Every finding on record at Jurupa Hills Post Acute

Based on observation, interview, and record review, the facility failed to ensure care and treatment was provided, for two of six residents reviewed (Residents 1 and 2), when:1.For Resident 1, the facility did not provide ongoing assessment and monitoring for the left upper extremity (LUE - left arm) edema (swelling caused by an abnormal buildup of excess fluid trapped in the body's tissues). In addition, the licensed nurse did not notify the physician that the resident's apixaban medication (blood thinner) was on hold for two days when the resident had a positive result of an active deep vein thrombosis (DVT, a serious medical condition where a blood clot forms in a deep vein); and2.For Resident 2, the facility did not provide ongoing assessment and monitoring for the resident's altered mental status while the urinalysis (a simple test that checks urine for signs of infection) results were pending.These failures had the potential for a delay in treatment and placed the residents' at risk for complications. Findings: 1.On [DATE], at 10:03 a.m., an unannounced visit was conducted at the facility to investigate a complaint involving quality of care.On [DATE], Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidney failure) and dependence on renal dialysis (kidneys can no longer remove extra fluid that a person relies on a machine to do the kidneys job to stay alive).A review of Resident 1's physician orders, dated [DATE], indicated, Apixaban Oral Tablet 5 mg (milligram - unit of measurement), give 1 tablet by mouth two times a day for DVT prophylaxis.A review of Resident 1's Minimum Data Set (MDS- an assessment tool), dated [DATE], indicated Resident 1 had a BIMS (Brief Interview of Mental Status - a cognitive assessment tool) score of 10 (moderate cognitive impairment).A review of Resident 1's COC (Change of Condition)/eINTERACT Assessment Evaluation, dated [DATE], at 12:02 p.m., indicated, .change in condition: edema (new or worsening) .started on [DATE], .describe edema (swelling): pitting edema to L (left) arm/hand.A review of Resident 1's Progress Note: Change of Condition, dated [DATE], at 12:19 p.m., indicated, .During routine assessment, resident noted with edema to the left upper extremity. Affected extremity observed to be swollen without redness, warmth, drainage, discoloration, or open areas noted. Resident denied pain, numbness, tingling or discomfort to the extremity.denied any recent falls, trauma, injury or other known cause for the swelling.able to move extremity freely and without difficulty.no signs of acute distress observed.attending physician notified and made aware of assessment findings.resident continues to be monitored for progression of edema, signs and symptoms of fluid overload (too much fluid or blood volume in the body).A review of Resident 1's Progress Notes: Change of Condition, dated [DATE], at 12:51 p.m., indicated, .New order received.for a venous ultrasound (a diagnostic procedure which uses sound waves to produce images of the veins in the body, commonly used to search for blood clots).of the affected extremity.to rule out DVT.order was noted and carried out.ultrasound is expected to be completed between today and tomorrow.A review of Resident 1's physician orders indicated the following:-On [DATE], indicated, Venous U/S (ultrasound) to LUE R/T (related to) swelling to R/O (rule out) DVT one time only for 4 days;- On [DATE], HOLD Blood Thinner Medication on [DATE] - [DATE]. Before Dialysis Port Treatment on Monday, [DATE], at 1030, every shift for Dialysis Port Treatment for 2 (two) days CN/RN (charge nurse/registered nurse) needs to get order to continue after procedure on [DATE]; On [DATE], STOP Blood Thinner Medication on [DATE] - [DATE]. Before Dialysis Port Treatment on Monday, [DATE], at 1030 (10:30 a.m.).A review of Resident 1's Appointment Reminder, dated [DATE], indicated, .appointment date and time: [DATE], at 10:30 A (a.m.) .dialysis center.consult your referring physician regarding taking your regularly prescribed medications.do not take blood thinners.A review of Resident 1's Care Plan, dated [DATE], indicated, .resident presents with edema to the left upper extremity.resident will demonstrate reduced or stable left arm edema as evidenced by no increase in swelling, pain, redness, or functional impairment.assess and document edema to the left arm each shift and as needed.noting location, severity, skin condition, warmth, redness, pain, and changes from baseline.A review of Resident 1's Patient Report, dated [DATE], indicated, .left duplex scan (a safe medical test that uses sound waves to see inside your blood vessels), veins, extremity, unilat (unilateral - one sided)/limited study.ulnar vein.thrombus.impressions: positive left ulnar (deep blood vessel in forearm) vein DVT.A review of Resident 1's Medication Administration Record (MAR), dated [DATE], through [DATE], indicated apixaban oral tablet, 5 mg give 1 tablet by mouth two times a day for DVT prophylaxis was not administered on [DATE] -[DATE], and was resumed on [DATE]. Further review of Resident 1's record indicated the following:-Venous ultrasound to LUE to rule out DVT was not ordered as stat (immediately or at once);- there was no documented evidence ongoing assessment conducted to indicate the status or condition of the left arm and hand edema, after there was a change in condition of the left arm and hand on [DATE];- There was no documented evidence that the attending physician and nephrologist were notified of the ultrasound results done on the left arm swelling on [DATE], and that the blood thinner medication was on hold for two days from [DATE] to 22, 2026.On [DATE], at 9:28 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated following:-For a COC for a new onset or worsening edema, the expectation was the Licensed Nurse (LN) to monitor and assess the edema for improvement or worsening by visual scan, palpation of the resident's skin and artery to assess the skin temperature, circulation, pitting/grade or non-pitting status, and to assess if any pain was present, every shift, for 72-hours;- The LN was expected to document their skilled assessment in a progress note every shift, for 72 hours;- The LN was expected to report any changes to the physician;- The process when the facility received diagnostic results, was for the LN to review the results and notify the physician for further orders and recommendations. LVN 1 stated the LN was expected to document a progress note that the physician was notified of the diagnostic testing results, whether it's negative or positive;- The possible complications of a DVT were swelling, tenderness/discoloration/warmth to the affected extremity, pain, and possible pulmonary embolism (sudden blockage of an artery in the lungs) which could cause shortness of breath, chest pain and an elevated heart rate.On [DATE], at 10:32 a.m., an interview was conducted with Administrative Operations Manager at the Mobile Radiology Facility. The AOM stated the following:- Facilities typically would order ultrasounds with venous and arterial concerns such as to rule out a DVT as STAT (right away, with no delay) as it was an urgent matter. The AOM stated these ultrasounds should be ordered as STAT;- The facility called with a routine order for Resident 1's left arm ultrasound on [DATE]. The AOM stated a routine order meant that it could be done anytime and that it was not urgent;- If the potential concern for Resident 1 was a DVT, then the ultrasound should have been ordered as STAT;- The left arm US was done by the radiology technician on [DATE], at 3:15 p.m., and the results were sent back to the facility by the radiologist (a medical doctor who specializes in diagnosing and treating diseases and injuries using medical imaging techniques like X-rays, CT [computer tomography - a detailed medical imaging test using cross-sectional pictures], MRIs [Magnetic Resonance Imaging - non-invasive medical test that uses a strong magnet and radio waves to make clear pictures of the inside of your body], and ultrasounds) on [DATE],at 4:51 p.m. (more than one hour from time the US was conducted);- The result of the US was faxed to the facility on [DATE], at 4:49 p.m., and re- faxed on [DATE], at 8:21 p.m.;- The US result was also called in to the facility on [DATE], at 5:02 p.m. and report was given to Registered Nurse Supervisor (RNS) 1.On [DATE], at 1:41 p.m., an interview was conducted with RNS 1. RNS 1 stated that when the facility received an abnormal diagnostic test result, the LN should initiate the change of condition process and notify the physician for further orders and recommendations. RNS 1 stated she did not receive results of Resident 1's US of the left arm nor receive a call from the radiology provider.On [DATE], at 2:10 p.m., an interview was conducted with LVN 2. LVN 2 stated the LN was expected to document assessment of edema monitoring which included characteristics of the edema such as color, temperature, pitting/non-pitting, presence of pain, and interventions implemented to address the edema. LVN 2 stated the status of the edema would not be determined if worsening or improves if there is no ongoing assessment for edema. On [DATE], at 3:15 p.m., an interview was conducted with LVN 3. LVN 3 stated the expectation with a COC was to monitor the resident for 72 hours every shift r/t the COC concern. LVN 3 stated if the condition worsened the LVN would notify the RNS to assess the resident's condition and then notify the physician. LVN 3 stated for a resident with a COC r/t edema, the LN should monitor and document for 72 hours, each shift. LVN 3 stated the LN documentation regarding edema should include presence of any pain, pitting or non-pitting, temperature of skin, and discoloration. In addition, LVN 3 stated LN documentation should include the interventions implemented r/t to the edema such as elevating the extremity or reinforcing fluid restrictions if ordered.On [DATE], at 4:23 p.m., an interview was conducted with Medical Doctor (MD). The MD stated Resident 1's edema was not typical because it is unilateral (one-sided) and was more of an urgent concern. The MD stated he wanted to find out what was causing the swelling and he ordered for US and should have ordered STAT considering the concern was that a DVT was high on the differential. The MD stated he received text message of the US report on [DATE], at 5:01 p.m., and he asked through text on [DATE], at 5:27 p.m., if the resident was on blood thinners, but did not receive response from the LN not until [DATE], at 2:49 p.m., indicating Resident 1 on apixaban. The MD stated, however, he was not informed by the LN that Resident 1's apixaban was held on [DATE] to 22, 2026.On [DATE], at 5:02 p.m., a concurrent interview and review of Resident 1's record were conducted with the Assistant Director of Nursing (ADON) and Director of Nursing (DON). The DON stated the LN was expected to document edema characteristics such as pitting/grade or non-pitting, the location/extremity, color, if any redness, warmth, pain, pulses palpable/circulation on the progress notes every shift for 72 hours following a change of condition related to a new onset or worsening edema. The DON stated the 72-hour documentation would only include detailed description of the edema if the edema was worsening. The DON stated the LN was expected to document and notify the physician if edema was worsening. A concurrent review of Resident 1's COC/eINTERACT Assessment Evaluation on [DATE], the ADON verified that the LN did not document how severe Resident 1's left arm/hand pitting edema was. The ADON stated the LN should have the pitting grade documented since pitting edema can change from pitting to non-pitting edema. The ADON stated the concern was not knowing the severity of the edema on [DATE], and for the following 72 hours, especially when Resident 1 was a dialysis resident with a dialysis port to his left upper chest. A concurrent review of Resident 1's physician orders on [DATE], for venous U/S to LUE R/T Swelling to R/O DVT one time only for 4 Days, stated the LN should have verified with MD if it should be routine or STAT and that the LN should have informed the MD that the resident was a dialysis patient. A concurrent review of Resident 1's LUE ultrasound report dated [DATE]. The ADON verified Resident 1 was positive for a DVT to the left ulnar vein. The ADON stated the facility process when receiving diagnostic test reports was the LN was expected to notify the physician and document in a progress note. The ADON verified there was no documentation notifying the MD of Resident 1's LUE ultrasound report or that Resident 1's apixaban was on hold for a dialysis procedure for two days on [DATE], and [DATE]. The ADON stated the concern was Resident 1 had an active DVT with treatment in place. The ADON stated Resident 1 was at risk because complications related to the active DVT could travel and become a pulmonary embolism. The ADON stated the LN should have documented a progress note regarding notifying the MD of Resident 1's ultrasound report and other pertinent information related to Resident 1's plan of care. The DON stated the LN should have notified both the attending MD and the nephrologist (kidney doctor) of the LUE ultrasound report. The DON stated the LN should have initiated the COC process for the new onset of the DVT identified on Resident 1's LUE ultrasound.A review of the facility's policy and procedure titled, Acute Condition Changes-Clinical Protocol, revision date [DATE], indicated, .the physician will help identify individuals with a significant risk for having acute changes of condition.during their stay.in addition, the nurse shall assess and document/report.the following baseline information.onset, duration, severity.all active diagnoses.all current medications.before contacting a physician.about someone with an acute change of condition.the nursing staff will collect pertinent details to report to the physician.the nursing staff will contact the physician based on the urgency of the situation.the nurse and physician will discuss and evaluate the situation.the staff and physician will discuss possible causes of the condition change based on factors.including resident/patient history.current symptoms.medication regimen.and diagnostic test results.the physician will help identify and authorize appropriate treatments.the staff will monitor and document the resident/patient's progress and responses 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.A review of the facility's policy and procedure titled, Lab and Diagnostic Test Results-Clinical Protocol, revision date [DATE], indicated, .when test results are reported to the facility.a nurse will first review the results.before contacting the physician, the person who is to communicate results to a physician.will gather, review, and organize the information.and be prepared to discuss the following.the individual's current condition.details of any recent changes in status.major diagnoses.current medications.actions already taken to address results and treat the resident/patient.why the diagnostic test were obtained.how test results may related to the individual's current condition and treatment.any concerns and questions the physician will be expected to address regarding the resident.a nurse will identify the urgency of communicating with the attending physician based on.the seriousness of any abnormality.and the individual's current condition.a nurse will try to determine whether the test was done.to assess a condition change.or recent onset of signs and symptoms.the nursing staff will consider the following factors to help identify situations.requiring prompt physician notification.concerning diagnostic test results.whether the resident/patient's clinical status is unclear.he/she has signs and symptoms of acute illness.or condition.is not stable or improving.facility staff should document information about when, how and to whom the information was provided and the response.this should be done in the progress notes section.of the medical record.and not on the results report.because test results should be correlated.with other relevant information .such as the individual's overall situation, current symptoms.direct voice communication with the physician.is the preferred means for presenting any results requiring immediate notification.especially when the resident's clinical status is unstable or current treatment needs review or clarification.physician decisions.when responding to notifications of test results.the physician and staff.will discuss the implications of the test results.as well as subsequent actions.new or modified medication orders.additional monitoring.A review of the facility's policy and procedure titled, Charting and Documentation, revised date [DATE], indicated, .any notable changes in the resident's medical, physical, functional or psychosocial condition.observed by staff.should be documented in the resident's medical record.the medical record is a format that facilitates communication between the interdisciplinary team.documentation that may be included in the resident medical record.objective observations.medication administered.treatment or services performed.changes in the resident's condition.documentation of procedures and treatments should include.care-specified details.the assessment data and/or any unusual findings obtained during the procedure/treatment.A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revision date [DATE], indicated, .the facility promptly notifies the resident, resident's attending physician .or provider.and the resident representative of changes.in the resident's condition and/or status.the nurse will notify the resident's attending physician, provider, or physician on call.when there has been a need to alter the resident's medical treatment significantly.specific instructions to notify the physician of changes in the resident's condition.a significant change of condition is a major decline or improvement in the resident's status that.will not normally resolve itself without intervention.prior to notifying the physician.the nurse will make detailed observations and gather relevant and pertinent information for the provider.including information prompted by the INTERACT SBAR (a simple, four-part tool used to share important information) Communication Form.the nurse will record in the resident's medical record information.relative to changes in the resident's medical/mental condition or status. 2.On [DATE], at 11:07 a.m., Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic systolic (congestive) heart failure (heart muscle is weak and enlarged causing fluid to back up lungs and legs) and chronic kidney disease, stage 4 (severe) (kidneys are severely damaged and working poorly).A review of Resident 2's Minimum Data Set (MDS- an assessment tool), dated [DATE], indicated Resident 2 had a BIMS (Brief Interview of Mental Status-a cognitive assessment tool) score of 10 (moderate cognitive impairment).A review of Resident 2's COC (Change of Condition)/eINTERACT Assessment Evaluation, dated [DATE], at 12:37 p.m., indicated, .change in condition: seems different than usual.started on [DATE].during med pass.writer noticed patient was speaking about.topics that had nothing to do with.the questions writer was asking patient.patient believed it was 2 am.when it was 7 am.reoriented patient to actual time.CNA (certified nurse assistant) also noticed that patient seemed confused.asked patient if he had any pain while urinating.patient denied pain or discomfort.notified MD (medical doctor) and family.recommendations.urinalysis with C&S (culture and sensitivity).A review of Resident 2's Progress Note:72-hour Charting, dated [DATE], at 7:25 p.m., indicated, .resident on monitoring for increased confusion.resident refused to the urine collection.x4 (four times).staff explained the risk and benefits of refusing urine collection.to rule out possible UTI.A review of Resident 2's Physician Orders, dated [DATE], indicated, .urinalysis with C&S.r/t (related to) increased confusion.A review of Resident 2's Care Plan, dated [DATE], indicated, .risk for injury.r/t confusion.resident will remain free from injury.related to altered cognition.monitor for changes in cognition and behavior.maintain a safe environment and implement safety precautions.report significant changes in mental status to the provider.order UA with C&S per MD dated [DATE].A review of Resident 2's Progress Note: Nurse's Note, dated [DATE], at 7:59 a.m., indicated, .collected urine.@ 0330 (at 3:30 a.m.) .put in specimen refrigerator.order put into.ready for pick up.A review of Resident 2's Lab Results Report, dated [DATE], indicated, .Preliminary.protein 1+.blood 3+.leukocyte esterase 3+ (high number of white blood cells in urine).red blood cells > (greater than) 30 (normal range is 0-2).white blood cells >50 (normal range is 0-4).A review of Resident 2's Progress Note: Laboratory, dated [DATE], at 11:01 a.m., indicated, .UA (urinalysis) results sent to doctor.for review.per MD.NNO (no new order) and wait for final urine culture results.A review of Resident 2's Progress Note:72-hour Charting, dated [DATE], at 10:16 p.m., indicated, .resident on monitoring for increased confusion.resident resting in stable conditions.in his bed.RR (respiratory rate) are deep, even and unlabored.resident remains confuse .asking staff to get him up.resident is unable to stand by himself.A review of Resident 2's Progress Notes, dated [DATE], at 6:15 a.m., indicated, .Resident was reported unresponsive by charge nurse at 4;25 am (a.m.) Resident was in bed, unable to arouse, not breathing, no pulse palpated.CPR (cardiopulmonary resuscitation - a life-saving emergency procedure performed when someone's breathing or heartbeat has stopped) was initiated, 911 was called.Paramedic arrived at 5 am (a.m.) and took over CPR.After 20 minutes, resident still not responding, CPR was terminated. Time of death 5:20 am (a.m.).Further review of Resident 2's record indicated there was no documented evidence of assessment of Resident 2 related to increased confusion and awaiting urine culture results, prior to Resident 2 becoming unresponsive on [DATE], at 4:35 a.m.On [DATE], at 3:15 p.m., an interview was conducted with LVN 2. LVN 2 stated the expectation with a COC was to monitor the resident for 72 hours every shift r/t the COC concern. LVN 2 stated if the condition worsened the LVN would notify the RN supervisor to assess the resident's condition and then notify the physician. On [DATE], at 5:37 p.m., a concurrent interview and record review were conducted with the Assistant Director of Nursing (ADON) and Director of Nursing (DON). A concurrent review of Resident 2's COC/eINTERACT Assessment Evaluation on [DATE], the ADON verified that Resident 2's had a change of condition related to a new onset of altered mental status with orders to obtain a urinalysis and urine culture. A concurrent review of Resident 2's Progress Note:72-hour Charting, dated [DATE], at 7:25 p.m., the ADON verified that Resident 2 refused the urine collection x4. The ADON stated the LN should have notified the physician as it could have caused the resident's condition to worsen and a delay in treatment. A concurrent review of Resident 2's Progress Note:72-hour Charting, dated [DATE], at 10:16 p.m., the ADON verified that Resident 2 was still confused. The ADON verified that there was no documentation/monitoring of the resident's altered mental status for an entire shift on [DATE] while Resident 2 was still confused and the UA results were still pending. The ADON stated the LN should have monitored the resident closely for orientation status, pain, and elimination status.A review of the facility's policy and procedure titled, Acute Condition Changes-Clinical Protocol, revision date [DATE], indicated, .the physician will help identify individuals with a significant risk for having acute changes of condition.during their stay.in addition, the nurse shall assess and document/report.the following baseline information.cognitive and emotional status.onset, duration, severity.recent labs.all active diagnoses.all current medications.before contacting a physician.about someone with an acute change of condition.the nursing staff will collect pertinent details to report to the physician.the nursing staff will contact the physician based on the urgency of the situation.the nurse and physician will discuss and evaluate the situation.the staff and physician will discuss possible causes of the condition change based on factors.including resident/patient history.current symptoms.medication regimen.and diagnostic test results.the physician will help identify and authorize appropriate treatments.the staff will monitor and document the resident/patient's progress and responses 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.A review of the facility's policy and procedure titled, Charting and Documentation, revised date [DATE], indicated, .any notable changes in the resident's medical, physical, functional or psychosocial condition.observed by staff.should be documented in the resident's medical record.the medical record is a format that facilitates communication between the interdisciplinary team.documentation that may be included in the resident medical record.objective observations.medication administered.treatment or services performed.changes in the resident's condition.documentation of procedures and treatments should include.care-specified details.the assessment data and/or any unusual findings obtained during the procedure/treatment.A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revision date [DATE], indicated, .the facility promptly notifies the resident, resident's attending physician .or provider.and the resident representative of changes.in the resident's condition and/or status.the nurse will notify the resident's attending physician, provider, or physician on call.when there has been a refusal of treatment.two (2) or more consecutive times.

Based on interview and record review, the facility failed to ensure the appropriate dosage of the medication Doxycycline (antibiotic used to treat bacterial infection) was given in treating the syphilis infection (a contagious sexually transmitted disease), for one of three residents reviewed for quality of care (Resident 1).This failure resulted in Resident 1 to not get the therapeutic dose of doxycycline required for treating the syphilis infection from March 8, 2026, to March 22, 2026, placing the resident at high risk for complications from delayed treatment.FindingsOn May 5, 2026, at 1:02 p.m., an interview was conducted with Resident 1. Resident 1 stated the following:- Sometime in March 2026, she was readmitted to the facility from the acute hospital Emergency Department with a diagnosis of syphilis;- She was given the medication Doxycycline for syphilis one tablet once a day for 15 days beginning March 8, 2026, until March 22, 2026.- The Doxycycline order for one tablet once a day was incorrect, she did a google search on the Doxycycline syphilis treatment and she should be getting two tablets instead of one; - She discussed with the Nurse Practitioner (NP) that she should be receiving two tablets of the medication instead of one, and the NP changed her Doxycycline dose order to one tablet twice a day for another 15 days beginning March 23, 2026.On May 5, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE].A review of Resident 1's History and Physical, dated March 16, 2026, indicated Resident 1 had the capacity to understand and make decisions.A review of Resident 1's physician's orders indicated the following:- Doxycycline Monohydrate Oral Tablet 100 MG (milligram - unit of measurement) Give 1 tablet by mouth one time a day for syphilis for 15 Days.Start date 03/08/2026. and- Doxycycline Monohydrate Oral Tablet 100 MG. Give 1 tablet by mouth two times a day for syphilis for 14 Days.Start Date 03/24/2026.A review of Resident 1's acute hospital document titled, (Name of Acute Hospital) emergency room After Visit Summary, dated March 7, 2026, indicated the laboratory test, Syphilis AB to Treponema Pallidum (type of blood test used to check for syphilis antibody) result was reactive (tested positive). The acute hospital document did not indicate a discharge order for Resident 1 to receive Doxycycline one tablet once a day for syphilis upon admission to the facility.A review of Resident 1's Progress Notes, indicated the following:- On March 8, 2026, at 2:55 p.m., Licensed Vocational Nurse (LVN) 1 documented, .LATE ENTRY.Resident to start Doxycycline monohydrate PO (by mouth) one time a day x (for) 15 days. Order was provided by (Name of Acute Hospital) Emergency room.; and- On March 8, 2026, at 2:56 p.m., LVN 2 documented, .Resident had labs done at Riverside University Health System. Reactive result for Syphilis AB to Treponema pallidum. An order was given by (Name of Acute Hospital) provider for Doxycycline r/t (related to) reactive results.(Name of Physician) and (Name of NP) aware and order to continue with medication.A review of Resident 1's NP (Nurse Practitioner) Progress Notes indicated the following:- On March 10, 2026, at 5:08 p.m., .Pt (Patient) sent out to ER (Emergency Room) and returned withing (sic.) 24 hrs (hours) for significantflank (sic.) pain . On doxy (doxycycline) for 14 days.;- On March 12, 2026, at 4:58 p.m., .Pt on doxy (doxycycline).Prior infection and trep antibodies positive.;- On March 16, 2026, at 5:54 p.m., .Impression/Plan.Syphilis.doxy for 14 days.; and- March 24, 2026, at 4:45 p.m., .Discovered pt only received doxy once a day. Incomplete tx (treatment) for syphilis and reinstated for doxy 100mg bid for 14 days.On May 6, 2026, at 12:28 p.m., an interview was conducted with LVN 1. LVN 1 stated:- He was the licensed nurse who documented the progress notes on March 8, 2026, at 2:55 p.m.;- Resident 1 informed him upon re-admission to the facility that she was given Doxycycline in the emergency room (ER) but she did not receive a discharge order for it;- He called the acute hospital ER, and received an order to continue Doxycycline one tablet one time a day for 15 days for syphilis;-He verified the order with the NP, and he received the order to carry out Doxycycline monohydrate 100 mg one tablet once a day for 15 days for syphilis.On March 6, 2026, at 3 p.m., the NP was interviewed. The NP stated:- Resident returned from the ER in March and she had an order for Doxycycline to be continued at the facility. The NP stated the discharge order from the ER was to give Doxycycline one tablet once a day for 15 days and it was carried out on March 8, 2026;- She visited the resident on March 24, 2026, and the saw the completed Doxycycline antibiotic therapy in March 22, 2026, was only given once a day and this dose was incorrect; and- The correct dose to treat the syphilis infection should have been Doxycycline monohydrate 100 mg one tablet by mouth two times a day for 15 days. She placed an order for the resident to continue with this dose on March 24, 2026. The DailyMed (an online drug reference for prescription and non-prescription drugs) indicated, .Patients who are allergic to penicillin should be treated with doxycycline 100 mg, by mouth, twice a day for 2 weeks. obtained from the U.S National Library of Medicine (NLM) DailyMed database, updated September 19, 2025.

