAL CONDITION] device), gown and enteral feeding tube (provide nutrition to patients who cannot obtain nutrition by mouth, and unable to swallow safely) . During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 3:50 a.m., indicated, Writer entered resident's room to check on resident, found resident with dislodged trach. Posey and ties were attached [MEDICAL CONDITION]. During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 9 p.m., indicated, Charge nurse went to give medications to resident at (8:30 p.m.), resident'[MEDICAL CONDITION] in her left hand, with ties and Posey . During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 9:20 p.m., indicated, Resident pulled [MEDICAL CONDITION] (9:20 approximately). Nurse became aware resident had pulled [MEDICAL CONDITION] she was getting ready to administer medication . During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 3:13 a.m., indicated, . Writer found resident with Posey [MEDICAL CONDITION] undone by resident.[MEDICAL CONDITION] still in place . During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 12 p.m., indicated, at (10:30 a.m.) during round, nurse [MEDICAL CONDITION] out . During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 1:18 p.m., indicated, . resident continues pulling on medical devices and ripped off Posey [MEDICAL CONDITION] done . During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 11:02 a.m., indicated, At (7:45 a.m.) nurse noted that resident [MEDICAL CONDITION] out, her both hands around her neck, resident is itching and seemed restless . During the review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 10 a.m., indicated, Resident is febrile, flushed, has expiratory wheeze, increased restlessness throwing her legs over the bed and repetitive pulling on [MEDICAL CONDITION] and ties . (MD 1) visited examined (Resident 1) and ordered . to apply bilateral hand mittens to avoid pulling her [MEDICAL CONDITION] During an interview with the RT, on [DATE], at 7:59 a.m., he stated Resident 1 was taken off the ventilator on [DATE] and was left with her [MEDICAL CONDITION] device. The RT stated Resident 1 was not connected to a ventilator on [DATE]. The RT stated when Resident 1 pulled out her [MEDICAL CONDITION] device it needed to be reinserted in less than two minutes. The RT stated Resident 1's plan was to continue to have her [MEDICAL CONDITION] device to help her breathe. During an interview with the AP, on [DATE], at 8:50 a.m., he stated the expectation of the staff at the skilled nursing facility was for the mittens to be on as ordered for Resident 1's protection. During an interview with LVN 2, on [DATE], at 10:05 a.m., she stated she was familiar with Resident 1's care. LVN 2 stated she was unaware Resident 1 required bilateral hand mittens and was not provided the information during report. LVN 2 stated bilateral hand mittens were ordered because Resident 1 had extubated herself multiple times. LVN 2 stated on [DATE] and [DATE] she cared for Resident 1, and Resident 1 did not have bilateral hand mittens on [DATE] or [DATE]. LVN 2 stated she realized bilateral hand mittens were ordered when she looked at the Medication Administration Record [REDACTED]. LVN 2 stated she notified RN 1 she needed to locate another mitten to apply to Resident 1. During a review of the clinical record for Resident 1, the Physical Restraint assessment dated [DATE], at 11:15 a.m. indicated, TYPE OF PHYSICAL RESTRAINT 1. Hand Mitt . REASON FOR PHYSICAL RESTRAINT 8. Pulls at feeding/(intravenous)/other tubes . 1B Medical justification for restraint. r/t (related to) repetitive behaviors of pulling [MEDICAL CONDITION], blow by mask and Posey resulting in multiple episodes of self extubation. During a review of the clinical record for Resident 1, the Care Plan dated [DATE], indicated, I use r/l soft hand mitten physical restraints r/t repetitive behaviors or pulling [MEDICAL CONDITION], blow by mask, and Posey resulting in multiple episodes of self extubation . Interventions/Tasks . Monitor R/L soft hand mitten restraint. Remove (every) 2 hours for 15 minutes. Wash hands and dry thoroughly before re-applying mitten, assess skin. During a review of the clinical record for Resident 1, the Progress Notes dated [DATE], at 11:28 a.m., indicated, IDT (interdisciplinary team- a group of health care professionals who work in a coordinated fashion toward a common goal for the patient) met and discussed the resident's multiple self extubations. Resident experiences restlessness and anxiety, pulls on her tubing [MEDICAL CONDITION] . The IDT is in agreement for the use of hand mittens . to avoid further extubation. During a review of the clinical record for Resident 1, the Death Certificate dated [DATE], indicated, IMMEDIATE CAUSE (A) CARDIOPULMONARY ARREST (B) PNEUMONIA, ETIOLOGY UNKNOWN, (C) CHRONIC [MEDICAL CONDITION] . Review of the facility policy and procedure titled, Care Plans dated [DATE], indicated, The resident's care plan is to be reviewed and revised by the IDT after resident's initial assessment, quarterly, and more often as warranted by the changes in a resident's condition The focus/problem list is to identify those areas that the resident has actual or potential risk for injury, illness and other impairments . Each goal is to be realistic, measurable, directed towards the focus and individualized to the resident. The goal is to build upon the resident's strength . Interventions are those services, items and approaches that specific staff is to carry out to aid the resident in attaint and maintaining their highest functional level and preventing further decline. Review of the Lippincott Manual of Nursing Practice 10th Edition dated 2014, page ,[DATE] indicated, Standards of practice General Principles . 1 b. These standards provide patients with a means of measuring the quality of care they receive. Common Departures from the Standards of Nursing Care . failure to follow physician's orders .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan based on the assessment of a resident's identified risks for falls for three of 20 sampled residents, (Resident 1, Resident 2, and Resident 3), when: 1. Resident 1 did not have individualized fall prevention interventions developed and implemented after falls occurred. 2. Resident 2 was assessed as impulsive and independent-minded with poor safety awareness, and required a one person assist for transfer, toileting and mobility. Specific interventions for fall risk prevention based on Resident 2's assessed needs and behaviors were not implemented. 3. Resident 3's fall was not identified in his fall care plan and there were no updated fall interventions documented after a fall occurred. As a result of these failures Resident 1 sustained six falls. Resident 1's fifth fall on [DATE] resulted in multiple facial fractures with bleeding behind the eye which required emergency transfer to the general acute care hospital (GACH) for evaluation and treatment. Resident 2 sustained six falls within 48 days of admission to the skilled nursing facility (SNF). Resident 2's sixth fall resulted in a right sided scalp hematoma (collection of blood under the skin) and a change in mental status which required transfer to the GACH for observation and treatment. Resident 2 expired on [DATE] in the GACH from unknown causes. Resident 3 was placed at risk for injury from falls. Findings: 1. Review of Resident 1's undated clinical record, titled, Face sheet (a document with personal identifiable information) indicated Resident 1 was admitted to the SNF on [DATE] with medical [DIAGNOSES REDACTED]. Review of Resident 1's clinical record, titled, Minimum Data Set (MDS) assessment (a resident assessment tool used to plan care), dated [DATE], indicated, Resident 1's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) score was five of 15 points, which indicated severe cognitive (pertaining to memory, judgement and reasoning) impairment. The MDS assessment indicated Resident 1 required extensive assistance (staff provided weight-bearing support) for bed to chair transfers. The MDS indicated Resident 1 was unsteady when moving from one surface to another and was only able to stabilize with staff assistance. Review of Resident 1's clinical record, titled, Admission fall risk assessment, dated [DATE], indicated Resident 1 had a fall risk score of 19 which indicated the resident was a high risk for falls (High Risk ,[DATE], Moderate Risk ,[DATE], Low Risk ,[DATE]). Review of Resident 1's clinical record, titled, Fall care plan dated [DATE], indicated an actual fall occurred [DATE] with no injury secondary to poor balance. On [DATE] at 11:50 a.m. during a concurrent observation and interview, Resident 1 sat in her wheelchair on the facility patio. Resident 1's left eye was swollen shut and had dry crusted drainage surrounding the eye. Resident 1 stated, I fell . That's why my eye is swollen. On [DATE] at 12 p.m. during a concurrent observation and interview, Physical Therapist (PT) 3 stated Resident 1's swollen eye occurred as the result of a fall on [DATE]. PT 3 stated Resident 1 should have been placed on the falling star program (a program to alert staff a resident was a high risk for falls) when she was first identified as a high fall risk. PT 3 stated residents who were high risk for falls should have a falling star sign on the back of their wheelchair and on their room door name plate. Resident 1's wheelchair was observed and no falling star sign was seen. PT 3 stated there was no falling star sign on the back of Resident 1's wheelchair or on her door name plate. On [DATE] at 12:45 p.m., during an interview, Licensed Nurse (LN) 7 stated, The falling star sign is our first intervention for high fall risk residents. On [DATE] at 7 a.m., during an interview, LN 11 stated the falling star sign should be placed on the resident's door name plate and wheelchair. LN 11 stated the falling star sign alerted staff that a resident was a high fall risk. LN 11 stated, If there is no falling star sign the staff from the other station or a new employee will not know that the resident is a high fall risk. On [DATE] at 4:35 p.m., during a concurrent interview and record review, PT 1 reviewed Resident 1's Physical Therapy Plan of Care dated [DATE]. PT 1 stated Resident 1 was evaluated on [DATE] and required moderate assistance (requires 26 to 75 percent assistance of staff to accomplish activity) with bed mobility and a one person assist with walking while using a walker. PT 1 stated Resident 1's balance was not steady enough to transfer on her own without staff assistance. Review of Resident 1's PT (Physical Therapy) Daily Treatment Note dated [DATE], indicated, Resident fatigues easily and tends to lean to her R (right) side, needed assistance to assume upright sitting .impaired safety awareness needing constant redirection, resident also noted to have impaired vision, unable to see what is in front of her, unable to manage obstacle avoidance. On [DATE] at 3:49 p.m., during a concurrent observation and interview, Resident 1 sat in a wheelchair in the hallway across from the nurses' station. Resident 1 was observed to have bruising under both eyes. Resident 1 stated she fell from her wheelchair. Resident 1 stated she had fallen three or four times. Resident 1 started to lean forward in her wheelchair. Resident 1 was asked why she was leaning forward and Resident 1 stated the middle of her back hurt since her last fall (fall on [DATE]). On [DATE] at 4 p.m., during an interview, LN 2 stated Resident 1 was impulsive and required redirection to sit back down in wheelchair. LN 2 stated one on one staff supervision for Resident 1 was the last intervention left to implement for fall prevention. LN 2 stated the facility did not use one on one staff assistance due to not having enough staff available to implement the intervention. On [DATE] at 2:25 p.m., during a concurrent interview and record review, LN 2 stated Resident 1 had a witnessed fall (first fall in the facility) without injury on [DATE] (the day Resident 1 was admitted to the SNF). LN 2 stated a certified nursing assistant (CNA) observed Resident 1, on [DATE], stand up unsteadily from her bed and fall onto the floor on her knees. LN 2 stated she should have looked at the care plans to make sure a fall care plan was in place after Resident 1's fall. LN 2 reviewed Resident 1's clinical record and stated she was unable to find a fall care plan created for Resident 1's fall on [DATE]. LN 2 stated it was her responsibility to create the fall care plan. On [DATE] at 11:22 a.m., during a concurrent interview and record review, the Chief Nurse Executive (CNE) stated a fall care plan for Resident 1's fall of [DATE] was initiated on [DATE] and revised on [DATE]. The CNE stated the fall care plan dated [DATE] indicated Resident 1 had fallen but had no identified interventions to prevent further falls for Resident 1. Review of Resident 1's clinical record, titled, Care plan dated [DATE], indicated, Resident 1 fell on [DATE] secondary to poor balance. The care plan section titled, Goals indicated, .The resident will resume usual activities without