Based on observation, interview, and record review, the facility failed to ensure a safe environment was provided, for four of four residents, when the residents were smoking in an area not designated for smoking and without supervision, according to the facility's smoking contract.This failure has the potential to place the residents for smoking-related safety risks. Findings:On March 30, 2026, at 12:15 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse and quality of care issues.On April 3, 2026, at 10:05 a.m., arrived at the facility and observed four residents sitting on their wheelchair in front of the facility off to the left in the parking area. The four residents were observed to be smoking. In a concurrent interview with the four residents, they stated they were not allowed to smoke outside in front of the facility.On April 3, 2026, at 10:20 a.m., during an interview with the Administrator (ADM), the ADM stated the back of the facility is the designated area for smoking and being supervised by the staff. The ADM stated the residents were not allowed to smoke in front of the facility, or other areas that were not designated for smoking. The ADM stated the residents were being evaluated if able to smoke independently and then to sign a contract. The ADM stated if the residents who do not follow the contract for smoking, they would lose their smoking privileges.On April 3, 2026, at 3:20 p.m., Resident 1 was interviewed. Resident 1 stated he was one of the four residents smoking in front of the facility. Resident 1 stated he usually does not smoke but was approached by the other residents and started smoking in front of the facility. Resident 1 stated he was aware they were not allowed to smoke out front but only the designated area.On April 3, 2026, Resident 1's record was reviewed. A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar levels).A review of Resident 1's History and Physical, dated November 21, 2025, indicated the resident has the capacity to understand and make decisions.A review of the facility's policy and procedure titled, Smoking Contract, indicated, .This facility has established and maintains safe resident smoking practices.Prior to, and upon admission, residents are informed of the facility's smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences.Smoking is only permitted in the designated resident smoking area located in the back patio next to room [ROOM NUMBER].

Based on observation, interview, and record review, the facility failed to ensure residents are free from verbal abuse from staff, for one of four residents reviewed (Resident 3).This failure had the potential for Resident 3 to experience emotional and psychosocial distress related to verbal abuse from staff.Findings:On March 30, 2026, at 12:15 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse.On April 3, 2026, at 3 p.m., during an interview with Resident 3, the resident stated Certified Nursing Assistant (CNA) 1 provided care to her a week ago during the NOC (11 p.m. to 7 a.m.) shift. Resident 3 stated CNA 1 threw the wipes at her groin and looked at her disgusted and CNA 1 told her, Looks like the diaper does not fit, you are too fat, and left the room. Resident 3 further stated CNA 1 talked to CNAs 2 and 3 outside her door and called the resident the fat bitch and the CNAs started laughing. Resident 3 stated she told the social services staff and filed a complaint the next day. Resident 3 stated CNA 1 was not suspended and continued to work and would smirk at her when CNA 1 saw her.A review of Resident 3's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which indicated morbid obesity (a serious, chronic disease defined by extreme excess body fat that poses severe health risks).A review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated January 7, 2026, indicated the resident has a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact).A review of facility document Grievance Report, dated March 30, 2026, indicated Resident 3 complained about CNA 1 left her during care due to brief not fitting and had an attitude. The grievance report included the Director of Staff Development (DSD) response that CNA 1 was texted on March 30, 2026, at 10:44 a.m., to work on communication skills in a professional manner. The document did not indicate the Administrator or designee conducted further investigation on what was the attitude of CNA 1 towards Resident 3. On April 3, 2026, at 3:45 p.m., the Social Services Assistant (SSA) was interviewed. The SSA stated that he did not receive any complaint from Resident 3 regarding the statement made by CNA1 about her. The SSA stated calling a resident a derogatory (comments, attitudes, or actions that are insulting, disrespectful, or intended to lower the reputation and value of a person or thing) statement is a form of verbal abuse and the expectation would be to start an investigation and remove the staff member from caring for the resident.On April 6, 2026, at 11 a.m., the Social Services Director (SSD) was interviewed. The SSD stated Resident 3 came to her office on March 30, 2026, and complained about a CNA had been in her room, changed her brief, CNA became frustrated when he could not adjust the brief to his liking, on March 29, 2026. The SSD stated she did not ask further questions and had the impression CNA 1 left Resident 3 without completing the care and could be considered neglected. The SSD stated she referred the issue to the Director of Staff Development (DSD) to follow up. The SSD stated the staff members are not allowed to speak with the resident in an inappropriate manner, that is unprofessional, and further investigation should be carried out.On April 6, 2026, at 11:30 a.m., the DSD was interviewed. The DSD stated CNA 1 was not the assigned to care for Resident 3. The DSD stated CNA 1 answered Resident 3's call light and completed the task. The DSD stated the staff member should not talk to the resident with inappropriate remarks, and it is a form of verbal abuse, and neglect if the task was not completed.On April 6, 2026, at 12:20 p.m., CNA 2 was interviewed. CNA 2 stated she worked with CNA 1 on March 29, 2026. CNA 2 stated CNA 1 went to answer Resident 3's call light and when CNA 1 came out of the resident's room and commented that he does not like fat people, that the resident was complaining about the brief did not fit her right, and joked about the resident being fat and called Resident 3 a fat bitch out in the hallway. CNA 2 stated the DSD called her earlier today and asked if she was helping CNA 1 the night before and she responded to the DSD that she was not in the resident's room during provision of care. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2001, indicated, .All reports of resident abuse.neglect, exploitation .are reported to local, state and federal agencies.and thoroughly investigated by facility management. Finding of all investigations are documented and reported.if resident abuse, neglect.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.The administrator or the individual making the allegation immediately reports his or her suspicion to.the state licensing/certification agency responsible for surveying/licensing the facility.immediately.within two hours of an allegation involving abuse or result in serious bodily injury.Upon receiving any allegations of abuse.the administrator is responsible for determining what actions (if any) are needed for the protection of residents.All allegations are thoroughly investigated.Any employee who has been accused of resident abuse is placed on leave with resident contact until the investigation is complete.The individual conducting the investigation.interviews the person(s) reporting the incident.interviews any witnesses to the incident.interviews the resident.staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated.

Based on interview and record review, the facility failed to ensure the facility's policy on abuse was implemented on conducting a thorough investigation when Resident 3 alleged she heard a Certified Nursing Assistant (CNA) made derogatory statements about her to other staff. This failure had the potential for a delay in the investigation of Resident 3's abuse allegation and could subject the resident and other residents for further abuse by the CNA. Findings:On March 30, 2026, at 12:15 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse and quality of care issues.On April 3, 2026, at 3 p.m., during an interview with Resident 3, the resident stated Certified Nursing Assistant (CNA) 1 provided care to her a week ago during the NOC (11 p.m. to 7 a.m.) shift. Resident 3 stated CNA 1 threw the wipes at her groin and looked at her disgusted and CNA 1 told her, Looks like the diaper does not fit, you are too fat, and left the room. Resident 3 further stated CNA 1 talked to CNAs 2 and 3 outside her door and called the resident the fat bitch and the CNAs started laughing. Resident 3 stated she told the social services staff and filed a complaint the next day. Resident 3 stated CNA 1 was not suspended and continued to work and would smirk at her when CNA 1 saw her.A review of Resident 3's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which indicated morbid obesity (a serious, chronic disease defined by extreme excess body fat that poses severe health risks).A review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated January 7, 2026, indicated the resident has a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact).A review of facility document Grievance Report, dated March 30, 2026, indicated Resident 3 complained about CNA 1 left her during care due to brief not fitting and had an attitude. The grievance report included the Director of Staff Development (DSD) response that CNA 1 was texted on March 30, 2026, at 10:44 a.m., to work on communication skills in a professional manner. The document did not indicate the Administrator or designee conducted further investigation on what was the attitude of CNA 1 towards Resident 3. On April 3, 2026, at 3:45 p.m., the Social Services Assistant (SSA) was interviewed. The SSA stated that he did not receive any complaint from Resident 3 regarding the statement made by CNA1 about her. The SSA stated calling a resident a derogatory (comments, attitudes, or actions that are insulting, disrespectful, or intended to lower the reputation and value of a person or thing) statement is a form of verbal abuse and the expectation would be to start an investigation and remove the staff member from caring for the resident.On April 6, 2026, at 11 a.m., the Social Services Director (SSD) was interviewed. The SSD stated Resident 3 came to her office on March 30, 2026, and complained about a CNA had been in her room, changed her brief, CNA became frustrated when he could not adjust the brief to his liking, on March 29, 2026. The SSD stated she did not ask further questions and had the impression CNA 1 left Resident 3 without completing the care and could be considered neglected. The SSD stated she referred the issue to the Director of Staff Development (DSD) to follow up. The SSD stated the staff members are not allowed to speak with the resident in an inappropriate manner, that is unprofessional, and further investigation should be carried out.On April 6, 2026, at 11:30 a.m., the DSD was interviewed. The DSD stated CNA 1 was not the assigned to care for Resident 3. The DSD stated CNA 1 answered Resident 3's call light and completed the task. The DSD stated the staff member should not talk to the resident with inappropriate remarks, and it is a form of verbal abuse, and neglect if the task was not completed.On April 6, 2026, at 12:20 p.m., CNA 2 was interviewed. CNA 2 stated she worked with CNA 1 on March 29, 2026. CNA 2 stated CNA 1 went to answer Resident 3's call light and when CNA 1 came out of the resident's room and commented that he does not like fat people, that the resident was complaining about the brief did not fit her right, and joked about the resident being fat and called Resident 3 a fat bitch out in the hallway. CNA 2 stated the DSD called her earlier today and asked if she was helping CNA 1 the night before and she responded to the DSD that she was not in the resident's room during provision of care. On April 6, 2026, at 12:50 p.m., during a concurrent interview and review of Resident 3's grievance form with the Administrator (ADM), the ADM stated the grievance placed by Resident 3 should have been investigated thoroughly.A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2001, indicated, .All reports of resident abuse.neglect, exploitation .are reported to local, state and federal agencies.and thoroughly investigated by facility management. Finding of all investigations are documented and reported.if resident abuse, neglect.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.The administrator or the individual making the allegation immediately reports his or her suspicion to.the state licensing/certification agency responsible for surveying/licensing the facility.immediately.within two hours of an allegation involving abuse or result in serious bodily injury.Upon receiving any allegations of abuse.the administrator is responsible for determining what actions (if any) are needed for the protection of residents.All allegations are thoroughly investigated.Any employee who has been accused of resident abuse is placed on leave with resident contact until the investigation is complete.The individual conducting the investigation.interviews the person(s) reporting the incident.interviews any witnesses to the incident.interviews the resident.staff members (on all shifts) who have had contact with the resident during the period of the alleged incident.If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated.

Based on observation, interview, and record review, the facility failed to ensure medications were assessed/evaluated for continued use, for one of three residents reviewed (Resident 2), when propranolol (medication to treat high blood pressure) was held multiples times during the months of February, March, and April 2026.In addition, propranolol was administered to Resident 2 when the SBP (systolic blood pressure - the top number in a blood pressure reading which is the highest pressure in your arteries, measured in mmHg (millimeters of mercury) when the heart muscle contracts and pumps blood) < (less than) 110, according to the physician's order.These failures had the potential to place Resident 2 at risk for unnecessary medication and to experience adverse reactions of low blood pressure. Findings:On March 30, 2026, at 12:15 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse and quality of care issues.On April 3, 2026, at 1:25 p.m., Resident 2 was interviewed inside the resident's room. Resident 2 stated she rarely takes her propranol because she has low blood pressure.On April 3, 2026, a review of Resident 2's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues).A review of Resident 2's History and Physical, dated December 27, 2025, indicated the resident has the capacity to understand and make decisions.A review of Resident 2's Order Summary Report, included a physician's order, dated December 24, 2025, which indicated, .Propranolol HCl (hydrochloride) Oral Tablet 20 MG (milligram - unit of measurement).Give 1 (one) tablet by mouth in the morning for Hypertension (high blood pressure) Hold if SBP (systolic blood pressure - the top number in a blood pressure reading which is the highest pressure in your arteries, measured in mmHg (millimeters of mercury) when the heart muscle contracts and pumps blood) < (less than) 110 or HR < 60.A review of Resident 2's Medication Administration Record, for the months of February, March, and April 2026, indicated Propranolol was not administered to Resident 2 because SBP was below 110 on the number of times per month:-February 2026 = 21 out of 28 times per month;-March 2026 = 22 out of 31 times per month; and-April 2026 = seven times (April 1 to 7, 2026).A review of Resident 2's Medication Administration Record (MAR), for the months of February and March 2026, indicated Propranolol was administered to the resident when the SBP was below 110 on the following dates:-February 13, 2026; SBP = 108;-February 25, 206; SBP= 90;-March 2, 2026; SBP = 88;-March 10, 2026; SBP = 97; and-March 15, 2026; SBP = 100.On April 6, 2026, at 4:10 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the physician should be notified if the resident's medication was being held multiple times because it was outside parameter to evaluate the need of the medication. The ADON stated the licensed nurse should follow the physician's order to hold the medication if it is outside the vital signs parameter, to prevent having the resident's blood pressure going so low for resident safety.A review of the facility's policy and procedure titled, Administering Medication, dated April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed.The following information is checked/verified for each resident prior to administering medications.Vital signs, if necessary.

Based on observation, interview, and record review, the facility failed to ensure Eliquis (blood thinner medication) was resumed 48 hours post (after) procedure, as ordered by the physician, for one of seven residents reviewed (Resident 1).This failure had the potential to increase the resident's risk of developing blood clots and placed the resident at risk for further complications. Findings:On March 17, 2026, at 12:45 p.m., an unannounced visit was conducted at the facility to investigate a complaint involving quality of care. On March 17, 2026, at 4:29 p.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was observed in bed, alert, and calm. Resident 1 stated she had a procedure to replace her suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower belly directly into the bladder to drain urine) on March 11, 2026. Resident 1 stated her Eliquis was supposed to be resumed 48 hours after her procedure on March 14, 2026. Resident 1 stated the licensed nurse (LN) did not administer her Eliquis as ordered by the physician on March 14, 2026, until she reminded the LN.On March 17, 2026, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (a fast, irregular heart rhythm, increasing risks of stroke and blood clots).A review of Resident 1's care plan, dated June 4, 2024, indicated, .potential for bleeding or abnormal bruising.r/t (related to) .use of Eliquis.r/t diagnosis Afib (Atrial fibrillation) .will minimize ASE (Adverse Side Effect) .from medication.Medication as ordered.A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated February 14, 2026, indicated Resident 1 had a BIMS (Brief Interview of Mental Status - a cognitive assessment tool) score of 15 (cognitively intact - able to understand and make decisions). A review of Resident 1's medical records indicated the following physician orders:- Eliquis Oral Tablet 5 milligrams (mg - unit of measurement), (Apixaban) Give 5 mg by mouth two times a day for atrial fibrillation, date ordered June 4, 2024; - Appointment for suprapubic catheter placement on March 11, 2026, at 8 a.m., date ordered February 16, 2026;- Eliquis 5 mg hold from March 9, 2026, to March 12, 2026, date ordered on February 16, 2026;- Eliquis 5 mg hold from March 12, 2026, for two days (March 14, 2026, at 8:59 a.m.) post procedure, date ordered March 12, 2026;A review of Resident 1's Medication Administration Record (MAR), dated March 2026, indicated,-Eliquis was held on March 9, 2026, 6 am dose, to March 14, 2026, at 6 a.m. dose;-Eliquis 5 mg was administered on March 14, 2026 at 10:22 a.m.A review of Resident 1's written physician order, dated March 12, 2026, at 11 a.m., indicated, .Resume Eliquis sat (Saturday) AM (morning).A review of Resident 1's Nurse's Notes, dated March 14, 2026, at 11 a.m., indicated, .resident stated her Eliquis.was supposed to be held for 48 hours.and restarted today.undersigned after research discovered order written by NP (Nurse Practitioner).to resume Eliquis Saturday.medication given to resident by charge nurse.On March 18, 2026, at 11:15 a.m., a concurrent interview and record review were conducted with the Assistant Director of Nursing (ADON) and Director of Nursing (DON). The ADON stated the facility's process when a resident returns from a follow up appointment or procedure was to review the after-visit summary then verify any orders or instructions with the appointment physician. The ADON stated the LN would then verify the new orders with the attending physician and enter orders in the resident's electronic medical record (EMR). The ADON verified Resident 1's physician order to resume Eliquis 5 mg on March 14, 2026, was not followed as ordered by the physician. The ADON stated the LN should have administered Resident 1's Eliquis at 6:00 a.m., on March 14, 2026.A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated, .medications are administered .in accordance .with prescriber orders .medications are administered within one (1) hour .of their prescribed time .

Based on interview and record review, the facility failed to implement interventions to address aggressive behavior towards other residents were provided, for one of seven sampled residents (Resident 4), when Resident 4 continued to have aggressive behavior towards other residents placed in the room with Resident 4. In addition, the facility continued in assigning a roommate to Resident 4, even after a trigger for the resident's aggressive behavior had been identified.This failure resulted in foreseeable risk of harm, escalation of behaviors and decline in the resident's psychosocial well-being. Findings:On March 17, 2026, Resident 4's medical record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (a progressive brain disease that destroys memory and thinking skills), dementia (loss of brain function impacting memory, thinking, and daily tasks), and psychosis (when a person has trouble telling the difference between what's real and what's not).A review of Resident 4's Psychologist Progress Note: CHE Behavioral Health, dated April 4, 2025, indicated, .SSD (Social Services Director) reported the patient .expressing a desire to physically harm .his roommate .history of present illness .the patient continued .to express that his roommate .does not belong in his room .he wants to kill him .for stealing his space .difficult to redirect .does not understand that .he is not at home .due to cognitive impairment .A review of Resident 4's Psychiatry Progress Note, dated December 5, 2025, indicated, .patient recently attacked his roommate .wanting to kick him out of room .each time a new resident is placed in his room .will need psychotropic (medications that change how the brain works, affecting mood, thoughts and behavior) med (medication) adjustment .or patient may hurt himself .or others .A review of Resident 4's History & Physical, dated December 11, 2025, indicated, .started to have episodes of altered mental status.with episodes of aggression and verbally abusive behavior.was sent out to the emergency department.for further evaluation.of these behavioral changes.representing a change from his baseline.functioning at the facility.assessment and plan.monitor for worsening behaviors.does not have the capacity to understand and make decisions. A review of Resident 4's care plan, dated January 24, 2025, indicated, .Altered Behavior Pattern: Resident is at risk for behavioral symptoms (i.e. striking out, grabbing others, combative, verbally, or physically abusive.).Interventions.Document and record behavioral episodes.Manage environmental factors to optimize comfort.Observe and document changes in behavior, including frequency of occurrence and potential triggers.Observe whether the behavior endangers the resident and/or others. (Intervene if necessary; removing others from the surrounding area.Reduce stimulation.A review of Resident 4's care plan, dated December 1, 2025, indicated, .Resident involved in altercation.Aggression towards peer: resident (B) was holding a butter knife against resident's (A) chest.Both residents separated immediately and placed on monitoring for emotional and psychosocial distress.Further review of Resident 4's care plans showed no new interventions for aggressive behavior beyond separating the residents.A review of Resident 4's Psychiatry Progress Note, dated December 19, 2025, indicated, .patient seen for an urgent psychiatry re-evaluation.patient seen pacing back and forth.talking to himself in Spanish.attempted to speak to patient.patient used curse words.patient does not like having a roommate.becomes aggressive.attacks staff or resident that is placed in his room.patient is angry.with disorganized thoughts and speech.behavior: agitated.speech: pressured yelling.mood: irritable.plan: continue Ativan 0.5 mg po (by mouth) q6h (every 6 hours) prn (as needed) for anxiety m/b anxiousness with inability to relax.monitor and report.any changes in behaviors/mood to Psychiatry for urgent evaluation.A review of Resident 4's Psychiatry Progress Note, dated January 9, 2026, indicated, .patient seen standing at the doorway of his room .per translator .cursing in Spanish .with other erratic speech .not allowing staff in his room .to setup for new resident to move in .will need psychotropic med adjustment .or patient may hurt himself .or others .A review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated January 21, 2026, indicated Resident 4 had a BIMS (Brief Interview of Mental Status-a cognitive assessment tool) score of 3 (severe cognitive impairment). A review of Resident 4's Progress Notes, indicated the following: -March 12, 2026, at 8:20 p.m., .Anger issue towards having a room mate noted at 17:35 (5:35 p.m.) today while LVN (Licensed Vocational Nurse) passing medication. Pt (patient was given education regarding having a room mate. Pt refused to follow instruction.-March 14, 2026, at 11:29 p.m., .Resident displayed multiple out burst (sic) unable to calm self down.resident is not easily redirected.Roommates room changed d/t (due to) incompatibility.-March 15, 2026, at 11:40 p.m., .Resident displayed multiple out burst unable to calm self down.Resident is noted cursing staff and roommate and requires staff to defuse (sic) situation by leaving until resident is calm.-March 16, 2026, at 2:05 p.m., .Resident's daughter, (name of family member), arrived at approximately 1:00 p.m. to drop off food for the resident. During her visit, she observed the resident displaying antagonistic behavior toward his roommate. The roommate later approached staff requesting a room change due to ongoing incompatibility. According to the roommate, the resident had been behaving in a hostile manner, including repeatedly opening the roommate's privacy curtain, turning the lights on and off, and moving the roommate's personal belongings. Staff intervened and redirected the resident to prevent further escalation. Due to continued behavior and the roommate's request, the roommate was relocated to another room.;-March 16, 2026, at 3:10 p.m., .patient noted exhibiting antagonizing behavior toward roommate creative (sic) disruptive environment by standing over patient, turning on and off lights, not allowing privacy for patient, staff attempted verbal redirection and escalation, however patient continued behavior toward roommate despite interventions. Due to ongoing behaviors and inability to redirect, MD (physician) was notified and decision made to transfer to (name of general acute care hospital) for psych (psychiatric) eval (evaluation).resident continued using profanity towards staff and transportation staff, unable to be redirected.Further review of Resident 4's record indicated there was no documented evidence the facility addressed the resident's behavior of anger outbursts and antagonizing behavior towards roommates and continued to place a roommate with Resident 4. On March 17, 2026, at 3:40 p.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed inside his room watching television. In a concurrent interview, Resident 2 stated he was admitted to the facility on [DATE], and was roomed with Resident 4. Resident 2 stated Resident 4 was disruptive and was using profanity towards him when he was admitted to the room on March 15, 2026. Resident 2 stated Resident 4 touched his feet while he was laying in bed, was walking around the room while looking at him, was waving his finger, opening and closing the privacy curtain, turning the lights on and off. Resident 2 stated he felt scared at that time but felt safe now that Resident 4 was sent to the hospital.On March 19, 2026, at 1:01 p.m., an interview was conducted with LVN (Licensed Vocational Nurse) 1. LVN 1 stated Resident 4 always had issues with his roommates after his wife passed away. LVN 1 stated Resident 4 would complain that he didn't want a roommate in his room. LVN 1 stated Resident 4's behavior issues were only when he had a roommate. LVN 1 stated if Resident 4 had his own room it would have been a calmer environment for the resident.On March 20, 2026, at 12:26 p.m., a group interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON stated Resident 4 has behavior of anger outbursts towards any roommate placed with Resident 4. The DON stated the facility did not implement interventions to prevent Resident 4's triggered behavior of anger outburst towards roommates as they could not provide a private room for the resident. The DON stated the staff should have monitored Resident 4 frequently and should have provided one on one monitoring to ensure residents' safety if a roommate was to be placed with Resident 4.A review of the facility's policy and procedure titled, Behavioral Health Services, revised February 2019, indicated, .the facility will provide .residents will receive .behavioral health services .as needed to attain or maintain .the highest practicable .physical, mental and psychosocial well-being .in accordance with the comprehensive assessment .plan of care .behavioral health services .are provided to residents .as needed as part of the interdisciplinary, person-centered approach to care .staff must promote dignity .autonomy .privacy .safety .as appropriate for each resident .staff training regarding behavioral health services includes .recognizing changes in behavior .implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs .monitoring care plan interventions and reporting changes in condition .A review of the facility's policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, revised February 2025, indicated, .resident will have minimal complications associated with the management of .altered or impaired behavior .new onset or changes in behavior .are evaluated and documented .regardless of the degree of risk to the resident or others .the interdisciplinary team (IDT - a group of healthcare professionals) thoroughly evaluates new or changing behavioral symptoms .to identify causes and address any modifiable factors .that may have contributed to the resident's change in condition .including .environmental factors .alteration in routine .sleep disturbances .noise .the IDT evaluates behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident .develops a plan of care accordingly .safety strategies are implemented immediately .if necessary to protect the resident and others from harm .the care plan includes .a description of the behavioral symptoms .targeted and individualized interventions for the behavioral and/or psychosocial symptoms .the rationale for the interventions and approaches .specific and measurable goals for targeted behaviors .how staff will monitor the effectiveness of the interventions .non-pharmacologic approaches are used to the extent possible .to avoid or reduce the use of psychotropic medications to manage behavioral symptoms .the IDT monitors for and documents any new, worsening, or improved symptoms in the resident's behavior, mood, and function .Interventions are adjusted based on the impact on behavior and other symptoms .

Based on observation, interview, and record review, the facility failed to ensure, for one of four residents reviewed for quality of care (Resident 5):1. A physician's order to schedule a follow up orthopedic (branch of surgery concerned with conditions involving the musculoskeletal system) appointment, related to left shoulder rotator cuff tear (RCT - injury to the group of muscles and tendons that stabilize the shoulder causing pain, weakness, and limited arm movement) was done.This failure resulted to the delay treatment and services, putting Resident 5 at high risk for complications from the left shoulder rotator cuff tear; and2a. An assessment was conducted and documented prior to obtaining an order to increase dose in Gabapentin (medication used to relieve nerve pain) on November 11, 2025. This failure placed the resident at risk for complications due to lack of assessment to meet the resident's appropriate needs; and2b. An assessment was conducted prior to obtaining an order for neurology referral for Resident 5 on December 12, 2025.These failures had the potential to place Resident 5 at risk for complications if needs were not appropriately met due to insufficient information on required resident's health care needs.Findings:On January 14, 2026, at 8:15 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care.1.On January 14, 2026, at 8:30 a.m., an observation with a concurrent interview was conducted with Resident 5. Resident 5 was observed in bed, alert, and conversant. Resident 5 stated he had limited movement and some pain in the left shoulder due to an RTC sustained prior to his admission to the facility. Resident 5 stated he had been at the facility for 90 days and he had been requesting to see an orthopedic doctor related to his RCT but it was not being done.On January 14, 2026, Resident 5's medical record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses including rotator cuff tear of left shoulder and strain of muscles and tendons of the rotator cuff of left shoulder.A review of the acute hospital document, dated October 9, 2025, indicated, .Hospital course.The patient complained of left shoulder pain and overall weakness.ortho (orthopedic) was consulted and recommended outpatient follow-up.Patient had MRI (Magnetic Resonance Imaging - non invasive scan that used strong magnets, radio waves, and computer to create detailed pictures of body's internal structure, bones, and organs) of shoulder and was found to have RCT.Discharge Instructions.Follow-up Appointments.PLEASE FOLLOW UP WITH YOUR PCP (Primary Care Physician).(Name of PCP).Specialty: orthopaedic Surgery.Consult follow up timeframe: In 2-3 weeks.A review of the physician's order, dated October 10. 2025, indicated, .May have following: Consulting Provider 1: (name of physician).Specialty: Orthopaedic Surgery.Follow up Timeframe: In 2-3 weeks. Resident 5's physician order did not indicate the reason for the follow up appointment with the orthopedic doctor.A review of the care plan dated October 10, 2025, indicated, .Musculoskeletal Disorder: Resident is a risk for pain, joint stiffness, and/or spontaneous/pathological fracture related to.Rotator cuff tear of left shoulder. The care plan did not indicate Resident 5's physician's order to see an orthopedic doctor in two to three weeks.In addition, there was no documented evidence that an appointment was scheduled for Resident 5 to see an orthopedic doctor in two to three weeks from the time it was ordered on October 10, 2025.On January 14, 2026, at 10:05 a.m., an interview with a concurrent record review was conducted with Registered Nurse (RN) 1. RN 1 stated Resident 5 had an admission order for an orthopedic follow-up within two to three weeks from October 10, 2025, but there was no record of the appointment being scheduled in that timeframe. RN 1 stated Resident 5's physician order to see an orthopedic doctor did not specify the reason for the follow-up appointment, and the order was not included in the care plan. RN 1 stated Resident 5's appointment to see the orthopedic doctor was not scheduled until February 2026.On November 14, 2025, at 11:23 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the following:- Resident 5's physician's order, dated on October 10, 2025, for an orthopedic consult was not done as ordered;- The staff were expected to call and set up an appointment within 72 hours after the order was made. The DON stated no one from the facility made the call;-The licensed nurse should have indicated the reason for the orthopedic consult in the physician's order and added the order in the care plan. The DON stated this was not done; and- Resident 5 not seeing the orthopedic doctor in two to three weeks as ordered by the physician on October 10, 2025, resulted in the delay of treatment care and services to Resident 5.A review of the facility's policy and procedure titled, Referrals, Social Services, dated December 2008, indicated, .Social services personnel shall coordinate most resident referrals with outside agencies.Referrals for medical services must be based on physician evaluation of resident need and a related physician order.Social services will collaborate with the nursing staff or other pertinent discipline to arrange for services that have been ordered by the physician.A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person- Centered, dated March 2022, indicated, .A comprehensive person-centered care plan that inlcuded measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being.which professional services are responsible for each element of care.Assessments of residents are ongoing and care plans are revised as information about the residents and resident's condition change.2a. On January 14, 2026, at 8:15 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care.On January 14, 2025, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses including neuropathy (nerve damage that can cause symptoms like pain, numbness, or muscle weakness).Resident 5 had an admission physician's order, dated October 10, 2025, to give Gabapentin 100 milligrams (mg - unit of measurement) three times a day orally for neuropathy (Order discontinued November 10, 2025).A review of the physician's order, dated October 10, 2025, indicated to monitor Resident 5's pain level every shift.A review of the physician's order, dated November 10, 2025, indicated to give Resident 5 Gabapentin 300 mg orally three times a day for neuropathy.A review of the Pain Level Summary, dated October 27, 2025, to November 10, 2025, indicated Resident 5's pain level every shift was at 0.There was no documented evidence of an assessment conducted by the licensed nurse prior to obtaining an order to increase the dose of Gabapentin from 100 mg three times a day to 300 mg three times a day on November 10, 2025. In addition, the licensed nurse did not document the rationale for the increased dose of Gabapentin.On January 14, 2026, at 11:20 a.m., an interview with a concurrent record review was conducted with Registered Nurse (RN) 1. RN 1 stated the following:- Resident 5 had a current order for Gabapentin 300 mg orally to be given three times a day for neuropathy (Order Date November 10, 2025);- Licensed Vocational Nurse (LVN) 1 carried out the order on November 10, 2025, to discontinue the Gabapentin 100 mg orally by mouth three times a day and increase the dose of Gabapentin to 300 mg by mouth three times a day but did not document in the progress notes of an assessment conducted and the indication for the increased Gabapentin dose; and- LVN 1 should have documented in the progress notes the reason for the increased dose of Gabapentin.On November 14, 2025, at 11:23 a.m., an interview with a concurrent record review was conducted with the Director or Nursing (DON). The DON stated LVN 1 should have conducted an assessment and documented in the nursing progress notes the reason why Resident 5's Gabapentin dose was increased on November 10, 2025.On January 14, 2026, at 11:30 a.m., an interview was conducted with LVN 1. LVN 1 stated:- He was the licensed nurse who obtained and carried out Resident 5's physician order to increase the dose of Gabapentin to 300 mg orally three times a day for neuropathy on November 10, 2025;- During his shift on November 10, 2025, Resident 5 asked LVN 1 to call his physician because his medication for pain (Gabapentin) was not working with his neuropathy.- He called Resident 5's physician and obtained the order to increase the dose from Gabapentin 100 mg orally three times a day to 300 mg orally three times a day;- He did not perform an assessment before obtaining an order to increase the dose. LVN 1 stated he should have conducted a pain assessment on Resident 5 prior to obtaining the order.A review of the facility's policy and procedure titled, Pain Assessment and Management, dated 2001 indicated, .Pain management is a multidisciplinary process that included the following. Identifying signs an symptoms of and assessing existing pain.identifying the underlying causes, intensity, duration type, and characteristics of pain.developing and implementing approaches to pain management based on accepted standards of practice.modifying approaches as necessary.Steps in Procedure.Recognizing pain.Assessing pain.Identifying underlying Causes of Pain.Defining Goals and Appropriate Interventions.Implementing Pain Management Strategies.Monitoring and Modifying Approaches.2b. On January 14, 2026, at 8:15 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care.On January 14, 2025, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses including neuropathy (nerve damage that can cause symptoms like pain, numbness, or muscle weakness).The physician's order, carried out by Licensed Vocational Nurse (LVN) 2 on December 12, 2025, indicated, .Resident may have referrals for neurology.There was no documented evidence of an assessment conducted indicating the need to refer Resident 5 to a neurologist on December 5, 2025, and there was no documented evidence of a care plan developed to address the physician's order for neurology referral.On January 14, 2026, at 10:50 a.m., an interview with a concurrent record review was conducted with Registered Nurse (RN) 1. RN 1 stated LVN 2 did not document the progress notes the reason why a neurologist referral was needed for Resident 5 and the order for neurology referral was not care-planned. RN 2 stated LVN 2 did not document the reason for the neurology consult so he did not know what it was for.On January 14, 2026, at 10:55 a.m., an interview with concurrent record review was conducted with the Director of Nursing (DON). The DON stated there was no assessment conducted and documentation in the progress notes why a neurology referral was needed for Resident 5. The DON stated LVN 2 should have documented in the progress notes why a neurology referral was needed for Resident 5 and he should have added this order in the care plan so then nurses know what they are addressing.On January 14, 2025, at 11:05 a.m., an interview was conducted with LVN 2. LVN 2 stated:- He was the licensed nurse who carried out the order for neurology referral for Resident 5 on December 12, 2025;- He called Resident 5's physician because Resident 5 informed him that he wanted to be seen by a neurologist because of his neuropathy;- He did not document the reason for the neurology referral, nor did he add it to Resident 5's care plan. LVN 2 stated he should have done these.A review of the facility's policy and procedure titled, Referrals, Social Services, dated December 2008, indicated, .Referrals for medical services must be based on physician evaluation of resident need and a related physician order.A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person- Centered, dated March 2022, indicated, .A comprehensive person-centered care plan that inlcuded measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being.which professional services are responsible for each element of care.Assessments of residents are ongoing and care plans are revised as information about the residents and resident's condition change.

Based on observation, interview, and record review, the facility failed to ensure, for one of three residents (Resident 1):1. An environment free from accident hazards, when a resident (Resident 1) was able to gain access and ingest a packet of hydrocortisone (steroid ointment) without the staff knowledge. This failure resulted in the hydrocortisone packet getting lodged to the resident's throat causing the resident to choke while eating, which could subsequently obstruct the resident's airway leading to a loss of consciousness and death. Resident 1 was transferred to the general acute hospital (GACH), for evaluation and treatment; and2. The incident related to finding the hydrocortisone packet lodged in the resident's throat was thoroughly investigated. This failure placed the resident at risk of recurrence and further harm. Findings:On August 7, 2025, at 9:28 a.m., an observation was conducted with Resident 1. Resident 1 was observed sitting in a wheelchair in the dining room. Resident 1 was alert but not responding to interviews.On August 7, 2025, Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included right side hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of body), and dementia (memory loss).A review of Resident 1's Progress Notes, dated July 30, 2025, indicated Resident 1 did not have the capacity to understand and make decisions.A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated May 11, 2025, indicated Resident 1 had a BIM (Brief Interview for Mental Status) Score of 3 (meant severe cognitive impairment). The MDS data further indicated Resident 1 was non-ambulatory and needed .substantial/maximal assistance. on eating and oral hygiene.A review of Resident 1's Care Plan Report, indicated the following:- On July 2, 2023, .Focus.Resident 1 at risk for aspiration (breathing in a foreign object) r/t (related to) difficulty in swallowing.Goal.Utilize aspiration precautions and swallow safely. The care plan indicated this Focus was resolved on August 26, 2024;- On August 7, 2025, Resident 1 had .history of putting uneatable items in mouth and choking.episode 7/2/2023 (July 2, 2023).episode 7/31/2025 (July 31, 2025). The care plan was initiated and created on August 7, 2025.Further review of Resident 1's care plan indicated there was no active care plan addressing aspiration or history of putting uneatable items in mouth before the episode on July 31, 2025. A review of Resident 1's, .Change in Condition Evaluation. dated July 31, 2025, at 10:18 a.m., indicated, .Signs & (and) Symptoms Identified.other change in condition.unknown substance lodged in throat.Functional Status Evaluation.Swallowing Difficulty.Describe the swallowing difficulty.Associated with new onset or progressive choking, aspiration.A review of Resident 1's, Progress Notes, dated July 31, 2025, indicated the Resident 1 was transferred to the GACH by the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital ) on July 31, 2025, at 10:41 a.m. A review of Resident 1's GACH emergency room progress notes, dated July 31, 2025, indicated, .Patient Visit Information.You were seen today for.H/O (history of) swallowed foreign body.FOREIGN BODY REMOVAL FROM BACK OF THROAT.WE REMOVED A HYDROCORTISONE PACKET FROM THE BACK OF PATIENT'S THROAT.Foreign Object in Throat, Removed.Objects that are swallowed can get stuck in the throat.A stuck object can cause coughing, choking, pain when swallowing, or trouble swallowing.A review of Resident 1's GACH document titled, .HPI (history of present illness) - General Illness, dated July 31, 2025, at 11:22 a.m., indicated:- .Chief Complaint Swallowed a foreign body, possibly a packet of sugar.The patient has some kind of foreign body located in the posterior pharynx (cavity behind nose and mouth) it is unclear what it is at this time. Because the patient's dementia, he is unable to follow directions I am unable to remove it at this time without sedation (administer sedative drug to produce sleep or state of calm).Procedural Sedation Note.Once the patient was adequately sedated, I was able to open the patient's mouth and pulled out a small medication packet from the back of his throat. It was a packet of hydrocortisone.A review of Resident 1's Progress Notes, at the Skilled Nursing Facility (SNF), dated July 31, 2025, at 3:50 p.m., indicated Resident 1 returned to the facility from the GACH.A review of Resident 1's Order Summary Report, at the SNF, for the month of August 2025, indicated Resident 1 did not have a current order for a hydrocortisone treatment.Further review of Resident 1's record indicated there was no documented evidence of an investigation conducted to determine the cause of the incident resulting in finding a foreign object (hydrocortisone packet) in Resident 1's mouth on July 31, 2025. In addition, there was no documented evidence that the facility initiated or developed a care plan to address or prevent the incident from re-occurring since July 31, 2025.On August 7, 2025, at 10:36 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated the following:- On July 31, 2025, he saw Resident 1 in bed at around 7 a.m., and he did not notice anything unusual;- While he was passing medications on July 31, 2025, Certified Nursing Assistant (CNA) 1 alerted him that there was something lodged in Resident 1's throat while she was trying to feed him;- He could not tell what it was and tried to suction (a procedure of mechanically removing secretions, like mucus or other fluids, from a patient's airway) and get it out of Resident 1's mouth; - He called (name of an ambulance company) to send Resident 1 out to the hospital. LVN 1 stated the hospital later informed the facility it was a hydrocortisone packet lodged in Resident 1's throat; - Resident 1 did not have a current order for hydrocortisone treatment; - Resident 1 did not have a behavior of putting things into his mouth. LVN 1 stated Resident 1 can grab things, but he was wheelchair bound (non-ambulatory) and bed bound (confined in bed due to disability making it difficult or impossible to move around or leave bed);- It was not acceptable that a hydrocortisone packet was found lodged in Resident 1's throat;- The hydrocortisone packet lodged in Resident 1's throat could impact his breathing and could cause discomfort, and placed the resident's life in danger; - The incident could have been prevented by making sure Resident 1's environment was clear of choking hazards; and- Maintaining Resident 1 on close monitoring.On August 7, 2025, at 10:55 a.m., an interview was conducted with CNA 1 and she stated the following: - She was the CNA assigned to render care to Resident 1 on July 31, 2025. Resident 1 was a feeder (someone that requires assistance with being fed during meals); - She was assisting Resident 1 to eat when observed Resident 1 choking. Resident 1 was typically able to clear out his airway and cough;- She informed LVN 1 of the resident's situation and Resident 1 was transferred to the GACH; and - Resident 1 did not have a behavior of putting things in his mouth and it was not acceptable for Resident 1 to have something lodged in his throat. On August 8, 2025, at 1 p.m., a concurrent interview and record review was conducted with Treatment Nurse (TN) 1. TN 1 stated that she was the Licensed Nurses (LN) providing skin and wound treatment at Resident 1's station. TN 1 stated that the hydrocortisone medication was stored in a locked cart and at the central supply room, and there was no possibility a CNA or resident would have access to the hydrocortisone packet. On August 7, 2025, at 4:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the following: - Resident 1 had a change of condition on July 31, 2025, when Resident 1 was kinda choking. There was something in Resident 1's throat and staff thought it was a piece of paper and could not remove it; - She was not aware it was a hydrocortisone packet lodged in Resident 1's throat, and she thought it was a sugar packet; - Resident 1 was transferred to the GACH on the morning of July 31, 2025 and returned in the afternoon the same day; - Resident 1 had a history of grabbing and shoving uneatable items in his mouth and the staff were not aware of this behavior. This behavior history was not relayed to the staff;- She did not investigate to determine the cause of Resident 1's ingesting a hydrocortisone packet when it happened on July 31, 2025. The facility should have investigated the incident for Resident 1's sake and the sake of others. The DON stated regardless of what it was, the facility should have figured out why the incident happened. The DON stated the consequence of not investigating the cause of the incident in a timely manner had the potential for a re-occurrence and may cause an ill effect on Resident 1. The DON stated she should have investigated the cause of the incident the next day (August 1, 2025); - There had been no changes in Resident 1's care plan since the incident on July 31, 2025. There was no care plan addressing the incident of a hydrocortisone packet found lodged in Resident 1's throat, on July 31, 2025. There should be a care plan to address the incident to prevent recurrence. The facility's policy and procedure titled, Accidents and Incidents - Investigating and Reporting, dated July 2017, was reviewed. The policy indicated, .The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.The nurse supervisor/charge nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident.Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities .A review of the facility's policy and procedure titled, Medication Labeling and Storage, revised February 2023, indicated, .The facility stores all medications.in locked compartment.Only authorized personnel have access to keys.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications.are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility did not ensure that new medical orders were implemented in a timely manner after an orthopedic (specialty focusing on musculoskeletal system) consultation for one of one resident (Resident 2) reviewed. This failure caused a delay in treatment and services for Resident 2.Findings:On August 6, 2025, at 9:50 a.m., Resident 2 was interviewed. Resident 2 stated that his right arm was broken. Resident 2 stated that he needed to have an order from the Medical Doctor (MD) to start therapy exercises on his right arm. Resident 2 further stated that he has not had any physical therapy (PT) on his right arm since he was admitted to the facility.On August 6, 2025, at 9:45 a.m., Resident 2's medical record was reviewed. Resident 2 was admitted on [DATE], with a primary diagnosis of unspecified displaced fracture of surgical neck of right humerus (fractured upper arm bone).A review of Resident 2's, History and Physical, dated June 7, 2025, indicated Resident 2 had the capacity to understand and make decisions.A review of Resident 2's, Order Summary Report, as of August 6, 2025, indicated Resident 2 had a follow up orthopedic consult on July 30, 2025, at 11 a.m. In addition, Resident 2 had a physician's order, dated June 8, 2025, to have an arm sling to right arm to immobilize and support the arm in a comfortable position to reduce movement at the fracture site of humeral (upper arm bone).Resident 2 did not have a current active order for therapy exercises on his right arm.A review of Resident 2's, Progress Notes, dated July 30, 2025, indicated Resident 2 went out for orthopedic appointment at approximately 10 a.m. and returned to the facility at approximately 1 p.m. the same day.There was no documentation of evidence that the facility had followed up with the orthopedic doctor for new orders or recommendations that had been given for Resident 2 when he went out for his appointment with the orthopedic doctor on July 30, 2025.On August 6, 2025, at 11:05 a.m., Occupational Therapist Assistant (OTA) 1 was interviewed. OTA 1 stated Resident 2's arm had a sling, so she did arm exercises to his left arm only. OTA 1 further stated Resident 2 was admitted with a broken right arm and he should be reassessed if he needed an exercise therapy to his right arm.On August 6, 2025, at 3:30 p.m. an interview was conducted with Social Service Assistant (SSA) 1. SSA 1 stated Resident 2 had an orthopedic appointment on July 30, 2025, but there was no documentation pertaining to the visit. The SSA 1 further stated if there was no documentation of the visit, it could lead to complications and cause delays in the care or attention that Resident 2 needed. On August 7, 2025, at 2:49 p.m., an interview with a concurrent record review was conducted with SSA 1. A review of Resident 2's, Referral Letter, dated and signed by the Medical Doctor (MD) on August 7, 2025, indicated, .Reason for Referral.physical therapy for elbow and wrist 12 session.Start Date.07/31/2025.In a concurrent interview, SSA 1 stated the Physical Therapy (PT) orders (referring to the Referral Letter) from the orthopedic consultation on July 30, 2025, for the right arm were received on August 7, 2025. SSA 1 stated when a resident was sent out for an appointment, they were supposed to come back with an AVS (After Visit Summary). SSA 1 stated Resident 2 did not have an AVS when he came back from his appointment on July 30, 2025.On August 7, 2025, at 4:30 p.m., an interview with a concurrent record review was conducted with the Director of Nursing (DON). The DON stated the following:- The facility staff expects an AVS when a resident returns from an appointment and the social services and nursing were expected to follow up on the results from the consultation; - Resident 2 went out for a follow up appointment with the orthopedic doctor on July 30, 2025. The SSD did not document anything about the following up on the orthopedic doctor recommendation for Resident 2 up until August 6, 2025;- The orthopedic doctor's new orders for exercises to the right arm was ordered on July 31, 2025, and there was a seven-day delay in implementing this new order; and- The lack of follow-up on new recommendations from the doctor resulted in a delay in services for the resident and it was not acceptable.A review of Resident 2's (name of orthopedic office) consultation notes, dated July 30, 2025, indicated, .Chief Complaint.Right shoulder.Impression.IMPACTED RIGHT PROXIMAL HUMERAL NECK FRACTURE.Treatment.Referral To: Physical Therapist.Reason: physical therapy for elbow and wrist 12 sessions.Follow up.2 Weeks (Reason: repeat x-rays elbow and wrist.The facility was not able to provide their policy and procedure on following up new orders or recommendations from a consulting doctor for residents who went out for a specialty doctor appointment.

Based on observation, interview, and record review, the facility failed to ensure professional standards for food safety were upheld when:1. Several kitchen staff did not wear hairnets properly; and2. The Dishwasher did not change gloves after touching dirty kitchenware and before touching the clean and sanitized large SS pans coming from the dishwashing machine. In addition, during the dishwashing process, multiple kitchenware which had crusted food residue on them, were rinsed above and beside beverage cups and glasses.This failure had the potential to cause food-borne illness in a highly susceptible population of residents who could consume food.Findings:On June 30, 2025, at 3:05 p.m., an unannounced visit was conducted at the facility to investigate complaints regarding dietary services and infection control.On July 1, 2025, at 10:50 a.m., a concurrent kitchen observation was conducted with the Dietary Supervisor (DS). The following were observed:1. The Dietary Supervisor, Dietary Aide (DA) 1, and DA 2 were wearing hairnets that did not fully contain or cover the hair at the top and sides of their heads, as well as the nape of their necks. Hair was observed escaping the hairnets.In a concurrent interview, the DS stated she expected the kitchen staff's hair should be tucked in the hairnets, and that hairspray was suggested during training to make sure that hair stayed in place while using the hairnets.A review of the facility's undated policy and procedure titled, DRESS CODE, from Healthcare Menus Direct, LLC 20123, indicated, Hat for hair, if hair is short, which completely covers the hair.Hair net for hair, if hair is long (over the ears or longer).2a. During the dishwashing process, the DA 3, who was the dishwasher, was observed rinsing various dirty kitchenware and dishware with his gloved hand at the dirty side of the dishwashing station. The dishwashing machine to his left finished a washing cycle and 2 large stainless pans emerged from the farther side of the dishwashing machine towards the clean side of the dishwashing station. DA 3 proceeded to touch the clean and sanitized stainless steel pans without removing his dirty gloves and changing into clean ones.In a concurrent interview, DA 3 confirmed he touched the clean and sanitized kitchenware with his dirty gloves, and stated he should have changed his gloves.The DS, who witnessed the event and was concurrently interviewed, stated DA 3 should have removed his dirty gloves, washed his hands and donned new gloves before touching or handing the cleaned and sanitized stainless steel pans to avoid cross-contamination.2b. During the dishwashing process, DA 3 was observed rinsing multiple kitchenware which had crusted food residue on them using the sprayer, above and beside beverage cups and glasses which were placed upside down on the compartment glass racks/trays.In a concurrent interview, the DS stated she expected kitchen staff to scrape off the food debris from kitchenware used during the meal preparation process and soak them prior to trayline (food assembly process), and before the dishwasher came in, to make the dishwashing process easier and more efficient. In addition, the DS stated she expected the DA 3 to wash the kitchenware used for meal preparation first before washing the beverage cups and other dishware that came in from the patient care areas, to ensure dishware were not soiled with food debris from the meal preparation process.A review of the facility's undated policy and procedure titled, Dishwashing, from Healthcare Menus Direct, LLC 20123, did not indicate the procedure for transitioning from dirty to clean or clean to dirty tasks.