further incident through the review date (review date not indicated). The care plan section titled, Interventions/Tasks was left blank without any documented fall risk prevention interventions identified. Review of Resident 1's clinical record, titled, Progress note dated [DATE], indicated, Resident 1 had a fall (second fall) on [DATE]. The progress note indicated, Pt (patient) was found on the floor by nursing staff, yelling help on the floor next to her bed . On [DATE] at 10:28 a.m., during a concurrent interview and record review, LN 11 stated she was the nurse on duty on [DATE] when Resident 1 fell the second time. LN 11 stated she initiated the falling star program after Resident 1 fell on [DATE]. LN 11 stated she verbally alerted the CNAs on duty on [DATE] to include Resident 1 in the falling star program. LN 11 stated she did not document the fall alert in the electronic record, Resident 1's care plan or the Kardex (a written system used by staff including CNAs that provided pertinent resident care information) and she should have. LN 11 stated she did not update Resident 1's fall risk assessment on [DATE] and she should have after the fall. LN 11 stated Resident 1's fall risk care plan should have been updated after the fall to include new interventions to prevent falls and she was responsible to complete the updates. LN 11 reviewed Resident 1's care plan and stated she could not find an updated fall risk care plan for [DATE] with interventions to prevent falls. Review of Resident 1's clinical record, titled, Interdisciplinary (IDT) (a team of healthcare providers including nurses, social service, activity and dietary staff who meet to plan resident care) notes, dated [DATE], indicated Resident 1 had a witnessed fall (third fall) without injury on [DATE]. On [DATE] at 10:30 a.m., during an interview, CNA 3 stated she was assigned to provide care for Resident 1 on [DATE] (the day of the third fall). CNA 3 stated she started to propel Resident 1's wheelchair when Resident 1 leaned forward and stated she wanted to lay down. CNA 3 stated she assisted Resident 1 to the floor as she leaned forward. CNA 3 stated Resident 1 constantly leaned forward while sitting in her wheelchair and made statements that she was going to fall. Review of Resident 1's clinical record, titled, Fall Risk assessment dated [DATE] following the third fall indicated Resident 1 had a fall risk score of 22 (high risk for falls). Review of Resident 1's clinical record, titled, IDT Meeting Summary dated [DATE], indicated, 1. Meeting Type a) fall .4. IDT Recommendations .allow resident to have choices as possible and have resident by the nurses station . Review of Resident 1's clinical record, titled, Revised care plan, dated, [DATE], indicated, Focus .The resident is high risk for falls (related to) Confusion, Deconditioning, Gait/balance problems, [MEDICAL CONDITION], Poor communication/comprehension, Vision/hearing problems, (history) of falls .Goal .Risk for fall/injury will be minimized with interventions thru (through) next review .Interventions .Anticipate and meet the resident's needs for toileting, mobility, and nourishment. Inquire to the resident's needs throughout shift and before leaving the resident's room .Be sure the resident's call light is within reach at all times and encourage the resident to use it for assistance as needed .Educate the resident/family/caregivers about safety risk factors .The resident needs a safe environment free from spills or clutter, and adequate, glare-free light. Inspect resident's room (every) Shift and when providing care . The revised care plan dated [DATE] did not include the IDT recommendations of allowing Resident 1 to have choices as possible and to have Resident 1 by the nurses' station. On [DATE] at 9:26 a.m. during a concurrent interview and record review, Minimum Data Set Coordinator (MDSC) 3 reviewed Resident 1's fall care plan interventions created on [DATE]. MDSC 3 stated the care plan interventions were not individualized to Resident 1's fall risk needs. MDSC 3 stated the care plan interventions to keep the call light within reach and to provide a safe environment were standard interventions used for all residents in the facility and not specific for Resident 1's fall risks. On [DATE] at 10:56 a.m., during a concurrent interview and record review, the Chief Nurse Executive (CNE) reviewed Resident 1's risk for falls care plan dated [DATE] and stated the intervention for anticipating Resident 1's needs were not specific to Resident 1. The CNE reviewed the intervention regarding educating resident/family/caregiver about safety risk factors and stated the intervention did not specify the specific education to be provided. The CNE stated all residents in the facility had an intervention to keep the environment safe; it was not specific for Resident 1's needs. The CNE could not explain what individual approaches would be made to meet Resident 1's need for safety. Review of Resident 1's clinical record, titled, Progress notes dated [DATE], indicated Resident 1 had a witnessed fall (fourth fall) on [DATE]. Resident 1's nurse's note dated [DATE], indicated, (Resident 1) was observed by writer, lowering herself to the floor on her knees. (Resident 1) had left knee on the floor, holding onto door knob of utility room. (Resident 1) stated (Resident 1) on the floor . On [DATE] at 11:35 a.m., during an interview, the CNE stated the fall on [DATE] was considered a fall because Resident 1 had lowered herself onto the floor on her knees. The CNE stated there no fall risk assessment, incident note, or IDT note completed after Resident 1's fall on [DATE]. The CNE stated the fall risk assessment and incident note should have been completed following the fall per facility policy. On [DATE] at 10:17 a.m., during a concurrent phone interview and record review, LN 1 stated she was on duty on [DATE] and witnessed Resident 1's (fourth) fall. LN 1 stated Resident 1's fall care plan and interventions were not updated following the fall on [DATE] and should have been. LN 1 stated, In hindsight, (Resident 1) needed supervision. Review of Resident 1's clinical record, titled, Incident note, dated, [DATE] at 7:03 p.m., indicated, Resident 1 had an unwitnessed fall (fifth fall) on [DATE]. Resident 1's incident note dated [DATE], written by LN 3, indicated, At 7:03 p.m. writer at nursing station area, heard loud noise thump like sound in front of nursing station, ran to check, found resident on floor laying on her left side .noted abrasion at left lower eye lid .approximately 5 cc (cubic centimeter, unit of volume measurement) fresh blood dripped from left nostril .paramedic arrived .(Resident 1) left facility via stretcher . Review of Resident 1's GACH clinical record dated [DATE], indicated, History Chief Complaint .Fall (from) wheelchair sent from (Skilled Nursing Facility) .female who presents to the ED (Emergency Department) via ambulance for [MEDICATION NAME] trauma. Per (Emergency Medical Service), the patient fell out of her wheelchair at her skilled nursing facility and landed on her left face at approximately (7 p.m.) .En route, she was hypertensive (high blood pressure) in the 220's (normal: less than 120 millimeters of mercury). In the ED now, the patient complains of a headache and (nausea and vomiting) .CT (computed tomography scan) (specialized x-ray that provides cross-sectional images of the bones, blood vessels and soft tissues inside the body) Head .Left facial trauma including multiple facial fractures, retro-orbital hemorrhage (bleeding behind the eye) in pro[DIAGNOSES REDACTED] (bulging of the eye) .CT Maxillofacial (the jaw and face) . Fractures of the left lateral orbital wall, orbital floor, maxillary sinus (below the cheeks, above the teeth and on the sides of the nose), and zygomatic arch (the bony arch at the outer border of the eye socket) .Lateral canthotomy (a procedure used to decompress bleeding or swelling of the eye) performed emergently (required to be completed urgently). Review of Resident 1's GACH clinical record titled, Discharge Summary, indicated, Resident 1 remained in the GACH for five days following the fall on [DATE] for treatment of [REDACTED]. On [DATE] at 3:55 p.m., during a concurrent interview and record review, LN 3 reviewed Resident 1's care plan dated [DATE] (following the fifth fall) and stated the only intervention identified was Sent to acute ( GACH). The care plan did not include any new interventions to prevent future falls for Resident 1. Review of Resident 1's clinical record, titled, Face sheet indicated Resident 1 was readmitted to the SNF from the GACH on [DATE]. Resident 1's revised fall care plan dated [DATE], indicated, Focus .The resident has a history of falls resulting in fracture of face, [MEDICAL CONDITION], Poor Balance, Unsteady gait .Goal .Resident will not experience an avoidable fall with a major injury within next 30 days .Interventions/Tasks .Assist the resident with (Activities of Daily Living) and transfers as indicated .Determine causal factors related to previous falls. Address each causal factor in the care plan .Ensure the resident has adequate light in their room .Instruct the resident to use the call light to request assistance. Ensure the call light is within reach of the resident . The care plan did not include any new resident specific interventions related to causal factors to prevent future falls for Resident 1. Review of Resident 1's clinical record, titled, Incident note dated [DATE] at 4:20 p.m., indicated Resident 1 had a fall (sixth fall) on [DATE]. The incident note indicated, .informed by nursing staff that (Resident 1) fell .found that resident is on the floor .Resident is on her R (right) side lying position, right arm is underneath her, both lower extremities are extended .It has been noted that resident is very impulsive, tries to get out of her chair constantly. Yelling for help and when staff goes and asked what she needs she will state I just need you to be here.When resident was asked what happened, resident cannot give definite answer and stated I don't know. I just can't help it .complaint of pain on her right side of face/head . On [DATE] at 10:25 a.m., during an interview, CNA 10 stated Resident 1 required someone with her at all times because Resident 1 frequently moved from her wheelchair. CNA 10 stated if Resident 1 moved from her wheelchair or bed she could fall down. On [DATE] at 10:50 a.m., during an interview, CNA 11 stated since Resident 1 was first admitted to the SNF, Resident 1 would get up by herself from her wheelchair. CNA 11 stated staff needed to watch Resident 1 for safety. On [DATE] at 12:22 p.m., during a telephone interview, LN 8 stated Resident 1 had a behavior of attempting to stand up on her own for no known reason since she was first admitted to the SNF. LN 8 stated staff offered to take Resident 1 to the toilet every two hours to decrease her risk of falling. LN 8 stated the intervention was not always effective because Resident 1 would continue to stand up from her wheelchair. LN 8 stated staff monitored Resident 1's behavior every 30 minutes to decrease her risk for falls. LN 8 stated other licensed nurses in the facility told her the SNF did not provide one to one supervision for residents for fall prevention. LN 8 stated Resident 1 was impulsive and needed someone to watch her. LN 8 stated Resident 1 had a fall on [DATE] which could have been prevented if Resident 1 had been provided with one on one supervision by staff. The facility policy and procedure titled, Care Plans dated [DATE], indicated .To standardize the development and update of resident care plans that address the physical, mental and psychosocial needs of the resident .5. The resident's care plan is to be updated per the resident's request, including their preferences. If a resident's preference could cause harm to the resident, the IDT is to discuss the risks vs benefits of the resident's preference(s) .8. Interventions are those services, items and approaches that specific staff is to carry out to aide the resident in attaining and maintaining their highest functional level and prevent further decline, when possible . The facility policy and procedure titled, Fall Program dated [DATE], indicated, Purpose: To identify resident's who are at risk of falling and prevent accidents by providing an environment that is free from hazards. To enhance each resident's mobility by removing the risk of falls when possible and reduce the incidence of falls and injuries that may accompany falls. Policy: It is the policy of this facility that each resident is to be evaluated upon admission, quarterly and as needed by a Licensed Nurse to determine factors that place the resident at a risk for falls. The resident's care plan is to be developed by the interdisciplinary team to include the least restrictive methods possible to keep the resident safe. The resident's environment is to remain as free of accident hazard as is possible and all residents are to receive adequate supervision and assistive devices to prevent accidents .5. The Fall Risk care plan should include those factors identified on the risk assessment and interventions to prevent falls. 