Based on interview and record review, the facility failed to ensure a copy of the notice of transfer/discharge was provided to the State Long-Term Care Ombudsman (assists with conflict resolution and protection of resident rights) prior to the planned discharge date , for two of two sampled residents (Residents 1 and 2). This failure had the potential to violate the resident's rights to appeal their discharge. Findings: On June 3, 2025, at 10:05 a.m., an unannounced visit was conducted at the facility to investigate a complaint on discharges. On June 4, 2025, at 1:50 p.m., during a concurrent interview and record review with the Social Services Director (SSD), the SSD stated the following information for Residents 1 and 2: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection) and sepsis (a systemic infection that triggers a dysregulated host response, leading to life-threatening organ dysfunction). Resident 1 was planned for discharge to home on April 30, 2025. The Notice of Proposed Transfer/Discharge, was provided and acknowledged by Resident 1 on April 29, 2025. A copy of the Notice of Proposed Transfer/Discharge, was sent to the Ombudsman on April 30, 2025, after Resident 1 was discharged from the facility; and 2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included heart failure. Resident 2 was planned for discharge to home on April 30, 2025. The Notice of Proposed Transfer/Discharge, was provided and acknowledged by Resident 2 on April 28, 2025. A copy of the Notice of Proposed Transfer/Discharge, was sent to the Ombudsman on April 30, 2025, after Resident 2 was discharged from the facility. The SSD further stated a copy of the Notice of Proposed Transfer/Discharge, for Residents 1 and 2 should have been provided to the Ombudsman prior to the discharge date of April 30, 2025, to ensure the Ombudsman had an opportunity to discuss with the residents to be discharged of any concerns they have. On June 4, 2025, at 3:32 p.m., during an interview with the Director of Nursing (DON), the DON stated the Case Manager (CM) coordinated all the discharge process. The DON stated the CM should have notified the Ombudsman before the resident leaves the facility. On June 4, 2025, at 3:50 p.m., during an interview with the Administrator (ADM), the ADM stated discharge documents were not provided to the Ombudsman for Residents 1 and 2. The ADM stated the CM should have provided discharge documents to Ombudsmman within the time required. A review of the facility's policy and procedure titled, Transfer or Discharge Notices, dated March 2025, indicated, .Residents )or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Ombudsman.

Based on interview and record review, the facility failed to ensure pain management was provided according to the physician's order and plan of care, for one of ten (Resident A). This failure had the potential to result in Residents A's pain to not be managed. Findings: On May 9, 2025, at 10:45 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care. On May 9, 2025, a review of Resident A ' s medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included morbid obesity (a body mass index [BMI] of 40 or higher, or a BMI of 35 or higher with obesity-related health problems). Resident A's Order Summary Report, included the following orders for pain medication and management: - .MONITOR PAIN EVERY SHIFT: DOCUMENT PAIN LEVEL: 0= no pain, 1-3=mild pain, 4-5= moderate pain, 6-9= severe pain 10=excruciating pain ., date ordered January 3, 2022; - .Percocet (a pain medication) 10-325mg (milligram-a type of measurement) .give one tablet every eight hours as needed for severe pain level of 7-10 ., date ordered January 3, 2024; - .Hydrocodone (a pain medication used to treat moderate to severe pain) 10-325 mg .give one tablet every six hours as needed for pain for 30 days ., date ordered on April 29, 2025, and re-ordered on May 29, 2025; Resident A ' s care plan, dated January 3, 2022, indicated, .Alteration in comfort related to pain .Administer pain medication as ordered . Resident A ' s IDT (Interdisciplinary team) Conference Summary, dated April 16, 2025, at 2:53 p.m., indicated, .pain medication management reviewed . Resident A's Medication Administration Record (MAR), for the month of March 2025, indicated Hydrocodone-Acetaminophen 10-325 mg one table every six hours as needed for moderate pain (4-6) was given for pain scale of 7 and above multiple times on the following months: - March 2025; four (4) times; - April 2025; 29 times; and - May 2025; 25 times. On May14, 2025, at 12:10 p.m., an interview was conducted with Resident A. Resident A stated he gets pain medications for his knees and back, he gets Norco (Hydrocodone) in the morning and the afternoon, and the Percocet about 6 a.m. and 10 p.m. Resident A stated he was getting pain medication about four times a day and the medication would help. On May 14, 2025, at 4:45 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated the physician ' s orders were not being followed as written, the pain scale number should match with the medication to be given. The DON stated Resident A was taking PRN pain medications multiple times each day, and the nurses should have called the physician and asked for one of his pain medications to be changed from as needed to scheduled and the other pain medication to be used as needed for breakthrough pain. A review of the facility ' s procedure titled Pain Assessment and Management, dated October 2022 , indicated, .help the staff identify pain in the resident, and to develop interventions that are consistent with the resident ' s goals and needs and that address the underlying causes of pain .pain management program .appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident ' s choices .chronic pain the resident ' s pain and consequences of pain are assessed at least weekly .review the medication administration record to determine how often the individual requests and receives PRN (as needed) pain medication, and to what extent the administered medications relieve the resident ' s pain .when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Residents 57 and 48, the nursing staff failed to properly clean and disinfect the shared blood pressure (BP-pressure of blood in blood vessels) cuffs and stethoscope according to the disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms), for two of four residents observed during medication administration observation; and 2. For Resident 65, Certified Nursing Assistant (CNA) 2 failed to use the disposable gown while providing high contact resident care activities, for one of 51 residents requiring Enhanced Barrier Precautions (EBP - an infection prevention practices using gowns and gloves during high-contact resident care activities to reduce the spread of multidrug-resistant organism). This failure had the potential for vulnerable residents to be exposed to cross-contamination and development of infections. Findings: 1. On March 24, 2025, at 9:01 a.m., during a medication pass observation, Licensed Vocational Nurse (LVN) 1 was observed wiping the shared automatic wrist BP cuff with a Micro-Kill One disposable wipe. LVN 1 stated he needed to wait for one minute for the BP cuff to dry. After one minute, LVN 1 applied the automatic BP cuff to Resident 57's left wrist. After obtaining Resident 57's BP reading, LVN 1 removed the automatic BP cuff from Resident 57's left wrist. LVN 1 did not disinfect the shared automatic wrist blood pressure cuff according to the manufacturer's specified contact time. On March 24, 2025, at 9:40 a.m., during a medication pass observation, LVN 4 was observed using a shared manual BP cuff and stethoscope to measure Resident 48's BP. LVN 4 was observed wiping the shared manual BP cuff and stethoscope with a Micro-Kill Bleach disposable wipe and stated, It takes three (3) minutes for the disinfectant to dry. LVN 4 did not disinfect the shared manual blood pressure cuff and stethoscope according to the manufacturer's specified contact time. On March 24, 2025, at 11:21 a.m., during an interview with the Infection Preventionist (IP), the IP stated the expectation was for nursing staff to disinfect all shared resident care equipment, such as blood pressure cuffs and stethoscopes, before and after use. The IP stated nursing staff should have looked on the disposable wipe container for the manufacturer's instructions regarding how long to let it sit. The IP stated the manufacturer instructions for Micro-Kill Bleach wipes indicated the shared resident care equipment needed to sit for three (3) minutes and the Micro-Kill One wipes needed one (1) minute. When asked to define needs to sit, the IP stated it meant the shared resident care equipment needed to air dry for one (1) or three (3) minutes depending on the manufacturer's instructions. During the same interview, the IP reviewed the manufacturer's labeled instructions on the disposable wipe bottles and acknowledged nursing staff should have been instructed to keep the shared resident care equipment wet for one (1) minute when using the Micro-Kill One wipes or three (3) minutes when using the Micro-Kill Bleach wipes to achieve contact time when they wiped shared resident care equipment according to the manufacturer's instructions. The IP stated it was important to follow the manufacturer's instructions to prevent the spread of infection. On March 24, 2025, at 4:17 p.m., during an interview with the Director of Nursing (DON), the DON stated the expectation was for nursing staff to disinfect shared resident care equipment according to the disposable wipe manufacturer's instructions. The DON stated the nursing staff needed to let the equipment stay wet according to the manufacturer's instructions. The DON stated it was important to follow the manufacturer's instructions to kill germs and prevent further spread of infection. A review of the facility's policy and procedure titled, Assistive Devices and Equipment, dated January 2020, indicated, .equipment that is designated as reusable or shared is used by more than one resident .Durable medical equipment (DME) is cleaned and disinfected before being reused by another resident and decontaminated according to manufacturer's instructions . A review of the manufacturer's instructions for contact time for the Micro-Kill One disposable wipes provided by the facility, the manufacturer's instructions indicated, .Contact time: Allow surface to remain wet for 1 full minute . A review of the manufacturer's instructions for contact time for the Micro-Kill Bleach disposable wipes provided by the facility, the manufacturer's instructions indicated, .Contact time: Allow surface(s) to remain visibly wet for 30 seconds to kill the bacteria and viruses on the label . 29623 2. On March 23, 2025, at 12:22 p.m., Resident 65's room was observed with an EBP sign posted outside the door. Resident 65 was observed asleep with the dressing on his head, oxygen at two liters per minute through nasal cannula (a small thin plastic tube with a prong connected to the nose that delivers oxygen), and a urinary indwelling catheter (a thin flexible tube inserted into the bladder to drain urine). A review of Resident 65's Admission Record, indicated Resident 65 was readmitted to the facility on [DATE], with diagnoses which included burns involving 20-29 % (percent) third degree of body surface, pressure ulcer of the head, and post colostomy (an opening in the abdominal wall to divert the stool from the colon directly to the outside of the body). A review of Resident 65's Order Summary Report, included a physician's order, dated February 12, 2025, which indicated, .Enhanced barrier precautions during high contact resident care activities secondary to (Chronic Wound/Colostomy/Foley), every shift . A review of Resident 65's care plan, dated June 14, 2024, indicated, .Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities .Interventions .Utilize .gown and gloves .as indicated .during high-contact resident care activities (e.g. dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care . On March 24, 2025, at 11:46 a.m. Resident 65 was observed lying in bed with his eyes closed, with oxygen on at two liters per minute through nasal cannula, head wound dressing intact, and a urinary indwelling catheter. CNA 2 was observed providing care to Resident 65 without a disposable gown. On March 24, 2025, at 11:58 a.m., CNA 2 was interviewed. CNA 2 stated she was aware Resident 65 was on EBP, as indicated for Resident 65's wounds, colostomy, and urinary indwelling catheter. CNA 2 stated she forgot to wear the disposable gown before providing care for Resident 65. On March 24, 2025, at 12:06 a.m , the IP was interviewed in front of Resident 65's room. The IP stated Resident 65 was on EBP. The IP stated CNA 2 should have used the disposable gown during direct care of Resident 65, to prevent cross contamination between resident's care. A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated March 2024, indicated, .Enhanced Barrier Precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities .Gloves and gown are applied prior to performing the high contact resident care activity .EBPs are indicated .for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .

Based on observation, interview, and record review, the facility failed to ensure an assessment and evaluation for self-administration (taking medication or substance by oneself, rather than by a healthcare professional) of medication albuterol inhaler (used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung disease such as asthma) was completed, for one of 27 residents reviewed (Resident 180). In addition, the facility failed to ensure the medication was stored safely and securely. This failure increased the potential for unsafe self-administration and duplication of administered medication for Resident 180, and potential for visitors, and other residents to have access to the medication at bedside. Findings: On March 25, 2025, at 4:30 p.m a concurrent observation and interview was conducted with Resident 180. Resident 180 was observed awake, alert, sitting up on his bed and was able to verbalize his needs. Resident 180 was observed to reach into his pant's pocket and removed an albuterol inhaler. Resident 180 stated he had asthma, and had used the albuterol inhaler for a long time, paid his own prescription, and got it from his own doctor. Resident 180 stated he wanted to have the albuterol inhaler handy in case he had an asthma attack. Resident 180 was observed talking in fast tone, raising his voice, jitters with sudden movements scratching his left arm, and placed the inhaler back into his pant's pocket. Resident 180 did not want to talk about his albuterol inhaler. A review of Resident 180's Admission Record, indicated Resident 180 was admitted to the facility on [DATE], with diagnoses which included asthma and cellulitis (a bacterial skin infection). Resident 180 was alert, and oriented to time, place, person, and situation. A review of Resident 180's Medication Administration Record (MAR), dated March 26, 2025, included a physician's order, dated March 13, 2025, which indicated, Albuterol Sulfate Inhalation Aerosol Solution, 2 puffs inhale orally two times a day for asthma. A review of Resident 180's Self -Administration Of Medication Observation, dated March 13, 2025, indicated Resident 180 did not want to self-administer medication, electronically signed by the Registered Nurse (RN) when Resident 180 was admitted to the facility. On March 26, 2025, at 11:51 a.m., a concurrent observation and interview was conducted with Resident 180. Resident 180 was observed sitting upright on his bed. The medication albuterol inhaler was observed on top of Resident 180's bedside table. In a concurrent interview with Resident 180, he stated the nurse gave the albuterol inhaler for him to keep. On March 26, 2025, at 12:15 p.m. a concurrent interview and review of Resident 180's MAR was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 confirmed Resident 180 had an order for the albuterol inhaler. LVN 1 stated he administered the albuterol inhaler to Resident 180 at 9 a.m. LVN 1 stated he was not aware the albuterol inhaler was at the bedside. On March 26, 2025, at 2:20 p.m., a concurrent interview and record review was conducted with the MDS (Minimum Data Set - an assessment tool) Coordinator. The MDS Coordinator stated the facility's document titled,Self- Administration Of Medication Observation, dated March 13, 2025, indicated Resident 180 did not want to self-administer his medication. The MDS stated Resident 180 should not be administering his own albuterol inhaler. On March 26, 2025, at 3:35 p.m., an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated she was not aware Resident 180 had the albuterol inhaler with him. The RNS stated when Resident 180 was admitted on [DATE], she conducted his assessment and completed the self- administration of medication form for Resident 180. However,the RNS stated there was no albuterol inhaler with Resident 180 at the time he was admitted to the facility. On March 26, 2025, at 4:05 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 180 should not have self-administered his albuterol inhaler without the licensed staff assessment and physician's order. A review of the facility's policy and procedure titled, Self-Administration of Medications, dated February 2021, indicated, .Resident 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 .Self-administered medications are stored in a safe and secure place,which is not accessible by other residents .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 or responsible party .

Based on observation, interview, and record review, the facility failed to accommodate the needs, for one of two residents reviewed (Resident 56), when Resident 56 was not provided appropriate bed for the resident's height. This failure resulted in Resident 56 not to have his preference to use a bed tall enough to accommodate his height and had discomfort when lying in bed. Findings: On March 23, 2025, at 4:18 p.m., a concurrent observation and interview was conducted with Resident 56. Resident 56 was observed in bed, awake and alert. Resident 56 was observed with a bed footrest made out of cardboard from a carton box. In a concurrent interview, Resident 56 stated he was about 6'7 - 6'8 tall (79 to 80 inches), and his current bed was too small. Resident 56 stated he asked a few months ago for a tall bed to accommodate his height, but it was not provided to him. On March 26, 2025, at 9:26 a.m., a concurrent observation and interview was conducted with Resident 56. Resident 56 was observed again, lying in bed, with the same cardboard at the foot of the bed. Resident 56 was observed keeping his feet on each side of the bed's footrest. In a concurrent interview, Resident 56 stated otherwise his feet would reach the foot of the bed and he had to bend his legs while lying in bed. Resident 56 stated because the bed was a regular bed and he was tall guy, it was very uncomfortable for him while lying in bed. Resident 56 stated he told staff about the short bed a few months ago. Resident 56 stated the maintenance supervisor put the cardboard at the foot of bed a few months ago. On March 26, 2025, at 9:34 a.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she took care of Resident 56 and was familiar with him. CNA 1 observed the bed with the cardboard and stated, he needs a longer bed. CNA 1 confirmed Resident 56 kept his feet on each side of footrest, and if he fully extended his legs, he would hit the footrest and had to bend his knees. On March 26, 2025, at 9:44 a.m., a concurrent observation and interview was conducted with the Maintenance Director (MD) and the Central Supplies Director (CSD). The MD confirmed he was the one who put the cardboard box at the foot of the bed at the request of the resident. The MD confirmed the cardboard box was a make-shift set-up that should not be there. The CSD stated the current bed had a small extension at the head of the bed and a small extension at foot of bed. The CSD stated the extensions were still not enough, and Resident 56 needed a bed that would accommodate his height. On March 26, 2025, at 9:47 a.m., a concurrent observation and interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the cardboard footrest should not be at the foot of the bed, in place of the footrest. The ADON confirmed Resident 56 kept his feet on each side of the footrest and stated he needed a bed tall enough to accommodate his height. Resident 56's record was reviewed. Resident 56 was admitted to the facility on [DATE], with diagnoses which included cervical disc degeneration (a condition where the intervertebral discs in the neck [cervical spine] deteriorate over time), inclusion body myositis (a rare condition that causes muscle weakness and damage), polyneuropathy (peripheral nerves become damaged, creating problems with sensation, coordination, or other body functions), and difficulty in walking. A review of Resident 56's Weights and Vitals Summary, indicated Resident 56 was 80 inches tall (6 feet and 8 inches). A review of Resident 56's care plan, dated April 3, 2024, indicated, .Resident has actual for ADL (Activities of Daily Living)/mobility decline and requires assistance related to weakness, impaired mobility, Cervical disc degeneration .Will have needs anticipated and met by staff .Will have no complications of immobility .At risk for pain or discomfort due to .general body weakness with lack of coordination .Inclusion body myositis .Polyneuropathy .cervical disc degeneration .lower extremity with episodes of sliding out at the edge of the bed uncontrolled .position for comfort . A review of the facility's policy and procedure titled, Accommodation of Needs, revised March 2021, indicated, .The resident's individual needs and preferences are accommodated to the extent possible .including the need for adaptive devices and modifications to the physical environment .To accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom .Examples of such adaptations may include .providing a variety of types .sizes (height and depth) .of furniture in rooms .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene of resident's fingernails, for one of 27 residents reviewed (Resident 115). This failure had the potential to negatively impact the physiological and psychological well-being of Resident 115. In addition this failure had the potential to result in cross contamination of bacteria underneath the dirty fingernails to Resident 115's food during meals. Findings: On March 23, 2025, at 11:04 a.m., Resident 115 was observed sitting at the edge of the bed alert, oriented, and able to verbalize his needs. Resident 115 was observed with blackish materials underneath all his long fingernails. Resident 115 stated it had been a month since his nails were cleaned. Resident 115 stated he would not mind if staff would clean his nails. On March 23, 2025, at 12:06 p.m., Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated she took care of Resident 115 on March 22, 2025, today, and two weeks ago. CNA 3 stated she did not notice Resident 115's fingernails were dirty. CNA 3 stated the dirty fingernails could be a source of bacteria if not cleaned. On March 23, 2025, at 12:15 p.m., a concurrent observation of Resident 115 and interview with the Infection Preventionist (IP) was conducted. The IP stated Resident 115's fingernails were dirty. The IP stated the CNAs were responsible of providing skin, and nail care daily. The IP stated the dirty fingernails could be a source of infection. On March 23, 2025, at 4:06 p.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed. The DON stated the CNAs were responsible in giving daily hygiene to the residents including the cleaning of resident's fingernails. A review of Resident 115's record indicated, Resident 115 was admitted to the facility on [DATE], with diagnoses which included peripheral arterial disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Resident 115's care plan, initiated on January 9, 2025, indicated, .Activities of daily living (ADL)/Mobility: Resident had actual risk for ADL/Mobility decline and requires assistance .Goal .Will have needs anticipated and met by staff . A review of the facility's policy and procedure titled, Activities of Daily Living (ADL) , dated March 2018, indicated, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal .hygiene .

Based on interview and record review, the facility failed to ensure care and treatment according to the professional standards of practice and physician's order was provided, for one of 24 residents (Resident 105) when Insulin Lispro (a type of insulin medication) was administered to Resident 105 when the blood sugar level was below below the hold parameter). This failure had the potential for Resident 105 to experience hypoglycemia (a condition in which the body's blood sugar level goes below the standard range). Findings: On March 23, 2025, at 12:54 p.m., during a concurrent observation and interview with Resident 105, Resident 105 was observed lying in bed, awake and alert. Resident 105 stated a nurse gave him insulin when his blood sugar was low. Resident 105 stated he was half asleep when his blood sugar was taken and when he was given the insulin, he did not feel good and knew his blood sugar was low. Resident 105 stated he asked the nurse to check his blood sugar, and it was 32. Resident 105 stated the incident happened a month ago, during the day shift. On March 25, 2025, Resident 105's record was reviewed. Resident 105 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (DM - a disorder characterized by poor blood sugar control). A review of Resident 105's history and physical, dated March 6, 2025, indicated Resident 105's decision making capacity was intact. A review of Resident 105's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated March 3, 2025, indicated Resident 105 had a BIMS (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (cognitively intact). A review of Resident 105's Order Summary Report, included a physician's order, dated February 18, 2025, which indicated, .HumaLOG Solution 100 UNIT/ML (a unit of measurement) (Insulin Lispro (Human) Inject 3 (three) unit (sic) subcutaneously (under the skin) before meals for diabetes HOLD if BS Blood sugar) < (less than) 90 . A review of Resident 105's Medication Administration Record (MAR), for the month of February 2025, indicated, Resident 105 received 3 (three) units of Insulin Lispro subcutaneously for BS of 89 which was below the hold parameter of 90, on February 21, 2025, at 6:30 a.m. On March 26, 2025, at 2:43 p.m., in a concurrent interview and record review with the Director of Nursing (DON), she stated Resident 105's blood sugar was 89 on February 21, 2025, at 6:30 a.m. The DON stated Resident 105 received 3 (three) units of Insulin Lispro subcutaneously for a blood sugar of 89, which was below the parameter of 90. The DON stated the Licensed Vocational Nurse (LVN) should have held the insulin and should have documented the reason for not giving the insulin. The DON stated the LVN did not follow the physician's order. A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated, .Medications are administered in a safe .manner .and as prescribed .Medications are administered in accordance with prescriber orders .

Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means (directly to the gastrointestinal system or stomach) receives the appropriate care to prevent complications of enteral feeding when, one of one resident reviewed for tube feeding (Resident 122), was positioned with the head of the bed (HOB) not elevated 30-45 degrees while receiving tube feeding (nutrition provided through a tube inserted into the stomach). This failure had the potential for Resident 122 to experience complications from tube feeding, such as aspiration (when food or liquid or other materials enters the airway and lungs instead of being swallowed) , nausea, vomiting, or abdominal pain. Findings: On March 24, 2025, at 8:57 a.m., Resident 122 was observed laying flat on the bed and was receiving tube feeding nutrition. On March 25, 2025, at 9:11 a.m., during a concurrent observation of Resident 122 and interview with Licensed Vocational Nurse (LVN) 3, Resident 122 was observed lying on bed with the head of bed (HOB) flat, and the tube feeding was running. In a concurrent interview with LVN 3, she stated Resident 122's head of bed was too low and should be elevated at least 45 degrees. On March 27, 2025, at 9:50 a.m. an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 122's HOB during tube feeding and 30 minutes after should be elevated at 30 - 45 degrees. A review Resident 122's Admission Record, indicated, Resident 122 was admitted to the facility on [DATE], with diagnoses which included dysphagia (condition that affects your ability to swallow) following cerebral infarction (stroke). A review of Resident 122's care plan, dated February 8, 2025, indicated, .Risk for aspiration as resident on tube feeding .Patient will have no aspiration and complication from feeding tube .Keep HOB elevated during feedings . A review Resident 122's Order Summary Report, included the following physician orders: - .HOB elevated to tolerance or 30 degrees during and 30 mins (minutes) after feeding, date ordered February 9, 2025; and - .every shift Formula Jevity 1.2 via G tube (gastrostomy tube, type of tube feeding method) method of administration via epump (electronic pump for delivering the feeding formula) .@ (at) rate of 65cc (milliliter -unit of measurement)/hr (hour) x (times) 20 hours or until dose met. Start at 2pm (p.m.), stop at 10am (a.m.) or until dose met . A facility policy titled, Enteral Nutrition, dated November 2018, stated .The provider will consider the need for supplemental orders, including .Head of bed elevation .Risk of aspiration is assessed by the nurse and provider and addressed .Improper positioning of the resident during feeding .

Based on interview and record review, for one of three residents reviewed (Resident A), the facility failed to ensure the effectiveness of the interventions to prevent falls were evaluated, and new interventions were implemented to address Resident A ' s repeated falls due to behavior of getting up unassisted and prevent further falls. These failures resulted in Resident A to have 16 falls from October 16, 2023, to February 13, 2024, while at the facility. Resident A ' s fifth (5th) fall resulted to the resident to sustain a laceration (cut) on the back of his head and was treated in the emergency room (ER) with two staples (used to close wounds) placed on the laceration. Resident A ' s ninth (9th) fall resulted to the resident to sustain a skin tear on the right elbow. Resident A ' s 15th fall resulted to the resident to be transferred to the acute hospital and sustained multiple left rib fractures (broken bone) and thoracic compression fractures (a break in a bone in the middle section of the spine). Findings: On August 5, 2024, at 8:54 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care and accidents. A review of Resident A's Admission Record, indicated Resident A was initially admitted to the facility on [DATE], with diagnoses which included spinal stenosis (spaces inside the bones of the spine get too small), chronic atrial fibrillation (irregular heart beat that causes poor blood flow), emphysema (lung disease), history of falling, difficulty walking, and alcohol dependence. A review of Resident A's Fall Risk Observation/Assessment, dated October 12, 2023, indicated a score of 26 (high risk for falls score of 16-42). A review of Resident A's care plan, developed on October 12, 2023, indicated, .Falls: Resident is at risk for falls with or without injury related to impaired safety awareness due to episodes of confusion and forgetfulness, history of falls, hx (history) of alcohol dependence, anxiety, multiple medications, and hx of vertigo (a sensation in which you feel as though you are moving, spinning, or off balance) .Goal .Will have no serious injury til (sic) next review .Interventions/Tasks .Anticipate and meet needs .Educate/remind resident to call for assistance with all transfers .keep call light within reach and reorient during routine care .keep bed to lower position .keep personal items within reach .PT/OT (physical therapy/occupational therapy) eval (evaluation) as indicated . A review of Resident A's Minimum Data Set (MDS- a standardized comprehensive assessment and care planning tool), dated February 29, 2024, indicated the following: - Resident A had a Brief interview for Mental Status (BIMS -a tool used to screen and identify cognitive [process of thinking] condition of residents) score of 3 (severe cognitive impairment); and - Resident A required moderate to maximum assistance with ADL ' s (activities of daily living includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating). Further review of Resident A's documents indicated the resident had multiple falls during his stay at the facility as follows: 1. A review of Resident A's Change of Condition Evaluation, dated October 16, 2023, at 1:26 p.m., indicated, .resident found on floor near bed on both knees @ (at) 0930 (9:30 a.m.). pt (patient) awake and alert c/o (complain of) left rib pain. no redness or any discoloration noted to site. denies pain to touch. fall matts beside bed and call light noted within reach. MD (doctor) notified . A review of Resident A's Post Fall Review, dated October 16, 2023, indicated, Unable to independently come to a standing position, exhibits loss of balance while standing, Strays off the straight path of walking, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, Changes gait pattern when walking through doorways, has lurching, swaying, or slapping gait . A review of Resident A's care plan, dated October 17, 2023, included additional interventions which indicated, .encourage and assist to activity to keep self-occupied .move to room closer to nursing station . A review of Resident A's Interdisciplinary Team (IDT-staff from different health care disciplines discuss to help people receive the care they need) Notes, dated October 17, 2023, indicated, .resident was not able to explain what happened not explained what he was trying to do due to resident with episodes of confusion and forgetfulness . 2. A review of Resident A's Change of Condition Evaluation, dated November 10, 2023, at 6:54 p.m., indicated, .Resident was in hallway trying to sit in his wheelchair when the wheelchair rolled away and resident fell and landed on buttock. He did not hit his head and does not c/o any pain or discomfort at this time. MD notified and his order was to monitor patient for now . A review of Resident A's Post Fall Review, dated November 10, 2023, indicated, .Exhibits loss of balance while standing, requires hands-on assistance to move from place to place, uses as assistive device, e.g. (example) cane, walker, etc. A review of Resident A's care plan, dated November 10, 2023, included additional interventions which indicated, .PT/OT (physical therapy/occupational therapy) focusing on wheelchair mobility, application of brakes, redirection, assist with verbal cues Further review of Resident A's medical record did not indicate IDT notes after the Resident A's fall on November 10, 2023. 3. A review of Resident A's Progress Notes, dated November 14, 2023, at 7:35 p.m., indicated, .At 1530 (3:30 p.m.), Resident had an unwitnessed fall in the unit hallway. Resident stated he was attempting to get up to get coffee and forgot to lock his wheelchair. Resident stated he hit his head and complained of pain 7/10 (severe pain). Resident was assisted by 2 person back into wheelchair and educated on risks and benefits of noncompliance with ADLs. MD was notified, RP (responsible party) notified. MD (doctor) recommended to send to hospital due to patient being on blood thinner . Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were completed after Resident A had a fall on November 14, 2023. 4. A review of Resident A's Progress Notes, dated November 20, 2023, at 9:15 p.m., indicated, Staff reported res (resident) fell on the hallway. Res attempting to sit down without locking the wheelchair first. Res fell back and hit the head. Res is awake, alert with confusion as res baseline .Staff assisted res to bed. Body assessment no injury noted. Res denies any headache or dizziness. No redness or swelling. Denies any pain or discomfort . Educated res to call nurse for assistance and remind res to lock the wheelchair prior sitting on the w/c (wheelchair) . A review of Resident A's Change of Condition Evaluation, dated November 20, 2024, at 9:27 p.m., indicated, .resident is noncompliant with asking for help and insist on ambulating on his own . Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were completed to reflect new interventions after Resident A had a fall on November 20, 2023. 5. A review of Resident A's Change of Condition Evaluation, dated November 28, 2023, at 7:32 a.m., indicated, .Resident was on the floor at the foot of the bed holding on to the back of his head. Upon assessing resident, he had a minor cut on the back of his head that was bleeding . A review of Resident A's Progress Notes, dated November 28, 2023, at 7:35 p.m., indicated, .At 19:20 (7:20 p.m.,), resident returned from (name of hospital) after being treated for laceration (cut) to scalp, had 2 (two) staples inserted to be removed in 7-10 days, keep dry for first 2 (two) days. Resident appears drowsy with slurred (not clear) speech .bed at lowest position, call light within easy reach . A review of Resident A's Change of Condition Evaluation, dated November 28, 2023, at 11:38 p.m., indicated, .patient is noncompliant with asking staff for help. Resident has been educated multiple times. He understands and still chooses to walk without assistance . A review of Resident A's Progress Notes, dated November 28, 2023, at 11:38 p.m., indicated, .Resident found on floor by staff. Resident refused help from staff, attempting to strike nurses. Resident was assisted back to bed, MD, DON (Director of Nursing), and RN (Registered Nurse) notified immediately . Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were completed after Resident A fell on [DATE]. A review of Resident A's care plan, dated November 28, 2023, included additional interventions which indicated, .move to room closer to nursing station with minimal stimulation due to noise on the surrounding area and made him restless and agitated when being redirected for safety . 6. A review of Resident A's Change of Condition Evaluation, dated December 5, 2023, at 12:15 a.m., indicated, .resident found sitting on floor at bedside, leaning on right side against his bed, body assessment and neuro checks (to check mental status and speech) performed .no visible injuries at time .he stated that he was trying to go to the bathroom and he fell down .Noncompliant with fall prevention, not utilizing call light, constantly attempts to get off bed unaided . A review of Resident A's Post Fall Review, dated December 6, 2023, indicated, .Exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses an assistive device, e.g. cane, walker, etc . Further review of Resident A's medical record did not indicate IDT notes and new interventions were placed after resident had a fall on December 5, 2023. 7. A review of Resident A's Change of Condition Evaluation, dated December 9, 2023, at 6:30 p.m., indicated, .CNA (certified nursing assistant) was helping resident to use restroom. while getting resident back on wheelchair resident lost balance and fell on his right side. CNA and resident denied hitting head. resident c/o pain to right side of hip resident encouraged to stay in w/c and ask for assistance when needed . A review of Resident A's hip x-ray, dated December 12, 2023, indicated bilateral hips no fractures .minor degenerative changes (a progressive loss of structure or function in tissues or organs identified . Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were completed and no new interventions were implemented after resident had a fall on December 9, 2023. . A review of Resident A' s Change of Condition Evaluation, dated December 14, 2024, at 10:45 p.m., indicated, .Resident stated he attempted to go to the restroom and fell . Resident verbalized pain to buttocks and head. RN assessed resident and no apparent dislocation (a separation of two ends of the bones where they meet at a joint). or visible injuries. Resident was assisted to the wheelchair and then back to the bed .resident noted to have pain to buttocks and head . A review of Resident A's Post Fall Review, indicated, .Exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses an assistive device, e.g. cane, walker, etc . Further review of Resident A's medical record did not indicate IDT notes and new interventions were placed after resident had a fall on December 14, 2023. 9. A review of Resident A's Change of Condition Evaluation, dated December 20, 2023, at 3:31 p.m., indicated, .Resident attempted to stand on his own, upon standing resident witnessed to have tripped over footrest and land on right side next to wheelchair. Head to toe assessment rendered, small skin tear 1.5x1.2cm (centimeters - unit of measurement) to right elbow noted. MD made aware .72-hour neurochecks . A review of Resident A's care plan, dated December 20, 2023, included additional intervention to remove wheelchair footrest. Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were completed after Resident A fell on [DATE]. 10. A review of Resident A's Change of Condition Evaluation, dated December 23, 2023, at 7:30 p.m., indicated, .Resident observed trying to sit in wheelchair when he tripped on sneaker. He is alert, able to move all limbs, denies any pain, did not hit head, fell on right shoulder . A review of Resident A's Post Fall Review, dated December 23, 2023, indicated, .Exhibits loss of balance while standing, requires hands-on assistance to move from place to place, uses an assistive device, e.g. cane, walker, etc., decrease in muscle coordination . A review of Resident A's care plan, dated December 23, 2023, indicated additional intervention for Resident A to wear proper footwear and provide slip on shoes without string . Further review of Resident A's medical record did not indicate IDT notes was completed after resident had a fall on December 23, 2024. 11. A review of Resident A's Change of Condition Evaluation, dated December 25, 2023, at 1:50 p.m., indicated, .Resident noted to have unwitnessed fall. CNA passing the hallway noted that the resident was on the floor next to his bed laying on his back. Resident noted to have unwitnessed fall wearing nonskid socks. Resident noted to have pull pants down and a recently soiled brief .no complain of pain. Resident denies hitting his head and noted to have a minor scrape to right forearm no bleeding noted. Neuro checks started and patient assisted back to bed . A review of Resident A's Post Fall Review, dated December 25, 2023, indicated, .Unable to independently come to a standing position, exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, has lurching, swaying, or slapping gait, wears poorly fitting shoes . Further review of Resident A's medical record did not indicate IDT notes and no new interventions were implemented after resident had a fall on December 25, 2023. 12. A review of Resident A's Change of Condition Evaluation, dated December 30, 2023, at 4:00 p.m., indicated, .Was called to Nurses station, on assessment, resident seen sitting on floor, stated he was trying to get up and fell to the floor, fall was unwitnessed by staff .Patient is alert, can move all limbs, no visible injuries noted . A review of Resident A's Post Fall Review, dated December 30, 2023, indicated, .Exhibits loss of balance while standing, requires hands-on assistance to move from place to place, decrease in muscle coordination . A review of Resident A's care plan, dated December 31, 2023, indicated additional intervention to apply pad alarm (wireless emergency alert placed on the resident). Further review of Resident A ' s medical record did not indicate IDT notes was completed after the resident had a fall on December 30, 2023. 13. A review of Resident A's Change of Condition Evaluation, dated January 8, 2024, at 6:59 a.m., indicated, .the resident is trying to stand up from the wheelchair. CNA and LVN (Licensed Vocational Nurse) keep telling the resident to stay but he never listen (sic) and he lose (sic) his balance standing up and fell on the floor . A review of Resident A's care plan, dated January 8, 2024, indicated additional intervention to ambulate with handheld assist when trying to get up and not being redirected, and assist up in chair and keep by nursing station for immediate visual monitoring when restless in bed. Further review of Resident A's medical record did not indicate a Post Fall Review and IDT notes were completed after Resident A fell on [DATE]. 14. A review of Resident A's Change of Condition Evaluation, dated January 11, 2024, at 4:29 a.m., indicated, .Was called into resident's room re: fall. On assessment resident seen lying on floor out on hallway in supine (lying face upward) position with knees drawn up. CNA verbalized that he was trying to grab a bottle off nurses desk when he stumbled, fell backwards, hitting head against door frame. Neuro checks performed, is able to state name and move all limbs, c/o having headache and back pain . A review of Post Fall Review, dated January 11, 2024, indicated, .Unable to independently come to a standing position, exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, exhibits jerking or instability when making turns . A review of Resident A's care plan, dated January 14, 2024, indicated for resident to be placed in a merry walker (a mobility aid that combines the features of a walker and a wheelchair, allowing users to walk independently and safely) when up and out of bed. Further review of Resident A's medical record did not indicate IDT notes after resident had a fall on January 11, 2024. 15. A review of Resident A's Change of Condition Evaluation, dated February 2, 2024, at 12:44 p.m., indicated, .Loud noise heard down the hallway. Resident was found on floor in room next to bed A. RN notified. Resident assessed by charge nurse and RN resident assisted to side of bed. resident observed to be holding back of head and forehead. Resident unable to state how he fell . A review of Resident A's Post Fall Review, dated February 2, 2024, indicated, .Exhibits loss of balance while standing, strays off the straight path of walking, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, changes gait pattern when walking through doorways, has lurching, swaying, or slapping gait, exhibits jerking or instability when making turns, wears poorly fitting shoes . A review of the facility document titled, Transfer Form, dated February 2, 2024, at 2:57 p.m., indicated Resident A was transferred to the general acute hospital (GACH). A review of Resident A ' s GACH document titled, History of Present Illness, dated February 2, 2024, indicated, .on Eliqius (medication to thin the blood) presenting from his nursing care facility for ground level fall when he fell off his bed hitting his head . A review of Resident A's radiology report for CT (Computerized Tomography - a medical imaging procedure that uses x-rays to create detailed images of the body) of the Lumbar Spine (lower back region of spine) Region, dated February 2, 2024, indicated, .Subacute (happened about 5 to 14 days) to chronic (old) 6-9 (rib fractures) left lateral fractures .There is 10% superior endplate vertebral (round, thick, weight-bearing bones in the spine) body height loss at T1 and T2 (first two bones in the middle part of the spine) .These may represent acute (new) to subacute compression fractures[EC12] (a break in a bone in the spine that collapses) . A review of Resident A's GACH document, dated February 5, 2024, indicated, .plan .remains at risk to fall again. Would not leave a wheelchair by his bedside with this being his primary mobility prior to his fall and injury . A review of Resident A's IDT Notes, dated February 5, 2024, indicated IDT discussed resident condition and director of nursing assess resident upon returned from hospital and no change in mental status noted, no external trauma including any open skin not discoloration noted, no tenderness no swelling noted. IDT discuss plan of care and to continue currently in place . A review of Resident A's care plan related to the fall incidents from October 16, 2023, to February 5, 2024, included the following interventions: - keep resident clean and dry; - maintain hazard free environment; - proper footwear; - keep frequently use personal items within reach; - assist with needs as anticipated and as needed; - lowest bed position; floor mats when in bed; - assist to activity to keep self-occupied; - room closer to the nursing station for immediate and frequent visual check; and - taken for a walk within the facility and outside patio when restless, provide simple activity book, and other noncomplicated activity when up in the chair to keep self-busy, assist with needs as anticipated and as needed. 16. A review of Resident A's Change of Condition Evaluation, dated February 13, 2024, at 2:26 p.m., .Resident was sitting in wheelchair in front of station. Writer turned away from med (medication) cart. Writer heard loud bang, resident found sitting on floor against the wall in front of station, resident holding back of head. RN made aware and assessed resident . A review of Resident A's Progress Notes, dated February 13, 2024, indicated, .@ (at)approx. (approximately) 1300 (1:00 p.m.) Resident was sitting in wheelchair in front of station. Writer turned away from med cart. Writer heard loud bang, resident found sitting on floor against the wall in front of station, resident holding back of head. RN made aware and assessed resident .Resident assisted back into bed by charge nurse and assigned CNA .MD made aware .orders for CT scan of head and spine. MD made aware that CT are not done in facility. MD agreed .send to (name of GACH) . A review of Resident A's IDT Notes, dated February 14, 2024, at 3:43 p.m., indicated, On 2/13/2024 (February 13, 2024) at approx. (approximately) 1300 (1:00 p.m.,) patient was found sitting on buttock with back facing the wall. Patient was holding back of head, complains of slight pain. Nurse notified MD and patient was sent to acute care hospital for further observation. IDT interviewed nurse that was in care of patient at the time of fall. Nurse stated that patient had been monitored at nursing station majority of the early afternoon, she stated she turned around to print something (still standing at station) and when she turned around patient was sitting on the floor . On August 5, 2024, at 2:16 p.m., during an interview LVN 2, he stated Resident A was alert and oriented to his name and place. LVN 2 stated the staff would assist him in the seat but would get up right away. LVN 2 stated Resident A's mobility was limited and had to keep an eye on him constantly, even if staff turned for a second, Resident A could get up. LVN 2 stated Resident A would take off the alarm from the wheelchair and tried to break the cord because the resident did not like the sound. LVN 2 stated Resident A had multiple falls and a 1:1 (staff assigned only to one resident to prevent falls) sitter was not used all the time. LVN 2 also stated Resident A's falls could have been prevented if he had a 1:1 sitter. On August 5, 2024, at 2:52 p.m., during a concurrent interview and record review of Resident A's therapy notes with the Director of Rehabilitation (DOR) and the Physical Therapist (PT), the PT stated Resident A was not steady on his feet and was high risk for falls, and had no dynamic balance (ability to remain standing and be stable). The DOR stated a reassessment was completed after every fall and if there were no changes, and continued with the therapy goals. On August 5, 2024, at 3:55 p.m., during concurrent interview with the Director of Nursing (DON), the DON stated the residents were being assessed for falls upon admission, quarterly, annually and when the resident had a change of condition. The DON stated Resident A had a history of dementia (cognitive impairment with memory loss) had interventions in place to address risk for falls but Resident A would get up constantly. The DON stated most of Resident A ' s falls were from the edge of the bed and a complete fall risk assessment was done and discussed with the IDT team and interventions to monitor the resident. On August 13, 2024, at 9:26 a.m., during a concurrent interview and record review of Resident A's post fall review with the DON, she stated a Post Fall Review should be completed by nursing after every fall. The DON stated Post Fall Reviews were not completed for the following dates: - November 14, 2023, after the third fall; - November 20, 2023, after the fourth fall; - November 28, 2023, after the fifth fall; - December 9, 2023, after the seventh fall; - December 20, 2023, after the ninth fall; - January 8, 2024, after the 13th fall; and - February 13, 2024, after the 16th fall. The DON stated IDT meetings were to be held to discuss a resident ' s plan of care after a fall incident. The DON stated an IDT meeting was held after each of Resident A's falls and the plan was discussed with the team, but there was no documentation in Resident A ' s medical record. The DON stated the IDT notes were not completed to address each of Resident A's fall incidents on the following dates: - November 10, 2023, after the 2nd fall; - November 14, 2023, after the third fall; - November 20, 2023, after the fourth fall; - November 28, 2023, after the fifth fall; - December 5, 2023, after the sixth fall; - December 9, 2023, after the seventh fall; - December 14, 2023, after the eighth fall; - December 20, 2023, after the ninth fall; - December 23, 2023, after the 10th fall; - December 25, 2023, after the 11th fall; - December 30, 2023, after the 12th fall; - January 8, 2024, after the 13th fall; - January 11, 2024, after the 14th fall; and - February 13, 2024, after the 16th fall. The DON stated they did a trial for Resident A to use the merry walker but was not implemented thereafter as was not working for the resident after the 14th fall. The DON stated the staff on the unit took turns to watch Resident A, but a 1:1 sitter was not assigned to him despite the multiple falls. The DON stated if a 1:1 staff was assigned to Resident A, it could have minimized the repetitive falls because most of the falls were a result of Resident A trying to get up unassisted. The DON stated Resident A's multiple falls were not properly evaluated to address the cause of the fall and implement appropriate interventions to prevent injuries and repeat falls. A review of facility's policy and procedure titled, Falls-Clinical Protocol with a revision date of [DATE], indicated, .physician will help identify individuals with a history of falls and risk factors for subsequent falling .risk factors for subsequent falling include .musculoskeletal (related to muscles and bones) abnormalities .gait and balance disorders, cognitive impairment, weakness .confusion .the physician will identify medical conditions affecting fall risk .and the risk for significant complications of falls .Cause Identification .after a first fall, the staff .should watch the individual rise from a chair without using his or her arms, walk several paces and return not sitting .if the individual has difficulty or is unsteady in performing this test, additional evaluation should occur .Treatment/Management .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .Monitoring and Follow-Up the staff, with the physician ' s guidance, will follow up on any fall with associated injury until the resident is stable .the staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling .

Based on observation, interview, and record review, the facility failed to provide adequate supervision while smoking, to one of three sampled residents (Resident C). In addition, the facility failed to ensure smoking paraphernalia was not kept in possession of the residents in accordance with the facility policy and procedure. These failures resulted in Resident C to cause physical harm to Resident A and Resident B. Resident C hit Resident B in the face; and Resident C burnt Resident A's arm with a lit cigarette while at the smoking patio, on June 9, 2024, resulting in Resident A to sustain a cigarette burn on the right arm. Findings: On June 20, 2024, at 8:35 a.m., an unannounced visit to the facility was conducted to investigate a safety concern. On June 20, 2024, at 10:50 a.m., during a concurrent observation and interview conducted with Resident A, Resident A was in his wheelchair, next to his bed, with a blanket covering his lower extremities. Resident A stated he was outside on June 9, 2024, and one of the residents burned him with a cigarette on his right arm. Resident A held out his right forearm (section of the arm from the elbow to the wrist), a circle was noted to his skin, whitish in color with pink edges surrounding the area, the approximate size of a cigarette. Resident A stated, he went to the back patio to get a soda from the vending machine, and Resident C was out on the patio. Resident A stated he said Hi to Resident C, and as he was placing a dollar into the vending machine for a soda, Resident C came over to him, and touched a lit cigarette to his right forearm, and burned him. Resident A stated, he told the charge nurse what happened, and Registered Nurse 1 (RN 1) looked at his arm, took a picture, and did not treat the burn site. On June 20, 2024, at 11:05 a.m., an observation and concurrent interview were conducted with Certified Nursing Assistant 1 (CNA 1). CNA 1 was observed on the back patio with approximately eight residents, most residents were smoking, none of the residents smoking wore a smoking apron (an assistive device used to protect a resident from burning themselves), the smoking aprons were hanging on the corner of the building. CNA 1 stated, when the residents are done with their cigarettes, the butts should be placed in the safety receptacle, pointing to a large stand, with a hole to drop in the used tobacco products. A resident was observed throwing a smoldering (burning slowly with smoke but no flame) cigarette in the grass, and another resident went over and stepped on the cigarette to extinguish it. CNA 1 stated if she sees any cigarettes in the grass area, she will pick them up and throw them in the safety receptacles. CNA 1 stated the residents were allowed to keep their own cigarettes and lighters with them, smoking aprons are only used when a resident need one. On June 20, 2024, at 11:15 a.m. during an interview with Resident F, he stated he was Resident A ' s roommate. He stated when Resident C burned Resident A with a cigarette, Resident A told him what happened. Resident F stated Resident A showed him the burn mark on his right arm. Resident F stated, there was no staff outside on the smoking patio on June 9, 2024. He stated there was never a staff outside to supervise the residents while smoking. On June 20, 2024, at 11:22 a.m., an interview was conducted with Resident F. Resident F stated he was at the patio the day Resident C attacked the two male residents. Resident F stated Resident C came out to the patio, in her sandals, a hospital gown, and a sheet wrapped around her, and was notably upset about something, Resident C walked over to the metal trash can, and kicked it real hard, and made a dent in it (pointed to the metal trash can, noted a small dent). Resident F stated, Resident B had walked over to the soda machine to get their drinks, because his (Resident B) legs work, and the rest of them were in wheelchairs. Resident F stated as Resident B walked up to the soda machine, Resident C was standing in front of it, and as Resident B stated excuse me to Resident C, she punched Resident B in the face with her left hand. Resident F chuckled and stated Resident C ' s hospital gown was falling off and she was trying to hold onto the sheet, Resident C exposed herself a few times, Resident C was definitely having a bad day. Resident F stated, they were allowed to keep their cigarettes and a plastic lighter. On June 20, 2024, at 11:30 a.m., an interview was conducted with Resident B, at the smoking patio. Resident B stated he was trying to get sodas out of the machine for some of the residents, and he noticed Resident C and Resident A were both by the soda machine when he walked up to it. He stated he was kneeling down to read the labels on the machine, and when he stood up Resident C hit him in the face, on his left side. Resident B stated no staff comes to watch them, and he stated staff only come out in the patio if they are looking for a resident. On June 20, 2024, at 3:50 p.m. Resident C ' s medical record was reviewed. Resident C was admitted to the facility initially on December 8, 2023, and readmitted on [DATE], with diagnoses which included COPD (Chronic Obstructive Pulmonary Disease-a group of lung diseases that block airflow and make it difficult to breathe) and bipolar disorder (associated with mood swings ranging from depressive lows to manic highs). A review of Resident C ' s smoking observation assessment, dated June 3, 2024, indicated adaptive equipment needed: Supervision, May smoke with supervision, patient will have supervision during smoke break for safety. A review of Resident C ' s care plan, dated June 4, 2024, indicated Resident C has potential for injury related to smoking with episodes of non-compliance to smoking rules, smoking schedule, smoking supervision, smoking materials to be given and retained by staff. The care plan indicated interventions which included cigarette and lighter will be stored in Nurse ' s station. A review of Resident C ' s nurse ' s note, dated June 9, 2024, indicated the following: - at 12:56 p.m., .Notified [family] .resident has been refusing medication .encouraged resident to take medications but resident refusing . - at 12:59 p.m., .Resident noted to be verbal aggressive towards staff. Resident refused all morning and noon medication. I tried to explain what each medication is for and as well r/b (risks and benefits) of not taking medication and still refused. Resident was [sic] flicked a lit cigarette to staff. RN (Registered Nurse) supervisor spoke with resident as well as [family] was made aware and s/w (spoke with) resident and she still refused to take medication and still noted with verbal aggression. Dr [name] is made aware . A review of Resident C ' s SBAR (type of communication stands for Situation, Background, Assessment, and Recommendation) Summary for Providers, dated June 9, 2024, 3:52 p.m. indicated .fell ow resident c/o (complain of) that [Resident C] slapped him 2 X in the face and another c/o being burnt with cigarette on his hand in the arm she was hallucinating (a false sense something is real), threatening student nurse .Physical aggression .verbal aggression .other behavioral symptoms, worse delusions (a false belief of reality, occurs in mental conditions), hallucinations noted . On June 21, 2024, at 11:15 a.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated they all keep an eye on residents who are smokers. She stated most of them are independent and are able to freely smoke. The DSD stated if there is a smoker who is not independent, that smoker will be supervised by a staff member to ensure their safety, it is important to ensure no resident goes outside to smoke with oxygen on. The DSD stated Resident C would talk with herself, would wear a gown and a sheet, and had her purse with her. The DSD stated, Resident C kept her cigarettes and lighter, in her purse, if Resident C did flick ash or a cigarette at an employee or visitor, she should have had her cigarettes and lighter taken away, Resident C may not be willing to give up those items, when that occurs, the staff have to call the Sheriff. On June 21, 2024, at 12:20 p.m., an interview was conducted with the Activities Director (AD). The (AD) stated between the DSD and activities department, they work together to ensure residents on the smoking patio, have supervision. The AD stated, on Sunday, June 9, 2024, the activity assistant was at the facility from 8:00 a.m.to 4:30 p.m. The AD was told about the incident with Resident C the following day, but the activity assistant was not outside when it occurred and did not witness the incident. The AD stated Resident A and Resident B stated they were fine, felt safe, were not having any distress, Resident A had small red area to his arm but stated it did not hurt. The AD stated there is no formal schedule regarding who would monitor the residents on the patio while smoking, most staff know to watch. The AD stated the activity assistants were trained if they see anyone yelling, they need to intervene quickly, before the situation escalates, step in to remove the resident from the area, and report it immediately. The AD concluded if proper intervention had occurred, the harm to Resident A and Resident B could have been prevented. On June 21, 2024, at 1:25 p.m., a telephone interview was conducted with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated, she was the charge nurse for Resident C on June 9, 2024, the day the incident occurred. LVN 1 stated it was reported to her that Resident C had flicked a lit cigarette at a student in the front of the facility. LVN 1 stated Resident C was in front of the facility building smoking a cigarette and flicked a lit cigarette at one of the students the day of the incident. LVN 1 stated the residents were not allowed to smoke on the front patio. On June 25, 2024, at 10:30 a.m., an interview was conducted with the DSD Assistant. The DSD Assistant stated she was working at the reception desk on the day shift, on June 9, 2024. The DSD Assistant stated she could see Resident C smoking out front; she seemed a little agitated and went to visit Resident C but kept her distance, Resident C had already yelled at the DSD Assistant and was told to leave her alone, and though the DSD Assistant knew Resident C was not to smoke out front she did not want to agitate her more. The DSD Assistant stated there were staff and students out front, and she saw Resident C, flicked a cigarette at the staff and students, but when she asked the resident about it, the resident stated she was offering a cigarette to them. On June 25, 2024, at 3:35 p.m., Resident B ' s medical record was reviewed. Resident B was admitted to the facility on [DATE], with diagnoses which included spondylosis with radiculopathy (weakness in the bones of the spine). Resident B ' s smoking observation/assessment, dated May 15, 2024, indicated .Resident denies smoking or use of all tobacco products (assessment completed) . Resident B had another smoking observation/assessment, dated June 14, 2024, which indicated .Resident is smoker .adaptive equipment needed: supervision .may smoke with supervision .Resident has potential for injury related to smoking .Resident safety and hygiene will be maintained q (every) shift through review date . Resident B ' s progress notes were reviewed, dated June 9, 2024, at 3:27 p.m., indicated, .change in condition .Resident reported being slapped on the face by another resident .no orders from MD (medical doctor) . Resident B ' s nurse ' s note, dated June 9, 2024, at 8:15 p.m., indicated, .resident came to nurses' station, reported that he was at soda machine when a female approached him and slapped him twice in the face, he seemed alarmed . Resident B ' s nurse ' s note, dated June 10,2024, at 9:00 a.m., indicated, .resident came into office .what part of his face did he get slapped by the other resident .'this one (touching his left side of his face) ' .he said he was by the vending machine helping another patient when resident walked toward him and slapped him on his face . Resident B ' s care plan dated June 14, 2024, indicated, .resident has potential for injury related to smoking with episodes of non-compliant to 1. smoking rules 2. Smoking schedule 3. Smoking supervision 4. Smoking materials to be given and retain by staff . Interventions .cigarettes and lighter will be stored in the nurse ' s station . On June 25, 2024, at 4 p.m., Resident A ' s medical record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included paraplegia (Paralysis that affects the lower portion of the body) and cerebral palsy (an abnormal development in parts of the brain that control movement). Resident A ' s SBAR, dated June 9, 2024, at 4:00 p.m., indicated, .change in condition .Resident reported to charge nurse getting a cigarette burn to R (right) arm by another resident when getting a soda from vending machine .monitor site . Resident A ' s activities note, dated June 10, 2024, at 8:48 a.m., indicated, .Resident is doing fine and commented that he was surprised about the way the other resident acted . and Resident A ' s Interdisciplinary team (IDT) note, at 3:00 p.m., indicated, .Resident reported an allegation that another resident burned his right forearm with cigarette on 06/09/2024 (June 9, 2024) while outside by the smoking area using the vendo [sic] machine .said he is fine and it ' s not a big thing . A review of the facility ' s Smoking Policy/Procedure, dated June 8, 2018, that is read and signed by all residents identified as smokers indicated, .A designated smoking area outside the building is available .No lighting materials (e.g. matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the residents .residents who desire to smoke will be assessed for their ability to do so safely. The Interdisciplinary Team will assess residents by using the Smoking Assessment form and a review of the resident ' s clinical record .the resident will be offered to smoke .under staff supervision .no lighting materials .tobacco products, or smoking devices will be allowed to be kept in the possession of the resident either on their person or in their room .The frequency of smoking for residents under staff supervision will be: 8:00 am, 11:00 am, 1:30 pm, 4:00 pm, 7:00 pm these times will be no more than twenty (20) minute increments .all smoking materials will be retained by staff . A review of the facility ' s policy titled Smoking Policy-Residents, dated October 2023, indicated, .This facility has established and maintains safe resident smoking practices .smoking is only permitted in designated resident smoking areas .resident smoking status is elevated upon admission .ability to smoke safely with or without supervision .A resident ' s ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) .any smoking related privileges, restrictions, and concerns .need for close monitoring .are noted in the care plan .any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member .or volunteer worker at all times while smoking .Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision .

Based on observations, interviews, record review, and facility document and policy review, the facility failed to implement a system that allowed staff to quickly and accurately identify code status (describes the type of interventions to be provided when an individual is found without a pulse or not breathing) in the event of an emergency and failed to honor the advance directive of 1 (Resident #32) of 4 sampled residents reviewed for advance directives. Specifically, on [DATE], staff initiated cardiopulmonary resuscitation (CPR) when Resident #32 was found unresponsive, despite the resident having a signed physician's order for life sustaining treatment (POLST) and an advance directive on file that indicated the resident elected do not resuscitate (DNR) in the event they were found not breathing or without a pulse. Resident #32 received CPR at the facility, endured painful resuscitation procedures, sustained injuries, was hospitalized , and expired in the hospital the following day. 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, 483.24(a)(3) (Quality of Care) at a scope and severity of J. The IJ began on [DATE] when Resident #32 received CPR from staff, dishonoring the resident's advance directive and physician-signed POLST form that specified DNR, resulting in injuries sustained during CPR procedures, hospitalization , and prolonged death until [DATE]. The Administrator and Director of Nursing (DON) were notified of the IJ and provided a copy of the IJ template on [DATE] at 6:43 PM. A removal plan was requested. The Removal Plan was accepted by the state survey agency on [DATE] at 8:49 PM. The IJ was removed on [DATE] at 4:03 PM, after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F678 remained at the lower scope and severity of G, actual harm. Findings included: A review of a facility policy titled, Advance Directives, revised in [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy. The policy indicated, 9. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The policy further indicated, 14. In accordance with current OBRA [Omnibus Budget Reconciliation Act] definitions and guidelines governing advance directives, our facility has defined advanced [sic] directives as preferences regarding treatment options and include, but are not limited to: a. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated, e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used, and h. Life-Sustaining Treatment - treatment that, based on reasonable medical judgement, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but not those that are considered palliative or comfort measures. A review of a facility policy titled, Do Not Resuscitate Order, revised in [DATE], revealed, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation 1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record, 3. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include: a. Physician Orders for Life-Sustaining Treatment (POLST). The policy further specified, 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. a. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. b. Both witnesses must have heard the request, and both individuals must document such information on the physician's order sheet. c. The Attending physician must be informed of the resident's request to cease the DNR order. A review of Resident #32's Admission Record revealed the facility admitted the resident on [DATE] and most recently readmitted the resident on [DATE] with diagnoses that included unspecified symptoms and signs involving cognitive functions following a cerebral infarction (stroke), type two diabetes mellitus, essential hypertension, hyperlipidemia (high cholesterol), and unspecified severe protein-calorie malnutrition. The section of the Admission Record for Advance Directive information was blank. A review of a POLST form, dated [DATE] and signed by a physician and Resident #32, revealed that at the time of admission, Resident #32's POLST specified, If patient has no pulse and is not breathing, Attempt Resuscitation/CPR. The Form also included, the following guidance, Reviewing POLST: It is recommended that POLST be reviewed periodically. Review is recommended when: -The patient is transferred from one care setting or care level to another, or -There is substantial change in patient's health status, or -The patient's treatment preferences change. Modifying and voiding POLST: -A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent to revoke it. It is recommended that revocation be documented by drawing a line through Sections A through D, writing VOID in large letters, and signing and dating this line. -A legally recognized decision maker may request to modify orders, in collaboration with the physician/NP [nurse practitioner]/PA [physician's assistant], based on the known desires of the patient, or, if unknown, the patient's best interests. A review of Resident #32's California Advance Health Care Directive, dated [DATE], notarized and signed by the resident and the resident's power of attorney (POA), indicated a Choice NOT To Prolong Life: I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits. On [DATE] at 3:50 PM, a review of Station #2 and Station #3's POLST book, revealed a more recent copy of a POLST form for Resident #32, dated [DATE] and signed by a physician and Resident #32's POA. Resident #32's [DATE] POLST indicated, If patient has no pulse and is not breathing, Do Not Attempt Resuscitation/DNR. (Allow Natural Death). A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. Section S of the MDS, related to POLST and code status, was not completed. A review of Resident #32's comprehensive Care Plan revealed there were no Focus areas or interventions related to the resident's end of life wishes. There was, however, a Focus area, initiated on [DATE], that indicated the resident required transfer to an acute care setting due to being unresponsive, and the resident's condition was unable to be managed in the facility. An intervention directed staff to send a copy of the resident's code status/POLST to the acute care facility. A review of Resident #32's Order Summary Report, listing active orders as of [DATE], revealed an order dated [DATE] for DNR. A review of Resident #32's Progress Notes revealed the following entries: - a Change of Condition note, dated [DATE] at 1:51 PM that indicated Resident #32 yelled Help at 1:20 PM. Per the note, a registered nurse (RN) went in right away and found the resident unresponsive, and a Full code was confirmed and a Code Blue was paged overhead. The note further indicated no respirations or heartrate were found. According to the note, CPR was initiated, the resident's blood sugar was checked, suctioning was performed, and the physician was notified. Per the note, at 1:24 PM, a pulse was felt, but the resident remained unresponsive, and after ongoing CPR, at 1:27 PM, staff were unable to obtain a pulse, respiratory rate, or blood pressure. Intravenous (IV) fluids were given, and paramedics arrived at 1:32 PM and took over CPR. The note indicated that at 1:38 PM, 18 minutes after calling the code, the nurse notified Resident #32's POA, and the POA agreed to Full code CPR. The paramedics and fire department continued CPR and transported Resident #32 to a local hospital at 1:57 PM; and - a Nurse's Note documented by Registered Nurse (RN) #9, dated [DATE] at 2:31 PM, that indicated at 1:20 PM, the resident called out for help, and RN #9 responded and found the resident on the bed with their eyes open and breathing, but unresponsive. Per the note, the resident's pulse was initially 75 beats per minute and their oxygen saturation was 100 percent (%), but the resident suddenly stopped breathing and had no pulse. The note further indicated a code blue was initiated, 911 was called, and CPR was initiated. A review of Resident #32's hospital record revealed an HPI [History of Present Illness]- General Illness note, dated [DATE] at 2:38 PM, that indicated Resident #32 was found unresponsive and pulseless, and CPR was initiated. Per the note, emergency medical services (EMS) reported that upon arrival at the skilled nursing facility, Resident #32 was found to be in ventricular fibrillation (VFib) arrest (when the lower heart chambers contract in a very rapid and uncontrolled manner, resulting in no blood pumped to the rest of the body). The note indicated CPR was performed for around 25 minutes, in conjunction with four rounds of epinephrine and four rounds of shock. The note indicated that on [DATE] at 3:50 PM, upon a Physical Exam, Resident #32 was intubated, pulseless, and on a vent, bilateral breath sounds present. The note further indicated, On arrival [to the hospital], patient lost pulses so CPR was restarted. Patient was intermittently going into Vtach [ventricular tachycardia], therefore patient given one more round of shock. The note also detailed conversations with Resident #32's POA regarding the resident's end of life wishes. The note indicated Resident #32's POA reported to the hospital that the resident told them many times that they wanted to be DNR, but the paperwork was not completed, and the current paperwork reflected the resident was a full code. Per the note, the POA requested the hospital place the resident on hospice care with no further workup or treatment at this time and wants to focus on comfort care. On [DATE] at 9:21 AM, a phone call was placed to Resident #32's POA. A voicemail was left, but no return call was received. A review of computed tomography (CT) results, performed in the hospital on [DATE], revealed the IMPRESSION included, 5. Acute, nondisplaced fracture of right anterolateral 2nd rib. Acute, mildly displaced fractures of the right anterior 2nd-5th ribs at the costochondral junction. 6. Acute, displaced fractures of the left anterior 3rd-6th ribs. 7. Suspected acute nondisplaced sternal fracture. Findings are most likely due to chest compressions. A review of a hospital Multidisciplinary Team Note, dated [DATE] at 4:14 PM, revealed, Patient extubated at 1614 [4:14 PM]. Patient subsequently went agonal and asystole on the monitor. Per the note, asystole and no pulse were verified by two nurses, and a physician was notified. Resident #32's time of death was [DATE] at 4:25 PM. A review of Resident #32's deceased Discharge Summary, dated [DATE] at 4:42 PM, revealed, Preliminary cause of death included VFib cardiac arrest status post ROSC [return of spontaneous circulation] and Acute hypoxic respiratory failure status post intubation on mechanical ventilation. During an interview on [DATE] at 8:35 AM, RN #9 stated she was the nurse that performed CPR on Resident #32. She stated she was sitting at the nurse's station and heard the resident call for help. When she went to the room, the resident's eyes were open, but the resident did not respond. According to RN #9, Licensed Vocational Nurse (LVN) #5 and MDS Nurse #2 were at the nurse's station at the time. RN #9 said she told LVN #5 to call a code blue. Per RN #9, MDS Nurse #2 looked in the POLST book at the nurse's station and could not find Resident #32's POLST, so she used the POLST that was scanned into the resident's electronic health record (EHR), which indicated Resident #32 was a full code. RN #9 stated the paramedics arrived and were given a copy of the POLST printed off the computer that indicated the resident was a full code. RN #9 could not recall the date on the POLST form they pulled from the computer and subsequently provided to the paramedics, but she confirmed the document indicated Resident #32 was to be a full code. During an interview on [DATE] at 12:53 PM, LVN #5 stated she was at the nurse's station and heard Resident #32 scream for help. Per LVN #5, RN #9 went to check on the resident and told LVN #5 to call a code blue and to check the resident's POLST. RN #9 said when she and MDS Nurse #2 located a POLST that indicated full code, CPR was initiated and 911 was contacted. LVN #5 stated she was the one that called Resident #32's POA and informed them facility staff were performing chest compressions, and the POA agreed to continue them. During an interview on [DATE] at 7:41 AM, MDS Nurse #2 stated she was the on-call nurse and was at the nurse's station at the time of Resident #32's code. She stated RN #9 called out for a code blue. According to MDS Nurse #2, Resident #32 had a POLST that reflected full code, so CPR was initiated. MDS Nurse #2 said a copy of the POLST reflecting full code was given to EMS, and they continued the code as the resident was leaving the facility to go to the hospital. During the interview, MDS Nurse #2 was shown a copy of Resident #32's POLST dated [DATE] that reflected the resident was to be DNR. MDS Nurse #2 said she was shocked and did not know what happened. MDS Nurse #2 then looked in the POLST book, which was present in the office at the time of the interview, and verified Resident #32's POLST form was no longer in the book. MDS Nurse #2 then walked with this surveyor to the Medical Records office to see where Resident #32's POLST form was located. During an interview on [DATE] at 8:04 AM, the Medical Records Director (MRD) stated the process for POLST forms was for the admissions department and social services to get a POLST completed and signed upon admission, if the resident did not currently have one in place. The POLST was then given to the physician for signature, and once signed, medical records uploaded the form into the resident's EHR and placed the original in the POLST book. During an interview on [DATE] at 8:08 AM, the Medical Records Assistant (MRA) stated that when a new POLST form was completed and signed, it should be placed in the POLST book, and scanned into the EHR. The MRA provided Resident #32's [DATE] POLST form indicating DNR and stated she pulled it from the POLST book that morning, [DATE], due to the resident no longer being in the facility. During an interview on [DATE] at 7:36 AM, the Director of Nursing (DON) reviewed Resident #32's EHR and said the POLST completed in 2016 (reflecting full code) was the only one available. The surveyor then showed the DON a copy of the [DATE] POLST reflecting the resident had elected DNR and informed her the copy was located in the POLST book at the nurse's station on [DATE]. The DON said that when a POLST form was completed and signed, medical records staff should scan a copy into the EHR and place the form in the POLST book. The DON further stated that a code status order should be transcribed into the EHR so that it would be listed in the EHR in the same area resident allergies were listed. She indicated this allowed for ease of access to that pertinent information. The DON said that if there were residents who did not have a POLST available, then evidently the staff were not following through with the process correctly. A review of Resident #32's EHR revealed no code status was reflected in the area where the resident's allergies were listed, as the DON indicated it should be. During a subsequent interview on [DATE] at 10:26 AM, the DON stated the breakdown in the process for Resident #32's code was that the facility was converting from paper charts to all EHR over the prior weekend. According to the DON, Resident #32's chart was one that still had documents that needed to be scanned. She further stated the resident's POLST dated [DATE] must have been in the resident's old chart and a copy was not placed in the POLST book by medical records staff when it was signed three years ago. The DON said the previous POLST from 2016 that reflected full code was in the POLST book at the time of Resident #32's code. Per the DON, Resident #32's paper chart was disassembled over the prior weekend, and on Monday, [DATE], medical records staff placed the POLST from 2021 that indicated DNR into the POLST book at the nurse's station, which is why the surveyor was able to view it on Tuesday, [DATE]. The DON confirmed that for the past three years, Resident #32 desired to be DNR, but a copy of their prior POLST reflecting full code was in the POLST book instead. During an interview on [DATE] at 9:58 AM, the Administrator stated he understood there were two issues that needed addressed: the POLST process was broken, and the CPR event with Resident #32. The Administrator said at the time of the code, Resident #32's [DATE] POLST that showed the resident was a full code was the one available to staff. The Administrator further stated the resident's current POLST, dated [DATE], that reflected the resident's DNR status was located in a physical chart in medical records in the back of the facility, not readily accessible to staff during the code. The Administrator said the POLST should not have been located in the physical chart because the facility no longer used physical charts and indicated the form should have been in the POLST book instead. The Administrator stated that when staff were looking for a code status, they should first look in the EHR, and secondarily or simultaneously look in the POLST book to identify a resident's code status. During an interview on [DATE] at 1:26 PM, the DON stated her expectations for the POLST and advance directives process was that upon admission the staff would ask the resident or their responsible party what their wishes were. A POLST should then be completed and signed, and a copy scanned into the EHR. The DON said a nurse would then input the code status order into the EHR. The DON said she wanted her end of life wishes to be respected and her decisions to be followed, and she wanted that for others as well. The DON said the failure to honor a resident's advance directive or POLST was not only not honoring their wishes but also a life and death decision. During an interview on [DATE] at 2:17 PM, the Administrator stated he expected staff to implement residents' advance directives and POLSTs in the event of an emergency. He stated he expected staff to be able to locate the POLST and to understand the importance of checking them in the event of an emergency. The Administrator further stated it was important to honor a resident's advance directive because it was their wishes and a resident's right. During an interview on [DATE] at 10:37 AM, the Medical Director stated he expected staff to complete POLSTs and advanced directives thoroughly, obtain the appropriate signatures, and to always honor and follow each resident's wishes. On [DATE] at 8:49 PM, a Removal Plan was submitted by the facility and accepted by the state survey agency. It read as follows: 1. Medical Records on [DATE] will conduct a facility wide audit to determine if all residents have the code status uploaded into the electronic health records of the resident's chart. 2. A list of Residents that are identified by Medical Records as to not having a POLST will be given to Social Services, Case Manager, and Director of Nursing. Social Services will inquire if the residents want to complete a POLST form with the resident's corresponding facility Physician. Residents that refuse to sign a POLST will be considered full code unless their advance directive says otherwise. This will be completed on [DATE]. 3. Medical Records staff will remove the POLST binder from the nursing station and Medical Records will provide each Resident with a physical chart containing the face sheet, the signed POLST, and the personal inventory of the resident. This will be completed on [DATE]. 4. The Director of Nursing (DON) and designee conducted an in-service to Licensed Nurses and Department Heads during their shift on [DATE] and [DATE]. The in-service was about the location of the code status of the resident which is made available on the resident's physical chart as well as on the scanned documents of the resident's electronic health record. Every nurse will be in-serviced in person or through a phone call on [DATE]. DON will check off each nurse to ensure completion. Twenty-Eight licensed vocational nurses (LVNs) and seven registered nurses (RNs) will be in-serviced prior to working their shift. 5. DON and Administrator conducted an in-service with Medical Records Staff on [DATE] on the importance of uploading signed POLST forms in the resident's electronic health record within 72 hours of admission and providing each Resident with a physical chart containing the face sheet, the signed POLST, and the personal inventory of the resident. 6. The DON conducted an in-service with the interdisciplinary team (IDT) on [DATE]. After a care conference with the resident or the responsible party, and when the POLST is confirmed, the IDT will verify if the POLST is available in the resident's electronic health record and will notify Medical Records Staff accordingly. Care conferences are completed within 14 days of admitting to the facility, quarterly, annually, and when there is a significant change of condition. 7. Medical Records Staff will conduct audits for newly admitted and readmitted residents to ensure POLST forms are uploaded in the electronic heath record of the resident's chart and available in the resident's physical chart. This will be done within 72 hours of admission. 8. Medical Records Staff will conduct twice a week audit of all the nursing stations to ensure POLST forms are uploaded in the electronic health record of the resident's chart and available in the resident's physical chart. This will be done twice a week for 3 months, and then weekly after indefinitely. 9. The Administrator notified the facility Medical Director of this recent survey findings, and he will conduct a follow up in-service with the Licensed Nurses (Twenty - Eight licensed vocational nurses (LVNs) and seven registered nurses (RNs)), on [DATE]. All AM/PM shifts will be present. The in-service will be recorded and sent to the nurses that cannot be present. This will be done by [DATE]. 10. Newly hired Licensed Nurses and IDT will be oriented by the Director of Staff Development (DSD) or designee on where to locate the Code Status of the residents which are on the electronic health record or the resident's chart and available in the resident's physical chart. This will be completed on the day of orientation. 11. The DON will conduct monthly in-services to licensed nurses for 3 months on where to locate the code status of the resident which is made available on the resident's physical chart as well as on the scanned documents of the resident's electronic health record. The POLST is located in the documents tab on the electronic health record. 12. Medical Records Director will report during monthly QA meeting the findings of the audits on POLST and Quality Assurance (QA) committee will monitor trends. This will be done for 3 months. 13. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE]. This meeting was to discuss the IJ findings and to develop a plan to get it removed. The Director of Nursing, Administrator, and Medical Records Director attended. Per the facility, all immediate corrective actions would be completed by [DATE]. Onsite Verification: The IJ was removed on [DATE] at 4:03 PM, after the survey team verified the implementation of the Removal Plan as follows: 1. Medical Records audits were reviewed for completion with spot checks done to ensure each resident had a POLST uploaded into their EHR. 2. Review of the residents identified as not having a POLST consisted of one resident, who was not able to make the decision themselves. Multiple calls were placed to their responsible party (RP) without a response. Until a signed POLST is obtained, the resident will remain a full code. Facility staff will continue to reach out to the RP. 3. Nurse's stations were checked with verification of each resident having their own chart containing their POLST, face sheet, and personal inventory. 4. The in-service conducted by the DON was reviewed for content along with the sign in sheet to ensure nurses were being in-serviced prior to their next shift if not in the building during the in-service. Nurses and Department Heads were interviewed to ensure they received the in-service and questions were asked to ensure they understood the processes. 5. Inservice Training Reports were reviewed for content. Interviews with Medical Records staff revealed an understanding of the process and their role in ensuring the POLST is available to staff for review. 6. The Inservice Training Report was reviewed and revealed the interdisciplinary team (IDT) was inserviced on the POLST process. Members of the IDT were interviewed regarding their knowledge of the process and their role in the process. 7. The audit form to be used by Medical Records for admissions going forward was reviewed for content. 8. The audit form to be used for the twice a week audit of the POLST forms was reviewed for content. 9. The Inservice Training Report for the education provided by the Medical Director was reviewed, as well as all the content of the education. Attendance signatures were reviewed. An interview was conducted with the Medical Director on [DATE] at 10:37 AM. The Medical Director confirmed he had educated staff regarding POLSTs, including completing each section thoroughly, ensuring all sections were signed, and his expectations for staff to honor POLST and advance directive wishes. The Medical Director also stated he discussed multiple scenarios with staff while providing the education, and staff interacted and asked pertinent questions. 10. The Inservice Training Report for the education provided to the DSD regarding newly hired nurses was reviewed. The material used to orient new nurses was reviewed with the DSD and an interview was completed to ensure she understood her role in the process of obtaining and honoring POLSTs and advance directives. 11. The in-service to be conducted monthly by the DON was reviewed for content, and the DON was interviewed on her role in the process of ensuring POLSTs and advance directives are honored by staff. Dates for the next three monthly in-services were supplied. 12. The Medical Records Director was interviewed on [DATE] at 8:23 AM regarding her role in the process. She was able to verbalize the process and indicated she would report audit findings during QA meetings each month. 13. The Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting's signature page was reviewed.