6. Residents identified as being High Risk for falls should have specific interventions that address each of the resident's factors and potential factors .8. Residents at High Risk may be placed on a Falling Star Program that alerts staff to monitor residents who have a higher risk of falling. a. Place a star on the resident's door name plate or door frame .b. Alerts should be added to the Special Instructions in the electronic record .c. Indicate participation in the resident's care plan that is sent to the Kardex . 2. Review of Resident 2's clinical record, titled, Face sheet indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident 2's physician orders [REDACTED]. Review of Resident 2's clinical record, titled, Nursing Admission assessment dated [DATE], indicated Resident 2 had falls in in the past six months prior to admission to the facility. Review of Resident 2's clinical record, titled, Fall Risk assessment dated [DATE] at 4:26 p.m., indicated a fall risk assessment was completed for the resident with a fall score of 18 which reflected the resident was at a high risk for falls. Review of Resident 2's clinical record, titled, Fall care plan dated [DATE], indicated, Focus .The resident states having a recent fall, and has a high risk for falls r/t (related to) Vision/hearing/gait problems . Resident 2's initial fall care plan interventions dated [DATE], indicated, .Anticipate and meet the resident's needs for toileting, mobility and nourishment. Inquire into the resident's needs throughout shift and before leaving the resident's room .Be sure the resident's call light is within reach at all times and encourage the resident to use it for assistance as needed .PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed) . Review of Resident 2's clinical record, titled, Care plan revealed, Focus . The resident has limited physical mobility r/t (related to)Weakness . dated [DATE], indicated, .Interventions .Mobility: The resident requires 1 staff participation for mobility . Review of Resident 2's clinical record, titled, Nurses notes dated [DATE] at 6:43 p.m., indicated, Per family Resident has a history of falls. Resident loves to walk and use the toilet whenever possible. However, resident has tendency getting out of the bed anytime without using the call light button. Family is requesting bed/chair alarm for the resident . Review of Resident 2's clinical record, titled, Physician orders [REDACTED]. Resident 2's physician orders [REDACTED]. Review of Resident 2's clinical record, titled, Care plan revealed, Focus .The resident is resistive to care r/t adjustment to nursing home . dated [DATE], indicated, Interventions Allow the resident to make decisions about treatment regime, to provide sense of control .Educate the resident/family/caregivers of the possible outcome of not complying with treatment or care .Encourage as much participation/interaction by the resident as possible during care activities .Give clear explanation of all care activities prior to and as they occur during each contact . The care plan indicated no further updated interventions were developed. Review of Resident 2's clinical record, titled, Admission Minimum Data Set assessment, (MDS) (an assessment of a resident's functional and cognitive status) dated [DATE], indicated Resident 2's BIMS score was 11 of 15 points, which indicated moderate cognitive impairment. The MDS indicated Resident 2 required extensive assistance with one-person physical assist for transfer, limited assistance with one-person physical assist for walking in her room, and limited to extensive one-person physical assist for locomotion with a wheelchair. The MDS indicated Resident 2 was not steady and was only able to stabilize with staff assistance when moving from seated to standing position, ambulating with and without a device, moving on and off the toilet and during transfers from bed to chair or wheelchair. Review of Resident 2's clinical record, titled, Progress notes indicated Resident 2 had six unwitnessed falls on the following dates: [DATE], [DATE], [DATE], [DATE], and [DATE]. Resident 2's fall on [DATE] resulted in an injury and transfer to the acute hospital. Review of Resident 2's progress notes indicated Resident 2 had an unwitnessed fall (first fall in facility) on [DATE] in her room. Resident 2's progress notes indicated Resident 2 was found sitting on the floor in the bathroom door frame and stated she hit her head. Resident 2's record indicated there was no post fall risk assessment completed for Resident 2. Review of Resident 2's clinical record, titled, Interdisciplinary Team (IDT) (facility department managers, including the director of nursing, licensed nurses, MDS coordinators, who review resident care needs and create recommendations to be implemented in the residents plan of care) Meeting Summary dated [DATE] at 9:22 a.m., indicated Resident 2 had a fall on [DATE]. The IDT summary indicated under Root Cause/ Contributing Factors, poor safety awareness, attempting to maintain independence. Review of Resident 2's clinical record, titled, Fall care plan dated revised [DATE], indicated, .toileting program AC (before meals) and HS (at bedtime) . Review of Resident 2's clinical record, titled, Progress notes dated [DATE] at 6:44 a.m., indicated on [DATE], Resident 2 had an unwitnessed fall (second fall in facility) in her room. Resident 2's progress notes indicated Resident 2 was found sleeping on the floor next to her bed. The progress notes indicated Resident 2 had a skin tear on her left elbow from the fall. Resident 2's record indicated a fall risk assessment was completed for Resident 2 with a score of 21 which indicated a high risk for falls. Review of Resident 2's clinical record, titled,IDT Meeting Summary dated [DATE] at 9:19 a.m., indicated Resident 2 had a fall on [DATE]. The IDT summary indicated under Root Cause/ Contributing Factors, Resident wanted to sleep on the floor. The IDT recommendation was to place nonskid strips on the floor next to the resident's bed. Review of Resident 2's clinical record, titled, Fall care plan indicated, .Family refused to be close to nurse station .Initiated: [DATE] .NON skid strips on floor next to bed .Initiated: [DATE]. Review of Resident 2's clinical record, titled, Care plan for Activities of Daily Living (ADL, bathing, grooming, eating and other activities of daily living) indicated, Focus .the resident states she needs assistance with ADL Self Performance Deficit r/t Limited Mobility . The updated care plan interventions initiated on [DATE], indicated Resident 2 required one staff assistance for toilet use and transfer, and one staff participation for mobility. On [DATE] at 10:20 a.m., during an interview, LN 18 stated Resident 2 fell (2nd fall) on [DATE]. LN 18 stated he and LN 19 found Resident 2 lying on the floor next to her bed with a pillow under her head and covered with a blanket. LN 18 stated Resident 2 stated she wanted to sleep on the floor. LN 18 stated he did not think Resident 2 fell , but deliberately got out of bed and laid on the floor. LN 18 stated Resident 2 understood others and directions but was not consistent with the use of her call light. LN 18 stated the staff often observed Resident 2 getting up, unassisted, to go to the bathroom. LN 18 stated Resident 2 wanted to be independent with her ADLs. LN 18 stated Resident 2 had an unsteady gait and needed to be supervised when she ambulated. LN 18 stated a resident with frequent falls should have care plan interventions based on why the resident was falling and the interventions should be specific to that resident's needs. LN 18 stated because Resident 2 wanted to be independent and did not always use the call light for assistance, she (Resident 2) needed one on one supervision. On [DATE] at 3:20 p.m., during an interview CNE stated non-skid strips were placed on the floor at the side of Resident 2's to prevent a resident from slipping and falling. The CNE stated she was not aware LN 18 thought Resident 2 had got up out of bed and just laid down on the floor on [DATE]. The CNE stated the IDT reviewed the incident note regarding the fall but did not necessarily talk to the nurse about the fall. Review of Resident 2's progress notes dated [DATE] at 2 p.m., indicated Resident 2 had an unwitnessed fall (third fall in the facility) on [DATE] in the hallway. Resident 2's progress notes indicated Resident 2 was found sitting on the floor next to her wheelchair in the hallway. The progress note indicated Resident 2 reported she stood up, her legs were tired and she sat down. The progress notes indicated a fall risk assessment was completed for Resident 2 with a score of 17 which indicated a high risk for falls. Review of Resident 2's clinical record, titled, Care plan revealed, .Focus The resident states she has had an actual fall on [DATE] with no injury, Poor Balance, Unsteady gait and dated [DATE] indicated, .Interventions .Apply bed alarm (a device that alarms when the resident gets out of bed) q (every) shift and check for its functional .Continue with interventions on the at-risk (falls) plan .Neuro checks (assessment of a resident's alertness, ability to follow directions and reaction of pupils to light as indicators of possible nervous system damage) x (times) 72 hours . The interventions were dated [DATE]. Review of Resident 2's clinical record, titled, Physician orders [REDACTED]. Review of Resident 2's clinical record, titled, IDT Meeting Summary dated [DATE] at 9:51 a.m., indicated Resident 2 had a fall on [DATE]. The IDT summary indicated under Root Cause/ Contributing Factors, poor safety awareness, resident chooses to ambulate independently. Review of Resident 2's clinical record, titled, Fall care plan dated [DATE], indicated, Interventions .anti roll back bars on wheelchair .initiated [DATE] . On [DATE] at 9:10 a.m., during an interview, LN 1 stated Resident 2 had a tab alarm (an alarm attached to a resident's clothing and to the bed or wheelchair intended to alert staff when the resident stands up) for a while but it was discontinued and she did not remember when it was removed. On [DATE] at 2:48 p.m., during an in

Based on interview and record review, the facility failed to provide supervision to prevent accidents for one of twenty sampled residents, (Resident 2) when Resident 2, who was assessed as impulsive, independent minded and having an unsteady gait, was not provided one staff supervision for mobility and transfers as identified in the care plan, and when Resident 2 was allowed to use a device which had not been evaluated by the therapy department for safety. These failures resulted in Resident 2 sustaining six falls within 48 days of admission to the skilled nursing facility (SNF). Resident 2's sixth fall resulted in a right sided scalp hematoma (collection of blood under the skin) and a change in mental status which required transfer to the General Acute Care Hospital (GACH) for observation and treatment. Resident 2 expired on [DATE] in the GACH from unknown causes. Findings: Review of Resident 2's undated face sheet (a document with personal identifiable information) indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident 2's Physician orders dated [DATE] indicated Resident 2 was admitted to the facility for skilled nursing services with a [DIAGNOSES REDACTED]. Review of Resident 2's Nursing Admission assessment dated [DATE], indicated Resident 2 had falls in in the past six months prior to admission to the facility. Review of Resident 2's Fall Risk assessment dated [DATE] at 4:26 p.m., indicated a fall risk assessment was completed for the resident with a fall score of 18 which reflected the resident was a high risk for falls. Resident 2's fall care plan dated [DATE], indicated, Focus .The resident states having a recent fall, and has a high, risk for falls r/t (related to) Vision/hearing/gait problems . Resident 2's initial fall care plan interventions dated [DATE], indicated, .Anticipate and meet the resident's needs for toileting, mobility and nourishment. Inquire into the resident's needs throughout shift and before leaving the resident's room .Be sure the resident's call light is within reach at all times and encourage the resident to use it for assistance as needed .PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed) . Review of Resident 2's care plan titled, Focus . The resident has limited physical mobility r/t Weakness . dated [DATE], indicated .Interventions .Mobility: The resident requires 1 staff participation for mobility . Review of Resident 2's nurses notes dated [DATE] at 6:43 p.m., indicated, Per family Resident has a history of falls. Resident loves to walk and use the toilet whenever possible. However, resident has tendency getting out of the bed anytime without using the call light button. Family is requesting bed/chair alarm for the resident . Review of Resident 2's admission Minimum Data Set (MDS) assessment (an assessment of a resident's functional and cognitive status) dated [DATE], indicated Resident 2's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) score was 11 of 15 points, which indicated moderate cognitive (pertaining to reasoning, judgment and memory) impairment. The MDS indicated Resident 2 required extensive assistance with one-person physical assist for transfer, limited assistance with one-person physical assist for walking in her room, and limited to extensive one-person physical assist for locomotion with a wheelchair. The MDS indicated Resident 2 was not steady and was only able to stabilize with staff assistance when moving from a seated to a standing position, ambulating with and without a device, moving on and off the toilet and during transfers from bed to chair or wheelchair. Review of Resident 2's Progress notes dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] indicated Resident 2 had six unwitnessed falls on those dates. Resident 2's fall on [DATE] resulted in a right sided scalp hematoma and transfer to the acute care hospital. Review of Resident 2's Progress notes dated [DATE] indicated Resident 2 had an unwitnessed fall (first fall in facility) on [DATE] in her room. Resident 2's Progress notes indicated Resident 2 was found sitting on the floor in the bathroom door frame and stated she hit her head. Review of Resident 2's Interdisciplinary Team (IDT) (facility department managers, including the director of nursing, licensed nurses, MDS coordinators, who review resident care needs and create recommendations to be implemented in the residents plan of care) Meeting Summary dated [DATE] at 9:22 a.m., indicated, Resident 2 had a fall on [DATE]. The IDT summary indicated under Root Cause/ Contributing Factors, Poor safety awareness, attempting to maintain independence. Review of Resident 2's Progress notes dated [DATE] at 6:44 a.m., indicated on [DATE], Resident 2 had an unwitnessed fall (second fall in facility) in her room. Resident 2's progress notes indicated Resident 2 was found sleeping on the floor next to her bed. The progress notes indicated Resident 2 had a skin tear on her left elbow from the fall. Resident 2's record indicated a fall risk assessment was completed for Resident 2 with a score of 21 which indicated the resident was a high risk for falls. Review of Resident 2's IDT Meeting Summary note dated [DATE] at 9:19 a.m., indicated Resident 2 had a fall on [DATE]. The IDT summary indicated under Root Cause/ Contributing Factors, Resident wanted to sleep on the floor. The IDT recommendation was to place nonskid strips on the floor next to the resident's bed. Review of Resident 2's Care plan for Activities of Daily Living (ADL- bathing, grooming, eating and other activities of daily living) dated revised [DATE] indicated, Focus .the resident states she needs assistance with ADL Self Performance Deficit r/t (related to) Limited Mobility . The updated care plan interventions initiated on [DATE], indicated Resident 2 required one staff assistance for toilet use and transfer, and one staff participation for mobility. On [DATE] at 10:20 a.m., during an interview, Licensed Nurse (LN 18) stated Resident 2 fell (2nd fall) on [DATE]. LN 18 stated he and LN 19 found Resident 2 lying on the floor next to her bed with a pillow under her head and covered with a blanket. LN 18 stated Resident 2 stated she wanted to sleep on the floor. LN 18 stated Resident 2 understood others and directions but was not consistent with the use of her call light. LN 18 stated the staff often observed Resident 2 getting up, unassisted, to go to the bathroom. LN 18 stated Resident 2 wanted to be independent with her ADLs. LN 18 stated Resident 2 had an unsteady gait and needed to be supervised when she ambulated. LN 18 stated because Resident 2 wanted to be independent and did not always use the call light for assistance, she (Resident 2) needed one on one supervision. Review of Resident 2's Progress notes dated [DATE] at 2 p.m., indicated Resident 2 had an unwitnessed fall (third fall in the facility) on [DATE] in the hallway. Resident 2's progress notes indicated Resident 2 was found sitting on the floor next to her wheelchair in the hallway. The progress note indicated Resident 2 reported she stood up, her legs were tired and she sat down. Review of Resident 2's care plan titled, .Focus The resident states she has had an actual fall on [DATE] with no injury, Poor Balance, Unsteady gait and dated [DATE] indicated, .Interventions .Apply bed alarm (a device that alarms when the resident gets out of bed) q (every) shift and check for its function . Review of Resident 2's physician orders dated [DATE] at 7:07 p.m., indicated a pad alarm while in bed and chair for 30 days was ordered. Resident 2's physician orders dated [DATE] at 9:55 a.m., indicated the pad alarm was discontinued. Review of Resident 2's physician orders for (MONTH) (YEAR) indicated no new orders were written for a bed alarm for Resident 2. Review of Resident 2's IDT Meeting Summary note dated [DATE] at 9:51 a.m., indicated, Resident 2 had her third fall on [DATE]. The IDT summary indicated under Root Cause/ Contributing Factors, Poor safety awareness, resident chooses to ambulate independently. On [DATE] at 9:10 a.m., during an interview, LN 1 stated Resident 2 had a tab alarm (an alarm attached to a resident's clothing and to the bed or wheelchair intended to alert staff when the resident stands up) for a while but it was discontinued and she did not remember when it was removed. On [DATE] at 2:48 p.m., during an interview, LN 15 stated she was Resident 2's nurse on [DATE] (the day of the third fall). LN 15 stated Resident 2 was found sitting on the floor next to her wheelchair in the hallway. LN 15 stated a fall care plan intervention was initiated to place anti roll back bars on Resident 2's wheelchair. On [DATE] at 2:56 p.m., during a concurrent interview and record review, LN 15 stated Resident 2 was a high risk for falls and should have been on the falling star program after the first fall. LN 15 reviewed Resident 2's care plans and was unable to find an intervention which indicated Resident 2 was placed on the falling star program. LN 15 stated the falling star program was, One of the basic interventions for a resident at a high risk of falls. LN 15 stated the falling star program consisted of placing small signs with yellow stars on a resident's door name plate, wheelchair, and on the head of the resident's bed to alert staff to a resident at a high risk of falls. Review of Resident 2's Progress notes dated [DATE] at 7:32 p.m., indicated Resident 2 had an unwitnessed fall (fourth fall in the facility) on [DATE] in the hallway. Resident 2's progress notes indicated at 6:35 p.m. the LN was told by a resident that Resident 2 was on the floor in the hallway. Resident 2 was found lying on the hallway floor just a few doors down from her room. The progress notes indicated a fall risk assessment for Resident 2 was completed by the LN with a score of 23, which reflected a high risk for falls. Review of Resident 2's IDT Meeting Summary note, dated [DATE] at 9:51 a.m., indicated Resident 2 had a fall (fourth fall) on [DATE]. The IDT summary indicated under Root Cause/ Contributing Factors, Poor safety awareness, resident chooses to ambulate independently. The IDT recommendation was to educate the resident and responsible party on the risks versus benefits of independent ambulation. Review of Resident 2's Progress notes dated [DATE] at 4:38 a.m., indicated Resident 2 had an unwitnessed fall (fifth fall in the facility) on [DATE] in her room. Resident 2's progress notes indicated Resident 2 was found on the floor at the side of her bed putting on her pants. The progress notes indicated Resident 2 reported she fell while changing her clothes. Review of Resident 2's IDT Meeting Summary note dated [DATE] at 9:44 a.m., indicated, Resident 2 had a fall on [DATE]. The IDT summary indicated under Root Cause/ Contributing Factors, Poor safety awareness, resident chooses to ambulate independently. The IDT recommendation was to place neon green tape on the resident's call light to remind the resident to call for help. On [DATE] at 2:30 p.m., during an interview, LN 15 stated Resident 2 knew she needed assistance with ADLs but was impulsive and would not wait for assistance. LN 15 stated Resident 2 often refused assistance. LN 15 stated Resident 2 would change her clothes multiple times, often unassisted. On [DATE] at 10:50 a.m., during an interview, LN 19 stated she was Resident 2's nurse when Resident 2 had the fifth fall on [DATE]. LN 19 stated Resident 2 was sitting on the floor at the side of her bed putting on her pants. LN 19 stated Resident 2 often got up out of bed without assistance. On [DATE] at 3:04 p.m., during an interview, LN 1 stated Resident 2 was impulsive and did not always use her call light for assistance. Review of Resident 2's progress notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] indicated Resident 2 got up unassisted, did not use her call light, ambulated without assistance, wandered into other residents' rooms, and had an unsteady gait. Review of Resident 2's Progress notes dated [DATE], [DATE], [DATE], [DATE], [DATE] indicated the LNs provided Resident 2 education on the use of her call light for assistance in transferring and ambulating. Resident 2's progress notes indicated education on the use of the call light was not effective. Review of Resident 2's Progress notes dated [DATE] at 2:20 a.m., indicated Resident 2 had an unwitnessed fall (sixth fall) on [DATE] in her room. Resident 2's progress notes indicated, Writer (LN 22) was alerted by CNA in hallway that resident (Resident 2) had fallen. Writer entered resident room, resident was laying on right side on ground with approximately 30 ml (milliliter-a liquid unit of measure) of blood under right side of head .Emergency services called. Resident breathing w/ (with) small amount of white foam coming from mouth. Not responsive to name or situation .Pupils equal, sluggish to respond (indicative of a head injury) .transferred to (GACH) .for acute care. Review of Resident 22's GACH records with an admitted [DATE] indicated, CHIEF COMPLAINT .Fall Found down, unresponsive, at SNF (Skilled Nursing Facility), pt (patient) is a GCS (Glasgow Coma Scale- a scoring system used to gauge the severity of an acute [MEDICAL CONDITION]) of 8 (8 or less indicated severe [MEDICAL CONDITION]) .bleeding hematoma (a collection of clotted blood under the skin) .CT ( Computerized Tomography) (a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) head showed hematoma with no fracture or [MEDICAL CONDITION] (bleeding). CT C (cervical-pertaining to bones in the neck) spine showed no fracture. The GACH clinical record indicated, Invasive Procedures: 1. Intubation (tube placed into the lungs to assist breathing) 2. NG (nasogastric) tube (tube placed through the nose into the stomach for the purpose of administering medications, food or fluids). Review of Resident 22's acute hospital records dated [DATE] indicated, Expiration Discharge Summary .Patient pronounced dead at: 20:29 (8:29 p.m.) on [DATE] .Findings and Hospital events leading to death: R (right) scalp (skin on head) hematoma .Presumed cause of death: unknown . Review of Resident 2's IDT Meeting Summary note, dated [DATE] at 9:40 a.m., indicated Resident 2 had a fall on [DATE] (sixth fall.) The IDT summary indicated under Root Cause/ Contributing Factors, Poor safety awareness, resident chooses to ambulate independently. The IDT recommendation indicated, Resident sent out to acute hospital for further evaluation related to head injury and L[NAME] (loss of consciousness). On [DATE] at 4:35 p.m., during a telephone interview, Certified Nurse Assistant (CNA) 9 stated she was Resident 2's CNA when she fell (6th fall) on [DATE]. CNA 9 stated she knew Resident 2 was a high fall risk and needed more attention, monitoring and assistance with ADLs. CNA 9 stated at approximately 2 a.m. on [DATE] she heard Resident 2 crying and went into Resident 2's room. CNA 9 stated Resident 2, was awake and wanted to go to the bathroom. CNA 9 stated she transferred Resident 2 from her bed to the wheelchair, took her to the bathroom and transferred her onto the toilet. CNA 9 stated after Resident 2 was toileted, she transferred the resident on to her wheelchair and to the sink to wash her hands. CNA 9 stated she then took Resident 2 to the side of her bed. CNA 9 stated she aligned Resident 2's wheelchair lateral to the side of the bed and facing the wall at the head of her bed. CNA 9 stated Resident 2 began to straighten the blue disposable pad on her bed and she (CNA 9) did not want to rush getting the resident back into bed. CNA 9 stated she wanted to get Resident 2 back into bed but Resident 2's roommate had disrobed and had her legs over the side of her bed. CNA 9 stated she told Resident 2 to stay seated, Resident 2 nodded and said Okay. CNA 9 stated she turned away from Resident 2, took two to three steps and attended to Resident 2's roommate. CNA stated less than one minute later, she heard a flop, turned and saw Resident 2 on the floor. CNA 9 stated Resident 2's head was between the bedside cabinet and the head of the bed. CNA 9 stated she left the room and called for assistance. CNA 9 stated she could have called for assistance to help Resident 2's roommate and not left Resident 2 unattended. CNA 9 stated the correct thing to do was to finish the task and put Resident 2 back into bed before she assisted Resident 2's roommate. On [DATE] at 10:20 a.m., during an interview LN 18 stated he had been a CNA and his training was to stay with the resident until the task was completed. On [DATE] at 11:15 a.m., LN 19 stated she knew about Resident 2's fall on [DATE]. LN 19 stated the CNA caring for Resident 2 on [DATE] should have completed the task of assisting Resident 2 to bed before assisting another resident. On [DATE] at 9:10 a.m., during an interview, LN 1 stated Resident 2 was identified as a higher risk for falls because of a history of falls. LN 1 stated Resident 2 was slightly confused, restless, very active and would frequently get up and walk by herself without calling for assistance. LN 1 stated Resident 2 wanted to exert her independence and provide her own care, which included ambulation. LN 1 stated Resident 2 could not relax or sit still, .she was busy . and not easily redirected. On [DATE] at 9:10 a.m., during an interview, LN 1 stated a Restorative Nurse Assistant (RNA) would ambulate with Resident 2 while she (Resident 2) used a front wheel walker. LN 1 stated Resident 2's gait was not steady when she ambulated with or without her walker. LN 1 stated Resident 2 would lose her balance with the walker when she turned or went through doorways. LN 1 stated Resident 2 was able to self-propel in the wheelchair and was Quick. LN 1 stated she did not think Resident 2 understood the risks and safety concerns of ambulating without assistance and did not understand the consequences of her actions. On [DATE] at 2:30 p.m., during an interview, LN 15 stated Resident 2 was a high risk for falls. LN 15 stated Resident 2 was frantic, impulsive, and anxious about walking; it stemmed from wanting to go home with her (Resident 2's) family. LN 15 stated Resident 2 needed to be watched closely because she would get up unassisted and it was difficult to redirect the resident. LN 15 stated the RNA would walk with Resident 2 and used a front wheel walker. On [DATE] at 9:06 a.m., during an interview, CNA 7 stated Resident 2 always needed supervision when she (Resident 2) ambulated. CNA 7 stated Resident 2 needed assistance for all ADLs. CNA 7 stated she observed Resident 2 ambulating in the hallway at times with no supervision. CNA 7 stated sometimes Resident 2 used a four wheel walker instead of the front wheel walker ordered by physical therapy. On [DATE] at 9:15 a.m., during an interview, CNA 8 stated Resident 2 was impulsive. CNA 8 stated Resident 2 would sometimes ambulate, unsupervised, with her walker or her wheelchair. On [DATE] at 4:05 p.m., during an interview, LN 16 stated on [DATE], she observed Resident 2 ambulating down the hallway, unsupervised, with her four-wheel walker. LN 16 stated within a minute another resident came up to the nurses' station and said Resident 2 fell (4th fall) in the hallway. LN 16 stated she did not know how Resident 2 fell . LN 16 stated Resident 2 needed to be supervised when she ambulated with her walker but she (LN 16) was on the phone at the time of the fall and did not assist the resident. LN 16 stated Resident 2 was spontaneous and ambulated alone despite being told it was not safe to ambulate without assistance. LN 16 stated Resident 2 would Sometimes use her call light. LN 16 stated Resident 2's care plan fall interventions were not effective. LN 16 stated Resident 2 should have had one on one supervision for safety. On [DATE] at 9:30 a.m., during an interview, Physical Therapist Aid (PTA) 1 stated he observed Resident 2 walking unsupervised with a walker. PTA 1 stated Resident 2 had a shuffling gait and was not safe ambulating unsupervised. PTA 1 stated Resident 2 needed stand by supervision when she ambulated with or without her walker. PTA 1 stated Resident 2 would sometimes park her walker and ambulate without any device. On [DATE] at 9:36 a.m., during an interview, PTA 2 stated Resident 2 was not safe ambulating unsupervised, We (PT staff) told staff (nursing staff) she (Resident 2) was not safe by herself. Review of Resident 2's PT- Therapist Progress & Discharge Summary dated [DATE] indicated, .Transfers, Stand to Sit .contact guard assist (contact with patient (resident) due to unsteadiness) .Transfers, Bed< > (to and from) Chair .contact guard assist .Gait tasks: Assistive Devices .The patient requires front wheeled walker and contact guard assist (contact with patient due to unsteadiness) for safe ambulation for about 400 ft (feet) with rest breaks . Review of Resident 2's physician orders dated [DATE], indicated, RNA (Restorative Nursing Aide) 5 x/wk (five times per week) to be reviewed every 4 weeks for ambulation using FWW (front wheel walker) as tolerated . On [DATE] at 10:15 a.m., during an interview, CNA 5 stated Resident 2 was always walking in her room and in the hallways unsupervised. CNA 5 stated supervision means being near the resident to assist when help was needed. On [DATE] at 10:50 a.m., during an interview, LN 19 stated Resident 2 needed to be supervised when she was out of bed or ambulating. LN 19 stated Resident 2's family brought the resident's pink colored four-wheel walker (not PT ordered) to the facility for the resident. LN 19 stated she had observed Resident 2 ambulating with her four-wheel walker in the hallway unsupervised. LN 19 stated Resident 2 was not stable when she ambulated and Resident 2's four-wheel walker was too fast for Resident 2. LN 19 stated Resident 2 did not know how to use her four-wheel walker properly. On [DATE] at 11 a.m., during an interview, LN 21 stated Resident 2 was compulsive about ambulating. LN 21 stated if Resident 2 was not monitored, she would be up ambulating without assistance. LN 21 stated, I think she should have been a one to one (one staff providing supervision to Resident 2 at all times). On [DATE] at 11:09 a.m., during a concurrent interview and record review, LN 19 stated Resident 2's fall care plan interventions did not adequately address Resident 2's assessed risk for falls such as being impulsive, independent minded and inconsistent with use of her call light. LN 19 stated a bed alarm, a room closer to the nurses' station and one on one supervision could have reduced Resident 2's risk for falls. On [DATE] at 12 p.m., during an interview, the RNA stated she provided stand by assistance while Resident 2 ambulated with the physical therapy ordered front wheel walker. The RNA stated Resident 2's gait and balance were unsteady and needed assistance. On [DATE] at 3:40 p.m., during an interview and concurrent record review, the Chief Nursing Executive stated care plan interventions did not reflect and address Resident 2's impulsive behavior and ambulation without supervision. On [DATE] at 12 p.m., during an interview and concurrent record review, LN 1 stated she was part of the IDT. LN 1 reviewed Resident 2's IDT root causes after the falls on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. LN 1 stated the IDT root causes after Resident 2's falls were basically the same. LN 1 stated the root causes for Resident 2's falls were not specifically identified by the IDT. LN 1 stated the facility did not adequately evaluate Resident 2's risk for falls or her behaviors which placed her at a high risk for falls. LN 1 stated We could have done better. On [DATE] at 9:25 a.m., during an interview PT 2 stated any resident devices brought into the facility needed an evaluation by the therapy department for safety. PT 2 stated she knew Resident 2 had a personal four-wheel walker in the facility. PT 2 stated Resident 2 was supposed to be ambulated with the facility's front wheel walker. PT 2 stated Resident 2 needed to be checked for safe use of the four-wheel walker if it was used for ambulation. PT 2 stated a four-wheel walker would not be safe for a resident if the resident was not able to properly use the brakes on the handles. On [DATE] at 9:33 a.m., during an interview and record review, PT 3 stated devices brought from home should have a referral by nursing to the therapy department. PT 3 stated the therapy staff screened and evaluated the device and the safe use of the device by the resident. PT 3 stated the nursing referral to the therapy department should be in the resident's chart. PT 3 was unable to find documentation of a safety evaluation of Resident 2's personal four-wheel walker. On [DATE] at 11 a.m., during an interview LN 1 stated Resident 2's family brought a four-wheel walker for Resident 2. LN 2 stated when a device was brought into the facility, it was the facility policy to notify physical therapy to evaluate the device and the resident's safe use of the device. LN 1 stated the LN should document if an evaluation of a device was done by physical therapy. On [DATE] at 2:15 p.m., during an interview, the RNA stated Resident 2 ambulated with RNA five times a week with a front wheel walker, which was the order from the therapy department. The RNA stated every time she saw Resident 2 in the hallways walking alone, she (Resident 2) used the four wheel walker brought in to the facility by her family. The RNA stated she was not aware whether PT evaluated Resident 2 using the four wheel walker. On [DATE] at 2:30 p.m., during an interview, LN 20 stated Resident 2 used her four-wheel walker to ambulate but the RNA staff used the physical therapy ordered front-wheel walker when they ambulated Resident 2. LN 20 stated she did not know if physical therapy had evaluated Resident 2's use of the four-wheel walker for safety. LN 20 stated she often told Resident 2 to use the brakes on the four-wheel walker. LN 20 stated she knew Resident 2 needed to be supervised while ambulating with the walker but staff was not always able to supervise. LN 20 stated the staff supervised the resident, As much as we could. On [DATE] at 2:03 p.m., during an interview, Occupational Therapist (OT) 2 stated if a resident's walker was brought into the facility, nursing should have sent a referral to PT for a safety evaluation. OT 2 stated a resident who used a four-wheel walker needed to be screened for safe use of the brakes on the walker. OT 2 stated Resident 2 was not safe with a four wheel walker because it moved faster than a front wheel walker. OT 2 stated he did not know how or why Resident 2 was allowed to use her four-wheel walker. OT 2 stated the RNA ambulated Resident 2 with a front wheel walker. OT 2 stated nursing should have referred Resident 2 to PT and/or OT after her first fall and it was not done. OT 2 stated he was not aware of Resident 2's four wheel walker being checked for safety. On [DATE] at 2:50 p.m., during an interview, the Administrator (ADM) stated there was no referral from nursing to physical therapy for a safety evaluation of Resident 2's four-wheel walker. On [DATE] at 1:30 p.m., during an interview, Resident 2's Family Member (FM) 4 stated she informed the staff at a meeting that Resident 2 needed supervision all of the time. FM 4 stated she told the staff Resident 2 wanted to be independent and would get up without assistance. FM 4 stated she thought Resident 2 would have direct supervision but the staff did not have time to provide supervision. FM 4 stated staff said the facility did not provide one on one supervision for the residents. On [DATE] at 1:30 p.m., during an interview, FM 4 stated Resident 2's family brought in the four wheel walker for Resident 2 to use for walking. FM 4 stated the family thought the four wheel walker would be better for Resident 2 because it had a seat for Resident 2 if she became tired. FM 4 stated Resident 2 had not used the four wheel walker before it was brought to the facility. FM 4 stated she did not know if the facility PT checked the four wheel walker for safety but it should have been checked. FM 4 stated Resident 2 should not have used the four wheel walker if it was not safe. FM 4 stated the four wheel walker should not have been left in Resident 2's room. Review of the facility policy and procedure titled, Fall Program and dated [DATE] indicated, .each resident is to be evaluated upon admission, quarterly and as needed by a Licensed Nurse to determine factors that place the resident at a risk for falls .all residents are to receive adequate supervision and assistive devices to prevent accidents .Residents identified as being High Risk for falls should have specific interventions that address each of the resident's factors and potential factors .The higher a resident's risk for falls is, the more individualized interventions should be considered: .i. Supervised walking program .Residents at High Risk may be placed on a Falling Star Program that alerts staff to monitor residents who have a higher risk of falling .Consider previous occupation, social patterns, need for control or independence. These factors could produce a better understanding of the resident's activities as they relate to falls and help identify interventions that could decrease fall risk .

Based on staff interview, clinical record and administrative document review, the facility failed to identify environmental hazards and failed to provide supervision to prevent an accident for one of three residents (Resident 1) when Resident 1 fell and sustained a fractured arm after exiting through an outside door that failed to alert staff when exited by Resident 1. This failure resulted in an injury to Resident 1's left humerus (upper arm) which caused Resident 1 pain and a decline in physical function. Findings: Resident 1's face sheet (document which contains resident specific information) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS- an assessment tool used to identify physical and cognitive abilities) assessment dated [DATE], indicated Resident 1 had long and short term memory impairment. Resident 1's Fall Risk Assessment dated 5/14/15, indicated, Resident 1 had a score of 18 which revealed the resident was at a high risk for falls. The assessment revealed Resident 1 had a history of [REDACTED]. Review of Resident 1's physician orders [REDACTED]. Resident 1's plan of care (POC) dated 5/6/14 indicated, The resident is high risk for falls (related to) unaware of safety needs, confusion, gait balance problems; .The resident will not sustain serious injury .staff to anticipate and meet the resident needs . Resident 1's nursing progress notes dated 6/14/15 indicated, .CNA (Certified Nursing Assistant) reported to writer .patient is laying on the ground outside .Resident was laying on her side, resident had vomited .Resident was observed, with an abrasion on her right forehead, pain to left arm with softball size lump noted. Called to ambulance . resident sent to hospital . On 6/29/15 at 10:55 a.m., during an observation, Resident 1 was in bed asleep with a soft cast and a sling present on the left arm. On 6/29/15 at 11:20 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 required more assistance in activities of daily living (ADL's). LN 1 stated prior to Resident 1's fall and fracture, Resident 1 required extensive assistance (staff provide weight bearing support) with her ADL's and was able to propel around in the wheel chair. LN 1 stated Resident 1 now required maximum assistance (full staff performance) which required the assistance of two persons with ADL's. On 6/29/15 at 12:00 p.m., during an observation, LN 2 walked to the outside patio to indicate the location of where Resident 1 had fallen. LN 2 stated Resident 1 had gone outside in her wheelchair on 6/14/15 when the wheel of the chair tipped over the edge of the side walk, and the wheelchair and Resident 1 fell to the ground. An empty flower bed was unlevel, the ground lower than the sidewalk, was present alongside one side of the side walk. On the surface of the dirt three sprinkler heads protruded creating a trip and fall hazard. On 6/29/15 at 12:20 p.m., during an observation, the call light system displayed an alert to staff by signaling a light over each resident room and by sending an audible signal to the nursing station each time a call button was pressed. There was no light above the patio door exit to alert staff visually when Resident 1 exited the door. On 6/29/15 at 12:25 p.m., during an interview, LN 2 stated, There were no noise making alarms (an alarm triggering the attention of staff) at the doors during the day of (Resident 1's) fall. LN 2 stated the door to the patio was not set to alarm as a response to a wander guard alarm when a resident wearing an alarm exited the door. On 6/29/15 at 12:35 p.m., during an interview, CNA 1 stated at approximately 2:10 p.m., she was notified by another CNA that someone was in the outside patio on the ground. CNA 1 stated, We ran outside and we found (Resident 1), on the floor. CNA 1 stated she and another CNA ran back inside to call for help leaving the resident alone on the ground. CNA 1 could not explain how Resident 1 had gotten unassisted. CNA 1 stated Residents like (Resident 1) are not allowed to be outside on their own. CNA stated Resident 1 needed supervision because of her [DIAGNOSES REDACTED]. On 6/29/15 at 1:00 p.m., during an interview, LN 9 stated she was the nurse in charge on the day of Resident 1's fall. LN 9 stated, It was around 2 p.m., one CNA came to me and told me (Resident 1) was on the floor. LN 9 stated Resident 1 was found on her right side, and the resident stated to LN 9 she had a broken arm and was in pain. LN 9 stated Resident 1 can not be outside, she needs to have supervision. LN 9 stated there were no alarms at the door to alert her of Resident 1's exiting through the patio doors. LN 9 confirmed Resident 1's fall was avoidable. On 6/29/15 at 2:10 p.m., during an interview, the Director of Staff Development (DSD) stated there were no alarms triggered at the door because, there were no alarms at the doors prior to Resident 1's fall. On 6/29/15 at 3:15 p.m., during an interview, the Maintenance Director (MD) stated he was responsible for the safety check of the facility grounds. The MD stated he was part of a safety committee, and stated, I am responsible for my team of 12 members, we identify things or potential risks that can affect the safety of all in the building. The MD stated there had never been any discussion regarding the unleveled ground surface on the outside patio. On 6/29/15 at 3:20 p.m., during an observation and concurrent interview on the outside patio, the MD measured the unleveled ground along one side of the side walk where Resident 1 had fallen. There were three measurements taken along side the sidewalk, first measurement was the location where Resident 1 had fallen; it measured a drop of three and half inches from the cemented walkway to the ground. A second area measured a two inch drop from the sidewalk to the ground, and the third area measured a four inch drop from the side walk to the ground. The MD stated, Yes, I agree the ground is unleveled. On 7/1/15 at 11:45 a.m., during an interview, the Minimum Data Set Coordinator (MDSC) stated Resident 1 had a significant change in overall function following her fall and fracture. MDSC stated, (Resident 1) has had noted decline in several areas, she declined in transfers, locomotion on unit and off unit, dressing, eating, toilet use, and bathing. On 7/1/15 at 12:00 p.m., during an interview, The MD stated he had not done anything to the area on the patio that was unlevel. On 7/1/15 at 12:10 p.m., during an observation and concurrent interview with the Administrator (Adm) and the Operations Regional Director (ORD), a recording of Resident 1's fall from 6/14/15 was viewed. The recording revealed a date of 6/14/15 at 1:19 p.m. Resident 1 was observed sitting in her wheel chair in the hallway which led to the exit patio doors. LN 9 was observed standing in front of a medication cart in the hallway close to a doorway in which the hallway led to the exit out to the patio. LN 9 was seen going into a resident room at this time. Resident 1 was wheeling in the wheelchair toward the exit patio door at 1:20 p.m. The video recorded Resident 1's fall outside at 1:22 p.m. On 11/12/15 at 1:40 p.m., during an interview, the DON stated Resident 1 had sustained a fall on 6/14/15 because the ground was unlevel. Resident 1's POC dated 3/17/15, indicated, The resident is an elopement risk/wanderer (as evidenced by) Resident wanders aimlessly, Disoriented to place . The document indicated a goal, The resident will not leave facility unattended .The residents safety will be maintained . POC interventions indicated, Assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities .Wander Alert when up in chair to alert staff of whereabout. Resident 1's X- Ray report dated 6/14/15 at 4:51 p.m., indicated, There is a left humerus helical (spiral) midshaft (mid way between the end of a long bone) fracture .Extensive soft tissue swelling. The facility administrative document titled, Job description Maintenance Supervisor undated, indicated, .The primary purpose of your position is to assist .day to day activities of the Maintenance Department in accordance with current Federal, State and local standards .to assure that our facility is maintained in a safe and comfortable manner . The facility policy and procedure titled, Fall Prevention Program dated 12/1/2011 indicated, .To identify residents who are at risk of falling and prevent accidents by providing an environment that is free from hazards .all residents will receive adequate supervision and assistive devices to prevent accidents .

Based on observation, staff interview, clinical record and administrative document and manufacturer's guideline review, the facility failed to meet professional standards of quality when four of four sampled residents' (Resident 1, 2, 3, 4) Wander Guard transmitter (an alarm system designed to alert staff when a cognitively impaired resident wanders outside alarmed doorways) were not tested for functionality according to the physicians' orders and manufacturer's guidelines. This failure resulted in a fall and injury to Resident 1, and had the potential to result in a fall of Resident's 2, 3 and 4's who wore the Wander Guard alarm and were at risk for elopement. Findings: Review of Resident 1's face sheet (document which contains resident specific information) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS- an assessment tool for resident function and cognition ability) assessment, dated [DATE], indicated Resident 1 had long and short term memory impairment. Resident 1's nursing progress notes dated [DATE] at 10:49 a.m., indicated, Resident has wandering behavior noted .(Resident 1's physician) notified and order for Wander Guard received . Review of Resident 1's physician orders [REDACTED]. Resident 1's Treatment Administration Record, dated [DATE], and [DATE], indicated, Alarm: Wander Guard - Check placement and function Q (every) shift .related to Dementia. (memory loss affecting overall mood, behavior and physical function) On [DATE] at 10:55 a.m., Resident 1 was observed asleep in bed with a Wander Guard ankle bracelet on the right ankle. On [DATE] at 11:35 a.m., during an interview, LN 1 stated he did not have a device to test the Wander Guard. On [DATE] at 11:40 a.m., during an observation and concurrent interview, Licensed Nurse (LN) 1 pointed to the main entrance and a side entrance to the building equipped with the Wander Guard alarm (door alarm operates by monitoring motion through a doorway or hallway). LN 1 stated, These are the only two doors that have Wander Guard alarms. Facility map indicated there were a total of 11 exits. LN 1 did not know why the exit doors were not equipped with the Wander Guard alarm. On [DATE] at 12 p.m., during an interview, LN 2 stated Wander Guard testing was done on the night shift. LN 2 stated she had worked on the night shift and had never checked the functioning of the Wander Guard alarm. On [DATE] at 2:50 p.m., during an interview, LN 3 stated, the nurses had no way to check the Wander Guard alarm system other than walking the residents who wore the alarms through the doors which were set up for the alarm system. On [DATE] at 4 p.m., during an interview, a Central Supply (CS) worker stated he had not used a transmitter tester to verify the Wander Guard worked properly. The CS staff stated, The box (transmitter tester- used to check Wander Guard function) broke back in March and we haven't replaced it; I guess we forgot. On [DATE] at 4:05 p.m., during an interview, CS removed the transmitter from Resident 1's ankle in order to demonstrate how to test the Wander Guard. CS walked through the main entrance while holding Resident 1's Wander Guard in his hand; this triggered an audible alarm. CS stated he was following manufacturer guidelines in testing the Wander Guard transmitter. On [DATE] at 4:10 p.m., during an interview, LN 4 stated, I don't know what a Wander Guard is. LN 4 was unable to identify the Wander Guard on Resident 1's right ankle. On [DATE] at 4:45 p.m., during an interview, the Administrator (Adm) stated, There is no way the nurse is going to be bringing the resident to the door to check that the Wander Guard works. Adm stated she was not aware that the transmitter tester had been broken since [DATE]. On [DATE] at 10:45 a.m., during an interview, LN 5 stated, she checked the Wander Guard was around Resident 1's ankle and did not know anything about testing the Wander Guard. LN 5 stated, Once in a while, I take Resident 1 to the front entrance to check (the Wander Guard) but not every day. On [DATE] at 3:45 p.m., during an interview, the Staff Development Assistant (DSDA) stated Wander Guards were tested by taking the resident with a Wander Guard transmitter through the door ways that triggered the Wander Guard alarm to sound. On [DATE] at 4 p.m., during an interview, DSDA stated there had not been any staff training on how to test functionality of the Wander Guard. On [DATE] at 12:15 p.m., during an interview, LN 7 stated when she tested the Wander Guard transmitter with a newly acquired tester, she expected to hear one beep and see a green light to signal once; if it was working properly. On [DATE] at 3:20 p.m., during an interview, LN 8 was asked to demonstrate the process of conducting a Wander Guard transmitter test for Resident 2's Wander Guard. LN 8 pressed the side button on the transmitter tester which she placed on top of Resident 2's Wander Guard transmitter. LN 8 pressed the button to test the wander guard transmitter. After she heard the first beep and visualized the green light signal she released the button. On [DATE] at 3:30 p.m., during an interview, LN 6 was asked to demonstrate the process of conducting a Wander Guard transmitter test on Resident 3. LN 6 stated, I am not one hundred percent certain how to conduct the transmitter test. Review of Resident 2's face sheet indicated Resident 2 was admitted on [DATE]. Resident 2's Care Plan dated [DATE], indicated, The resident is an elopement risk . An intervention on the Care Plan indicated, Wander guard to right ankle. Resident 2's physician order [REDACTED]. Resident 2's Wandering Risk assessment dated [DATE], indicated Resident 2 had a [DIAGNOSES REDACTED]. Clinical record reviewed indicated Resident 3 was admitted on [DATE]. Resident 3's Order Summary Report, dated [DATE], contained an order initiated on [DATE] indicating, Check placement of wander guard every shift for resident history of wandering. Resident 3's Elopement Risk Assessment, dated [DATE], indicated Resident 3 was independent in mobility by ambulation (walking), wheelchair .Resident 3 had desire to exit facility .Resident 3 had confusion .Plan was to implement Wander guard. Resident 3's Care Plan, dated [DATE], indicated, The resident is an elopement risk/wanderer (as evidenced by) history of attempt to leave facility .CNA (Certified Nursing Assistant) to monitor placement and function of wander guard daily. Clinical record review indicated Resident 4 was admitted on [DATE]. Resident 4 had an admitting [DIAGNOSES REDACTED].-Check placement and function Q shift. The facility policy and procedure titled, Resident Elopement and Wandering dated [DATE], indicated, Facility administration and staff recognize that elopement poses a real danger to certain residents .functional alarm systems will be implemented in order to maintain the resident's safety .Apply Wander Guard bracelet to the resident wrist or wheelchair if the resident refuses to wear the bracelet or removes the bracelet .Placement and function of the Wander Guard should be checked at the start of each shift . Review of manufacturers guidelines titled, Wandering Management Transmitter User Guide dated [DATE], indicated, Users must read this Guide before using the Product. Under Required Transmitter Testing it indicated, You must test these transmitters prior to use to verify proper operation .Test the operation of the transmitter using the Transmitter Tester .The device beeps once when you initially press the button .While holding the button in, the indicator light flashes and a tone sound once per second, wait for at least 3 flashes of the indicator light and 3 tones from the transmitter tester to verify that the transmitter is functioning correctly .Required weekly testing for transmitters in use on residents .All steps are mandatory. Note: Transmitters in use must be tested at least weekly .Test the operation of transmitters in use weekly using the transmitter tester .Verify on a weekly basis that the warranty expiration date stamped on transmitters in use has not expired .Your facility must keep records of test and transmitter inspection. NOTE: Never take a resident to a door to test their transmitter .

Based on observation, interview, and clinical and administrative document review, the facility failed to ensure it was free of medication error rates in excess of 5 percent when the facility's medication error rate was 17.6 percent. There were 51 opportunities and there were nine medication errors for 5 of 6 sampled residents (Residents 32, 34, 35, 36, and 37). These failures had the potential to result in serious resident harm or death. On 10/30/13 at 3:30 p.m. Immediate Jeopardy was called with the Facility Administrator, the facility Compliance Officer, the Director of Nursing (DON), and the Administrator-in-Training. No system was in place to monitor missed medication administration or intervene in the facility's method of acquiring, administering, and reconciling physician ordered medications to meet the needs of the residents. Findings: 1. Clinical record review indicated Resident 37, who was diagnosed with [REDACTED]. four times a day. This medication is used to reduce swelling heat, redness, pain, and used to treat types [MEDICAL CONDITION] <http://www.nlm.nih> gov/medlineplus/druginfo/meds/a 2.html). Review of professional reference, "Medline Plus" website www.nlm.nih.gov/medlineplus/druginfo/meds/a 2.html On 10/24/13 at 8:15 a.m., during a medication pass observation at Station 300 and concurrent interview, Licensed Nurse (LN) 1 prepared Resident 37's medications for administration. LN 1 was unable to find the medication and stated, "I only have the 5 mg pills here, I will have to check the orders." Resident 37's [MEDICATION NAME] 4 mg dose was not administered on 10/24/13 at 9:00 a.m. On 10/24/13 at 5:30 p.m., during an observation and concurrent interview, the DON stated Resident 37's [MEDICATION NAME] medication was still not available for administration in the medication cart, "Its not here." Resident 37 had missed three doses of [MEDICATION NAME] 4 mg on 10/24/13, the 9:00 a.m., 1:00 p.m., and 5:00 p.m. doses. 2. Record review on 10/24/13 indicated Resident 34 was a new admission to the facility on [DATE]. Resident 34 had admitting [DIAGNOSES REDACTED]. Physician orders [REDACTED]. "[MEDICATION NAME] Capsule 100 mg, Give one capsule by mouth one time a day for [MEDICAL CONDITION], due at 9 a.m. [MEDICATION NAME] Tablet 20 mg, Give one tablet by mouth two times a day [MEDICAL CONDITION](Hypertension), due at 8 a.m. and 4 p.m. [MEDICATION NAME] HCl Tablet 10 mg, Give one tablet by mouth three times a day for HTN, due at 8 a.m., 12 p.m., and 4 p.m." On 10/24/13 at 8:30 a.m., during an observation and concurrent interview, LN 1 checked Resident 34's blood pressure reading 130/90 (normal range is systolic less than 120 and diastolic less than 80). LN 1 prepared to administer Resident 34's medications, but was unable to find the medications in the medication cart, stating, "They are not here." Resident 34's a.m. doses of [MEDICATION NAME] and [MEDICATION NAME] HCl medications were not administered. On 10/24/13 at 5:30 p.m. during an observation and concurrent interview, the DON stated Resident 34's [MEDICATION NAME], and [MEDICATION NAME] medications were still not available for administration in the medication cart, stating, "No, they are not here." On 10/24/13 Resident 34 missed the noon dose of the [MEDICATION NAME] HCl, and the 4 p.m. doses of [MEDICATION NAME] and [MEDICATION NAME] HCl. Progress Notes dated 10/25/13 at 7 a.m. contained documentation that Resident 34's blood pressure reading was 144/75 at that time. Review of professional reference, "Medline Plus" website www.http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm indicated abruptly stopping or not administering high blood pressure medications as ordered can result in rebound high blood pressure. Rebound high blood pressure is an elevation in blood pressure in response to stopping or reducing hypertension medications. Hypertension is a major risk for stroke, [MEDICAL CONDITION], heart failure and aneurysms (widening and weakening of the arteries). Review of professional reference, "American Heart Association - Understanding Blood Pressure Readings", updated March 1, 2013 indicated a systolic (top number) blood pressure of 140 millimeters of mercury (mm Hg - measurement of blood pressure) indicated Stage 1 hypertension; and a diastolic (bottom number) blood pressure of 90 - 99 indicated Stage 1 hypertension. 3. On 10/24/13 during clinical record review, Resident 32's face sheet indicated the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. On 10/24/13 at 9 a.m., during a medication pass observation, LN 2 prepared to administer Resident 32's medications. She retrieved [MEDICATION NAME] Nasal spray 27.5 mcg/spray, and administered one spray to both of the resident's nostrils. Review of professional reference "Lexicomp.com" at website http://online.lexi.com indicated [MEDICATION NAME] and [MEDICATION NAME] are both steroid type medications but are different compositions and different dosing. On 10/24/13 at 9:30 a.m., during an observation and concurrent interview, LN 2 removed the [MEDICATION NAME] Nasal Spray from the medication cart and compared the medication with the electronic order on the Medication Administration Record (MAR) for Resident 32. LN 2 was unable to find a current physician order [REDACTED]. On 10/24/13 at 2:50 p.m., during an interview, the Director of Staff Development (DSD) stated the resident had been receiving [MEDICATION NAME] spray two times per day since September, 2013, without a written physician's orders [REDACTED]. Review of Resident 32's Physician orders [REDACTED]. 4. Record review on 10/24/13 showed the facility admitted Resident 36, on 10/7/13. Resident 36 had admitting [DIAGNOSES REDACTED]. Physician orders [REDACTED]. "[MEDICATION NAME] Tablet 500 MCG Give one tablet by mouth one time a day for acute blood loss [MEDICAL CONDITION], acute upper GI (gastrointestinal) bleed." [MEDICATION NAME] is given for treatment of [REDACTED]. "[MEDICATION NAME] Tablet 20 mg Give one tablet by mouth one time a day [MEDICAL CONDITION](Hypertension)". [MEDICATION NAME] is a medication that causes water and salt wasting, reduces blood volume, and reduces blood pressure. Review of professional reference, "Medline Plus" website www.http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm "[MEDICATION NAME] HCl Tablet 100 MG Give one tablet by mouth one time a day for dietary supplement." [MEDICATION NAME] is used for prevention and treatment of [REDACTED].http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm On 10/24/13 at 10 a.m., during an observation and concurrent interview, LN 3 prepared to administer Resident 36's medications. She was unable to locate the three ordered medications in her medication cart. She walked to a second medication cart located nearby and searched for the medications. She returned and stated, "They ([MEDICATION NAME], and [MEDICATION NAME]) are not here." LN 3 did not administer Resident 36's medications as per physician order. Review of the Resident 36's Medication Administration Record (MAR) dated 10/24/13, indicated LN 3 documented the medications [MEDICATION NAME], and [MEDICATION NAME] were administered to Resident 36 for the 9 a.m. dose time. On 10/24/13 at 1:15 p.m., during an interview with LN 3 regarding her documentation that she gave Resident 36's medications when it was observed the medications were not given, LN 3 stated, "Yes, I know..." On 10/24/13 at 4:30 p.m., during an interview and concurrent record review, the Director of Nursing (DON) reviewed Resident 36's MAR and stated the MAR contained documentation all the medications were administered. "They are all documented as given (to the resident)." On 10/24/13 at 5:30 p.m. during an observation and concurrent interview, the DON verified Resident 36's [MEDICATION NAME] and [MEDICATION NAME] medications were not available for administration stating, "No, they are not here (in the medicine cart). 5. On 10/24/13 during clinical record review, Resident 35's face sheet indicated Resident 35 had been admitted on [DATE]. Resident 35 had admitting [DIAGNOSES REDACTED]. physician's orders [REDACTED]." [MEDICATION NAME] is used to treat conditions where the stomach produces too much acid. Review of professional reference, "Medline Plus" website: www.http://www.nlm.nih.gov/medlineplus/ency/article/ 5htm. On 10/24/13 at 10:30 a.m., during an observation and concurrent interview, LN 3 prepared Resident 35's medication for administration. LN 3 was unable to locate the NAME] medication in the medication cart, and did not administer the NAME] to Resident 35. Resident 35 refused the [MEDICATION NAME] Sodium and it was not administered to the resident. At 10/24/13 at 10:50 a.m., during an interview with LN 3 regarding missing medications, she stated, "Sometimes you can only reorder (medications) two days in advance, and it (the reordered medication) doesn't get here on time." Review of Resident 35's MAR on 10/24/13 indicated LN 3 documented [MEDICATION NAME] Sodium (for constipation) and [MEDICATION NAME] were administered to the resident, when the ordered [MEDICATION NAME] Sodium was refused and the [MEDICATION NAME] was not available and not given. On 10/24/13 at 1:15 a.m., during an observation and concurrent interview, LN 3 rechecked the MAR documentation for [MEDICATION NAME] Sodium, and stated, "Oh I did (document the medication as given)..." On 10/24/13 at 4:30 p.m., during an interview and concurrent clinical record review of Resident 35's MAR, the DON verified that the medications for Resident 35 had been charted as given even though they were not. She stated she was aware medication availability had been an ongoing problem in the facility. On 10/29/13 at 3:30 p.m., during an interview, the Pharmacy Nurse Consultant stated she had identified the issue of missing medications on 10/13/13. There was no documented evidence the problem had been addressed and acted upon. Immediate Jeopardy was abated on 11/1/13 at 1:30 p.m. with the facility Administrator, and Compliance Officer, when the facility provided an acceptable plan of action to implement an effective and accountable medication acquisition system including monitoring and evaluation through the Quality Assessment and Assurance process and to educate the Licensed Nurses on medication administration with training provided by acceptable qualified personnel.

Based on observation, interview, clinical record and administrative document review, the facility had multiple failures in acquiring and maintaining availability of medications ordered by physicians. The facility failed to ensure medications ordered for five of six residents (Resident 37, 34, 36, 35 and 32) observed during the medication pass on Station 300 and Station 400 were available for administration at scheduled times. See F332 for residents 32, 34, 35, 36, and 37. The facility failed to ensure a verbal medication order was entered into the resident's record accurately (Resident 32); failed to reconcile faxed orders with the physicians orders in the medical record (Resident 32); failed to ensure medications ordered for refill by faxed requests were received timely in 4 of 4 nursing stations (Station 100, Station 200, Station 300 and Station 400); failed to ensure medications with incorrect dosages, or Emergency Kits (E-Kit) with expired dates were not stored as medications available for use. The Pharmacy Nurse Consultant identified the problem of missing medications on 10/13/13. There was no documented evidence the problem had been addressed and acted upon. These failures resulted in a medication administration error rate of 17.6% and had the potential to result in serious injury, harm, or death to the residents. On 10/30/13 at 3:30 p.m. Immediate Jeopardy was called with the Facility Administrator, the facility Compliance Officer, the Director of Nursing (DON), and the Administrator-in-Training. No system was in place to monitor, or intervene in the facility identified problems of acquiring, administering, and reconciling of physician ordered medications to meet the needs of the residents. Findings: 1. Clinical record review indicated Resident 37, who was diagnosed with [REDACTED]. (milligrams) four times a day at 9 a.m., 1 p.m., 5 p.m., and 9 p.m. for [DIAGNOSES REDACTED] (brain cancer.) This medication is used to reduce swelling, heat, redness, pain, and used to treat types of cancer <http://www.nlm.nih> gov/medlineplus/druginfo/meds/a 2.html). Review of professional reference, "Medline Plus" website www.nlm.nih.gov/medlineplus/druginfo/meds/a 2.html On 10/24/13 at 8:15 a.m., during medication administration observation and interview at Station 300, Licensed Nurse (LN) 1 found Dexamethasone 5 mg. tablets available for administration to Resident 37. LN 1 stated, "I only have 5 mg pills here, I will have to check the orders." Resident 37's Dexamethasone 4 mg was not administered for the 9 a.m. dose when LN 1 could not find 4 mg tablets of Dexamethasone. On 10/24/13 at 5:30 p.m., during an observation and concurrent interview, the DON stated Resident 37's Dexamethasone medication was not available for administration in the medication cart, stating, "Its not here." The DON stated the resident had not received the 9 a.m. or the 1 p.m. dose of Dexamethasone 4 mg. 2. On 10/24/13 at 8:30 a.m., during a medication pass observation and concurrent interview, LN 1 checked Resident 34's blood pressure, reading 130/90 (normal range is systolic less than 120 and diastolic less than 80). LN had been unable to administer three of seven ordered medications for Resident 34. The following were unavailable in the medication cart for administration: Gabapentin (for nerve pain) 100 mg, Lisinopril (used to treat high blood pressure and heart failure) 20 mg, and Propranolol Hydrochloride (HCL) (used to treat high blood pressure) 10 mg. LN 1 stated these three medications were not available to be given as ordered for the 9 a.m. medication administration. Review of Resident 34's physician orders dated 10/23/13, indicated: "Gabapentin 100 mg Give one capsule by mouth every day for peripheral neuropathy (nerve damage to extremities). Lisinopril tablet 20 mg Give one tablet by mouth two times a day for hypertension. Propranolol HCL tablet 10 mg Give one tablet by mouth three times a day for hypertension (high blood pressure)." On 10/24/13 at 5:30 p.m., during an observation and concurrent interview, the DON stated Resident 34's Gabapentin, Lisinopril, and Propranolol medications were still not available for administration and stated, "No, they are not here." On 10/24/13 Resident 34 missed the noon dose of the Propranolol HCL, and the 4 p.m. doses of Lisinopril and Propranolol HCL. Progress Notes dated 10/25/13 at 7 a.m. contained documentation that Resident 34's blood pressure reading was 144/75 at that time. Review of professional reference, "Medline Plus" website www.http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm indicated abruptly stopping or not administering high blood pressure medications as ordered can result in rebound high blood pressure. Rebound high blood pressure is an elevation in blood pressure in response to stopping or reducing hypertension medications. Hypertension is a major risk for stroke, heart attack, heart failure and aneurysms (widening and weakening of the arteries). Review of professional reference, "American Heart Association - Understanding Blood Pressure Readings," updated March 1, 2013, indicated a systolic (top number) blood pressure of 140 millimeters of mercury (mm Hg - measurement of blood pressure) indicated Stage 1 hypertension; and a diastolic (bottom number) blood pressure of 90 - 99 indicated Stage 1 hypertension. 3. On 10/24/13 during clinical record review, Resident 36's face sheet indicated Resident 36 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders dated 10/7/13 indicated the following medication orders [REDACTED] "Cyanocobalamine (Vitamin B-12) Tablet 500 MCG (micrograms) Give one tablet by mouth one time a day for acute blood loss anemia, acute upper GI (gastrointestinal) bleed. Furosemide (a medication to remove fluid from the body) Tablet 20 mg Give one tablet by mouth one time a day for htn (Hypertension). Pyridoxine (Vitamin B-6) HCl Tablet 100 MG Give one tablet by mouth one time a day for dietary supplement." On 10/24/13 at 10 a.m., during an observation and concurrent interview, LN 3 prepared Resident 36's medications. She was unable to locate three of the ordered medications in the medication cart. LN 3 walked to a second medication cart located nearby and searched further for the ordered medications. She returned and stated, "They (Cyanocobalamine, Furosemide, and Pyridoxine) are not here." Resident 36 did not receive these medications as per physician order. On 10/24/13 at 5:30 p.m. during an observation and concurrent interview, the DON stated Resident 36's Cyanocobalamine and Furosemide medications were still not available for administration, "No, they are not here..." 4. On 10/24/13 during clinical record review, Resident 35's face sheet indicated the resident had been admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders dated 10/4/13 included the following medication order: "Pantoprazole Sodium Packet (Protonix) 40 MG Give one tablet by mouth one time a day for GERD (Gastric reflux)." On 10/24/13 at 10:30 a.m., during a medication pass observation, LN 3 prepared Resident 35's medication for administration. LN 3 was unable to locate the Pantoprazole Sodium (medication used to decrease stomach acid) 40 mg in the medication cart. Resident 35 did not receive the 9 a.m. dose of medication. 5. On 10/24/13 at 9 a.m., during a medication pass observation, LN 2 retrieved Resident 32's nasal spray (Veramyst) and administered one spray to each of Resident 36's nostrils. On 10/24/13 at 9:30 a.m., during a medication pass reconciliation, LN 2 compared the Veramyst Nasal Spray with Resident 32's medication orders on the electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No physician order for [REDACTED]. Review of the facility document titled, "NEW PRESCRIPTIONS," (form for nurses to communicate orders to the pharmacy) dated 9/17/13, indicated "Order Date: 9/17/13, Resident: (32), Drug: Veramyst, Directions: 1 spray in each nostril BID (two times per day)." The document indicated a facsimile (fax) dated 9/17/13 had been faxed to the pharmacy from the facility. On 10/24/13 at 4:30 p.m., during an interview, the DON stated the nurses were responsible for reconciling the physician orders to the MAR indicated [REDACTED]. The facility policy and procedure titled, "Physician Order Recap" dated 3/1/13, indicated..."4. Nursing is responsible for the following as part of the recap process: a. Reviewing the Order Listing to ensure accuracy and completion. b. Updating any orders that need to be clarified or modified, c. discontinue any orders that should no longer appear on the Order Listing..." 6. At 10/24/13 at 10:50 a.m., during an interview with LN 3, she stated, "Sometimes you can only reorder (medications) two days in advance, and it (the reordered medication) doesn't get here on time." On 10/24/13 at 4:30 p.m., during an interview and a concurrent record of Resident 35's MAR, the DON stated she had been aware of medication availability problems in the facility, stating, "We've been having a problem with this off and on..." On 10/25/13 at 9:30 a.m., during an interview, the General Manager (GM) of the facility's contracted pharmacy stated the contract with the facility was an, "On Demand Agreement" for acquiring medications. There were no cycled refills. No orders are refilled unless the facility initiates a request for the refills. New or admission orders [REDACTED]. The GM stated the contractor maintained agreements with local pharmacies to provide medications on an urgent and as needed basis. On 10/29/13 at 2:00 p.m., during an interview at nurses' Station 300, LN 3 stated she reordered medications when there was a three day supply remaining in the cart. She stated the administration did not like the nurses to order the medications too early. LN 3 stated medications were missing from her cart two to three times a week. On 10/29/13 at 2:05 p.m., during an observation and concurrent interview at nurses' Station 100, LN 6 stated she instructed the nurses to peel the bar code sticker and place it on the "Refill Reorder Form" and fax to the pharmacy. LN 6 stated often the pharmacy sent a return fax indicating it was too soon to refill the medication(s). She stated it was the responsibility of the LNs to follow-up on refill medications that were needed. On 10/29/13 at 2:15 p.m., during an interview at nurses Station 400, LN 4 stated she called the pharmacy directly for refills and stated it was "tough" getting medications. She stated often faxes from the pharmacy were sent to the facility which indicated medications had been ordered too soon and would not be refilled until a later date. She stated these faxes were placed and kept in a cardboard box in the medication room. On 10/29/13 at 2:18 p.m., during an observation, an 8 1/2 inch by 12 inch x 12 inch cardboard box was noted to be three quarters full of pharmacy faxes, "Refill Too Soon Notification" forms, and "Refill Reorder Form" documents which contained medication barcode stickers. On 10/29/13 at 2:20 p.m., during an interview at nurses Station 100, LN 7 stated she faxed refill requests to the pharmacy when the last row of medications, (indicated by a blue stripe on the medication card) remained on the card. She stated it could take up to seven days for delivery of refill medications. On 10/29/13 at 2:30 p.m., during an interview at nurses Station 400, LN 5 stated she faxed the need for refills to the pharmacy when medications remaining on the bubble pack were listed on the last row marked by a blue stripe. LN 5 stated at times she received a fax from the pharmacy which indicated it was "too soon" to refill the medication(s). She stated she often received two or three of these faxes per shift. She stated "we know the system is flawed. I feel it is the pharmacy..." LN 5 stated she had informed the unit manager and the DON medications had not arrived from the pharmacy timely. On 10/29/13 at 2:33 p.m., during an interview at nurses Station 200, LN 9 stated she reordered medications when there were nine doses remaining on the medication card. LN 9 stated medications were missing two to three times a month. On 10/29/13 at 2:50 p.m., during an interview at nurses Station 200, LN 8 stated resident medications are missing one to two times per month. On 10/29/13 at 4:30 p.m., during an interview, LN 5 stated she recently informed the DON that a resident's pain medication was unavailable for administration and had to be obtained from the E-Kit. The medication had not been available from the pharmacy for one week. Review of the contractor pharmacy policy and procedures titled, "LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual" dated May 2010, indicated four methods to order medications, "Written Orders: Reorders can be written and submitted on the Refill Order Form ...Verbal Orders: Refill orders can be submitted verbally...Facsimile Orders: reorders can be faxed to pharmacy...on the Refill Order Form...Electronic Orders:(e-Refill) Authorized Facility staff may use Omniview (an electronic tracking system) to electronically reorder resident medications." On 10/29/13 at 9:05 a.m., during an interview, the Pharmacist Consultant (PC) stated the Pharmacy Nurse Consultant (PNC) provided an e-mail summary of any concerns or trends identified during her last review on 10/13/13. The PC stated she received the last e-mail from the PNC but could not remember specific concerns of the PNC. On 10/30/13 at 8 a.m., during a phone interview, the PNC stated during her review in the facility she found problems with missing medications for one or more of the residents she had reviewed. The PNC also found problems with inaccurate labeling in the area of administration, time changes or changes in directions given by physician orders. On 10/29/13 at 10:45 a.m., during an interview, the DON stated she was unable to state the number of medications that were missing during the past month. On 10/29/13 at 4:50 p.m., the DON was asked for documented evidence she or the nurses had used the tracking mechanism (Omniview) for the nurses to follow the progress of medication from the pharmacy to the facility. The DON was unable to provide documentation of a system to ensure medications were available timely for resident use as ordered by the physician. 7. On 10/25/13 at 11 a.m., during an observation in the medication room at Station 100, an emergency kit contained an expired medication, one vial of Lorazepam (a medication for anxiety) 2 mg per one ml (milliliter). The expiration date for the vial of Lorazepam was September, 2013. On 10/25/13 at 11:05 a.m., during an interview with the nurse responsible to check the dates of the E-Kit, LN 6 stated the vial of Lorazepam in the E-Kit had expired and the E-Kit needed to be replaced. Review of the contractor pharmacy policy and procedures titled, "LTC Facility's Pharmacy Services and Procedures Manual" dated May 2010, indicated under "6.6 Emergency medication Supplies...11.3 Facility staff should be responsible for replacing the medication in the Emergency Medication Supply. 11.4. Facility staff should review the emergency medication supply for correct quantity and expiration. Facility should immediately report to pharmacy any discrepancies in quantity or expiration." Immediate Jeopardy was abated on 11/1/13 at 1:30 p.m. with the facility Administrator and the facility Compliance Officer when the facility provided an acceptable plan of action (POA) to implement a consistent, effective, and accountable medication acquisition system to ensure all medications were available for administration at scheduled times. The POA included a method to ensure the accurate documentation and reconciliation of physician orders, documentation, storage and administration of correct dosages, monitoring for expired medications available for use, to educate, train, and monitor the Licensed Nurses on medication administration provided by acceptable qualified personnel, and evaluation through the Quality Assessment and Assurance process.