Based on interview and record review, the facility failed to implement their policy and procedure for the facility investigation and reporting of all alleged incidents of abuse and neglect to the California Department of Public Health. The facility had 18 incidents of alleged physical abuse, five incidents of alleged verbal abuse, one incident of unspecified abuse, and one incident of neglect (unsupervised resident who eloped from the facility). The facility was unable to provide indications the incidents were investigated by the Abuse Coordinator, discussed by the Interdisciplinary Team (representatives from all departments in the facility), and resolved with the residents. The care plans for residents involved in the incidents were not updated with individualized interventions in an effort to reduce a reoccurrence of the alleged abuse. There was no indication the alleged victims of the abuse were protected from potential physical harm and serious impairment up to and including death from the alleged physical abuse. There was no indication the alleged victims were provided support after the incidents to ensure their emotional well-being or the that the alleged perpetrator was counseled and prevented from initiating a recurrence of the alleged abuse. Due to the facility's failure to implement their policy and procedure for abuse including report incidents of allege abuse or neglect, the Administrator and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy situation on January 12, 2017, at 12:45 p.m., The Immediate Jeopardy was removed in the presence of the Administrator and the Director of Nursing (DON) on January 13, 2017, at 3:22 p.m., after the facility provided an acceptable and immediate action plan of implementing to implement their policy and procedure for investigating and reporting incidences of abuse, neglect, and falls to the California Department of Public Health. Findings: On January 10, 2017, at 3:38 p.m., an interview was conducted with the Quality Assurance Nurse (QAN). A copy of the accident/incident log for October through December 2016 was requested. The QAN stated he was unable to print out the requested information. On January 11, 2017, at 3 p.m., an interview was conducted with the Administrator and the Director of Nursing (DON). The Accident and Incidents logs for October thru December 2016's were requested. On January 11, 2017 at 3:20 p.m., copies of the accident/incidents logs from October 17, 2016, thru January 11, 2017, were received. (a) The facility Accident and Incident log included 26 incidents of alleged abuse and neglect noted between October 17, 2016, thru January 11, 2017. There was no documentation to reflect investigations for the 26 incidents were conducted by the facility. There was no indication the 26 incidents were reported to the Department. In an interview conducted with the Administrator on January 11, 2017, at 3:45 p.m., he stated he was unsure if any of the resident-to-resident abuses or the elopement were reported to the Department. The Administrator stated he was not aware the alleged incidents of abuse and neglect needed to be reported to the Department of Public Health Licensing and Certification. In a concurrent interview with the Director of Nursing (DON) she stated she did not report alleged incidents of resident-to-resident conflict because the facility handled them in-house. The DON stated several of the incidents included physical altercations and minor injuries. In an interview conducted with the Administrator on January 12, 2017, at 11:30 a.m., he stated he had not completed any reports of the investigations for alleged abuse incidents. He further stated some investigations were very informal and he did not write reports. The Administrator stated the social service department wrote notes about most incidents and he considered those notes to be the reports of the incident. The Administrator stated he was the Abuse Coordinator. A review of the facility policy and procedure titled, Incident/Accident Management, with a revision date of December 2015, indicated: POLICY It is the policy of this center to investigate incidents and report them as required by law. FUNDAMENTAL INFORMATION Purpose .To meet the requirements of both state and federal law that incidents are investigated, documented and reported as mandated. .PROCEDURES: .6. The DON/designee and/or Administrator will continue the investigation process as warranted. .10. The Administrator/designee will notify the appropriate state agency of incident(s) in accordance with state and federal law . A review of the California Code Of Regulations, Title 22 indicated: Section . Patients' Rights. (a) . The facility shall established and implement written policies and procedures . A review of the All Facilities Letter (AFL) 12-50 dated December 19, 2012, indicated: .The time frame for reporting serious bodily injury will also change. The statute defines serious bodily injury to mean an injury involving extreme physical pain, substantial risk of death, or protracted loss of impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention that may include hospitalization , surgery or physical rehabilitation. After January 1, 2013, if suspected abuse results in serious bodily injury, then facilities must do the following: . Report the incident immediately and no later than two hours by telephone to local law enforcement, and, . Sent a written report within two hours to the local law enforcement agency, the L&C (Licensing and Certification) Program and the Ombudsman. If the suspected abuse does not result in serious bodily injury, the mandated reporter must: .Report the incident by telephone within 24 hours to local law enforcement agency. .Provide a written report to the local Ombudsman, the L&C Program and the local law enforcement agency within 24 hours .

Based on observation, interview, and record review, the facility failed to provide adequate supervision and prevention of accident risks, for two of 24 sampled residents, as evidenced by: 1. A lack of supervision by facility staff in the main dining room, when Resident 129 was left unattended and experienced a fall resulting in a fracture. In addition, the facility failed to update and revise the resident's Fall Risk care plan after the resident experienced multiple falls in order to decrease the resident's risk of falls; and 2. Facility staff stated they had no knowledge of Resident 69's use of a heating pad for four or five days after the heating pad was brought to the facility by family member. This facility failure increased the potential for Resident 69 to experience skin damage including burns from using the heating pad without supervision. These facility failures increased the potential for the residents to experience additional accidents with further decline in the clinical status of these medically compromised residents, which may have been prevented by appropriate supervision. Findings: 1. On February 2, 2016, at 10:03 a.m., during the initial tour of the facility with the Infection Prevention Nurse (IPN), Resident 129 was observed lying in bed with a sling (support placed to shoulder for arm injury) to the right shoulder. In a concurrent interview with the IPN, she stated Resident 129 was recently readmitted to the facility after a fall where the resident sustained [REDACTED]. On February 3, 2016, at 9:35 a.m., Certified Nurse Assistant (CNA 5) was interviewed. CNA 5 stated she had known Resident 129 for a long time, but this was her first time caring for the resident after her recent hospitalization . CNA 5 described Resident 129 not being as alert as she was before hospitalization . CNA 5 stated Resident 129 used to join all of the activities and was very social before the fall. CNA 5 further stated Resident 129 was previously able to walk using a walker with a two person assist with toileting. On February 4, 2016, at 9:35 a.m., Registered Nurse (RN 2) was interviewed. RN 2 stated Resident 129 was a two person assist with transfer because Resident 129 was heavy. RN 2 stated Resident 129 was a high risk for fall because she tried to get out of bed and stand up by herself. RN 2 also stated she tried to remind Resident 129 to stay in bed. RN 2 stated she did not witness the fall and stated the fall happened in the dining room. RN 2 stated there was supposed to be two Activity Assistants (AA) and two CNAs supervising both dining areas (main dining and back dining rooms) on the p.m. shift. On February 4, 2016, at 9:38 a.m., Resident 129 was interviewed in her room with RN 2 as a translator. Resident 129 stated she stood up by herself and felt something drop to the ground. Resident 129 stated she could remember feeling very weak during the fall incident and stated she felt like she was having a stroke. Resident 129 stated she felt her head was spinning, her heart pounding, felt terrible, and remembered having tremendous pain in her arm after she woke up in the hospital. On February 4, 2016, Resident 129's record was reviewed. Resident 129 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the form titled, Initial History and Physical, dated February 1, 2016, indicated Resident 129 had the capacity to understand and make decisions. A review of a Order Summary Report, dated January 31, 2016, indicated, .Seroquel (antipsychotic) 100 mg (milligrams) q8 (every 8 hours) .Fluoxetine (antidepressant) 10 mg daily .Depakote (medication for mental disorder) 125 mg TID (three times daily) .Metoprolol (blood pressure medication) 25 mg po (by mouth) BID (twice daily) . A review of the form titled, MDS (Minimum Data Set-an assessment tool), dated October 12, 2015, indicated Resident 129's functional status for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position) was coded as 3 for extensive assistance and coded as 2 for ADL (Activities of Daily Living) support provided with one person physical assist. A review of a care plan titled, ADLs, dated July 2015, indicated Resident 129's ADL deficits which required assistance with transfers with a one person assist. The care plan further indicated the resident required staff to assistance with ADL needs and needed staff monitoring for complications due to impaired ADL functioning. A review of a form titled, Fall Risk Assessment, dated January 15, 2016, indicated a score of 15, (high risk for falls greater than 14). The Falls Risk Assessment tool indicated the resident was assessed as a high risk for falls. The facility's record titled, CHARGE NURSES EVALUATION, dated May 26, 2015, indicated, .Resident found on Restroom floor, pt (patient) denies falling pt states she placed herself there . The facility's record titled, CHARGE NURSES EVALUATION, dated September 11, 2015, indicated, .Resident had an unwitnessed fall in her RM (room). Res (resident) stated she was reaching for her tray when she slipped out of W/C (wheelchair). Res (resident) was found by CNA . The facility's record titled, CHARGE NURSES EVALUATION, dated January 17, 2016, indicated, .pt was noted in the middle dinning (sic) room @ 1920 (7:20 p.m.) by another pt on the floor and immediately called for a nurses attention upon entering pt was seen in a sitting position on the floor with W/C (wheel chair) away from pt.upon assessment .pt refused to move right arm .stat (immediate) x-ray ordered and arrived by 8 pm. Upon during x-ray technician stated he could see a fx (fracture) present .order to send to (unnamed acute care hospital). Pt stated she was sitting in her W/C in the middle dining room when she wented (sic) to stand up and transfer herself to a regular chair and had lost balance and fell .c/o (complained of) continued severe pain 9/10 (9 of of 10 in pain scale) to right shoulder .pt transferred out via gurney (apparatus used to transport residents who require medical care) . A review of a care plan titled, FALL RISK, dated July 2015, indicated Resident 129 was At risk for falls with history of falls, use of antidepressants, poor safety awareness, medications Prozac (antidepressant), Norco (narcotic medicine for pain), and Metoprolol )medication for high blood pressure). The FALL RISK, plan of care indicated, .Will reduce the risk for falls x 90 days .call light w/in reach .maintain safe environment .assist w/ADL's (activities of daily living) as needed .remind resident to use assistive device .Keep frequently used items w/in (within) reach . The care plan goal did not indicate how the facility would measure if the risk of falls was decreased. The care plan goal was not resident oriented with the goal the resident could achieve. There was no documentation that indicated a FALL RISK plan of care was initiated after the first fall that occurred on May 26, 2015. There was no documentation that indicated the FALL RISK, plan of care was revised or the facility added interventions after the fall that occurred on September 11, 2015. There were no re-evaluation dates indicated for falls that occurred on May 26, 2015, and September 11, 2015. There was no documentation in the care plan that Resident 129's medications were adjusted or evaluated as a cause associated with the increased risk for falls. The was no documentation to reflect how the care plan goal for less falls would be measured. A review of a form titled, Interdisciplinary Team Meeting, dated January 19, 2016, indicated Resident 129 was able to transfer herself from bed to wheelchair or wheelchair to wheelchair. There was an inconsistency with the documentation of how the resident could transfer. The MDS, dated [DATE], indicated the resident's functional status for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position) was coded as 3 for extensive assistance and coded as 2 for ADL (Activities of Daily Living) support provided with one person physical assist. There was no documentation that indicated there was physician and/or pharmacist consulation or review of the resident's medications which had the potential to contribute to the resident's increased risk for falls, per the facility policy and procedure. A review of the form titled, PATIENT REPORT (radiology report), dated January 18, 2016, indicated, .Humeral neck fracture (a break in the upper arm bone) . A review of the record from (hospital name) titled, History and Physical, dated January 19, 2016, indicated Resident 129 was noted to be disoriented and confused and had a right shoulder fracture. A review of the care plan titled, At risk for fall r/t (related to) HX (history of) falls ., dated February 1, 2016, upon return to the facility from the hospital, indicated, Will reduce the risk for fall . There was no measurable outcome or resident oriented goal in the care plan. On February 4, 2016, at 9:50 a.m., an interview was conducted with the Director of Nursing (DON), the MDS 2 and the Assistant Director of Nursing (ADON). The DON acknowledged during Resident 129's fall on January 17, 2016, in the main dining room, there were no staff members present. The DON stated it was a normal routine for Resident 129 to go to the dining area in the evenings and watch television. The incident report was reviewed with the DON (Director of Nursing). The document indicated the fall was unwitnessed in the dining area. The document also indicated Resident 129 was trying to transfer herself from wheelchair to regular chair, lost her balance, and fell . The DON was interviewed regarding the facility's fall protocol. The DON stated after a fall, the care plan needed to be reviewed and updated with new interventions. On February 5, 2016, at 10:42 a.m., Resident 129's record was reviewed with LVN 4. In a concurrent interview with LVN 4, she stated the facility needed to update Resident 129's care plan for falls and needed more interventions after the multiple falls. There was no indication of any additional interventions added after each fall occurred. LVN 4 stated the facility should have updated the care plan after each fall and consulted with the physician. On February 5, 2015, at 3:25 p.m., the Activities Assistant (AA) was interviewed about supervision in the dining area. The AA stated the Activity staff and CNAs needed to be present in each dining area at all times, during all shifts. The AA stated Resident 129 should not been left alone in the main dining area. On February 8, 2015, at 9:30 a.m., the Director of Staff Development (DSD) was interviewed. The DSD stated there should be two CNAs in charge of the dining areas and until 6:30 p.m., the Activity staff should stay in the dining area. The DSD stated after 6:30 p.m., the licensed nurses should supervise the dining areas. On February 8, 2015, at 10:40 a.m., the ADON (Assistant Director of Nursing) and MDS 2 were interviewed regarding Resident 129's care plan. Both ADON and MDS 2 nurse stated more interventions needed to be added after each fall. The ADON and MDS 2 stated the care plans needed to be revised after each fall with physician consult. The facility's policy titled, Falls and Fall Risk, Managing, revised December 2007, indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . 3. In conjunction with the Consultant Pharmacist and nursing staff. The Attending Physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable Monitoring Subsequent Falls and Fall Risk .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified . 2. On February 2, 2016, at 9:55 a.m., during the initial facility tour conducted with the Director of Staff Development (DSD), a heating pad device was observed at Resident 52's bedside. In a concurrent interview with the DSD, she stated, she did not have any knowledge of resident's using an heating pad. On February 2, 2016, at 1:35 p.m., an interview was conducted with Licensed Vocational Nurse 4 (LVN 4), (who was assigned to Resident 52). She stated she did not know the resident was using a heating pad. On February 2, 2016, a review of Resident 52's record was conducted. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 52's physician order titled, Order Summary Report and Physician Telephone Order, dated February 2, 2016, indicated, there was no physician order for [REDACTED]. On February 2, 2016, at 2:41 p.m., an interview was conducted with Resident 52. Resident 52 stated her husband brought the heating pad to her and she had been using and applying the heating pad for about four to five days for pain on her back. Resident 52 declined to answer as to how long she kept the heating pad in place during an application. On February 2, 2016, at 3:05 p.m., an interview was conducted with DSD. The DSD stated Resident 52 should have an order for [REDACTED]. In a concurrent interview with the DON. the DON stated, the heating pad should not be used without a physicians order or without supervision by the licensed nurse. The facility was unable to provide a policy and procedure regarding the use of heating pad.

Based on interview and record review, the facility failed to immediately notify the physician of Resident 1's multiple episodes of [MEDICAL CONDITION] (high blood sugar). This failure resulted in delayed treatment which caused Resident 1 to develop diabetic ketoacidosis ( DKA - a serious diabetic condition that can lead to coma or even death if untreated timely) with admission to an acute care hospital's intensive care unit. Findings: On November 5, 2015, at 1:10 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding a quality of care issue. On November 5, 2015, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to American Diabetes Association, normal blood sugar ranges from 70- 140 mg/dL (milligram per deciliter- unit of measurement for blood sugar level). The form titled, Physician Order, dated October 18, 2015, indicated, . Accuchecks (blood sugar check) T.I.D. (three times a day) per alternating custom schedule. Call MD (medical doctor) if BS (blood sugar) > (greater than) 250. The form titled, Blood Glucose Testing Record, using the alternating custom schedule, indicated the following: 1. October 19, 2015, Frequency: before breakfast BS- 120, after breakfast BS- HI (high), before lunch BS- HI; and 2. October 20, 2015, Frequency: after breakfast BS- 294, before lunch BS- 363, after lunch BS 159. The glucometer (a machine used by licensed nursing staff to measure blood sugar - an accucheck) instruction manual provided by the Director of Nursing (DON) was reviewed. The glucometer manual titled, Assure Platinum Blood Glucose Monitoring System, indicated if the glucometer reading was HI, it meant the blood glucose was above 600 mg/dL. The form titled, Charge Nurses Evaluation, dated October 19 and 20, 2015, was reviewed. As written above in the Blood Glucose Testing Record, the blood sugar levels obtained on October 19, 2015, after breakfast (HI) and before lunch (HI) were reported at 11:30 a.m. and at 5 p.m. respectively. Resident 1's high blood sugar levels were reported two to five and a half hours late on October 19, 2015. There was no documented evidence Resident 1's high blood sugar of 294 after breakfast and 363 before lunch were reported as ordered by the physician. On November 10, 2015, at 1:18 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated the alternating schedule for accucheck was being used at the facility as ordered by the Medical Director. The accucheck schedule if ordered before breakfast should be done at 6:30 a.m., if after breakfast should be 9 a.m., before lunch at 11:30 a.m., after lunch at 2 p.m., before dinner at 4:30 p.m., after dinner at 7 p.m. and at bedtime at 9 p.m. The RN stated the MD should be notified immediately if the blood sugar was high according to the doctor's order. On November 10, 2015, at 1:45 p.m., The DON was interviewed. The DON was not able to explain the reason why the blood glucose levels obtained on October 19, 2015, were not reported right away. She stated she could not find any documented evidence the MD was notified of Resident 1's elevated blood glucose reading of 294 after breakfast and the reason why 336 and not 363 blood glucose reading was reported on October 20, 2015. The DON stated the elevated blood sugar levels should have been reported by the nurse. The form titled, Charge Nurses Evaluation, dated October 24, 2015, indicated Resident 1 started vomiting at 12:45 a.m., with elevated a blood sugar level that read HI. At 1 a.m., Resident 1 vomited two times with an elevated blood sugar level that read HI again. The form indicated the nurse waited for a response from the MD on both occasions. The resident's record indicated that at 1:25 a.m., Resident 1 had vomited again two times and blood sugar level read HI. Resident 1 requested to be sent to the hospital to further evaluate projectile vomiting (vomit that exits the mouth with such force in that it is propelled over a short but significant distance). When the Resident 1 arrived at the hospital's emergency room (ER), her first blood pressure was recorded as 89/47 (as defined in the 22nd Edition of Taber's Cyclopedic Medical Dictionary, normal blood pressure is between 100 and 120 systolic {top number} and 80 or below diastolic {bottom number}) at 2:40 a.m. The resident had other laboratory studies completed with a critical blood sugar reading of 1,430 mg/dL (normal 70 to 140 mg/dL). After the laboratory studies were completed, Resident 1 was diagnosed as having diabetic ketoacidosis. According to American Diabetes Association, Diabetic Ketoacidosis (DKA) is a serious condition that can lead to diabetic coma or even death .DKA usually develops slowly. But when vomiting occurs, life-threatening condition can develop in a few hours . Resident 1 was admitted to the hospital's intensive care unit (department of a hospital that is designed and equipped for the monitoring, care, and treatment of [REDACTED]. The facility policy and procedures was reviewed. The policy and procedure titled, Change in a Resident's Condition or Status, dated April 2011, indicated, .The Nurse Supervisor/charge Nurse will notify the resident's Attending Physician or On-call Physician when there has been: .d. A significant change in the resident's physical/emotional/mental condition .i. Instructions to notify the physician of changes in the resident's condition .

Based on interview and record review, the facility failed to provide prompt interventions when Resident 1 experienced multiple episodes of [MEDICAL CONDITION] (elevated blood sugar). This failure resulted in Resident 1 developing diabetic ketoacidosis (DKA- a serious condition that can lead to diabetic coma or even death) with admission to the acute care hospital's intensive care unit. Findings: On November 5, 2015, at 1:10 p.m., an unannounced visit was conducted at the facility to investigate a complaint regarding a quality of care issues. On November 5, 2015, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to American Diabetes Association, normal blood sugar ranges from 70- 140 mg/dL (milligram per deciliter- unit of measurement for blood sugar level). The document titled, History and Physical, dated October 16, 2015, sent to skilled nursing facility from the acute hospital was reviewed. The document related to Resident 1, and indicated, Impression: .[MEDICAL CONDITION]. The patient had diabetes with uncontrolled [MEDICAL CONDITION]. The patient needs aggressive insulin (hormone to treat high blood sugar) therapy along with fluid hydration and close monitoring to prevent her from going into DKA . The document titled, Discharge Medications, from the acute hospital, indicated Resident 1 was taking [MEDICATION NAME] (a long acting insulin with an onset of action of three to four hours and a duration of generally 24 hours) 20 units routinely subcutaneous (under the skin) every morning and was on high dose insulin sliding scale using [MEDICATION NAME] (rapid acting insulin- works quicker than other types of insulin). The document titled, Physician Order, dated October 18, 2015, indicated, Continue all meds (medications) Stop [MEDICATION NAME] Accucheck (blood sugar check) T.I.D. (three times a day) per alternating custom schedule. Call MD (medical doctor) if BS (blood sugar) > (greater than) 250. The document titled, Blood Glucose Testing Record, using the alternating custom schedule, dated October 19 to 23, 2015, indicated the following: 1. October 19, 2015, Frequency: before breakfast BS- 120, after breakfast BS- HI (high), before lunch BS- HI; and 2. October 20, 2015, Frequency: after breakfast BS- 294, before lunch BS- 363, after lunch BS 159. The glucometer instruction manual provided by the Director of Nursing (DON) was reviewed. The manual titled, Assure Platinum Blood Glucose Monitoring System, indicated if the glucometer reading was HI, it meant the blood glucose (blood sugar) was above 600 mg/dL (milligram/deciliter- concentration solution of blood sugar). The document titled, Charge Nurse Evaluation, dated October 19 and 20, 2015, indicated the following: 1. October 19, 2015, at 11:30 a.m., B/S read high .paged (name of doctor) . At 12 p.m., (name of doctor) returned call & (and) gave orders for [MEDICATION NAME] 20 units SQ (subcutaneous-under the skin) now, [MEDICATION NAME] 20 units insulin q (every) AM (morning) . At 5 p.m. Pt (patient) BS read HI, paged (name of doctor) . At 8 p.m., MD returned call c (with) n.o. (new order) to give [MEDICATION NAME] 20 u (units) SQ x (times) 1 now and ^ (increase) [MEDICATION NAME] to 30 u (units) q am .; 2. On October 20, 2015, on the 3-11 shift, .BS was 336. MD made aware. New order to increase AM (morning) [MEDICATION NAME] to 40 units SQ and to give ([MEDICATION NAME]) 20 units SQ now . There was no documented evidence Resident 1's condition was fully assessed when blood sugar levels continued to be elevated on October 19 and October 20, 2015. The document titled, Medication Administration Record [REDACTED]. On October 20, 2015, Resident 1 was given [MEDICATION NAME] 20 units one time at 5 p.m. (Resident 1's blood sugar was elevated in two consecutive times: after breakfast and before lunch). There was no documented evidence an intervention was provided when blood sugar level was elevated to 294 after breakfast and before lunch when blood sugar level read 363 on October 20, 2015. On November 5, 2015, at 4 p.m., the record was reviewed with Assistant Director of Nurses (ADON). The ADON stated if the medical doctor gave an order to continue all medications from the hospital, all the medications from the discharge lists would be carried out unless the medical doctor changed a specific order. There was no documented evidence the facility medical doctor gave an order to discontinue routine [MEDICATION NAME] which Resident 1 was taking at the acute hospital. There was no documented evidence the facility continued Resident 1 with routine [MEDICATION NAME] on admission. On November 10, 2015, at 1:18 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated the alternating schedule for Accucheck (blood sugar check) was being used by the facility medical director. The Accucheck schedule if ordered before breakfast should be done at 6:30 a.m., if after breakfast should be 9 a.m., before lunch at 11:30 a.m., after lunch at 2 p.m., before dinner at 4:30 p.m., after dinner at 7 p.m. and at bedtime at 9 p.m. The RN stated the medical doctor should be notified immediately if the blood sugar was high according to the doctor's order. There was no intervention provided on the blood sugar reading of 294 after breakfast on October 20, 2015. Resident 1 was given [MEDICATION NAME] in every hyperglycemic episodes from October 19 to 20, 2015, 3 to 8 hours after the blood sugar levels were read at HI. According to Lexi comp, Insulin [MEDICATION NAME] .([MEDICATION NAME]) .Long-acting .Pharmacodynamics/kinetics .Onset of action .3 to 4 hours .Durations: [MEDICATION NAME]: Generally 24 hours or longer . On November 10, 2015, at 1:45 p.m., the Director of Nurses (DON) was interviewed. The DON stated elevated blood sugar was considered a change of condition. She stated any change of condition should be reported to MD and should be documented in the resident's medical record, including the new order given by the MD. The DON stated, she could not answer for the nurses regarding the time frame the change of condition was reported. She further stated she could not find any documentation if the elevated blood sugar levels on October 20, 2015, were reported to MD. On November 30, 2015, at 9:32 a.m., Registered Nurse (RN) 2 was interviewed, she stated she took a picture of the list of Resident 1's discharged medications from the acute hospital using her personal phone and sent it to the MD when Resident 1 got admitted for medication verification. RN 2 stated the second page of the medication list which included the Accucheck order was blurred so she asked another nurse to verify the admission medications with the MD. RN 2 stated routine [MEDICATION NAME] and Accucheck orders were on the same page in the acute hospital discharged medications. The form titled, Charge Nurses Evaluation, dated October 24, 2015, indicated Resident 1 started vomiting at 12:45 a.m., with an elevated blood sugar level of HI. At 1 a.m., Resident 1 vomited two times with an elevated blood sugar level of HI. The form indicated the nurse was waiting for a response from the MD on both occasions. As documented at 1:25 a.m., Resident 1 had vomited again two times and blood sugar level read high. Resident 1 requested to be sent to the hospital to further evaluate her projectile vomiting (vomit that exits the mouth with such force in that it is propelled over a short but significant distance). A review of Emergency Department Record, dated October 24, 2015, indicated the following: 1. At 2:40 a.m., Initial vitals at presentation: BP (blood pressure) 89/47 . (low blood pressure) . As defined in the 22nd Edition of Taber's Cyclopedic Medical Dictionary, normal blood pressure is between 100 and 120 systolic {top number} and 80 or below diastolic {bottom number}). 2. At 4:11 a.m., laboratory findings indicated, . Beta [MEDICATION NAME]- ([MEDICATION NAME]- chemical substances that the body makes when it does not have enough insulin in the blood) . 9.85 (elevated - normal range 0.02 -0.27) .; 3. At 5:25 a.m., ABG analysis (arterial blood gas- to provide information about acid-base balance) .pH (numeric scale to identify acidity or alkalinity) 7.05 (meaning more acidic) . (chronically over acidic pH affects all cellular functions from the beatings of the heart to the neural workings of the brain.) Were completed. 4. At 5:54 a.m., indicated, Critical lab (laboratory) value received .glucose 1430 (normal 80-150 mg/dL), sodium (electrical signals in the body, allowing muscles to fire and the brain to work) 108 (low) (normal 136-145 mEq/L), and potassium (regulation of the heartbeat and the function of the muscles) 7.6 (high) (normal 3.5- 5.1) .; 5. Impressions: DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH (Diabetic) KETOACIDOSIS .; and 6. At 6:58 a.m., Resident 1 was started with, INSULIN REGULAR HUMAN (a short-acting medication to treat [MEDICAL CONDITION])* 8 unit(s) per hour IV (intravenous- within the vein) Medication Infusion . After the insulin drip (procedure in which insulin, mixed in an IV solution, is infused into a vein over time through a tube and needle) was started, Resident 1 was admitted to the hospital's intensive care unit (department of a hospital that is designed and equipped for the monitoring, care, and treatment of [REDACTED]. The document titled, History and Physical, dated October 24, 2015, at the acute hospital, indicated, . She (Resident 1) has uncontrolled diabetes last time as well. She comes in now with [MEDICAL CONDITION] (disease of the brain that alters brain function or structure), hypothermia (body core temperature dropped below normal), [MEDICAL CONDITION] (condition that occurs when the level of sodium in the blood is abnormally low), and diabetic ketoacidosis; it is unclear how this could have happened at the nursing facility . According to American Diabetes Association, Diabetic Ketoacidosis (DKA) is a serious condition that can lead to diabetic coma or even death .DKA usually develops slowly. But when vomiting occurs, life-threatening condition can develop in a few hours .What causes DKA? .Not enough insulin. Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness . The facility policy and procedures was reviewed. The policy and procedures titled, Administering Medications, dated April 2010, indicated, Policy . Medications must be administered in accordance with the orders, including any required time frame .

Based on observation, interview and record review, the facility failed to ensure one resident (Resident A) was free from verbal and mental abuse when: 1. A facility staff told the resident to shut up followed by foul language when Resident A requested to have his soiled brief changed, and 2. A facility staff put Resident A's call light on the floor under his bed so that he would not turn on the call light when the resident needed care. These failures had the potential for severe psychological harm for Resident A. Findings: On December 17, 2015, at 11:46 a.m., an unannounced complaint investigation was conducted at the facility. On December 17, 2015, at 12 noon, Resident A was interviewed. Resident A was observed in bed, unable to move without assistance and slow to speak. Resident A stated on Tuesday, December 15, 2015, Certified Nurse Assistant 1 (CNA 1) and CNA 2 were both in his room at one point. Resident A stated when he told CNA 1 that his clothes were in the wrong closet CNA 1 responded Shut up and (expletive) off! Resident A stated CNA 2 then Put the call light on the floor. Resident A stated the call light was left on the floor until CNA 3 came in and he asked her to pick it up. Resident A stated he told CNA 4 about CNA 1 and CNA 2. Resident A further stated he told the whole story to CNA 5 the following day, Wednesday, December 16, 2015. On December 17, 2015, at 12:15 a.m., Licensed Vocational Nurse 1 (LVN 1) was interviewed. LVN 1 stated he was the nurse in charge for Resident A. LVN 1 stated he was not aware of what had happened to Resident A. LVN 1 stated It should have been reported. On December 17, 2015, at 12:20 a.m., CNA 4 was interviewed. CNA 4 stated Resident A told her about the call light and that The lady (CNA 1) doesn't change my diaper. CNA 4 stated she told the nurse yesterday but could not remember the nurse's name. On December 17, 2015, at 12:30 p.m., Resident B was interviewed. Resident B was Resident A's roommate. Resident B stated Yes, I heard it. Resident B further stated The (skin color) nurses said shut up and (expletive) off! Resident B stated the incident happened on Tuesday. On December 17, 2015, at 12:40 p.m., CNA 3 was interviewed. CNA 3 confirmed that she did pick up Resident A's call light from the floor when Resident A asked her to pick it up on Tuesday. On December 17, 2015, at 12:45 p.m., CNA 5 was interviewed. CNA 5 stated Resident A informed her that on Tuesday when he told CNA 1 and CNA 2 that his clothes were in the wrong closet They (CNA 1 and CNA 2) told him to be quiet and (expletive) off. CNA 5 stated Resident A told her about the incident on Wednesday. CNA 5 stated No I didn't report it .I didn't want to point fingers. On December 17, 2015, at 12:58 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated she did not receive any report about what happened to Resident A. The DSD confirmed CNA 1 and CNA 2 worked and were assigned to Resident A's station on December 15, 2015. CNA 1 and CNA 2's employee files were reviewed with the DSD. CNA 1 had training on different types of abuse, abuse prevention and reporting on September 15, 2015. CNA 2 had the same abuse training on October 14, 2015. Resident A's record was reviewed. Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident A's history and physical dated September 10, 2015, indicated Resident A had the capacity to understand and make decisions. The Minimum Data Set (MDS - an assessment tool) dated October 5, 2015, indicated Resident A had a Brief Interview for Mental Status (BIMS - screener for mental and cognitive status) score of 15 (a score of 13-15 means cognitively intact). The MDS also indicated Resident A required extensive assistance with activities of daily living (includes moving in bed, transferring, personal hygiene, bathing and toileting.) Resident B's record was reviewed. Resident B's history and physical dated October 15, 2015, indicated Resident B had the capacity to understand and make decisions. The MDS dated [DATE], indicated Resident B had a BIMS score of 15. On December 17, 2015, at 1:28 p.m., the Administrator and Director of Nursing (DON) were interviewed. The Administrator stated the he was the facility's abuse coordinator. The Administrator stated what happened to Resident A was not reported to him. The DON stated It should have been reported. The facility Preventing Resident Abuse policy and procedure dated December 2006, indicated Our facility will not condone any form of resident abuse and will continually monitor .to assist in preventing resident abuse .The facility's goal is to achieve and maintain an abuse-free environment .

Based on interview and record review, the facility failed to: 1. Provide services to ensure Resident 1's highest practical physical condition by failing to consistently monitor the resident for signs and symptoms of [DIAGNOSES REDACTED]. 2. Have a policy which defined alternate schedule blood sugar monitoring and post [MEDICAL TREATMENT] assessments. 3. Communicate with the [MEDICAL TREATMENT] center regarding monitoring blood sugar levels during [MEDICAL TREATMENT], and resident's status and response to [MEDICAL TREATMENT] treatments. As a result, Resident 1 experienced two episodes of profound [DIAGNOSES REDACTED] and became unresponsive. The resident required treatment with [MEDICATION NAME] (a medication given by injection to increase blood sugar levels in diabetics with [DIAGNOSES REDACTED] (low blood sugar) who are unable to take a quick-acting source of sugar by mouth). Findings: Resident 1 was admitted to the facility on [DATE], at 6:15 p.m., with [DIAGNOSES REDACTED]. Resident 1 received [MEDICAL TREATMENT] treatments three days per week. Physician admission orders [REDACTED]BID (twice daily) alternate schedule. No specific times or directions were noted regarding an alternate schedule. Additionally, the physician ordered regular insulin to treat elevated blood sugar levels, per sliding scale with parameters given, and indicated staff was to call the physician if blood sugar values were less than 60 or greater than 450. [MEDICATION NAME] was ordered for blood sugars less than 60, resident unresponsive due to [DIAGNOSES REDACTED], call MD. Resident 1's record contained two blood sugar test logs. One, labeled, Blood Glucose Testing Record, Month - [DATE], contained testing times on the form designated at 6:30 a.m. and 11:30 a.m., and 4:30 p.m. and 9 pm. The second log labeled, After Meals Blood Glucose Testing - Month [DATE], listed test times as 9 a.m., 2 p.m., and 7 p.m. Resident 1's record reflected the first blood sugar test (result = 112) was performed on [DATE] at 4:30 p.m., 21 hours after admission. The next test was at 9 p.m., result = 118. Resident 1 was hospitalized from [DATE], to [DATE], for treatment of [REDACTED]. On [DATE], at 6:30 a.m., a blood sugar test result was 60. [MEDICATION NAME] was administered at 6 a.m. No 11:30 a.m. test result was recorded. A nursing note indicated at 2 p.m., the resident ' s wife reported her husband was clammy, wet, and non-verbal. His blood sugar level was tested and the results indicated it was 29. Resident 1 was given [MEDICATION NAME], and ten minutes later he was alert and able to eat. The Food Consumption Log for [DATE], indicated Resident 1 ate a fair breakfast and lunch, between 50 and 75 percent. At 4 p.m., the resident ' s blood sugar level was 71, and at 7 p.m., it was 106. On [DATE], the treating physician documented completion of the resident's history and physical. There was no indication the blood sugar values were reviewed by the physician. There was no indication an assessment for the use of [MEDICATION NAME] was conducted. On [DATE], [MEDICATION NAME] was administered at 6 a.m. At 6:30 a.m., Resident 1's blood sugar test result was 60, and at 11:30 a.m. the test result was 73. The nursing notes indicated, at 1:15 p.m., Resident 1 went for [MEDICAL TREATMENT] treatment. The [DATE], nursing notes indicated Resident 1 returned to the facility at 6:30 p.m. At 7:20 p.m., Resident 1 was found unresponsive. He became cyanotic and CPR was initiated. Blood sugar testing was completed and the results indicated Resident 1's blood sugar was low (less than 20, per the testing machine instruction sheet). Following administration of [MEDICATION NAME], the resident's blood sugar rose to 31 and then 70. Resident 1 remained unresponsive. Paramedics arrived and continued efforts to revive him. Resident 1 was pronounced dead at 7:56 p.m. Summary: Table of blood sugar test results: [DATE] 7: 05 p.m., readmitted no test performed [DATE] 6:30 a.m. result 60, 2 p.m. result 29, [MEDICATION NAME] given 4:30 p.m result 71, 7 p.m. result 106 [DATE] 11:30 a.m. result 75, 4:30 p.m. result 71. [DATE] 6:30 a.m. result 60, 11:30 a.m. result 73 7:20 p.m. result Low, [MEDICATION NAME] given, (unresponsive) No time - Recheck result 31 No time - 2nd recheck result 70 7:39 EMS notified / at scene, recheck, result-110. (EMS note) There was no time when the resident had an elevated blood sugar level requiring additional insulin, per the physician ordered sliding scale parameters. A review of Resident 1's clinical record revealed no initial care plans for diabetes, [MEDICAL TREATMENT], or [DIAGNOSES REDACTED] (glucose at or below 70 mg/ dL., American Diabetes Association) or [MEDICAL CONDITION]. A care plan for low blood sugar was developed on [DATE], after Resident 1 experienced profound [DIAGNOSES REDACTED] that required treatment. The care plan directed monitor BS for 72 (hours). No strategies, time frames, or directions for frequency were listed on the care plan. No changes were made to the existing blood sugar monitoring schedule. During an interview on February 2, 2015, the Medical Records representative stated the facility used a communication form to share information between the facility and the [MEDICAL TREATMENT] center. The representative and the director of nursing (DON 1) were unable to find a communication form for Resident 1. The DON 1 stated she did not know what occurred at [MEDICAL TREATMENT] and, maybe they have a record. During an interview on [DATE], the director of nursing (DON 2) indicated the facility had no policy regarding an alternate schedule for blood sugar testing. DON 2 stated, They just follow doctor orders. DON 2 stated the facility had no set times when an alternate schedule testing should be done. The facility failed to adequately monitor Resident 1 for signs and symptoms of [DIAGNOSES REDACTED]. Resident 1 did not have a care plan for diabetes, and had an inadequate care plan for [DIAGNOSES REDACTED]. The facility failed to conduct post [MEDICAL TREATMENT] assessments and to maintain communication with the [MEDICAL TREATMENT] center regarding the resident's status and response to treatments. The facility failed to have policy and procedures for any periodic blood sugar testing schedules ordered by the physician. The facility failed to prevent two episodes of acute [DIAGNOSES REDACTED] that occurred within 48 hours of each other and which required [MEDICATION NAME] treatments.

Based on interview and record review, the facility failed to ensure Resident 1 was free from verbal and mental abuse when Certified Nursing Assistant (CNA) 1 refused to assist the resident to use a bedpan and instructed the resident to soil himself. This failed practice resulted in Resident 1 feeling angry, agitated, and humiliated, in addition to being less trusting of nursing staff members. Findings: On September 16, 2015, an unannounced visit was made to the facility to investigate an entity reported incident that CNA 1 verbally and mentally abused Resident 1 by telling the resident to Shit on yourself after Resident 1 requested a bedpan. On September 16, 2015, at 10:04 a.m., an interview was conducted with Resident 1. The resident dictated his statement to the surveyor due to the resident's [DIAGNOSES REDACTED]. Resident 1 initialed and signed the statement to authenticate his statements. During the interview, Resident 1 stated he pushed his call button to summon a nurse to help him use the bedpan. He stated that, after about 30 minutes, CNA 1 came into the room and asked him what he wanted. Resident 1 told CNA 1 he needed to have a bowel movement. The CNA replied, I am with the family of another resident, what are you going to do, write me up? Resident 1 stated he protested to CNA 1, who told him, Then go[***]yourself. Resident 1 stated when CNA 1 returned and put the resident on a bedpan, he left him on the bedpan for 45 minutes. After that time, Licensed Vocational Nurse (LVN) 1 came into the room and helped the resident off the bedpan. In the written documentation provided by LVN 1, she documented Resident 1 was very upset and asked LVN 1 not to have CNA 1 come into his room again. Additionally, LVN 1 documented Resident 1 wanted to speak with Registered Nurse (RN) 1. Furthermore, LVN 1 documented RN 1 had referred LVN 1 to RN 2 for assistance with filling out the report on CNA 1. A record review was conducted for Resident 1 on September 16, 2015. The resident was admitted to the facility on [DATE]. An Initial History and Physical dated August 13, 2015, indicated Resident 1 was alert and oriented and had the capacity to understand and make his own decisions. During an interview conducted with the Director of Nursing on September 16, 2015, at 8:40 a.m., she stated the incident was substantiated by a facility investigation. The Social Services Director (SSD) documented in her progress notes dated September 10, 2015, SSD was made aware by nursing staff that Resident 1 had incident with CNA 1 on the night of September 9, 2015. Resident 1 stated he had his call light on because he had to go to the bathroom. Resident 1 stated when CNA 1 came in, CNA 1 told Resident 1 he had a lot to do, then CNA 1 told Resident 1, You can go ahead and[***]on the bed. What are you going to do, write me up? Resident 1 stated CNA 1 finally did put Resident 1 on the bedpan around 8 p.m., but did not get off until 8:45 p.m., when LVN 1 assisted him off the bedpan. Resident 1 stated he informed RN 1, RN 2, and LVN 1, on duty of the issues with CNA 1. A record review of the personnel file for CNA 1 was conducted on September 16, 2015. CNA 1 had documentation dated May 23, 2014, he attended Staff Abuse Training. Additionally, there was documentation CNA 1 was terminated on September 14, 2015. On September 16, 2015, the facility policy and procedure titled, Reporting Abuse to Facility Management, dated April 2011, was reviewed. The policy indicated, .Policy Interpretation and Implementation .1. Our facility does not condone resident abuse by anyone, including staff members . A second policy titled, Preventing Resident Abuse, dated December 2006, was reviewed. The policy indicated, .Policy Interpretation and Implementation .2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: .i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.); .

Based on interview and record review, the facility failed to ensure one Resident (Resident 1) was free from harm, when he fell from his bed on September 6, 2015. This failure caused Resident 1 to sustain a broken nose and head laceration from the fall that required him to be transported to the emergency department of the acute hospital via 911 in a paramedic staffed ambulance for further evaluation and treatment. Findings: On September 23, 2015, at 12 noon an unannounced visit was made to the facility to investigate two complaints. On September 23, 2015, at 12:26 and 4:15 p.m., observations were made of the resident in his room. Resident 1 was lying in bed, the head of his bed was raised, and side rails were raised and padded. The height of his bed was observed and was not in a low position. An interview was conducted with Resident 1's roommate (Resident 2) on September 23, 2015, at 12:28 p.m Resident 2 stated his roommate had a habit of kicking the side rail of the bed. When Resident 2 was asked about Resident 1's recent fall, Resident 2 stated he heard Resident 1 kicking the side rail. He further stated, Once the kicking stopped, he thought his roommate had gone to sleep. He then stated he heard noises coming from the floor and when he looked, he saw the bed side rail down and his roommate on the floor. On September 23, 2015, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. pain). A review of the Charge Nurses' Evaluation notes, entry date September 6, 2015, at 7 a.m., indicated, Pt (patient) found on floor, 2 lacerations to L (left) side of head, cut above L eyebrow bleeding, pt bleeding from nose .pt is awake .called requested ambulance transfer to acute hospital, concern for head injury . A review of the resident's Fall Risk Assessment, located three quarterly assessments, dated September 18, 2014, December 15, 2015, March 16, 2015, and an annual assessment dated [DATE], in the record. All assessment dates indicated a total score of 16. Directions on the assessment indicated, When the resident's total score is greater than or equal to 14, care plan this fall risk with interventions to decrease such a risk. A review of the Care Plan for Fall Risk, with an intervention date of November 4, 2013, indicated, Minimize hazards in resident's environment, including .locking moveable equipment . Section 5 indicated, Provide assistive interventions as necessary, including . No interventions were marked except two handwritten interventions, one of which indicated, side rails up when in bed . Section 7 indicated, Have SR (side rail) padded. The care plan titled, Fall Risk, dated June 2015, indicated, SR up as ordered .padded SR to prevent injury . Further review of the Resident 1's record located an Order Summary Report, (Physician's orders) that indicated, Both side rails up while in bed . The order was dated March 20, 2014. Additional review of the resident's record located a Short Term Care Plan, dated September 6, 2015. The Short Term Care Plan indicated, 5. Make sure bed rails are secure. A review of the Interdisciplinary Team Meeting, dated September 6, 2015, at 7 a.m., indicated, Resident found on the floor on his back next to his bed. Sustained laceration to L eyebrow and back of the head. Resident sent out to hospital for further evaluation. A review of the Emergency Provider Report, from the acute hospital, dated September 6, 2015, indicated laceration management to the left face, the wound length 1.000 cm (centimeter). The skin repair was noted as skin adhesive. A review of the History and Physical, dated September 6, 2015, from the acute hospital indicated, This is a [AGE] year old male who sustained a fall in the nursing home today, was transferred to the ER for further evaluation. The patient was found to be encephalopathic (generalized brain dysfunction) with evidence of hypernatremia (an elevated concentration of sodium in the blood); therefore, stabilized and referred for admission and management .The patient is referred for further management of electrolyte abnormalities and further medical management .CT (computerized tomography - a computer scan that takes data from several X-ray images of structures) of the head without contrast (a dye used for better visualization of certain x-rays) shows .nasal fracture . The Interdisciplinary Team Meeting, document dated September 16, 2015, after the resident returned from the hospital indicated, Continue bed in lowest position, and continue SR pads for seizure precaution, SR up in place to keep LAL (low air loss mattress- special mattress to help prevent bed sores) in place. This same Interdisciplinary Team Meeting, document dated September 16, 2015, indicated on the back of the document, Resident was heard kicking the side rail @ (at) time of incident. Roommate called staff when resident was seen on the floor. Resident was last seen during routine morning medication pass at 6:30 a.m., and all precautions were observed. No date was was noted on this entry. On September 23, 2015, at 4:28 p.m., an interview was conducted with the DON. When asked about Resident 1's fall, she stated Resident 1's son spoke with her and the Administrator. She stated she told the son the facility would conduct an investigation and inform him of their findings. When asked the findings of the investigation, the DON stated it was possible that the last staff member to care for the resident might not have locked the side bed rails completely. On September 30, 2015, at 12:57 p.m., Resident 1 was observed lying in bed. The bed was noted in low position with LAL mattress . No bed rails were observed. A mat was observed on the floor next to the bed. Attempts were made to interview the resident. Resident 1 was called by his name three times with no response. Resident 2 in Bed A stated, He doesn't talk. On October 27, 2015, at 9:50 a.m., the height of Resident 1's bed was measured by the Maintenance Supervisor (MS). The MS was asked if the bed was in the lowest position, he stated, Yes. The height of Resident 1's bed in the lowest position measured 19 inches from the top of the mattress to the floor. The bed was observed to have a LAL mattress in place. The MS was then asked to take the measurement of the LAL mattress. It measured 8.5 inches. The MS was then asked to measure Bed C. The MS was asked what position Bed C was in; the MS stated the Normal, or Regular, position. Bed C in the Normal, position from the top of the mattress to the floor was measured by the MS at 27 inches. Bed C was observed to have a thinner, non therapeutic mattress. A review of the facility policy and procedure titled, Falls and Fall Risk, Management, revised December 2007, indicated, Based on previous evaluations .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .