Every finding on record at Keystone Post-Acute

Based on interviews and record reviews the facility failed to meet the minimum requirement of a registered nurse (RN) on duty for eight consecutive hours per day, seven days per week when a RN was not on duty for a the minimum eight consecutive hours for 12 days in May 2026, 24 days in June 2026, and 17 days in July 2026.This failure had the potential to result in residents not receiving services required to be provided by a RN.Findings:During an interview on 7/17/26 at 9:48 a.m. with the Director of Nursing (DON), the DON stated, We had a lot of changes. The DON stated the RN went on medical leave and the facility has not hired any additional RNs. The DON stated the facility had a part-time RN, however they have not worked on the facility for more than three months The DON, stated, I do not have any RNs working on the weekend. The DON stated, It is important to have a RN on the floor for clinical practice. The DON stated RNs have full clinical practice and License Vocation Nurses practice were limited. The DON stated that when an RN is not at the facility it could cause residents to experience a delay in care and to not receive the services they need. The DON stated residents were at risk for hospitalization when they had delayed care and services. During an interview on 7/17/26 at 3:04 pm, with theAdmi nistrator (ADM) the ADM stated, the facility uses an on-call list of RNs, for residents with intravenous medications. The ADM stated the facility was expected to take care of the residents. The ADM stated the DON has had to come in after hours for coverage. The ADM stated there were not any RNs currently working eight consecutive hours for the facility. The ADM stated residents were at risk for hospitalization when the an RN was not present to do full scope clinical practices. During review of the facility's staff assignment calendar titled, Nursing Staffing Assignment dated 5/2026, the calendar indicated, that there was no RN working on 5/2/26, 5/4/26, 5/5/26, 5/10/26, 5/11/26, 5/17/26, 5/18/26. 5/19/26, 5/24/26, 5/25/26, 5/30/26, 5/31/26. The facility's Nursing Staffing Assignments indicated the facility did not schedule or have a RN to care for residents for 12 days in May of 2026.During review of the facility's staff assignment calendar titled, Nursing Staffing Assignment dated 6/2026, the calendar indicated, there was no RN working on 6/1/26,6/2/26, 6/6/26, 6/7/26, 6/8/26, 6/9/26, 6/13/26, 6/14/26, 6/15/26, 6/16/26, 6/17/26, 6/18/26, 6/19/26, 6/20/26, 6/21/26, 6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/26/26, 6/27/26, 6/28/26, 6/29/26, 6/30/26 . The facility's Nursing Staffing Assignments indicated the facility did not schedule or have a RN to care for residents for 24 days in June of 2026.During the facility's staff calendar titled, Nursing Staffing Assignment dated 7/2026, the calendar indicated, no RN was working on 7/1/26, 7/2/26, 7/3/26, 7/4/26, 7/5/26, 7/6/26, 7/7/26, 7/8/26, 7/9/26, 7/10/26, 7/11/26, 7/12/26, 7/13/26, 7/14,26, 7/15,26, 7/16/26, 7/17/26. The facility's Nursing Staffing Assignments indicated the facility did not schedule or have a RN to care for residents for 17 days in July of 2026.During a review of the facility's policy and procedures (P&P) titled, Staffing, Sufficient and Competent Nursing dated 4/2024, the P&P indicated, The facility provides sufficient numbers of nursing staff with.3.A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to eradicate and contain the presence of pests when:1. Cockroaches were observed in the kitchen on 7/14/26 and 7/15/26.This failure had the potential to place 64 out of 65 residents receiving food from the kitchen at risk for cross-contamination when cockroaches were observed in the kitchen, and throughout the facility, since 10/23/25. 2. A fly was observed on 7/14/26 in the shared room of Resident 34 and Resident 38 and Resident 34 was holding a fly swatter. Resident 22 was observed with a fly swatter in her container for personal items on her bedside table which was positioned over her bed, and a fly was observed in the hallway between the kitchen and dining room on 7/15 /26. This failure had the potential to place Resident's 22, 34 and 38 at risk of infection due to cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).Findings: During a concurrent observation and interview on 7/14/26 at 8:53 a.m. with the Certified Dietary Manager (CDM) and the Registered Dietician (RD), in the kitchen near the tray line table, a cockroach was observed on the floor crawling toward the tray line table. The CDM stated cockroaches had been observed throughout the kitchen for approximately a year, since he started. During a concurrent observation and interview on 7/15/26 at 12:12 p.m. with the CDM, in the kitchen during lunch tray line, [NAME] (CK) 1 was observed plating resident meals. A cockroach was observed on the floor crawling under the tray line table. Under the tray line table, a bug trap was observed with over 25 cockroaches, not moving. The CDM stated the facility received bug traps from pest control to help catch cockroaches. During an interview on 7/16/26 at 9:58 a.m. with Resident 3 and Resident 55, Resident 3 stated he observed a cockroach, 20 minutes prior, in the hallway crawling under the door into the kitchen. Resident 3 stated he observed cockroaches previously throughout the facility. Resident 3 stated it was, .gross., knowing cockroaches were in the kitchen where food was being stored, prepared and served. Resident 3 stated the pests were worse when and where it was hot. Resident 55 stated he observed cockroaches in the shower and throughout the facility. Resident 55 stated he felt uncomfortable knowing cockroaches were in the facility and near food in the kitchen. During a concurrent interview and record review on 7/17/26 at 9:22 a.m. with the Maintenance Director (MND), the facility's document titled, Pest Control Service Log, dated 10/23/25-7/15/26, was reviewed. The MND stated per the Pest Control Service Logs, cockroaches had been observed in the kitchen since 10/23/25. The MND stated he had observed cockroaches in the kitchen. The MND stated pest control came to the facility once a month and as needed. The MND stated it was important to adhere to facility policy and procedure to maintain an effective pest control program. The MND stated pest control was not effective if cockroaches had been present since 10/23/25. During a concurrent interview and record review on 7/17/26 at 9:52 a.m. with the RD, the facility kitchen audits titled, Dietary Sanitation/Infection Control Audit, dated 4/27/26, 5/15/26 and 6/19/26, were reviewed. The RD stated she had observed and documented cockroaches in the kitchen for 3 months. The RD stated cockroaches should not be in the facility kitchen. The RD stated it was not sanitary to have pests in the kitchen and posed an infection control risk. The RD stated there was a risk of pests contaminating resident food or kitchen equipment that residents ate off. During an interview on 7/17/26 at 2:11 p.m. with the Director of Nursing (DON), the DON stated it was expected, per facility policy and procedure, for the kitchen to always remain pest free. The DON stated an effective pest control program was not maintained when cockroaches had been observed in the kitchen and throughout the facility since 10/23/25. The DON stated residents were at risk of consuming contaminated food products when there were pests in the kitchen. During a review of the facility's document tiled, Pest Control Service Log, dated 10/23/25-7/15/26, the document indicated cockroaches had been observed in the kitchen, resident rooms, offices, and throughout the facility since 10/23/25. During a review of the facility's kitchen audits titled, Dietary Sanitation/Infection Control Audit, dated 4/27/26, 5/15/26 and 6/19/26, the kitchen audits indicated, .pest control.not met.roaches, need to constantly change our traps. During a review of the facility's document titled, Diet Type Report, dated 7/16/26, the document indicated 64 out of 65 residents received food from the kitchen. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Controlling Pests Section 6-501.111, the FDA Food Code indicated .the premises shall be maintained free of insects, rodents, and other pests . 2. During a concurrent observation and interview on 7/14/26 at 9:23 a.m. with Resident 34, in Resident 34's room, Resident 34 was observed dressed, lying in bed with a fly swatter in her left hand on her bed. Resident 34 stated she had been in the facility for one and one-half years due to a wound and previous infection in her ankle. Resident 34 stated she no longer had an infection in her left ankle, but it was an open wound that oozed fluid. A fly was observed flying in her shared room with Resident 38. Resident 34 stated she had flies often in her room due to staff leaving the front door and side doors to the facility open. Resident 34 stated she had a fly swatter given to her by staff to get the flies that go into her room. Resident 34 stated she could not get out of bed on her own. During a review of Resident 34's admission Record (AR - a summary of information regarding a patient), dated 7/17/26, the AR indicated Resident 34 was initially admitted to the facility from an acute care hospital on [DATE] and re-admitted on [DATE] with diagnoses of osteomyelitis (infection [the invasion and growth of germs in the body] in the bone) left ankle and foot, arthritis (joint inflammation) due to other bacteria, left ankle and foot, congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and muscle weakness. During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [involving the process of thinking, learning and understanding] and physical functional level assessment), dated 5/21/26, the MDS section C indicated Resident 34 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 34 was cognitively intact. During a concurrent observation and interview on 7/14/2026 at 9:35 a.m. with Resident 38, in Resident 38's room, resident 38 was observed dressed, lying in bed. Resident 38 stated she had been at the facility for one or two months due to having three wounds on her abdomen and did not want to go home without having proper treatment for her wounds first. Observed three bandages across Resident 38's abdomen with a vacuum-assisted device (wound vac – a device that pulls fluid and bacteria out of a wound to help it heal better) on the middle of her abdomen and an ileostomy (an opening (stoma) on your abdomen (belly) that connects the last part of your small intestine (ileum) to the outside of the belly) drainage bag on the right side of her abdomen, next to her wound vac dressing. Fly observed leaving the room. No questions asked regarding flies. During a review of Resident 38's AR, dated 7/16/26, the AR indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm (abnormal masses of tissue that grow and multiply) of retroperitoneum (the cavity behind the abdomen) and peritoneum (the membrane that lines the abdomen and pelvis), Ileostomy, acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), neoplasm (abnormal mass of tissue) of ovary, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), perforation (a hole that goes all the way through a membrane) of intestine, and right lower quadrant (location area of the abdomen) pain. During a review of Resident 38's MDS, dated 6/7/26, the MDS section C indicated Resident 38 had a BIMS score of 14, which indicated Resident 38 was cognitively intact. During a concurrent observation and interview on 7/14/26 at 9:43 a.m. with Resident 22, in Resident 22's room, Resident 22 was observed dressed, lying in bed with her bedside table across her bed. A fly swatter was observed in a container with her other personal items on her bedside table. Resident 22 stated the Activities Director (AD) gave her the fly swatter. Resident 22 stated she had been at the facility for 11 years due to falling too much at home. Resident 22 stated she had wounds on her back side, which staff were applying a cream. Resident 22 stated there are flies in her room, mostly in the evening as well as mosquitoes. During a review of Resident 22's AR, dated 7/17/26, the AR indicated Resident 22 was admitted on [DATE] from an acute care hospital with diagnoses of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), kidney failure (a condition when the kidneys are unable to filter waste products from the blood), muscle wasting and atrophy (a weakening, shrinking and loss of muscle caused by disease or lack of use). During a review of Resident 22's MDS, dated 5/24/26, the MDS section C indicated Resident 22 had a BIMS score of 14, which indicated Resident 22 was cognitively intact. During an observation and interview on 7/15/26 at 11:31 a.m. with the AD in the hallway between the kitchen and dining room, a fly was observed flying around the AD's head and throughout the hallway. The AD stated flies came in when the outside door was opened and flies in the facility had been a problem. The AD stated there were no bug zappers or fly traps in the facility. During an interview on 7/15/26 at 3:37 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had been at the facility since 4/28/26. CNA 1 stated she had seen flies in the facility and in residents' rooms. CNA 1 stated some residents had fly swatters in their rooms but was not sure what was being done to get rid of the flies. CNA 1 stated flies in the resident rooms were not sanitary. CNA 1 stated flies were dirty and could cause contamination of residents' items and a risk of infection for residents with wounds. CNA 1 stated there should not be flies in residents' rooms. During an interview on 7/16/26 at 8:50 a.m. with the Maintenance Director (MND), the MND stated flies barely became an issue. The MND stated he did not provide fly swatters to residents and did not know residents had fly swatters. The MND stated he was not aware of a fly problem in the facility. The MND stated flies were insects and could cause a contamination problem for the residents. The MND stated there should not be pests in the resident area. The MND stated he could only do the best of his ability to control pests. The MND stated the pest control company came once a month and was able to come to the facility more often if needed. The MND stated the current pest control program was not effective. During an interview on 7/16/26 at 11:35 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had seen pests in the facility and informed the maintenance department of flies and roaches in the facility, in person or by entering the notation in the maintenance binder. LVN 1 stated she had only seen one resident with a fly swatter, and she kept it in a bag. LVN 1 stated it was important to keep the fly swatter in a bag to prevent infection from cross-contamination. LVN 1 stated flies were a risk for causing diseases in residents and could cause maggots. LVN 1 stated if a resident had a wound, a fly might get on the wound and worsen the wound. LVN 1 stated there should not have been flies in residents' rooms or roaches on the floor. During an interview on 7/17/26 at 2:11 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the residents to have a pest free environment. The DON stated flies could have landed on resident wounds and irritate residents. The DON stated there was a risk for infection and maggots if the flies landed on resident wounds. The DON stated staff should not have given fly swatters to residents, as there was a risk for cross contamination from the fly swatter and the residents' belongings and environment. The DON stated the pest control company came to the facility regularly and there should not have been pests in the facility. The DON stated the current pest control program was not as effective as she would like. The DON stated the facility had not reached their goal of a pest free environment as stated in the facility's policy and procedure for a pest free environment. The DON stated the pest control program was not effective at this time. During a review of the facility policy and procedure (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated, .residents are provided with a safe, clean, comfortable and homelike environment. During a review of the facility document titled, Scope of Work – Pest Control Services, dated 10/23/25, the document indicated, .to provide comprehensive pest management services that ensure a clean, safe, and pest-free environment for residents, staff, and visitors .and infection control standards applicable to healthcare facilities.additional/on-call services [as needed].fly light maintenance.mosquito reduction treatments.

Based on observation, interview, and record review the facility failed to provide a clean, safe, and sanitary homelike environment for one of six sampled residents (Resident 32) when Resident 32's shared bathroom had a hole in the bathroom ceiling exposing white, cotton-like, dusty substance inside.This failure placed Resident 32 in an unclean, unsafe, unsanitary and non-homelike environment which could affect Resident 32's well-being. Findings:During a concurrent observation and interview on 7/14/26 at 10:25 a.m. with Resident 32, in Resident 32's room, Resident 32 was observed dressed, lying in bed. Resident 32 stated he had been in the facility for two and one-half months due to being paraplegic (paralysis-the loss of the ability to move and sometimes to feel anything on the lower half of the body) and having Clostridioides difficile (C. diff - a germ that causes an infection of the colon-the longest part of the large intestine). Resident 32 stated he did not feel the facility was being taken care of. Resident 32 complained about a hole in the bathroom ceiling, he was often hot and sweaty because the windows let the heat in, and the door handle to his room was loose. During a review of Resident 32's admission Record (AR - a summary of information regarding a resident), dated 7/17/26, the AR indicated Resident 32 was admitted to the facility from an acute care hospital on 4/2/26 with diagnoses of spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain) lumbar (low back) and thoracic (mid-back) regions, heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), muscle weakness, kidney failure (a condition when the kidneys are unable to filter waste products from the blood), and type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high).During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool used to identify thinking, learning, understanding and physical functional level assessment), dated 6/30/26, the MDS section C indicated Resident 32 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 32 was cognitively intact.During an interview on 7/16/26 at 8:50 a.m. with the Maintenance Director (MND), the MND stated staff informed him of any repairs by verbally telling him or logging the concern in a binder at the nurses' station. The MND stated any staff can put a request in the binder and he checked the binder every day. The MND stated he performed weekly checks of resident rooms and had a log of the room temperatures. The MND stated he had no issues or complaints regarding resident rooms. The MND stated he was aware of the hole in Resident 32's bathroom ceiling but had been too busy to finish repairing it. The MND stated the air conditioner was worked on this week due to a drain that became clogged and water had drained on the bathroom ceiling of Resident 32's room. The MND stated he cut a hole in the bathroom ceiling of Resident 32's room and cleared the drain. The MND stated there should not have been a hole in the ceiling of Resident 32's bathroom. The MND stated something could have fallen from the ceiling such as insulation. The MND stated a hole in the bathroom ceiling did not create a homelike environment, especially if Resident 32 complained about it.During an interview on 7/17/26 at 2:11 p.m. with the Director of Nursing (DON), the DON stated she participated in rounds with the residents to see if they were comfortable and to address any issues. The DON stated she brought up issues with holes in the walls and resident's ceiling. The DON stated having holes in the walls and the bathroom ceiling was not a homelike environment for the residents. The DON stated her expectation was for maintenance to make repairs in a timely manner. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated, .residents are provided with a safe, clean, comfortable and homelike environment.the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.During a review of the facility's job description document titled, Director of Environmental Services, dated 11/1/2016, the document indicated, .responsible for the building, the equipment and other materials located in and around the physical property.maintain the operations of the property and maintain it in good, clean, and safe order.maintain a safe and secure environment for all staff, residents and guests.

Based on observations, interviews, and record reviews, the facility failed to provide care and services in accordance with professional standards of practice for three of 12 sampled residents (Resident 2, Resident 25 and Resident 38) when:1. Resident 2 had edema (swelling caused by excess fluid trapped in your body's tissues) to the lower left extremity and no weekly progress skin assessment, change in condition and care plans were done.This failure had the potential to place Resident 2's at risk for increased edema and hospitalization.2. The physician and Resident Responsible Party (RP) were not notified when Resident 25 declined related to having their nails trimmed.This failure led to Resident 25's Responsible Party and physician to be unaware of Resident 25's refusal of treatment which placed Resident 25 at risk to attempt to perform his own nail care, possible injury, infection and hospitalization. 3. Resident 38 was not notified of the reason for the change in frequency of her pain medication from every six hours to every eight hours. There was no documentation for the change in Resident 38's pain medication frequency and no documentation of physician notification of Resident 38's increase in level of pain.This failure resulted in Resident 38 not receiving less pain medication then needed, which resulted in increased pain, reduced mobility, prolonged healing, and not having her needs met. Findings: 1. During a review of Resident 2's admission Record (AR - a summary of information regarding a patient), dated 7/17/26, the AR indicated Resident 2 was admitted to the facility from an acute care hospital on 3/14/26 with diagnoses of multiple sclerosis (MS- disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve), muscle weakness, foot drop (symptom meaning you cannot lift the front part of your foot, which causes your toes to drag, trip, or slap the ground when you wall), personal history of venous thrombosis (is a blood clot in a vein), shortness of breath, falls and lung cancer. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [involving the process of thinking, learning and understanding] and physical functional level assessment), dated 6/13/26, the MDS section C indicated Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 9 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 2 had moderate cognitive impairment. During a review of Resident 2's Progress Note (PN) titled, [Name of the facility] Progress Notes dated 7/17/26, the PN indicated, On 7/14/26 at 7: 30 p.m. [Patient] Pt seen by [Nurse practitioner] at bedside today. Per [Nurse Practitioner], pt to have [Lower left edema ultrasound related to] edema. Pt to begin [furosemide] (medication given to reduce edema) 20 mg [daily] for 14 days. During an observation and interview on 07/14/2026 at 10:34 a.m. in Resident 2's room, Resident 2 was in bed with edema from on her lower left leg, her calf and foot were swollen. Resident 2's legs were not elevated, and she was lying flat on the bed. Resident 2 stated her edema to the left lower extremity increase but could not recall how long it had been swollen. During a concurrent interview and record review on 7/16/2026 at 12:10 p.m. with License Vocation Nurse (LVN) 1, LVN 1 stated Resident 2 did not have any wounds and edema in the PN. LVN 1 stated there was no change in condition note for Resident's 2 edema. LVN 1 stated Resident 2 did not have a weekly skin assessment. LVN 1 stated it was important to look at the skin to see if there were changes in condition. LVN 1 stated, If resident has edema, we need to be aware of it and do a change of condition. LVN 1 stated Resident 2's edema could have been a blood clot (a semi solid mass which forms in the arteries clots can be dangerous if they form inside healthy blood vessels, potentially blocking blood flow and leading to conditions like heart attacks or strokes). LVN 1 stated without the weekly skin assessment we would not know what was happening to the Resident 2's skin and could not compare it to last week. LVN 1 stated it was important to complete a change in condition regarding increased edema so that the party responsible, physician and nurse were notified. During a concurrent interview and record review on 07/16/2026 at 4:21 p.m. with LVN 4, Resident 2's weekly skin assessment documentation dated from 3/14/26-7/16/26 were reviewed . LVN 4 stated there was no complete skilled nursing weekly skin assessment summary for Resident 2 since 3/14/26. LVN 4 stated it was important to compare how the residents were doing from week to week. LVN 4 stated, Her skin issues could go unnoticed, and we could not provide proper observation which could affect her care.During a concurrent interview and record review on 07/17/2026 12:33 p.m. with LVN 4, Resident 2 PN dated 7/17/226 was reviewed. The PN indicated Resident 2 was started on furosemide (a prescription water pill, used to treat fluid retention/edema and high blood pressure) 20 milligram (mg-type of measurement) daily for lower left edema for 14 days. LVN 4 stated, Resident 2's left lower leg was considered a changed in condition and there should have been a care plan for the edema. LVN 4 stated Resident 2's care plan should have been created so nurses would follow up on the progression of the edema. LVN 4 stated a change in condition would have allowed the nursing staff to monitor the edema and the care plan would have interventions on how to care for Resident 2's edema. LVN 4 stated the edema could worsen and Resident 2 could have been hospitalized . LVN 4 stated the nurse who took the new order for medication should have done both a change in condition and created a care plan for Resident 2. During an interview on 07/17/2026 at 3:02 p.m. with the Director of Nursing (DON), the DON stated, Nurses should be doing weekly skin assessment. The DON stated the weekly skin assessment should have been done so nurses would be able to easily identify any changes in condition. The DON stated we did not follow the professional standard of practice when the nurse did not do their weekly skin assessment. The DON stated the nurse should have completed a change in condition due to the increase in edema to the lower leg and when Resident 2 started her new medication. The DON stated the nurses should monitor the edema for 72 hours when there was a change in condition. The DON stated, It was important to monitor the edema for 72 hours to see if the swelling increased or decreased and if it worsened then the nurses should have notified the physician or nurse practitioner. The DON stated the change in condition should have triggered the nurse to do a care plan. The DON stated, there should have been a care plan for Resident 2's edema. The DON stated without a care plan it causes miscommunication and inconsistent care. The DON stated Resident 2's edema could have worsened, and she could have been hospitalized . The DON stated the nurses were expected to complete a change in condition and care plan. The DON stated the nurses did not meet expectations and they failed to follow standard practice. During a review of the facility's policy and procedures (P&P) titled, Change in a Resident's Condition or Status dated 2/2021, the P&P indicated, .A 'significant change' of condition is a major decline or improvement in the resident's status that: A. will not normally resolved itself without intervention by staff or by implementing stated disease related clinical interventions (is not self-limiting'.requires interdisciplinary review and/or revision to the care plan and. During a review of the facility P&P titled, Resident Examination and Assessment revision dated 2/2014, the P&P indicated, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. During a review of a professional article, titled, Chapter 14 Integumentary Assessment dated 2024, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK593218/#ch14integumentary.sec14.4The article indicated, Skin assessment should also be ongoing in inpatient and long-term care. A routine integumentary assessment. typically includes inspecting overall skin color, inspecting for skin lesions and wounds, and palpating extremities for edema, temperature, and capillary refill. 2. During a concurrent observation and interview on 7/14/2026 at 11:27 a.m. with Resident 25 in Resident 25's room, Resident 25 was observed dressed, sitting up in bed. Resident 25 stated he had been at the facility for 15 years because he was crazy and schizophrenic schizophrenic (a mental illness that affects a person's ability to think, feel, and behave clearly). Resident 25 stated he was not able to walk. Observed Resident 25 was missing his right leg above the knee, and his left foot was missing toes. Resident 25's right pointer fingernail was long and blackened, and his right thumbnail was jagged and cracked. Resident 25 stated staff did not have the right tool to cut his nails. Resident 25 stated the nurse took care of his nails. During a review of Resident 25's AR dated 7/16/26, the AR indicated Resident 25 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of type 2 diabetes mellitus (when the blood sugar levels in the body are too high), acquired absence (surgical removal of finger, toe, hand, foot, arm or leg) of right leg below the knee, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), schizophrenia, and acquired absence of other left toes. During a review of Resident 25's MDS section C indicated Resident 25 had a BIMS score of 13, which indicated Resident 25 was cognitively intact. During a concurrent interview and record review on 7/15/26 at 3:24 p.m. with LVN 2, Resident 25's shower log (a document that indicates if a resident received a shower, nail assessment and care, skin assessment, facial wash/shave) and is presented to the nurse for review. LVN 2 stated Resident 25 was scheduled for showers/baths on Wednesdays and Saturdays in the evening. Resident 25's shower sheet dated 7/11/26 was reviewed. The shower sheet indicated Resident 25 had a shower with no nail care or facial shave. Resident 25's shower sheet dated 7/8/26 was reviewed. The shower sheet indicated Resident 25 had a shower with nail trimming and facial trimming completed. LVN 2 stated the shower sheet had both the Certified Nursing Assistant (CNA) and LVN signatures indicating it was completed by the CNA and reviewed by the nurse. LVN 2 stated the CNAs notified nurses if a resident had dirty or long nails and did not let them clean or trim them. LVN 2 stated he was not sure why Resident 25's nails were not done. LVN 2 was shown the Resident 25's right fingernails. LVN 2 stated he was not aware of Resident 25's nail issues. LVN 2 reviewed Resident 25's Electronic Medical Chart (EMR) and stated Resident 25 had no care plan regarding long nails or refusal of nail care. LVN 2 stated there were no progress notes in Resident 25's EMR regarding his nails or if Resident 25 refused care. LVN 2 stated it was important to document if residents were refusing nail care. LVN 2 stated staff should have been documenting the monitoring of Resident 25 for of any signs or symptoms of outcomes from having long, jagged nails and to minimize danger to himself. LVN 2 stated staff needed to document long nails to protect staff in case Resident 25 lashed out with long nails during care and to be sure Resident 25's nail did not get caught on things. LVN 2 stated it was important for communication between staff and the physician for better resident outcomes and for the resident's wellbeing. During an interview on 7/15/26 at 3:37 p.m. with CNA 1, CNA 1 stated she did normal cleaning of resident nails during their shower or bath and if the resident was not diabetic, she also clipped the resident's nails. CNA 1 stated if she noticed a resident with long, jagged or dirty nails, she asked if she could clean or trim their nails. CNA 1 stated Resident 25 will refuse some care. CNA 1 stated if a resident refused care or if she saw anything out of the ordinary regarding a resident, she informed the nurse. CNA 1 stated the previous shift notified the CNAs if a resident refused showers. During an interview on 7/17/26 at 2:28 p.m. with the DON, the DON stated her expectation was for the CNAs to provide nail care during showers, unless the resident was diabetic then the nurses were to be notified and step in to provide nail care. The DON stated resident's nails should be kept up, even if the nails were long, they should be manicured. The DON stated she expected the CNAs to inform the Charge Nurses or nurses for both long nails and if the resident refused nail care. The DON stated her expectation was for the nurse to speak with resident and see if the nurse was able to give nail care. The DON stated if the resident refused nail care the nurse should have initiated a care plan for the refusal. The DON stated there should have been documentation if the resident refused nail care and if the resident wanted long nails. The DON stated staff notified the physician if the resident's long jagged nails were causing harm. The DON stated Resident 25's nails should have been addressed, and his nails could have gotten caught on items causing injury. During a review of the facility's P&P titled, Fingernails/Toenails, Care of, dated 2/2018, the P&P indicated, .the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.review the resident's care plan to assess for any special needs of the resident.stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.the following information should be recorded in the resident's medical record.any difficulties in cutting the resident's nails.if the resident refused the treatment, the reason[s] why and the intervention taken.notify the supervisor if the resident refuses the care.report other information in accordance with facility policy and professional standards of practice. During a review of the facility's P&P titled, Change in a resident's condition or Status, dated 11/2015, the P&P indicated, .our facility shall promptly notify the resident, his or her Attending Physician, and representative [sponsor] of changes in the resident's medical/mental condition and/or status.the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been.refusal of treatment or medications [i.e., two [2] or more consecutive times].a [significant change] of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff.requires interdisciplinary review and/or revision to the care plan.prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated, 3/2022, the P&P indicated, .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.assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.the resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. 3. During a concurrent observation and interview on 7/14/2026 at 9:35 a.m. with Resident 38, in Resident 38's room, Resident 38 was observed dressed, lying in bed. Resident 38 stated she had been in the facility for one to two months due to surgery and three surgical wounds and did not want to go home without proper treatment first. Observed Resident 38's abdomen with two dressings over wounds in the middle of her abdomen and left side of her abdomen, and a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) bag on the right side of her abdomen. Resident 38 stated she had cancer and took pain medications every eight hours. Resident 38 stated her pain medication used to be given every six hours, but the frequency was changed two days ago, and staff did not tell her why. Resident 38 stated she had let the nurse know she had cancer and had tumors that hurt. Resident 38 stated she had not heard anything more from the nurses. During a review of Resident 38's AR, dated 7/16/26, the AR indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm (abnormal masses of tissue that grow and multiply) of retroperitoneum (the cavity behind the abdomen) and peritoneum (the membrane that lines the abdomen and pelvis), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), neoplasm (abnormal mass of tissue) of ovary, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), perforation (a hole that goes all the way through a membrane) of intestine, and right lower quadrant (location area of the abdomen) pain. During a review of Resident 38's MDS, dated 6/7/26, the MDS section C indicated Resident 38 had a BIMS score of 14, which indicated Resident 38 was cognitively intact. During an interview on 7/15/26 at 3:37 p.m. with CNA 1, CNA 1 stated residents will usually tell her if they are in pain. CNA 1 stated if she noticed a resident grimacing or if the resident told her they were in pain during care, she notified the nurse. CNA 1 stated if the resident needed repositioning due to pain, she repositioned the resident and notified the nurse. During a concurrent interview and record review on 7/16/26 at 11:35 a.m. with LVN 1, Resident 38's Medication Administration Records (MAR), dated June 2026 and July 2026 were reviewed. The MARs indicated, .oxycodone [pain medication] 10 milligrams [MG – a unit of measurement] 1 tablet every six hours as need for pain management for pain level of 6 to 10 on a scale of 1-10 for 14 days.start date on 6/5/26.discontinue date 6/9/26.oxycodone 10 MG give 1 tablet by mouth every 6 hours as needed for pain management 6-10 on a scale 1-10 for 30 days.start date 6/9/26.Oxycodone 10 MG give 1 tablet by mouth every 8 hours as needed for severe pain 6-10 for 30 days.start date 6/4/26.discontinue date 6/5/26.oxycodone 10 MG give 1 tablet by mouth every 8 hours as needed for severe pain 6-10 for 30 days.start date 7/10/26.discontinue date 7/15/26.oxycodone 10 MG 1 tablet by mouth every 6 hours as needed for pain.start date 7/15/26. LVN 1 stated the frequency of Resident 38's oxycodone was changed to every eight hours on 7/9/26 with no note regarding why the medication frequency was changed. LVN 1 stated yesterday, 7/15/26, was the first time she was notified that giving Resident 38 her pain medication every eight hours was not working. LVN 1 stated there was no documentation of why Resident 38's pain medication was originally changed to be given every eight hours and there was no documentation of physician notification of Resident 38's pain medication being given every eight hours without adequate pain relief prior to yesterday, 7/15/26. LVN 1 stated there should have been documentation for a change in medication administration, so all staff knew what was going on with Resident 38 and to monitor if Resident 38's pain medications were working. During an interview on 7/17/26 at 2:28 p.m. with the DON, the DON stated she participated in performing rounds to check on residents and make sure they were comfortable and address any needs. The DON stated her expectation for residents in pain was if a resident continued to have pain, if the pain medication was not effective or if the pain was consistent, staff should have notified the physician immediately. The DON stated there should have been progress notes documented in Resident 38's EMR indicating why changes were made in her medication administration frequency. The DON stated documentation and care plans let nurses know what the plan of care was for the residents, what implementations were to be in place and to see what worked for the residents. The DON stated she was ultimately responsible for making sure residents had safe, appropriate care. During a review of the facility's P&P titled, Change in a resident's condition or Status, dated 11/2015, the P&P indicated, .our facility shall promptly notify the resident, his or her Attending Physician, and representative [sponsor] of changes in the resident's medical/mental condition and/or status.the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been.a significant change in the resident's physical/emotional/mental condition.a [significant change] of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff.prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. During a review of the facility's P&P titled, Pain – Clinical Protocol, dated 10/2022, the P&P indicated, .the physician and staff will identify individuals who have pain or who are at risk for having pain.this includes a review for any treatments that the resident currently is receiving for pain.the nursing staff will assess each individual for pain.whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.the nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated.the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain.the staff will reassess the individual's pain and related consequences at regular intervals.the staff will evaluate and report the resident/patient's use of standing and as needed {PRN] analgesics.

Based on observation, interview, and record review, the facility failed to provide nail care and treatment, in accordance with professional standards of practice for one of six sampled residents (Resident 25) when Resident 25 had long, overgrown and jagged fingernails. This failure had the potential to result in Resident 25 cutting his skin with his long fingernails, leading to poor wound healing, infection, and hospitalization. Findings:During a concurrent observation and interview on 7/14/2026 at 11:27 a.m. with Resident 25 in Resident 25's room, Resident 25 was observed dressed, sitting up in bed. Resident 25 stated he had been at the facility for 15 years because he was crazy and schizophrenic (a mental illness that affects a person's ability to think, feel, and behave clearly). Resident 25 stated he was not able to walk. Observed Resident 25 was missing his right leg above the knee, and his left foot was missing toes. Resident 25's right pointer fingernail was long and blackened, and his right thumbnail was jagged and cracked. Resident 25 stated staff did not have the right tool to cut his nails. Resident 25 stated the nurse took care of his nails.During a review of Resident 25's admission Record (AR - a summary of information regarding a patient), dated 7/16/26, the AR indicated Resident 25 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of type 2 diabetes mellitus (when the blood sugar levels in the body are too high), acquired absence (surgical removal of finger, toe, hand, foot, arm or leg) of right leg below the knee, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), schizophrenia, and acquired absence of other left toes.During a review of Resident 25's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive and physical functional level assessment), dated 6/9/26, the MDS section C indicated Resident 25 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 25 was cognitively intact.During a concurrent interview and record review on 7/15/26 at 3:24 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 25's shower log (a document that indicates if a resident received a shower, nail assessment and care, skin assessment, facial wash/shave) and is presented to the nurse for review. LVN 2 stated Resident 25 was scheduled for showers/baths on Wednesdays and Saturdays in the evening. Resident 25's shower sheet dated 7/11/26 was reviewed. The shower sheet indicated Resident 25 had a shower with no nail care or facial shave. Resident 25's shower sheet dated 7/8/26 was reviewed. The shower sheet indicated Resident 25 had a shower with nail trimming and facial trimming completed. LVN 2 stated the shower sheet had both the Certified Nursing Assistant (CNA) and LVN signatures indicating it was completed by the CNA and reviewed by the nurse. LVN 2 stated the CNAs notified nurses if a resident had dirty or long nails and did not let them clean or trim them. LVN 2 stated he was not sure why Resident 25's nails were not done. LVN 2 was shown Resident 25's right fingernails. LVN 2 stated he was not aware of Resident 25's nail issues. LVN 2 reviewed Resident 25's Electronic Medical Chart (EMR) and stated Resident 25 had no care plan regarding long nails or refusal of nail care. LVN 2 stated there were no progress notes in Resident 25's EMR regarding his nails or if Resident 25 refused care. LVN 2 stated it was important to document if residents were refusing nail care. LVN 2 stated staff should have been documenting the monitoring of Resident 25 for of any signs or symptoms of outcomes from having long, jagged nails and to minimize danger to himself. LVN 2 stated staff needed to document long nails to protect staff in case Resident 25 lashed out with long nails during care and to be sure Resident 25's nail did not get caught on things. LVN 2 stated it was important for communication between staff and the physician for better resident outcomes and for the resident's wellbeing.During an interview on 7/15/26 at 3:37 p.m. with CNA 1, CNA 1 stated she did normal cleaning of resident nails during their shower or bath and if the resident was not diabetic, she also clipped the resident's nails. CNA 1 stated if she noticed a resident with long, jagged or dirty nails, she asked if she could clean or trim their nails. CNA 1 stated Resident 25 will refuse some care. CNA 1 stated if a resident refused care or if she saw anything out of the ordinary regarding a resident, she informed the nurse. CNA 1 stated the previous shift notified the CNAs if a resident refused showers.During an interview with the Infection Preventionist 1/Director of Staff Development (IP/DSD) on 7/17/2026 at 9:14 a.m., the IP 1/DSD stated CNAs can complete a form for nail care or inform the nurse or Social Services Director (SSD) if a resident needed nail care. IP 1/DSD stated her expectation was for CNAs to perform resident nail care during resident showers or when providing care to the residents and to inform nurses if a resident needed nail care. The IP 1/DSD stated if resident nail care was not completed, the resident could get a skin tear if they scratched themself and put them at a risk for infection, especially if the resident was diabetic.During an interview on 7/17/26 at 2:28 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the CNAs to provide resident nail care during resident showers or baths, unless the resident was diabetic, then the nurses were to be notified by the CNA and step in to provide the resident's nail care. The DON stated resident's nails should be kept up, even if the nails were long, they should be manicured. The DON stated she expected the CNAs to inform the Charge Nurses or nurses for both long nails and if the resident refused nail care. The DON stated her expectation was for the nurse to speak with the resident if the resident refused nail care by the CNA and see if the nurse was able to provide nail care. The DON stated if the resident refused nail care the nurse should have initiated a care plan for the refusal. The DON stated there should have been documentation if the resident refused nail care and if the resident wanted long nails. The DON stated staff notified the physician if a resident's long jagged nails were causing harm. The DON stated Resident 25's nails should have been addressed, and his nails could have gotten caught on items causing him injury.During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated 2/2018, the P&P indicated, .the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.review the resident's care plan to assess for any special needs of the resident.stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.the following information should be recorded in the resident's medical record.any difficulties in cutting the resident's nails.if the resident refused the treatment, the reason[s] why and the intervention taken.notify the supervisor if the resident refuses the care.report other information in accordance with facility policy and professional standards of practice.During a review of the facility's P&P titled, Change in a resident's condition or Status, dated 11/2015, the P&P indicated, .our facility shall promptly notify the resident, his or her Attending Physician, and representative [sponsor] of changes in the resident's medical/mental condition and/or status.the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been.refusal of treatment or medications [i.e., two [2] or more consecutive times].a [significant change] of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff.requires interdisciplinary review and/or revision to the care plan.prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated, 3/2022, the P&P indicated, .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.assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.the resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on observation, interview, and record review, the facility failed to ensure effective pain management was provided consistent with professional standards of practice and comprehensive person-centered care plan for one of six sampled residents (Resident 38) when Licensed Nurses did not address Resident 38's frequent complaints of pain after her pain medication frequency was changed.This failure resulted in Resident 38's frequent complaints of pain going unrelieved and had the potential for Resident 38's needs to be unmet and her physical well-being to go unsupported.Findings:During a concurrent observation and interview on 7/14/2026 at 9:35 a.m. with Resident 38, in Resident 38's room, Resident 38 was observed dressed, lying in bed. Resident 38 stated she had been in the facility for one to two months due to surgery and three surgical wounds and did not want to go home without proper treatment first. Observed Resident 38's abdomen with two dressings over wounds in the middle of her abdomen and left side of her abdomen, and an ileostomy (an opening on the belly that connects the last part of your small intestine to the outside of the belly) bag on the right side of her abdomen. Resident 38 stated she had cancer and took pain medications every eight hours. Resident 38 stated her pain medication used to be given every six hours, but the frequency was changed two days ago to every eight hours, and staff did not tell her why it was changed. Resident 38 stated she had informed the nurse, Social Services Director (SSD) and another staff member that she had cancer and surgery pain, and had tumors that hurt, and the change in frequency of her pain medication was not managing her pain. Resident 38 stated she had not heard anything more from the nurses or staff regarding the change. During a review of Resident 38's admission Record (AR - a summary of information regarding a resident), dated 7/16/26, the AR indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm (abnormal masses of tissue that grow and multiply) of retroperitoneum (the cavity behind the abdomen) and peritoneum (the membrane that lines the abdomen and pelvis), ileostomy, acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), neoplasm (abnormal mass of tissue) of ovary, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), perforation (a hole that goes all the way through a membrane) of intestine, and right lower quadrant (location area of the abdomen) pain.During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [involving the process of thinking, learning and understanding] and physical functional level assessment), dated 6/7/26, the MDS section C indicated Resident 38 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 38 was cognitively intact.During an interview on 7/15/26 at 3:37 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated residents usually informed her if they were in pain. CNA 1 stated if she noticed a resident grimacing or if the resident told her they were in pain during care, she notified the nurse. CNA 1 stated if the resident needed repositioning due to pain, she repositioned the resident and notified the nurse.During a concurrent interview and record review on 7/16/26 at 11:35 a.m. with LVN 1, Resident 38's Medication Administration Records (MAR), dated June 2026 and July 2026 were reviewed. The MARs indicated, .oxycodone [pain medication] 10 milligrams [MG - a unit of measurement] 1 tablet every six hours as need for pain management for pain level of 6 to 10 on a scale of 1-10 for 14 days.start date on 6/5/26.discontinue date 6/9/26.oxycodone 10 MG give 1 tablet by mouth every 6 hours as needed for pain management 6-10 on a scale 1-10 for 30 days.start date 6/9/26.Oxycodone 10 MG give 1 tablet by mouth every 8 hours as needed for severe pain 6-10 for 30 days.start date 6/4/26.discontinue date 6/5/26.oxycodone 10 MG give 1 tablet by mouth every 8 hours as needed for severe pain 6-10 for 30 days.start date 7/10/26.discontinue date 7/15/26.oxycodone 10 MG 1 tablet by mouth every 6 hours as needed for pain.start date 7/15/26. LVN 1 stated the frequency of Resident 38's oxycodone was changed to every eight hours on 7/9/26 with no note regarding why the medication frequency was changed. LVN 1 stated yesterday, 7/15/26, was the first time she was notified that giving Resident 38 her pain medication every eight hours was not working. LVN 1 stated there was no documentation of why Resident 38's pain medication was originally changed to be given every eight hours and there was no documentation of physician notification of Resident 38's pain medication being given every eight hours without adequate pain relief prior to yesterday, 7/15/26. LVN 1 stated there should have been documentation for a change in medication administration, so all staff knew what was going on with Resident 38 and to monitor if Resident 38's pain medications were working.During a concurrent interview and record review on 7/16/26 at 11:35 a.m. with LVN 1, Resident 38's Care Plan (CP), undated was reviewed. The CP indicated, pain care plan.will voice or demonstrate via facial/body expression a level of comfort within 30 [minutes] to 1 hour after intervention[s] rendered. Will be managed through the next review date.date initiated: 6/4/26.target date: 9/20/26.identify, document and treat the resident's existing conditions which may increase pain and or discomfort.date initiated: 6/4/26.cancer careplan.resident at risk for complication as evidenced by [aeb] decrease or loss of appetite, signs or symptoms [s/s] of depression, excessive weakness, hair loss, nausea/vomiting, pain and weight loss related to: secondary malignant neoplasm of retroperitoneum and peritoneum.date initiated 7/3/26.medication as ordered.date initiated: 7/3/26. LVN 1 stated Resident 38 had a care plan for pain management, but she was not aware of Resident 38's change in medication frequency or that the frequency of her pain medication was not managing her pain until yesterday, 7/15/26.During an interview on 7/17/26 at 2:28 p.m. with the Director of Nursing (DON), the DON stated she participated in performing rounds to check on residents and make sure they were comfortable and address any needs. The DON stated her expectation for residents in pain was, if a resident continued to have pain, if the pain medication was not effective or if the pain was consistent, staff should have notified the physician immediately. The DON stated there should have been progress notes documented in Resident 38's medical record indicating why changes were made in her medication administration frequency. The DON stated documentation and care plans let nurses know what the plan of care was for the residents, what implementations were to be in place and to see what worked for the residents. The DON stated she was ultimately responsible for making sure residents had safe, appropriate care. During a review of the facility's P&P titled, Change in a resident's condition or Status, dated 11/2015, the P&P indicated, .our facility shall promptly notify the resident, his or her Attending Physician, and representative [sponsor] of changes in the resident's medical/mental condition and/or status.the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been.a significant change in the resident's physical/emotional/mental condition.a [significant change] of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff.prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments.During a review of the facility's P&P titled, Pain - Clinical Protocol, dated 10/2022, the P&P indicated, .the physician and staff will identify individuals who have pain or who are at risk for having pain.this includes a review for any treatments that the resident currently is receiving for pain.the nursing staff will assess each individual for pain.whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.the nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated.with input from the resident to the extent possible, the physician and staff will establish goals of pain treatment.the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain.the staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain.the staff will evaluate and report the resident/patient's use of standing and as needed [PRN] analgesics.

Based on observation, interview, and record review the facility failed to ensure food was stored, distributed, and served safely when the ice machine was observed with yellow, brown and black colored residue under the ice grate (a compartment within the ice machine that determines the size of the ice cubes that are produced).This failure resulted in the facility ice machine not being in a clean safe operating condition which can lead to the growth of microorganisms and result in foodborne illness for 64 out of 65 residents receiving ice at the facility. Findings:During a concurrent observation and interview on 7/14/26 at 9:18 a.m. with the Maintenance Director (MND) and the Registered Dietician (RD), in the kitchen, the ice machine was observed with yellow, brown, and black residue under the ice grate. The MND stated the discoloration was residue and should not be in the ice machine. The RD was observed wiping the residue under the ice grate with a white napkin. The yellow, brown and black residue was observed transferred from the ice grate to the white napkin. The RD stated the yellow, brown and black residue was sludge. The RD stated yellow, brown, and black sludge should not be in the ice machine because it could contaminate the ice. The RD stated ice was food and if residents ate contaminated ice, they were at risk for foodborne illness.During an interview on 7/17/26 at 9:22 a.m. with the MND, the MND stated he cleaned and sanitized the internal ice machine monthly. The MND stated the ice machine was constantly running and debris quicky built up each month.During an interview on 7/17/26 at 2:12 p.m. with the Director of Nursing (DON), the DON stated ice was food and all food was expected, according to facility policy, to be served under sanitary conditions. The DON stated the ice machine was to always be free from discoloration and/or residue to prevent contamination of ice which could result in foodborne illness if consumed.During a review of the facility's Policy and Procedure (P&P) titled, Ice Handling and Cleaning, dated 2020, the P&P indicated, .ice will be stored and served to residents in a sanitary manner.During a review of the facility's P&P titled, HACCP and Foodborne Illness, dated 2020, the P&P indicated, .common factors-according to the [Centers for Disease Control and Prevention], the following have been identified as common factors that are responsible for foodborne illness.using contaminated equipment.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for one of six sampled residents (Resident 38) when Resident 38 was not placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant bacteria that requires gown and glove use during high contact resident care activities) for her two surgical incision wounds and ileostomy (an opening on the belly that connects the last part of the small intestine to the outside of the belly)This failure placed Resident 38 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).Findings:During a concurrent observation and interview on 7/14/2026 at 9:35 a.m. with Resident 38, outside and inside Resident 38's room, resident 38's room was observed without an EBP sign posted on her door. There was no cart containing Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) outside or inside Resident 38's room. Resident 38 was observed dressed, lying in bed. Resident 38 stated she had been in the facility for one to two months due to surgery and three surgical wounds and did not want to go home without proper treatment first. Observed Resident 38's abdomen with a vacuum-assisted device (wound vac - a device that pulls fluid and bacteria out of a wound to help it heal better) covered with a dressing in the middle of her abdomen, a dressing on the left side of her abdomen, and an ileostomy bag on the right side of her abdomen. Resident 38 stated staff did not wear a gown when they changed her dressing, they just wore gloves for her wound care. Resident 38 stated her wound VAC was changed every Monday and her other dressing changes were every three days.During a review of Resident 38's admission Record (AR - a summary of information regarding a patient), dated 7/16/26, the AR indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm (abnormal masses of tissue that grow and multiply) of retroperitoneum (the cavity behind the abdomen) and peritoneum (the membrane that lines the abdomen and pelvis), ileostomy, acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), neoplasm (abnormal mass of tissue) of ovary, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), perforation (a hole that goes all the way through a membrane) of intestine, and right lower quadrant (location area of the abdomen) pain.During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [involving the process of thinking, learning and understanding] and physical functional level assessment), dated 6/7/26, the MDS section C indicated Resident 38 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 38 was cognitively intact. During an interview on 7/15/26 at 3:37 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she informed the nurse if she saw anything out of the ordinary during resident care. CNA 1 stated staff were made aware of residents with infection precautions by the signs posted on the resident's room doorway, and nurses informed the CNAs if a resident had a wound. CNA 1 stated the nurse and CNAs informed staff during shift change of resident wounds or changes in residents. CNA 1 stated staff received in-services and training on EBP. CNA 1 stated EBP was important to prevent others and self from getting infections and spreading it. CNA 1 stated EBP was for infection control.During an observation on 7/15/26 at 4:44 p.m. in Resident 38's room, LVN 1 was observed providing dressing changes and wound care on Resident 38. LVN 1 gathered supplies outside Resident 38's room, hand hygiene performed, gloves donned (the act of putting on) and LVN 1 informed Resident 38 of the procedure. LVN 1 disconnected Resident 38's wound vac machine from the tubing. The wound vac midline abdominal dressing was removed, the surgical wound on left abdomen's dressing was removed, and the ileostomy dressing on right abdomen was removed while wearing the same gloves. LVN removed her gloves and applied new gloves without performing hand hygiene or washing her hands prior to donning new gloves. LVN 1 removed a gauze pad from a cup with saline (a solution of salt and water) and proceeded to clean the left abdominal wound. Another gauze pad was removed from the same cup with the same gloves and Resident 38's ileostomy site was cleaned. LVN 1 then pulled another gauze from the same cup and proceeded to clean the middle wound. LVN 1 was observed pulling gauze from the same cup with saline without changing gloves or performing hand hygiene between surgical wound sites. After the sites were cleaned with the gauze, LVN 1 changed her gloves and proceeded to pull gauze from another cup of saline to wipe the skin around each site, pulling a different gauze pad from the same cup of saline without changing her gloves or performing hand hygiene after wiping each site. LVN 1 changed her glove and applied Skin Barrier using a prewrapped pad for each site. LVN 1 changed her gloves and donned new gloves without performing hand hygiene. All wound sites including the ileostomy were left open to air while LVN 1 prepared the new dressings on a bedside table. LVN 1 cut the wound vac dressing to size and the dressing for Resident 38's wound vac applied first with the edge of the dressing observed to touch the open ileostomy site and repositioned back toward the middle wound. No new gloves were applied after touching the open ileostomy site. LVN 1 proceeded to continue with the dressing application for the wound vac, left abdominal surgical site, and reapplying the ileostomy bag.During a concurrent interview and record review on 7/16/26 at 11:35 a.m. with LVN 1, Resident 38's Order Summary Report (OSR), dated 7/16/26 was reviewed. LVN 1 stated Resident 38 had no orders for EBP. Resident 38's Care Plan (CP), undated was reviewed. LVN 1 stated there was no CP for EBP during high contact care for Resident 38. LVN 1 stated Resident 38 was not on EBP. LVN 1 stated she had been the Wound Nurse for two to three months and was aware of what EBP was and what PPE were required. LVN 1 stated the Infection Prevention Nurse (IP) educated staff about infection prevention and EBP through in-services. LVN 1 stated if a resident had wounds, catheters, drains, or an ostomy the resident should have been on EBP. LVN 1 stated if a resident was on EBP a gown and gloves needed to be worn for high contract resident care. LVN 1 stated staff had huddles before each shift, and there were alert charting binders, and the resident's dashboard in the electronic system to notify staff if a resident was on EBP. LVN 1 stated the Admissions Director (ADMS) let nurses know if a resident coming to the facility needed to be on isolation precautions before the nurses got report. LVN 1 stated she asked if Resident 38 was to be on EBP and was told Resident 38 did not need to be on EBP, but she was unable to remember who gave her this information. LVN 1 stated Resident 38 should have been on EBP to protect Resident 38 from any germs during care and to protect her from cross-contamination from her roommate. During a concurrent interview and record review on 7/16/26 at 2:04 p.m. with IP 1 and IP 2, Resident 38's Electronic Medical Record (EMR) was reviewed. IP 1 stated if the facility was getting a new admit who needed infection precautions, IP 1 reviewed the reports and gave an in-service to staff on the type of infection the resident had and what PPE were required during care. IP 1 stated she performed audits of infection prevention by observing staff during hand hygiene and wound care techniques. IP 1 stated she followed staff and asked questions. IP 1 stated if she saw incorrect techniques, she gave in-services. IP 1 stated she followed the Centers for Disease Control (CDC) guideline for EBP or contact precautions. IP 1 stated she assessed wounds and wounds that were chronic and draining she put on EBP. IP 1 stated she was familiar with Resident 38's wounds but was not sure why she was not placed on EBP. IP 1 stated she had seen Resident 38's wound vac and had observed dressing changes. IP 1 stated her expectation was for Resident 38's ileostomy site to be separately cleaned from the surgical sites. IP 1 stated hand hygiene should have been performed prior to donning new gloves and in-between each site change. IP 1 stated hand hygiene was important to prevent cross contamination from each site. IP 1 and IP 2 both stated EBP were put in place to protect residents as well as self from infection and to prevent cross-contamination. The facility's EBP policy and procedure (P&P) was reviewed with IP 1 and IP 2 and indicated EBP was to include wounds and surgical wounds. IP 1 and IP 2 stated Resident 38 should have been placed on EBP.During an interview on 7/17/26 at 2:28 p.m. with the Director of Nursing (DON) the DON stated her expectation during wound care was for staff to follow infection prevention guidelines preventing cross contamination, which included removing gloves between cleaning surgical sites, washing hands before and after wound care, and wearing appropriate PPE for EBP residents. The DON stated her expectation was for the IP nurses to identify EBP residents and educate staff. The DON stated Resident 38 should have been on EBP. The DON stated EBP was put in place to protect residents from infections and to keep everyone one safe. The DON stated she was ultimately responsible for making sure residents had safe appropriate care. During a review of the facility's P&P titled, Enhanced Barrier Precautions, dated 9/27/24, the P&P indicated, .it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms [MDRO].refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition [e.g., residents with wounds or indwelling medical devices].staff receive training on high-risk activities and common organisms that require enhanced barrier precautions.clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment [PPE}, and the high-contact resident care activities that require the use of gown and gloves.an order for enhanced barrier precautions will be obtained for residents with any of the following.wounds [e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers] and/or indwelling medical devices [e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes] even if the resident is not known to be infected or colonized with a MDRO.high-contact resident care activities include.dressing.bathing.transferring.providing hygiene.changing linens.changing briefs or assisting with toileting.device care or use.wound care: any skin opening requiring a dressing.enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals.During a review of the facility's P&P titled, Wound Care, dated 10/2010, the P&P indicated, .verify there is a physician's order for this procedure.personal protective equipment [e.g., gown, gloves, mask, etc., as needed].arrange the supplies so they can be easily reached.wash and dry your hands thoroughly.put on exam glove. Loosen tape and remove dressing.pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly.wear gloves when physically touching the wound or holding a moist surface over the wound.place one [1] gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water.remove dry gauze. Apply treatments as indicated.dress wound.wash and dry your hands thoroughly.

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable working environment for kitchen staff when temperature readings exceeded 85 degrees Fahrenheit ( F -measurement of temperature) in the kitchen.This failure resulted in kitchen staff visible sweating during plating of meals in the kitchen which could increase the risk of unsafe and unsanitary handling of resident food.Findings:During a concurrent observation and interview on 7/14/26 at 8:45 a.m. with the Certified Dietary Manager (CDM), in the kitchen, no thermometer or thermostat was observed in the kitchen. The CDM stated there was no thermometer or thermostat in the kitchen to monitor temperatures.During a concurrent observation and interview on 7/14/26 at 10:00 a.m. with the Maintenance Director (MND) and the CDM, in the kitchen, the MND took the temperature in the kitchen. No food preparation or food serving was observed. The temperature was 85 F near the dishwasher, 85.1 F near the tray line table, and 86 F near the dry food storage wall. Cooking spices were observed stored in the kitchen environment, outside of the dry food storage room.During a concurrent interview and record review on 7/15/26 at 10:34 a.m., the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2023, was reviewed. The RD stated the P&P did not include kitchen temperature ranges. The RD stated the P&P indicated dry food needed to be stored between 50 F to 85 F. The RD stated if food was held or stored over 85 F it could spoil.During an observation on 7/15/26 at 11:47 a.m., in the kitchen during lunch tray line, [NAME] (CK) 1 was observed sweating during tray line, while plating resident food. During a concurrent observation and interview on 7/15/26 a.m. at 12:20 p.m. with the CDM, in the kitchen during lunch tray line, a wall thermometer was observed on the wall, near the kitchen entrance. The CDM stated he placed the wall thermometer yesterday. The wall thermometer was 90 FDuring a concurrent observation and interview on 7/15/26 at 2:13 p.m. with the CDM and Registered Dietician (RD), the kitchen wall thermometer was 94 F. The RD stated it was warm in the kitchen.During a concurrent observation and interview on 7/15/26 at 2:16 p.m. with Dietary Aide (DA) 1, DA 1 was observed sweating. DA 1 stated the kitchen was hot and not comfortable to work in. DA 1 stated kitchen temperature increased during food preparation and tray line which caused kitchen staff to sweat while handling food.During a concurrent observation and interview on 7/15/26 at 2:19 p.m. with CK 2, CK 2 was observed sweating. CK 2 stated the kitchen was always hot, even when food was not being made or served. CK 2 stated the facility kitchen was not comfortable to work in when temperatures were hot.During a concurrent observation and interview on 7/15/26 at 2:23 p.m. with the RD, the RD stated the kitchen was warm. The RD stated she observed kitchen staff sweating. The RD stated if kitchen staff were sweating in the kitchen it was not a comfortable environment.During a concurrent observation and interview on 7/15/26 a.m. at 3:58 p.m. with the CDM, in the kitchen, the wall thermometer was 94 F.During a concurrent observation and interview on 7/16/26 a.m. at 1:34 p.m. with the CDM and the MND, in the kitchen, the MND took the temperature in the kitchen. No food preparation or food serving was observed. The temperature was 90 F near the dishwasher, 95.4 F near the 3-compartment sink, 89.4 F near the dry food storage wall, and 90 F near the handwashing sink. During an interview on 7/17/26 at 9:41 a.m. with the CDM, the CDM stated prior to 7/15/26 temperatures in the kitchen were not taken or recorded by anyone. The CDM stated the kitchen temperature would be unknown without a thermometer or monitoring.During an interview on 7/17/26 at 9:52 a.m. with the RD, the RD stated prior to 7/15/26 there was no wall thermometer in the kitchen to monitor kitchen temperatures and no staff had been assigned to monitor kitchen temperatures. The RD stated kitchen staff were at risk of sweating or heat illness in a hot environment. The RD stated sweating while handling food posed an infection control risk if sweat got on resident food or kitchen equipment which could contaminate food.During an interview on 7/17/26 at 2:11 p.m. with the Director of Nursing (DON), the DON stated she expected the facility to provide a safe, comfortable and sanitary kitchen environment for staff and residents, per facility policy and food safety standards of practice. The DON stated hot kitchen temperatures were not safe or comfortable for staff if they were sweating. The DON stated there was a risk sweat could contaminate resident food which posed an infection control risk to residents. The DON stated prior to 7/15/26 kitchen temperatures were not monitored. The DON stated facility policy and procedure were not being implemented when kitchen temperatures were not monitored.During a review of the facility's policy and procedure (P&P) titled, Indoor Heat Illness Prevention, dated 1/1/26, the P&P indicated, .[facility name] will protect employees working in indoor areas where temperatures may reach 85 F or higher. the Dietary Manager or designee will check and document temperatures in the kitchen.when hot conditions are expected, during the hottest cooking period, and following prolonged delivery or open-door events.temperature records will include the date, time, location, reading, and corrective actions.During a review of the facility's P&P titled, Storage of Food and Supplies, dated 2023, the P&P indicated, .food and supplies will be stored properly and in a safe manner.recommended temperature is 50 [degrees] F- 85 [degrees] F - if dry food storage goes over 85 F take corrective action.During a review of the facility's P&P titled, Homelike Environment, dated 2/2021, the P&P did not include comfortable and safe kitchen temperature ranges. The P&P indicated the facility maintained a comfortable and safe temperature of 71 degrees F to 81 degrees F for residents.During a review of the professional weather service, National Weather Service, retrieved from https://www.weather.gov/, the recorded high temperature for Fresno, California was 104 degrees F on 7/14/26, 106 degrees F on 7/15/26, and 102 degrees F on 7/16/26.During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Ventilation Section 6-304.11 Mechanical, indicated .If necessary to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious odors, smoke, and fumes, mechanical ventilation of sufficient capacity shall be provided .

Based on interview and record review, the facility failed to ensure residents were free from accidents for one of three sampled residents (Resident 1) when Resident 1 was not assessed for safe transfer, seating, and supervision needs prior to being transferred and Resident 1 was left unattended in wheelchair despite documented weakness and limited mobility on 4/17/26This failure resulted in Resident 1 experiencing an unwitnessed fall from a wheelchair on 4/21/26 onto the floor. After the fall Resident 1 experienced facial abrasions and busing and was sent to the general acute care hospital (GACH) for evaluation.Findings:During a review of Resident 1's admission Record (AR- a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] for a five-day respite (temporary, short-term care provided to an individual to give their primary, unpaid family caregiver a break) hospice stay with a diagnosis of hemiplegia (muscle weakness) and hemiparesis (paralysis - no control over one side of the body) following cerebral infarction (stroke) affecting left non- dominant side, heart failure (conditions where the heart cannot pump enough blood to meet the body's needs for oxygen), and chronic obstructive pulmonary disease (COPD- on going lung disease caused by damage to the lungs).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/17/26, the MDS section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall on a scale of 1-15 ) score of 3 (a score of 0-7 severe cognitive impairment, 8-12 moderately impaired, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment.During a record review of Resident 1's Hospice Nursing Clinical Notes (HCN) dated 4/17/26, the HCN indicated, under musculoskeletal/activities Resident 1 had weakness and limited mobility/range of motion. The HNC did not identify Resident 1's transfer status, did not indicate whether Resident 1 was bedbound or chair bound, and did not document assistive devices needed.During a record review of Resident 1's Hospice Physician Order dated 4/17/26, the Hospice Physician Orders indicated, under physician communication: respite care [for] 5 days effective at 1:30 pm 4/17/26, No [Physical Therapy], [Occupational Therapy], and [Speech Therapy] and hospitalization without.consultation, .contact hospice for any concerns or questions.During a concurrent interview and record review on 5/8/26 at 10:00 a.m. Director of Nursing (DON), Resident 1's Facility Progress notes Administration Assessment dated 5/8/26, indicated Resident 1 was admitted for respite care on 4/17/26. resident [1] is bed bound with left sided weakness. Further review did not identify documentation of mobility, transfer, seating, or wheelchair safety evaluation completed prior to Resident 1 being transferred into a wheelchair on 4/21/26.During an interview on 5/8/26 at 9:40 a.m. with the Occupational Therapy Assistant (OTA), the OTA explained that before any resident is transferred or a decision is made about which assistive device to use, the resident should first undergo an evaluation to determine their mobility, transfer needs, and the safest equipment for positioning. The OTA specifically stated this process is critical for residents like Resident 1, who had documented weakness and limited mobility, as identified in both hospice and facility records. The OTA stated because Resident 1 demonstrated poor trunk control and was unable to sit upright from a stroke, the OTA stated that recliner or Geri chairs are often recommended for such individuals. The OTA stated the use of a Geri chair is important because it provides enhanced positioning and safety for residents who cannot safely sit upright in a standard wheelchair, helping to prevent falls and other accidents. The OTA stated in Resident 1's case, failure to complete a mobility and seating assessment resulted in staff transferring to a standard wheelchair without proper evaluation, ultimately contributing to an unwitnessed fall and injury.During a concurrent interview and record review on 5/8/26 at 10:00 a.m., with the DON, Resident 1's Electronic Medical Record (EMR), dated 5/8/26 was reviewed. The DON stated Resident 1 remained in bed during the respite stay until staff transferred Resident 1 into a wheelchair on 4/21/26 after repeated requests from Resident 1's daughter. The DON stated there was no documentation in Resident 1's EMR to indicate the transfer status or if Resident 1 was able to use a wheelchair. The DON confirmed Resident 1's EMR did not have documentation of communication from Resident 1's daughter to facility staff. The DON stated Resident 1 sustained an unwitnessed fall after being transferred into the wheelchair by staff on 4/21/26.During an interview on 5/8/26 at 10:28 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she transferred Resident 1 into a facility wheelchair on 4/21/26. CNA 1 stated she transferred Resident 1 on 4/21/26 at approximately 2:00 p.m., after receiving a request from Resident 1's daughter to have the resident sitting up. CNA 1 stated Resident 1 was moved using a hoyer lift (a mechanical device used to safely transfer individuals with limited mobility) and was placed into a standard facility wheelchair. CNA 1 stated Resident 1's personal wheelchair from home was not present in the facility. CNA 1 stated after she completed the transfer, she left Resident 1 unattended in the wheelchair. CNA 1 stated she was alerted by the hospice social worker, who was making a visit to Resident 1 and discovered Resident 1 was face down on the floor with facial bleeding. CNA 1 stated she did not receive specific instructions or information regarding mobility tolerance for Resident 1. CNA 1 stated she did not know where to locate that information in Resident 1's chart. During an interview on 5/8/26 at 10:55 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 was extensively dependent on staff for mobility and positioning. LVN 1 stated Resident 1 was transferred into a wheelchair by CNA 1, following repeated requests from Resident 1's daughter, even though there was no documentation regarding wheelchair use or a therapy evaluation. LVN 1 was not present during the transfer of Resident 1 by CNA 1 but later observed Resident 1 seated upright in the wheelchair, leaning slightly left. LVN 1 reported Resident 1 was left unattended for less than 15 minutes. LVN 1 was alerted by a hospice staff member that Resident 1 was found face down on the floor with facial bleeding. LVN 1 stated neither Resident 1 nor his roommate could provide details about what had happened. LVN 1 emphasized that Resident 1's mobility baseline required extensive assistance, as he was unable to reposition himself or independently transfer.During an interview on 5/8/26 at 11:23 a.m., with the Restorative Nursing Assistant (RNA), the RNA explained that hospice residents typically use reclining chairs after an evaluation is completed, due to poor trunk control, comfort needs, and positioning requirements. The RNA stated that performing assessments is essential before determining seating or transfer equipment, especially for residents with impaired trunk stability or limited mobility. The RNA stated the use of a reclining chair, such as a Geri chair, provided critical support and enhanced safety for those who cannot sit upright in a standard wheelchair, ultimately helping to prevent falls and injuries. The RNA stated facility practice involved evaluating each resident's individual needs prior to mobility and equipment decisions, underscoring the facility's responsibility to ensure resident safety through proper assessments and interventions.During a concurrent interview and record review on 5/8/26 at 2:00 p.m. with the Administrator (ADM), the facility document titled internal investigation dated 4/21/26 was reviewed, the internal investigation indicated Resident 1 was last observed seated upright in the wheelchair after transfer by CNA 1 on 4/21/26. The facility internal investigation indicated Resident 1 had an unwitnessed fall. The internal investigation indicated Resident 1 was found face down on the floor with facial bleeding. The internal investigation indicated CNA 1 left Resident 1 unattended after transfer into the wheelchair.During an interview on 5/8/26 at 2:20 p.m., with DON, the DON stated all residents should be evaluated prior to transfer and mobility changes; however, no evaluation was completed for Resident 1 prior to transfer into wheelchair. The DON stated staff should not have relied on information provided by Resident 1's daughter regarding Resident 1's use of assistive devices such as a wheelchair. The DON stated the facility should have followed up with hospice to confirm Resident 1's needs.During a record review of Review of Resident 1's general acute care hospital (GACH) emergency department records dated 4/21/26, the emergency department records, indicated Resident 1 sustained facial abrasions and bruising after an unwitnessed fall.During a review of the facilities Policy and Procedure (P&P) titled, Providing End of Life Care, dated 9/2/22, the P&P indicated, .providing the needed care and services to those residents at or approaching end of life in accordance with the residents preferences. to promote their highest practicable physical, mental, and psychosocial well-being. The facility will complete a comprehensive assessment to provide direction for the development of the residence care plan to address choices and preferences. the assessment will include.v. Level of activities desired and psychosocial needs vi. Functional/ ADL status.During a review of the facility P&P titled, Accident and Supervision, dated 9/22/22, the P&P indicated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents'.the facility should make a reasonable effort to identify the hazards and risk factors for each resident' . implementing interventions to reduce a resident's risk from hazards in the environment . Ensuring that the interventions are put into action . Monitoring and modification processes include. evaluating the effectiveness of interventions. modifying or replacing interventions as needed . adequacy of supervision . based on the individual resident's assessed needs and identified hazards in the resident environment.During a review of the facility P&P titled, Coordination of Hospice Services, dated 11/1/23, the policy indicated, The facility retains primary responsibility for implementing those aspects of care that are not related to the duties of the hospice . The care plan and any related forms shall be revised and updated as necessary to reflect the resident's current status . The facility will monitor and evaluate the resident's response to the hospice care plans . All residents receiving hospice will continue to receive the same facility services.including. ongoing monitoring or resident conditions.

Based on observation, interview, and record review, the facility failed to accept one of four resident's (Resident 1) back after hospitalization when Resident 1 required the services provided by the skilled nursing facility (SNF) and was sent to the hospital for an urgent transfer due to a critically low hemoglobin (protein in red blood cells that carries oxygen from the lungs to the rest of the body) level of 4.5 (normal hemoglobin levels for men range from 13.5-17.5). After being stabilized at the hospital, Resident 1 was denied readmission to the SNF.This failure resulted in Resident 1 not being readmitted to the skilled nursing facility. Findings:During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/4/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] from an acute care hospital. Resident 1 had the following diagnoses upon admission: muscle wasting and atrophy(the loss of muscle tissue and mass), muscle weakness (a lack of muscle strength that prevents a person from performing typical muscle contractions), type 2 diabetes ( a chronic condition where the body cannot regulate the amount of sugar in the blood), bipolar disorder (a mental health condition causing extreme shifts in mood, energy, and activity levels), non pressure chronic ulcer of lower leg(an open, long-lasting sore that develops between the knee and the ankle and is not caused by direct, prolonged pressure), chronic kidney disease ( a progressive condition where kidney damage prevents them from filtering waste from the blood effectively), schizophrenia (a serious brain disorder causing distorted perceptions of reality), nephrotic syndrome (a kidney disorder where damaged kidney filters leak excessive protein into the urine, resulting in low blood protein and severe swelling ), dependance on renal dialysis (when a person's life relies on machines to filter waste and fluid from their blood because their kidneys have failed), anemia (a condition where a person's blood doesn't have enough healthy red blood cells or hemoglobin to carry oxygen from your lungs to the rest of your body), hypertensive heart disease (heart disorders caused by chronic, untreated, or poorly managed high blood pressure), and acute kidney failure (sudden loss of kidney function, causing a rapid buildup of waste products in the blood). During an interview on 2/4/26 at 2:59 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was in the SNF to get help with medical care he needed. CNA 1 stated he had wounds to his legs, and he needed nursing care to help them heal. CNA 1 stated Resident 1 was transferred to the hospital for an issue with his blood. CNA 1 stated she was not sure if he was going to return to the SNF as they already assigned new residents to his room.During an interview on 2/4/26 at 3:12 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was admitted to the SNF on 1/20/26 with wounds to his right and left legs that he needed wound treatments for. LVN 1 stated Resident 1 had his legs wrapped with bandages that were dated 1/16/26. LVN 1 stated Resident 1 needed to have regular wound treatments to prevent the wounds from getting worse and to promote healing. LVN 1 stated Resident 1 was sent to the hospital due to a low hemoglobin (protein in red blood cells that carries oxygen from the lungs to the rest of the body) level of 4.6 on 2/1/26. Resident 1 needed hospital interventions to correct his low hemoglobin levels. LVN 1 was not sure if Resident 1 was scheduled to return to the facility as his room was already occupied by other residents.During a concurrent interview and record review on 2/4/26 at 3:52 p.m. with LVN 1, Resident 1's Medication Administration Record, dated 1/4/26 was reviewed. The Medication Administration Record indicated resident 1 was prescribed medications which included atorvastatin (medication that lowers cholesterol [fatty substance in the blood]), lidocaine patch (patch placed on the skin to provide pain relief, nifedipine (medicine that relaxes blood vessels to lower blood pressure and improve blood flow) , insulin (hormone that helps the body use sugar from food for energy and keeps blood sugar levels balanced), zinc (mineral that helps the immune system and promotes wound healing), furosemide (medicine that helps the body get rid of extra fluid in the body), metoprolol (medication that slows the heart rate and lowers blood pressure to help the heart work more easily), pantoprazole (medication that lowers stomach acid to help prevent heartburn and stomach irritation), and olanzapine (medication that helps balance brain chemicals to treat mood and thinking problems). LVN 1 stated Resident 1 needed the care the SNF provided, Resident 1 had a lot of health issues and a lot of medications for those health issues. LVN 1 stated Resident 1 could get sicker if he did not receive appropriate care for his health. During a concurrent interview and record review on 2/4/26 at 4:18 p.m. with LVN 2, Resident 1's Medical Diagnosis dated 1/20/26 was reviewed. LVN 2 read off some of the admitting diagnoses which included muscle wasting and atrophy, type 2 diabetes, schizophrenia, and bipolar disorder. LVN 2 stated Resident 1 needed physical therapy services for his muscle wasting, insulin medication for his diabetes, and psychotropic medications for his schizophrenia and bipolar disorder. LVN 1 stated Resident 1 was a medically fragile resident who required medical care to prevent from getting worse.During a concurrent observation and interview on 2/5/26 at 8:03 a.m. with restorative nurse assistant (RNA) 1, Resident 1's room was observed to be occupied by two other residents. RNA 1 stated Resident 1 was in the hospital. RNA 1 stated Resident 1's room was already occupied so she didn't think he would return.During a concurrent observation and interview on 2/5/26 at 8:42 a.m. with CNA 2, Resident 1's room was observed to be occupied by two other residents. CNA 2 stated she did not think Resident 1 would return to the SNF because the SNF had already given his room away to other residents. CNA 2 stated the SNF normally would hold a person's bed for seven days if they anticipated a return, and he left less than seven days ago. During a concurrent interview and record review on 2/5/26 at 9:07 a.m. with LVN 3, Resident 1's Medical Diagnosis dated 1/20/26, were reviewed. LVN 3 read off some of Resident 1's diagnoses which included: muscle weakness and wasting and hypertensive heart disease due to chronic kidney disease. LVN 3 stated Resident 1 was in the SNF because he had medical needs, and the SNF had the capability to take care of his medical needs. LVN 3 stated Resident 1 needed to receive care from the facility because he was a complex patient and he could have possibly gotten sicker if his medical needs were unmet. LVN 3 stated Resident 1's most pressing needs were getting dialysis for his kidney disease and therapy five times a week for his muscle wasting to prevent further decline.During an interview on 2/5/26 at 10:30 a.m. with the Social Services Director (SSD), the SSD stated Resident 1 was sent out to the hospital on 2/1/26 and the hospital wanted to send him back to the SNF on 2/2/26 after he was stabilized. The SSD stated he was a difficult resident to deal with due to his behaviors, but he had the right to come back to the facility because he was there for medical care and his bed was still on hold for him. The SSD stated beds are held for seven days while any resident gets transferred to the hospital and he had not gone over the 7 day period. During an interview on 2/5/26 at 10:40 a.m. with the Admissions Director (AD), the AD stated Resident 1 was originally admitted from a hospital outside of the area. The AD stated Resident 1 looked like an appropriate resident for the SNF before they admitted him and they were well suited to meet his care needs. The AD stated she and the Director of Nursing (DON), and the Administrator (ADM) met to discuss if he was a good fit for transfer to the facility and they agreed he was. The AD stated Resident 1 was transferred to the hospital from the SNF on 2/1/26 due to an issue with his blood levels and when the hospital was ready to release him back to the SNF on 2/2/26, the SNF refused to accept him because of his aggressive behaviors. The AD stated the hospital had wanted Resident 1 to return to the SNF but after the SNF refused him they dropped communication. The AD stated the SNF staff should have followed up with the hospital to ensure Resident 1 had found proper placement.During a concurrent interview and record review on 12/5/26 at 10:50 a.m. with the AD, the facilities, Policy and procedures (P&P) titled, admission Criteria, dated 3/19, Transfer or Discharge, Facility Initiated dated 10/22 and Bed Holds, dated 10/22, were reviewed. The admission Criteria P&P indicated, Our facility admits only residents whose medical and nursing care needs can be met . 1. The objectives of our admission criteria policy are to . b. admit residents who can be cared for adequately by the facility . e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission . The Bed-Holds and Returns P&P indicated, . 5. The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source . 6. Residents who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to their previous room, if available . The Transfer or Discharge, Facility Initiated P&P indicated . If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility . The AD stated the facility admitted Resident 1 because they were confident they could take care of him and manage all his medical needs. Resident 1's insurance was also willing to cover his stay so the facility thought he would be a good fit. The AD stated the records from the hospital did not have any red flags so the SNF accepted Resident 1. The AD stated when Resident 1 was sent out to the hospital on 2/1/26 he had a bed on hold for him for seven days, and it was his right to return to the SNF per the bed hold policy, but the facility did not want him back because of his behaviors even though he was only sent out for a medical issue, not a behavioral one. The AD stated the facility needed to accept him back to address his medical needs. The AD stated the policies follow the regulations and the SNF was responsible for ensuring he received medical care and returned back to his bed.During a concurrent interview and record review on 12/5/26 at 11:10 a.m. with the ADM and DON the facility's P&P's titled, admission Criteria, dated 3/19, Transfer or Discharge, Facility Initiated dated 10/22 and Bed-Holds and Returns, dated 10/22, were reviewed. The admission Criteria P&P indicated, Our facility admits only residents who's medical and nursing care needs can be met . 1. The objectives of our admission criteria policy are to . b. admit residents who can be cared for adequately by the facility . e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission .The Transfer or Discharge , Facility Initiated P&P indicated . If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility . The Bed-Holds and Returns P&P indicated . 5. The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source . 6. Residents who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to their previous room, if available . The DON stated originally the hospital he came from had asked the SNF if they were able to place Resident 1 in their care. The DON stated the hospital he came from stated he needed antibiotic administration and wound care. The DON, ADM and AD all reviewed his admission packet from the hospital to see if he was a good fit and they all agreed the SNF had the capabilities to properly care for Resident 1. The ADM stated the facility accepted responsibility for Resident 1 and their admission policy detailed how they only accept residents they can care for. The DON stated Resident 1 went out for dialysis and they reported he had a hemoglobin level of 4.6 and the physician ordered for him to be sent out to the hospital. The ADM stated Resident 1 was sent to the hospital on 2/1/26 and was ready to be discharged back to the facility the next day, 2/2/26. The ADM sent a message to the case management department in the hospital about how they did not want Resident 1 to return to the SNF. The ADM stated as far as they knew he was still at the hospital; no one followed up since the initial contact. The ADM stated they should have followed up with the hospital to see if he still needed placement since he was at the hospital for a medical issue and it had since been resolved, and he still fell within the bed hold period as detailed by the facility P&P.

Based on observation, interview and record review the facility failed to prepare and distribute food in accordance with professional standards for food service safety when one three-compartment sink in the kitchen did not contain air gaps (unobstructed vertical space between the water outlet and the flood level of a fixture) to prevent backflow of sewage (waste) water on 5/27/25 for 58 of 59 residents who consumed food prepared in the kitchen. This failure placed residents at risk for foodborne illness (illness caused by consuming contaminated food or drink) and food contamination. Findings: During an observation and interview on 5/27/25 at 9:15 a.m., with Kitchen Staff (KS) 1, during a tour of the kitchen, three-compartment sink did not have a visible air gap (unobstructed vertical space between the water outlet and the flood level of a fixture) to prevent backflow of sewage (waste) water. KS 1 stated the three-compartment sink was utilized by the cooks to clean their dishes. At the time of the observation, compartment 1 of the sink was filled with hot water and sanitizer. During an observation on 5/28/25 at 7:55 a.m., in the kitchen two turkey breasts were observed thawing under running water in compartment two of the three-compartment sink while compartment one contained sanitizer solution and dirty dishes. During an interview on 5/28/25 at 8:07 a.m., with Maintenance Director (MD), MD stated there were no air gaps for any of the sinks in the kitchen. During a concurrent observation and interview on 5/28/25 at 11:40 a.m., with [NAME] 1, lunch meat was observed thawing under running water in compartment two of the three-compartment sink, while dirty dishes were soaking in compartment one. [NAME] 1 stated there was no dedicated prep sink in the kitchen and the three-compartment sink was utilized for both food preparation and cleaning the dirty dishes. During a concurrent observation and interview on 5/28/25 at 12:17 p.m., in the kitchen, [NAME] 1 opened two large cans of diced pears and poured them into a colander (bowel used to strain off liquid) in compartment two of the two-compartment sink. At the time, compartment one was being used to soak dirty dishes. [NAME] 1 stated an air gap is used to prevent backflow. [NAME] 1 stated food could become contaminated if the sink backed up while being used for food preparation. During an interview on 5/30/25 at 9:19 a.m., with Certified Dietary Manger (CDM), the CDM stated there was potential for cross-contamination (transfer from one substance or object to another) to occur. The CDM stated if the sink were to become backed up, it could contaminate the food in the sink, which could lead to foodborne (a disease aquired from eating contaminated food or drinks) illness among the residents. During a review of the facilities policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .if a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system .an air gap is the most reliable backflow prevention device. It is the physical separation of the potable and on and non-potable water supply systems by an air space. All steam tables, ice machines and bins, food preparation sinks, display cases, soda fountains, espresso machines and other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink . During a review of the facilities policy and procedure (P&P) titled Thawing of Meats, dated 2023, the P&P indicated, .thaw in a clean and sanitized food sink separate from wash sinks . During a review of professional reference titled, FDA Food Code 2022, section 5-402.11 Backflow Prevention, (A) A direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. (B) Equipment and fixtures used for food preparation or utensil washing must be installed with an air gap or air brake as required to prevent backflow of sewage into the equipment.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services met the needs of two out of three sampled resident's (Resident 54 and Resident 166) when three controlled medication (medication with a high potential for physical and mental dependence) entries for Resident 54 and four controlled medication entries for Resident 166 did not have received by dates in the controlled drug disposition log. This failure resulted in inadequate record keeping of controlled medication which had the potential to lead to inaccurate controlled medication inventory, delayed medication destruction, diversion (when healthcare providers obtain or use prescription medicines illegally) of controlled medications and delayed identification of controlled medication diversion. Findings: During a concurrent interview and record review on 5/28/25 at 2:27 p.m. with the Director of Nursing (DON) the facility's Controlled Drug Disposition Log, dated 5/2025, was reviewed. The disposition log indicated, Resident 54 had three controlled medication entries listed on the log for disposition: oxycodone with acetaminophen (controlled medication commonly used to treat pain), lorazepam (controlled medication commonly used to treat anxiety or seizures), and morphine sulfate (controlled medication commonly used to treat pain). Resident 166 had four controlled medication entries listed on the log for disposition: lorazepam twice and hydromorphone (controlled medication commonly used to treat pain) twice. The DON stated Resident 54's and Resident 166's-controlled medications had been brought to her by the floor nurse for waste. The disposition log entries did not include received by dates from the floor nurse to the DON. The DON could not identify or state the date she received the seven controlled medications based on the disposition log. The DON stated it was expected every time she received a controlled medication for waste from the floor nurse that she documented the received by date on the disposition log. The DON stated this process was not completed for Resident 54's three controlled medications or Resident 166's four controlled medications. The DON stated the facility policy was for the floor nurse to bring the DON controlled drug waste, complete the controlled drug disposition log in entirety, and then the medication would be disposed of with the pharmacist monthly or as needed. The DON stated it was important to document the received by date for each controlled medication to ensure timely disposition of controlled medications. The DON stated all controlled medications needed to be disposed of with the pharmacist within three months. The DON stated it was important the controlled drug disposition log was correctly and accurately completed to prevent drug diversion and ensure all controlled medications were accounted for. During an interview on 5/29/25 at 2:25 p.m. with the Pharmacist (PC), the PC stated she visited the facility monthly or as needed to review the Controlled Drug Disposition Log with the DON and dispose of controlled medications. The PC stated when a floor nurse needed to dispose of a controlled medication it is brought to the DON. The PC stated the DON then documented the residents name, prescription number, quantity, floor nurses name, and received by date from the floor nurse in the disposition log. The PC stated it was important the Controlled Drug Disposition Log was correctly and accurately completed to prevent drug diversion and ensure all controlled medications were accounted for. The PC stated it was important the received by date was documented to ensure timely disposition of controlled medications. The PC stated all controlled medications were required to be disposed of within 3 months. The PC stated without a received by date for each medication the facility could not ensure controlled medications were disposed of timely. The PC stated she expected the Controlled Drug Disposition Log to be completed accurately by the floor nurse and the DON. During an interview on 6/3/25 at 9:56 a.m. with the DON, the DON stated the Controlled Drug Disposition Log had not be filled out and completed accurately for Resident 54's three controlled medications and Resident 166's four controlled medications. The DON stated the received by date was expected, per policy and procedure, to be documented by her and the floor nurse on the disposition log for each controlled medication entry. The DON stated it was facility policy and procedure to ensure timely and accurate disposal of controlled medications. The DON stated facility policy and procedure had not been followed when the floor nurse and herself did not follow controlled medication disposition procedures for Resident 54's three controlled medications and Resident 166's four controlled medications. During a review of the facility's policy and procedure (P&P) titled 72371. Pharmaceutical Service-Disposition of Drugs, undated, the P&P indicated, .medications will be disposed of in accordance with federal, state and local regulations .the name of the patient, the name and strength of the drug, the prescription number, the amount destroyed, the date of destruction and the signatures of the witnesses required above shall be recorded in the patient's health record or in a separate log . During a review of the facility's P&P titled Controlled Substances, dated 11/2022, the P&P indicated, .controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record .controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up .

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for three of 15 residents (Residents 3, 16, and 31) when Residents 3, 16 and 31 failed to receive insulin (a short-acting insulin [a hormone that lowers the levels of sugar in the blood] used to treat diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing]) prior to eating their meal per physician's orders and manufacturer's recommendations. This failure had the potential to place the Residents 3, 16, and 31 at risk of not receiving the desired amount of insulin which could result in hypoglycemia (low blood glucose [b/s - a simple sugar] the body's primary source of energy from food) and potentially lead to negative medical outcomes. Findings: During a concurrent observation and interview on 5/28/25 at 7:48 a.m. with Registered Nurse (RN) 1 in Resident 3's room, observed meal carts in the hallway outside Resident 3's room while RN 1 was observed checking Resident 3's blood sugar (b/s) levels. Resident 3 was observed dressed, sitting on the side of her bed with her bedside table in front of her. RN 1 stated she was checking Resident 3's b/s close to her mealtime so she could give Resident 3's insulin right before Resident 3 ate her meal. RN 1 stated she was behind with the resident's b/s checks. Observed RN 1 poke Resident 3 three times with a needle due to continued error messages from the glucometer (an instrument for measuring the concentration of glucose in the blood), which delayed Resident 3's insulin administration. During an observation on 5/28/25 at 8:18 a.m. in Resident 3's room, observed Resident 3 sitting on the side of her bed eating her breakfast. RN 1 interrupted Resident 3's meal and administered insulin in the left upper quadrant of Resident 3's abdomen. During a review of Resident 3's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/15/24, the AR indicated Resident 3 was admitted to the facility from an acute care hospital on 7/13/22 with diagnoses of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), and cognitive communication deficit (difficulty with thinking and how someone uses language). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 34/29/25, the MDS section C indicated Resident 3 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 0 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 3 was severely impaired. During a review of Resident 3's Order Summary Report (OSP), dated 6/3/25, the OP indicated, . insulin Regular (human) inject 13 units subcutaneously (under the skin) before meals for Type II Diabetes Mellitus (DM) . insulin Regular (Human) inject as per sliding scale . subcutaneously before meals for Type II DM . During a concurrent observation and interview on 5/28/25 at 8:55 a.m. in Resident 16's room, Resident 16 was observed dressed in his wheelchair. Resident 16 stated he already ate his meal. RN 1 observed checking Resident 16's b/s. RN 1 stated she would notify Resident 16's physician due to Resident 16 already ate his meal prior to his b/s check. During a concurrent observation and interview on 5/28/25 at 9:01 a.m. with RN 1 in Resident 16's room, RN 1 was observed administering insulin to Resident 16 in the right upper quadrant of the abdomen. RN 1 stated Resident 16's physician stated to administer insulin as ordered and monitor the resident. During a review of Resident 16's AR, dated 6/3/25, the AR indicated Resident 16 was admitted on [DATE] from a skilled nursing facility with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type II DM, acute respiratory failure, cognitive communication deficit, and acquired absence of right and left legs below the knees. During a review of Resident 16's MDS, dated 4/1/25, the MDS section c indicated Resident 16 had a BIMS score of zero, which indicated Resident 16 was severely impaired. During a review of Resident 16's OSR, dated 6/3/25, the OSR indicated, . (brand name insulin) . inject as per sliding scale . subcutaneously before meals . During a concurrent observation and interview on 5/28/25 at 8:23 a.m. with RN 1 in Resident 31's room, Resident 31 was observed dressed sitting in bed with his meal tray on his bedside table. RN 1 asked Resident 31 if he already ate his meal, which Resident 31 replied yes. RN 1 stated she needed to call Resident 31's physician as she had not checked Resident 31's fasting b/s prior to him eating his meal. During a concurrent observation and interview on 5/28/25 at 8:35 a.m. RN 1 observed administering insulin to Resident 31 in the right lower quadrant. RN 1 stated the physician ordered 2 units (unit of measurement) to be given and to monitor the resident. During a review of Resident 31's AR dated 6/3/25, the AR indicated Resident 31 was admitted from the acute care hospital on 3/25/25 and re-admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), type II diabetes mellitus, cognitive communication deficit, and partial amputation (surgical removal) of two or more left lesser toes. During a review of Resident 31's MDS, dated 5/28/25, the MDS section C indicated Resident 31 had a BIMS score of 12, which suggested resident 31 was moderately impaired. During a review of Resident 31's OSP, dated 6/3/25, the OSP indicated, . (brand name insulin) . inject as per sliding scale . subcutaneously before meals and at bedtime for DM2 . During an interview on 5/28/25 at 10:05 a.m. with RN 1 stated resident's b/s checks should be taken before the residents eat their meal to get an accurate reading of the resident's blood sugar. RN 1 stated residents could have gotten adverse (harmful) side effects from the medication. RN 1 stated staff needed to monitor the residents. During an interview on 6/03/25 at 9:13 a.m. with the Director of Nursing (DON), the DON stated her expectation was resident' b/s should have been taken prior to the residents eating their meals so the nurse would get an accurate reading of the resident's blood sugar. The DON stated the residents could have had a higher reading of their blood sugar after eating their meal than if they were fasting. The DON stated the resident's insulin should not have been given. During a review of the facility job description document titled, Registered Nurse, dated 1/22/25, the document indicated, . the Registered Nurse is responsible for providing direct nursing care to the residents. Such care must be delivered in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility . prepare and administer medications as ordered by the physician . During a review of professional reference titled, Insulin, Regular, dated 7/3/23, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK553094/#:~:text=Insulin%2C%20regular%20when%20administrated%20subcutaneously,injection%20sites%20to%20avoid%20lipodystrophy, indicated . Insulin, regular when administrated subcutaneously, should be injected 30 to 40 minutes before each meal . if insulin is administered not with meals or inappropriate dosage, it can be life-threatening. Untreated hypoglycemia (low blood sugar) can cause seizures, coma, and even death, especially in elderly patients . During a review of the Food and Drug Administration (FDA) information packet titled, INFORMATION FOR THE PHYSICIAN (Insulin brand name) REGULAR INSULIN HUMAN INJECTION, USP, (rDNA ORIGIN) 100 UNITS PER ML (U-100) DESCRIPTION, dated 3/20/11, retrieved from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/018780s120lbl.pdf indicated, . OVERDOSAGE Excess insulin may cause hypoglycemia and hypokalemia . hypoglycemia may occur as a result of an excess of insulin relative to food intake, energy expenditure, or both . adjustments in drug dosage, meal patterns, or exercise may be needed . DOSAGE AND ADMINISTRATION (Insulin brand name) U-100, when used subcutaneously, is usually given three or more times daily before meals .

Based on observations, interview, and record review, the facility failed to properly label medication in the medication room and in two of three medication carts when: 1. Resident 25's inhaler was stored in the medication room and not labeled. 2. Resident 11's, Resident 19's and Resident 28's eye drops, as well as Resident 167's liquid morphine sulfate (controlled medication used to treat pain) was stored in medication cart A and not labeled. 3. Resident 39's and Resident 216's eye drops was stored in medication cart B and not labeled. These failures had the potential to result in misidentification of a medication, for Residents 25, 11, 19, 28, 167, 39 and 216 and had the potential for needed medication to not be available for resident use. Findings: 1. During a concurrent observation and interview on 5/28/25 at 2:27 p.m. with the Director of Nursing (DON) in the medication room, Resident 25's albuterol sulfate (powder medication that is inhaled and used to treat shortness of breath) inhaler was observed with no resident or pharmacy label on the inhaler. The DON stated Resident 25's inhaler did not have a resident or pharmacy label on the inhaler. The DON stated all inhalers were expected to have a pharmacy label on the inhaler. The DON stated pharmacy was responsible to place pharmacy labels on all inhalers. The DON stated the nurse administering the inhaler should have identified that the inhaler did not have a resident or pharmacy label on the inhaler and notified pharmacy. The DON stated it was important to ensure all inhalers were labeled so the correct medication was administered to the correct resident as ordered. 2. During a concurrent observation and interview on 5/29/25 at 12:57 p.m. with Licensed Vocational Nurse (LVN) 6 at medication cart A, Resident 11's latanoprost (a liquid medication placed in the eye to treat conditions that cause increased pressure in the eye) eye drops, Resident 19's lubricant eye (a liquid medication placed in the eye to treat dry eyes) drops, and Resident 28's brinzolamide (a liquid medication placed in the eye to treat conditions that cause increased pressure in the eye) eye drops were observed with no resident or pharmacy label on the eye drop bottles. Resident 167's morphine sulfate (controlled drug medication used to treat pain) liquid bottle was observed with no resident or pharmacy label on the medication bottle. LVN 6 stated all eye drop bottles were expected to have resident or pharmacy labels on the bottle. LVN 6 stated it was important to have resident or pharmacy labels on eye drop bottles to ensure the correct medication was administered to the correct resident. LVN 6 stated eye drop bottles were at risk for falling out of their box and without a label the medication could not be linked to the correct resident accurately, especially if multiple residents were prescribed the same eye drop medication. LVN 6 stated all morphine sulfate liquid bottles were expected to have a resident or pharmacy label on the bottle. LVN 6 stated it was important to have a resident or pharmacy label on the bottle to ensure the controlled medication was administered to the correct resident. 3. During a concurrent observation and interview on 5/29/25 at 1:56 p.m. with Registered Nurse (RN) 2 at medication cart B, Resident 39's olopatadine (a liquid medication placed in the eye to treat eye itchiness) eye drops and Resident 216's bimatoprost (a liquid medication placed in the eye to treat conditions that cause increased pressure in the eye) eye drops were observed with no resident or pharmacy label on the eye drop bottles. RN 2 stated all eye drop bottles were expected to have resident or pharmacy labels on the bottle. RN 2 stated it was important to have resident or pharmacy labels on eye drop bottles to ensure the correct medication was administered to the correct resident. RN 2 stated if the eye drop bottles were lost it would not be known which medication belonged to each resident and could potentially lead to the incorrect medication. RN 2 stated there was a risk for spreading infections if the wrong eye drop bottle was administered to the wrong resident. During an interview on 5/29/25 at 2:18 p.m. with the Pharmacist in Charge (PIC), the PIC stated all resident medication within the medication room and medication carts were expected to be labeled with a resident pharmacy label on the bottle of the medication. The PIC stated Resident 25's albuterol sulfate inhaler was expected to have a resident pharmacy label on the inhaler. The PIC stated Resident 11's latanoprost eye drops, Resident 19's lubricant eye drops, and Resident 28's brinzolamide eye drops were expected to have a resident pharmacy label on the eye drop bottle. The PIC stated Resident 167's morphine sulfate liquid bottle was expected to have a resident pharmacy label on the bottle. The PIC stated Resident 39's olopatadine eye drops and Resident 216's bimatoprost eye drops were expected to have a resident pharmacy label on the eye drop bottle. The PIC stated pharmacy was responsible to ensure resident medication had pharmacy labels on the bottle. The PIC stated it was the floor nurse's responsibility to notify pharmacy if they identified a resident medication did not have a resident pharmacy label on the medication bottle. The PIC stated it was important each resident medication, inhaler or eye drop had a resident pharmacy label to ensure the correct medication bottle was used to administer medication to the correct resident. During an interview on 6/3/25 at 9:56 a.m. with the DON, the DON stated she expected every medication assigned to a resident to have a resident or pharmacy label on the inhaler, eye drop or medication bottle to ensure the medication was administered to the correct resident. The DON stated residents were at risk of infection if the wrong bottle of medication was administered to the wrong resident. The DON stated eye drops and inhalers touched the eyes and mouth of resident's and if not labeled there was a risk the medication was administered to the wrong resident with a similar prescription. The DON stated it was important to label morphine sulfate to ensure accurate controlled drug monitoring. The DON stated it was the policy of the facility to ensure pharmacy placed a resident label on each resident inhaler, eye drop and medication bottle. The DON stated the facility had not followed medication labeling policies for Resident 25, Resident 11, Resident 19, Resident 28, Resident 167, Resident 39 or Resident 216. During a review of the facility's policy and procedure (P&P) titled, 72357. Pharmaceutical Service- Labeling and Storage of Drugs, undated, the P&P indicated, .all drugs obtained by prescription shall be labeled . During a review of the facility's P&P titled, Medication Administration, dated 9/2/22, the P&P indicated, .compare medication source (bubble pack, vital, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .

Based on observation, interview and record review the facility failed to promote quality of life for two of 11 sampled residents (Resident 59 and Resident 30) when Resident 59 did not receive a shower on 5/8, 5/12, 5/15, 5/19, and 5/26 and Resident 30 did not receive a shower on 5/9, 5/13, 5/16, and 5/20. This failure resulted in nine missed opportunities for personal hygiene care and resulted in Resident 59 to feel dirty, neglected and isolated and Resident 30 to feel dirty and gross. Findings: During interview on 5/27/25 at 10:23 a.m. with Resident 59 in her room, Resident 59 stated she had not received a shower in three weeks and expressed a desire to have one. Resident 59 stated staff were not providing her scheduled showers and had not provided a reason for why she was not receiving them. Resident 59 stated she is supposed to be showered on Monday and Thursday. Resident 59 stated she had not refused any showers. Resident 59 stated this made her feel dirty and neglected, and as a result she mostly stayed in her room. During a review of Resident 59 ' s admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/29/255, the AR indicated Resident 59 was admitted to the facility from an acute care hospital on 4/10/25 with diagnoses of muscles weakness, type two diabetes mellitus ( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), fracture of left femur (a break in the bone of the thigh), and hypertension (HTN-high blood pressure). During a review of Resident 59 ' s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/15/25, the MDS section C indicated Resident 59 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 59 was cognitively intact. During an interview on 5/27/25 at 11:27 a.m. with Resident 30 in her room, Resident 30 stated she last received a shower two weeks ago and expressed that she would like to receive showers on her scheduled days. Resident 30 stated I feel dirty and smelly because she had not been receiving regular showers. Resident 30 stated she felt gross and wished she could have a shower. During a review of Resident 30 ' s AR, dated 5/30/25, the AR indicated Resident 59 was admitted to the facility from an acute care hospital on [DATE] with diagnosis of muscle weakness, type two diabetes mellitus, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 30 ' s MDS, dated 4/7/25, the MDS section C indicated Resident 30 had a BIMS score of 11, which suggested Resident 30 was moderately impaired. During an interview on 5/29/25 at 1:56 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated resident showers were scheduled and that residents should have received showers twice a week. CNA 7 explained the facility maintained a binder with the shower schedule and that staff were expected to complete a shower sheet was given. CN 7 stated the nurse would then sign the sheet. CNA 7 stated that residents had the right to be showered. During a concurrent interview and review of facility Shower Binder on 5/30/25 at 4:35 p.m. with CNA 7, dated for the month of May 2025, CNA 7 stated there were no completed shower sheet filed for Resident 59 on Thursday 5/8/25, Monday 5/12/25, Thursday 5/15/25, and Thursday 5/22. The record showed Resident received a shower on Monday 5/5/25 and refused a shower on Monday 5/19/25. During an interview on 5/30/25 at 10:42 a.m. with CNA 8, CNA 8 stated resident showers were documented in two areas. One area was the shower binder, where staff filled out the form and filed it according to the date. CNA 8 stated the second method was through the electronic medical record. CNA 8 stated if a shower was not provided, staff entered NA. CNA 8 stated the risk to the resident from not receiving regular showers included potential for infections, skin issues, self-esteem problems, matted hair and buildup of grime. During a concurrent interview and review of Shower Binder dated May 2025 and Documentation Survey Report, dated May 2025 on 5/30/25 at 4:35 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 30 was scheduled to receive showers on Tuesdays and Fridays. However, there were no shower sheets filed for Tuesday 5/6/25, Friday 5/9/25, Tuesday 5/13/25, Friday 5/16/25 or Tuesday 5/20/25. The shower sheet for Friday 5/23/25 indicated Resident 30 had refused the shower on that date. The Documentation Survey Report, dated May 2025 indicated for Resident 30 she had missed five scheduled showers during the month of May-on 5/9/25, 5/16/25, 5/20/25, 5/27/25 and 5/30/25. During a concurrent interview and record review on 5/30 at 4:35 p.m. with LVN 3, Resident 59 ' s Documentation Survey Report, dated May 2025 was reviewed. LVN 3 stated the Documentation Survey Report, and the information documented in the shower binder were accurate, Resident 59 had only received one shower for the month of May, on 5/5/25. LVN 3 verified there was no progress notes associated with missed or refused showers and no care plans addressing bathing/showering or potential refusal in Resident 59 and 30 ' s medical record. During an interview on 6/3/25 at 9:32 a.m. with Director of Staff Development (DSD) 2, the DSD 2 stated it was her expectation for CNAs to complete resident showers as scheduled. DSD 2 stated her expectation was CNAs to shower the residents on their scheduled days, complete the shower sheet and have the nurse sign it. The DSD 2 stated there should have been a shower sheet filed for each scheduled shower day, indicating whether the shower was given or not-there should not have been any blank spaces. DSD 2 stated blank spaces, and N/A indicated a missed shower. The DSD 2 stated a progress note should have been written by the nurse if a resident missed or refused a shower. During an interview on 6/3/25 at 11:38a.m. with the Infection Preventionist (IP) 1, the IP 1 stated that her expectation of the nursing staff was to address the reasons why residents were missing their scheduled showers. IP 1 stated staff should have escalated a reason why a shower was not given to a resident. IP 1 emphasized showers were important because they provided an opportunity to assess the resident and because it was the resident ' s right to receive them. The IP 1 stated that there had not been any recent issues with water or equipment that would have impacted the ability to provide showers during the month of May. During an interview on 6/3/25 at 11:45 a.m. with the Director of Nursing (DON), the DON stated, it was her expectation of staff to escalate the issue of missed showers. The DON emphasized that showering and bathing preferences are part of resident rights and should have been addressed accordingly.

Based on observation, interview and record review, the facility failed to ensure one of eleven sampled residents (Resident 38) was provided the opportunity to participate in his care process when the facility did not attempt to contact Resident 38's family or friends to act as a representative or decision maker on or throughout admission and did not involve Resident 38's, family, friends or a patient care representative prior to obtaining informed consents. This failure had the potential to result in Resident 38's wishes and preferences not being upheld by the acting facility representative which had the potential to lead to decreased autonomy (ability to make own decisions and control own actions) or participation in his care planning process. Findings: During a review of Resident 38's admission Record (AR- document containing resident personal information), dated [DATE], the AR indicated, Resident 38 was admitted to the facility on [DATE], with diagnoses which included dementia (decline in cognitive functioning that interfere with daily life), major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest), dysphagia (difficulty swallowing) and muscle weakness. The AR indicated Resident 38's decision maker and representative was the Administrator (ADM). The AR indicated Resident 38 had a Family Friend (FF) 1 allowed to obtain medical information. During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool) assessment, dated [DATE], the MDS assessment indicated Resident 38's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 10 out of 15 which indicated Resident 38 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 38's Informed Consent to Treat (ICT), dated [DATE], the ICT indicated, the administrator (ADM) signed the consent on [DATE]. The form indicated the ADM gave permission for the facility to treat Resident 38. The form was not signed or acknowledged by Resident 38, FF 1 or a resident representative. During a review of Resident 38's Physician Orders for Life-Sustaining Treatment (POLST- set of medical orders reflect a resident's wished for end-of-life intervention), dated [DATE], the POLST indicated, the ADM signed the consent on [DATE]. The form was not signed or acknowledged by Resident 38, FF 1 or a resident representative. During a review of Resident 38's Side/Bed Rail Informed Consent, dated [DATE], the Side/Bed Rail Informed Consent indicated, the ADM signed the consent on [DATE]. The form was not signed or acknowledged by Resident 38, FF 1 or a resident representative. During a review of Resident 38's Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device, dated [DATE], the Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device indicated, the medical provider obtained informed consent from the ADM on [DATE] for .Sertraline [psychotherapeutic drug-used to treat major depressive disorder] 12.5 mg [milligrams- unit of measurement for dosing medication] . The form was not signed or acknowledged by Resident 38, FF 1 or a resident representative. During a review of Resident 38's Medical Record (MR), dated [DATE], the MR did not indicate the facility completed interdisciplinary team (IDT) meetings prior to the ADM signing consents for the ICT, POLST, Side/Bed Rail Informed Consent, or Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device. The MR did not indicate Resident 38, FF 1 or a resident representative was involved, contacted or consulted for the ICT, POLST, Side/Bed Rail Informed Consent, or Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device. During an interview on [DATE] at 2:54 p.m. with the Family Friend (FF) 1, FF 1 stated Resident 38 had no family involved in his care. FF 1 stated he had known Resident 38 for a couple of years. FF 1 stated he was a patient advocate for Resident 38 at the previous facility Resident 38 was admitted to. FF 1 stated nobody from the facility contacted him to inquire if he would be Resident 38's decision maker or representative. FF 1 stated he had not received any updates on Resident 38's care or treatment. FF 1 stated Resident 38 and himself met with the Social Services Director (SSD) in February 2025 and Resident 38 agreed for FF 1 to receive medical updates and be involved in his care. FF 1 stated he had not been consulted or involved in obtaining any informed consents for Resident 38. FF 1 stated he did not know the ADM was Resident 38's decision maker or representative. FF 1 stated he did not understand how the ADM could make informed decisions for Resident 38 because he did not know him. FF 1 stated it was in Resident 38's best interest to include people who knew Resident 38 when making medical decisions to ensure Resident 38's wishes and preferences were upheld. During a concurrent interview and record review on [DATE] at 3:21 p.m. with the Social Services Director (SSD), Resident 38's MR, dated [DATE] was reviewed. The SSD stated, Resident 38 did not have the mental capacity to make his own medical decisions but was able to make his needs known. The SSD stated the ADM was Resident 38's acting decision maker and representative. The SSD stated Resident 38 was previously admitted to another facility within the same network and the ADM was assigned as the decision maker there. The SSD stated the facility assumed responsibility for each resident when they were admitted , regardless if the previous facility was in the same network. The SSD stated it was the responsibility of the facility to ensure each resident's decision maker was appropriately assigned on admission. The SSD stated there was no documentation in Resident 38's MR to reflect attempts were made to contact Resident 38's family, friends, or listed contacts to act as a decision maker or patient representative on admission. The SSD stated on [DATE] she met with Resident 38 and FF 1. The SSD stated Resident 38 gave permission for FF 1 to be involved in his care and receive medical updates. The SSD stated approximately a month ago the California Department of Aging provided an in-service on Interdisciplinary Team Process for Unrepresented Residents. The SSD stated the facility was expected to adhere to the in-service provided. The SSD stated if the facility received a medical treatment order requiring informed consent and no legal decision maker, family or friend was available to provide consent, an application was expected to be submitted to the California Department of Aging to assign a state-appointed patient representative. The SSD stated an IDT meeting was expected to be held for each medical decision requiring informed consent, and the family member, friend, or appointed patient representative was expected to participate. All IDT members were expected to agree on the treatment, document the meeting and decision, after which consent for the treatment could be obtained. The SSD stated this process was not followed for Resident 38. The SSD stated she was involved in IDT meetings. The SSD stated she could not recall attending IDT meetings for Resident 38's informed consents since admission. The SSD could not locate IDT meeting notes to determine the IDT met to discuss informed consents or consulted Resident 38's family, FF 1, or patient representative for the ICT, POLST, Side/Bed Rail Informed Consent, or Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device. The SSD stated it was important to ensure IDT meetings were performed for each medical treatment that required informed consent. The SSD stated it was important Resident 38, Resident 38's family, friends or a patient representative was involved in IDT informed consent meetings to ensure Resident 38's wishes and preferences were upheld. During a concurrent interview and record review on [DATE] at 9:03 a.m. with the Administrator (ADM), Resident 38's MR, dated [DATE], was reviewed. The ADM stated he was not related to Resident 38 and did not know Resident 38 prior to his admission to the facility. The ADM stated Resident 38 was previously admitted to another facility within the same network and he became the decision maker for Resident 38 before he was transferred to the current facility. The ADM was unable to locate IDT meeting notes to reflect attempts were made to contact Resident 38's family, friends or listed contacts to act as his decision maker on admission to the facility. The ADM could not locate any IDT meeting notes to indicate IDT met prior to obtaining informed consents for Resident 38's ICT, POLST, Side/Bed Rail Informed Consent, or Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device. The ADM could not locate any documentation to reflect Resident 38's, family, friends or patient representative were involved in obtaining informed consent for Resident 38's ICT, POLST, Side/Bed Rail Informed Consent, or Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device. The ADM stated himself, the Assistant Administrator (AADM), the Director of Nursing (DON), the SSD, the Minimum Data Set Coordinator (MDS), Infection Preventionist (IP), and Director of Staff Development (DSD) participated in IDT meetings and were responsible for making medical decisions that required informed consent for Resident 38. The ADM stated Resident 38 was at risk for not having his wishes or preferences upheld if there was no documentation to reflect Resident 38's, FF 1's, or a patient representatives' participation in the care planning process. During a concurrent interview and record review on [DATE] at 9:56 a.m. with the Director of Nursing (DON), Resident 38's MR, dated [DATE], was reviewed. The DON stated the ADM was Resident 38's decision maker. The DON stated the ADM became Resident 38's decision maker at the previous facility he was admitted to. The DON stated the facilities were within the same network and the ADM remained Resident 38's decision maker when he was transferred. The DON stated it was the responsibility of the facility to ensure Resident 38's decision maker was appropriate on admission. The DON stated the facility was responsible, on admission, for making their own attempts to reach Resident 38's family, friends or patient representative to inquire if they would be his decision maker or be involved in the decision-making process. The DON could not locate documentation to reflect the facility had attempted to contact Resident 38's family, friends, or a patient representative to act as Resident 38's decision maker or be involved in the decision-making process. The DON stated with the ADM as the acting decision maker the IDT was responsible to meet and discuss medical treatments that required informed consent for Resident 38. The DON stated it was expected Resident 38, family, friends, or a patient representative was involved in each IDT meeting to ensure Resident 38's preferences were upheld. The DON stated it was expected the IDT documented meetings and determinations for Resident 38's plan of care with each medical decision that required informed consent. The DON could not locate any IDT meeting notes to indicate IDT met or discussed Resident 38's plan of care prior to obtaining informed consents for Resident 38's ICT, POLST, Side/Bed Rail Informed Consent, or Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device. The DON could not locate any documentation to reflect Resident 38's, family, friends or patient representative were involved in obtaining informed consent for Resident 38's ICT, POLST, Side/Bed Rail Informed Consent, or Facility Verification of Resident Informed Consent for Physical Restraints, Psychotherapeutic Drugs, or Prolonged Use of a Device. The DON stated the facility placed Resident 38 at risk for not being represented accurately or honoring his wishes and preferences. During a review of the facility's handout provided by the California Department of Aging titled, Interdisciplinary Team Process for Unrepresented Residents, undated, the handout indicated, . as of [DATE], skilled nursing and intermediate care facilities that conduct interdisciplinary team (IDT) reviews of medical interventions requiring informed consent (California Health and Safety Code section 1418.8) must: include a patient representative when they convene an IDT to make medical decisions requiring informed consent for residents who lack capacity and have no legal surrogate .provide notices containing specified information both before and after an IDT review to the resident who is the subject of the IDT and to the resident's patient representative .provide specified data to the California Department of Aging (CDA), Office of the Long-Term Care Patient Representative as required .under these requirements, facilities are responsible for identifying a friend or relative, whose interests are aligned with the resident, to serve as a patient representative when an interdisciplinary team is convened .if the facility is unable to identify a representative, the Office of the Long-Term Care Patient Representative (OLTCPR), a program within the CDA, can help .the OLTCPR will provide trained representatives for specified residents who may need medical treatment but lack the capacity to make health care decisions, have no legal surrogate authorized to make decisions on their behalf, and have no friend or relative who can represent them on an IDT . During a review of the facility's policy and procedure (P&P) titled, 784.29. Informed Consent to Medical Treatment, undated, the P&P indicated, .verify that the client's health record contains documentation that the client has given informed consent to the proposed treatment or procedure . During a review of the facility's P&P titled, Resident Representative, dated 2/2021, the P&P indicated, .the resident's wishes and preferences are considered in the exercise of rights by the representative . resident representative is defined as: an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; b. a person authorized by state or federal law including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; legal representative, as used in section 712 of the Older Americans Act; or d. the court-appointed guardian or conservator of a resident . Whether or not the resident has been judged incompetent by a court of law, if it is determined that the resident understands the risks, benefits, and alternatives to a proposed health care decision and expresses a preference, the resident's wishes are considered to the degree practicable .the resident may exercise his or her rights not delegated to a resident representative, including the right to revoke a delegation of rights (except as limited by state law) .the director of nursing (or designee) is responsible for making reasonable efforts to obtain updates or changes that are made by the resident, including the resident's revocation of delegated rights, to ensure that the resident's preferences are being upheld . During a review of the facility's P&P titled, Resident Rights, dated 2/2021, the P&P indicated, .resident's rights to .appoint a legal representative of his or her choice .exercise rights not delegated to a legal representative . During a review of the facility's P&P titled, Advanced Directives, dated 2/2021, the P&P indicated, .prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives .upon admission the interdisciplinary team assesses the residents decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity .the interdisciplinary team conducts ongoing review of the residents decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision-making capacity. Changes are documented in the care plan and medical record .

Based on observation, interview and record review, facility failed to ensure one of 11 sampled residents (Resident 16) was provided with safe, clean, comfortable furniture that is in good working condition when the over-the-bed table had an approximate 2-inch by 1.5-inch chip out of the corner of the table with exposed sharp edges and a visible area that would be considered a porous surface leaving the area a potential for injury and unable to be cleaned. This failure had a potential to result in Resident 16 sustaining serious injuries, including skin tears and infection. Findings: During a review of Resident 16's admission Record (AR, a document containing resident personal information), dated 5/29/25, the AR indicated, Resident 16 was admitted to the facility on [DATE] with diagnoses which in included Cerebral Infarction (when part of the brain and brain cells does not get enough blood and oxygen because a blood vessel is blocked and those brain cells can die), Type 2 Diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and Cognitive Communication Deficit (when someone has a hard time talking or understanding because their brain is having trouble with thinking skills). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool) assessment dated 3/27/25, the MDS assessment indicated Resident 16's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 6 out of 15 which indicated Resident 16 had had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a concurrent observation and interview on 5/27/2025 at 4:04 p.m. with Resident 16 in Resident 16's room, Resident 16's over-the-bed table had a 2-inch by 1.5-inch chip out of the corner of the table with exposed sharp edges and a visible area that would be considered a porous surface. Resident 16 stated he had noticed a big chip on his over-the-bed table. Resident 16 stated the big chip had been there for approximately 6 months. Resident 16 stated he would like a new table. During a concurrent observation and interview on 5/29/25 at 1:52 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 16's room, CNA 2 stated that all furniture should be in good shape and that it may not look the prettiest, but it should be free of things that could harm the resident. CNA 2 stated that Resident 16's over-the-bed table had a large chip in the corner that had exposed sharp edges and a porous surface and that if Resident 16 fell onto the table he could get cut badly. CNA 2 stated Resident 16 should not have an over-the-bed table like that in Resident 16's room. During an observation on 5/29/25 at 3:47 p.m. Resident 16's over-the-bed table with the chip out of it remained in the room and Resident 16 has personal items placed on it. During an interview at the Nurse's station on 5/29/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 reviewed a picture dated 5/28/25 of the resident's over-the-bed table and LVN 4 stated that Resident 16 had an over-the-bed table that had exposed sharp edges and a porous surface. LVN 4 stated there was the strong possibility of a skin tear and a stronger possibility of a bacteria infection. LVN 4 stated that Resident 16 could fall on to it and sustain a serious injury. LVN 4 stated the exposed part could be a trap for food as well. LVN 4 stated that the table needs to be replaced. During an observation on 5/29/25 at 6:00 p.m. Resident 16's over-the-bed table with the chip out of it remained in the room and Resident 16 had personal items placed on it. During a concurrent observation and interview on 5/30/25 at 8:22 a.m. with the Director of Staff Development (DSD) 2, who also works as an Infection Preventionist part-time for the facility, in Resident 16's room, DSD 2 stated that Resident 16's over-the-bed table had exposed sharp edges and a porous surface and Resident 16 could sustain a bad skin tear from the sharp edge. DSD 2 stated from an infection control standpoint, the area where the table is chipped would be considered porous and would not be cleaned easily therefore blood or bacteria could stay in the porous areas. During a concurrent interview and record reviewed on 6/3/25 at 10:20 a.m. with the Director of Nurses (DON), the DON reviewed a picture of Resident 16's over-the-bed table dated 5/28/25 of Resident 16's over-the-bed table. The DON stated that the over-the-bed table has very rough edges and is porous. The DON stated that it is everyone's responsibility to maintain a safe environment by keeping equipment clean and intact, so no skin tears can occur, and no bacteria can harbor in the porous area. The DON stated the over-the-bed table should have been removed immediately. The DON stated the staff did not follow the policies by notifying the Maintenance department promptly and removing the over-the-bed table as soon as the chip occurred. During a review of the policy and procedure (P&P) titled, Patient Room Management, undated, P&P indicated, . patient rooms will be maintained in a manner . ensuring they are free from hazards . requires that patient rooms meet standards for cleanliness, safety and privacy .maintenance staff will address repairs in patient rooms promptly to ensure the room is safe and functional .rooms will be free of potential hazards . the Administrator or designee will conduct regular inspections to ensure rooms meet cleanliness, safety . During a review of the policy and procedure (P&P) titled Accidents dated 9/2/22 indicated .the resident environment will remain as free of accidents as is possible .hazards refers to elements of the resident's environment that have the potential to cause injury . During a review of the policy and procedure (P&P) titled Safe and Homelike Environment dated 12/19/22 indicated .report any furniture in disrepair to Maintenance promptly .

Based on observation, interview and record review, the facility failed to ensure a comprehensive individualized care plan was developed and implemented for one of 15 residents (Resident 57) when Resident 57 ' s care plan was not developed and implemented for monitoring and care of his central venous catheter port (a thin tube that goes into a vein in your arm or chest and ends at the right side of your heart and is attached to a device [port] under the skin) and surgical incision wound. This failure had the potential to put Resident 50 at increased risk for wound infection, pain, discomfort and medical complications of his indwelling central line due to improper care and monitoring of his device and surgical incision wound. Findings: During a concurrent observation and interview on 5/27/25 at 10:51 a.m. with Resident 57 in Resident 57 ' s room, Resident 57 was observed dressed sitting in a wheelchair with a dressing on his right upper chest. Resident 57 stated he had been at the facility for a couple of weeks. Resident 57 stated he had a port put in for chemotherapy (a drug treatment used to stop the growth of cancer cells). Resident 57 stated nurses have not changed his dressing and staff do not wear a gown or gloves when providing care. No enhanced barrier precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) sign was observed on Resident 57 ' s door. During a review of Resident 57 ' s admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/30/25, the AR indicated Resident 57 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of fracture of left femur (a break in the bone of the thigh), liver cell carcinoma (a cancer of the liver), cerebral ischemia (damage to tissues in the brain due to a loss of oxygen to the area), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 57 ' s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/4/25, the MDS section C indicated Resident 57 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of seven (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 57 was severely impaired. During an interview on 5/29/25 at 2:39 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated the CNAs did not look at resident ' s care plans (CP)s but received report on the residents from other CNAs or the nurse. CNA 4 stated residents on EBP because of a wound or catheter line would have had an EBP sticker by their name, and she would have gone to the nurse to find out what type of precautions the resident was on. CNA 4 stated she usually received report from the nurse or other CNAs on residents with wounds and on EBP. During a concurrent interview and record review on 5/29/25 at 4:15 p.m. with the Infection Preventionist (IP), Resident 57 ' s Care Plan (CP), undated was reviewed. The CP indicated there was no care plan for monitoring Resident 57 ' s catheter line or surgical incision. The IP stated Resident 57 did not have a care plan for his catheter line and Resident 57 ' s catheter line was new. The IP stated Resident 57 ' s catheter line was put in last week on 5/20/25. The IP stated Resident 57 should have had a CP for monitoring his catheter line site. The IP stated the CP was important to let staff know how to monitor for signs and symptoms of infection, behaviors, interventions to take, and if something happened to the resident, when to reach out to the doctor. The IP stated the CP was to ensure each resident received proper care. The IP stated Resident 57 ' s CP should have been put in when he returned to the facility after having his catheter line put in. The IP stated the CP needed to be individualized for each resident because everyone was different. The IP stated the CP needed to be personalized according to the needs and preferences of the resident. During an interview on 6/3/25 at 8:53 a.m. with the Director of Nursing (DON), the DON stated residents should have had a CP completed by the admission nurse, then followed up by the IP. If the IP was in the facility, she would have initiated the CP. The DON stated the nurses could have also updated a resident ' s care plan. The DON stated residents should have had a CP for EBP if they had wounds or central catheter lines, and the CP should have been resident specific. The DON stated the CP was important for staff to know how to take care of the resident. The DON stated if there was no CP for Resident 57, there was the risk of not giving Resident 57 the proper care needed. The DON stated if there was no care plan for catheter line site monitoring for Resident 57, he did not have a specific plan to meet his needs, and his CP would not have been individualized. During a review of the facility ' s job description document titled, MDS Coordinator, dated 11/24/16, indicated, . conduct resident assessments as required, develop plans of care, evaluate residents ' responses to intervention . complete . observations and care plans as needed . ensure all medications, treatments and at risk conditions . are included on resident ' s plan of care after the admission nurses have completed their admission care plans and significant change of condition care plans . During a review of the facility ' s job description document titled, Registered Nurse (RN), dated 1/22/25, indicated, . review care plans daily to verify that appropriate care is being rendered . verify that nurses ' notes reflect that the care plan is being followed when administering nursing care or treatment . ensure that assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNAs refer to the resident ' s care plan prior to administering daily care to the resident . During a review of the facility ' s job duties document titled, Director of Nursing, dated 11/1/16, indicated, . assist the Resident Assessment/Care Plan Coordinator in the scheduling of care plans and assessments to be presented and discussed at each committee meeting . ensure that all personnel involved in providing care to the resident are aware of the resident ' s care plan. Ensure that nursing personnel refer to the resident ' s care plan prior to administering daily care to the resident . review nurses ' notes to determine if the care plan is being followed . During a review of the facility ' s policy and procedure (P&P) titled, Care Planning, dated 12/19/22, indicated, . the facility will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment . the care planning process will include an assessment of the resident ' s strengths and needs . the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences . initially, at routine intervals, and after significant changes .

Based on observation, interview and record review the facility failed to follow professional standards for one of 11 sampled residents (Resident 216) when Resident 216 did not have his urinary catheter(a hollow tube inserted into the bladder to drain and collect urine) changed per physician order, the physician was not notified that the catheter was not changed and Resident 216 had signs that included mucus and sediment in the catheter tubing, amber-colored foul-smelling urine. This failure resulted in a missed urinary catheter change, and the lack of notification regarding Resident 216 ' s catheter tubing had the potential of delayed diagnosis and treatment of a urinary tract infection, increasing risk of worsening infection. Findings: During an observation on 5/27/25 at 10:38 a.m. in Resident 216 ' s room, Resident 216 ' s urinary catheter bag contained dark-colored urine and there was visible sediment and mucus in the catheter tubing. The room had a strong odor of urine. During a review of Resident 216 ' s admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/8/25, the AR indicated Resident 216 was admitted to the facility from an acute care hospital on 5/8/25 with diagnoses of urinary retention (unable to empty bladder completely), hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body), and cerebrovascular accident (CVA-a stroke, loss of blood flow to a part of the brain). During a review of Resident 216 ' s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/13/25, the MDS section C indicated Resident 216 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 216 was severely impaired. During a concurrent observation and interview on 5/29/25 at 10:32 a.m. at Resident 216 ' s bedside, Certified Nursing Assistant (CNA) 6 stated Resident 216 had dark-colored urine that was odorous and contained visible sediment. CNA 6 stated the symptoms of a urinary tract infection (UTI- an infection in the bladder/urinary tract) included confusion, pain foul-smelling urine and the presence of sediment. CNA 6 stated these findings should be alerted to the nurse. During an interview on 5/29/25 at 10:52 a.m. with CNA 7, CNA 7 stated symptoms of a urinary tract infection included bad smelling and abnormal colored urine. CNA 7 stated they were expected to notify the nurse if anything abnormal was found. During an interview on 5/29/25 at 11:05 with Licensed Vocational Nurse (LVN) 6, LVN 6 stated the symptoms of a urinary tract infection included foul-smelling urine. LVN 6 stated the entire catheter was to be changed monthly. LVN 6 stated if there was sediment in the catheter tubing, it should be changed, as this could be an indicator of an infection. During a concurrent interview and record review on 5/29/25 at 11:09 a.m. with LVN 6, Resident 216 ' s Order Summary Report, dated 5/29/25 was reviewed. The report indicated a physician order to change the catheter drainage bag on the 15TH of each month and as needed. During a concurrent interview and record review on 5/29/25 at 11:09 a.m. with LVN 6, Resident 216 ' s Treatment Administration Record (TAR), dated 5/1/25 - 5/31/25 was reviewed. LVN 6 stated the TAR indicated the physician ' s order for when to change Resident 216 ' s catheter was not generated as a task in the TAR and, therefore, was not scheduled or completed as ordered. LVN 6 stated the photo taken on 5/27/25 at 10:38a.m. of Resident 216 ' s catheter tubing indicated it should be changed. LVN 6 stated failing to timely identify or address these symptoms of a urinary track infection could lead to sepsis (a life-threatening blood infection). LVN 6 stated it was beneficial to the resident ' s health to catch these symptoms early. LVN 6 stated if they had been the nurse assigned, they would have assessed the urine, flushed the catheter, notified the physician, and documented the findings in a progress note. LVN 6 stated the physician would most likely have ordered a urinalysis (test that checks for infection in urine) to verify if Resident 216 had a UTI. During an interview on 6/3/25 at 11:38a.m. with the Infection Preventionist (IP)1, IP 1 stated catheter tubing should be clear and free from any discoloration or visible debris. IP 1 stated her expectation of staff was they should be competent in providing catheter care. IP 1 stated if there were any issues or concerns, they should have been escalated to the physician and nursing staff. IP 1 stated Resident 216 ' s catheter tubing should have been changed and the risk to the resident was the potential for developing an infection. During an interview on 6/3/25 at 11:45 a.m. with the Director of Nursing (DON), the DON stated it was her expectation of staff to be competent in inserting and maintaining a catheter. The DON stated if there were signs and symptoms of an infection-such as pain, foul odor, cloudy urine or sediment-staff were expected to escalate the finding by notifying the physician, changing the catheter tubing, completing a urinalysis and documenting a change in condition. The DON reviewed the picture of Resident 216 ' s catheter tubing taken on 5/27/25 at 10:38 a.m., the DON stated she would have expected staff to have taken those actions. During a review of Resident 216 ' s Indwelling Urinary Catheter Care Plan (CP), dated 5/9/25, the CP indicated, change catheter as ordered by physician .report to physician signs and symptoms of UTI: pain, burning, deepening of color, foul smelling urine. During a review of the facility ' s job description document titled Registered Nurse, dated 2025, the job description indicated, .initiate request for consultation or referral .discriminate between normal and abnormal findings, in order to recognize when to refer the resident to a physician for evaluation, supervision or directions .make written and oral reports/recommendations to the attending physician, medical director, or the DON, concerning the status and care of the residents . During a review of RegisteredNursing.org professional reference titled, Does a Nurse Always Have to Follow a Doctor ' s Orders?, dated 1/18/25, (found at https://www.registerednursing.org/articles/does-nurse-always-follow-doctors-orders/#:~:text=Unless%20there%20is%20a%20safety,not%20follow%20a%20doctor's%20order.) the reference indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed neglect. During a professional reference review from the Centers for Disease Control and Prevention (CDC) titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, dated 6/6/2019, (retrieved from https://www.cdc.gov/infection-control/media/pdfs/Guideline-CAUTI-H.pdf) indicated, .What are the best practices for preventing UTI associated with obstructed urinary catheters? The available data examined the following practices: .Methods to prevent/reduce encrustations or blockage .Catheter materials preventing blockage For this question, available relevant outcomes included blockage/encrustation. We did not find data on the outcomes of CAUTI .

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 7) was free from accidents, when Resident 7, who was identified as being at-risk for falls with a history of multiple falls in the facility, fell and was injured when left unattended in her unlocked wheelchair on 8/31/23. This failure resulted in Resident 7 being sent to the general acute care hospital (GACH) for evaluation. Resident 7 was diagnosed with an odontoid fracture (break of the second bone in the neck) and was hospitalized from 8/31/23 to 9/8/23. Findings: During a review of Resident 7's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included Alzheimer's Disease (a progressive disease with memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Disease involves parts of the brain that control thought, memory and language), Bilateral (both ears) hearing loss, age-related osteoporosis (bones become weak and brittle) without current fracture (broken bones). During Resident 7's stay at the facility, she had been diagnosed with cerebral vascular accident disease (CVA- an interruption of blood flow to the brain-stroke), generalized muscle weakness, and cognitive communication deficit (ability to think, learn and remember). During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 7's MDS assessment indicated Resident 7's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 99 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). A BIMS summary score of 99 indicated Resident 7 was unable to complete the interview. The BIMS assessment indicated Resident 7 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 7's Care Plan (CP), dated 9/12/22, the CP indicated, Focus .At risk for falls and fall related injuries due to history of falls, impaired safety awareness due to cognitive deficit (impairment of an individual's mental process which affects how an individual understands and acts in the world), diagnosis of Alzheimer's Disease .CVA, generalized weakness, osteoporosis, history of fracture .hearing loss .Resident requires extensive assist (direct physical help from another individual for weight-bearing support) with Activities of Daily Living (ADL- Activities such as toileting, brushing teeth, putting on clothes, feeding oneself), bed mobility and transfers. Resident observed with episode of bending forward when up in wheelchair .on 4/16/23 resident was noted lying on the floor in between the wheelchair and bed .on 6/4/23, residents' half of the body was laying on the floor mat with bed at the lowest position .on 8/31/23, resident fell forward from wheelchair .Goal: Minimize risk for falls and fall related injuries through next 90 day review .Interventions: .Continue with PT [Physical Therapy] focus on safe transfers and wheelchair positioning/posture, date initiated 4/19/23 . During a review of Resident 7's Fall- Nurses Note (NN), dated 8/31/23, the NN indicated, .CNA (Certified Nursing Assistant) writer, ' Resident is on floor in room, she fell from her wheelchair .I was going to put her in bed because she was sleepy, I walked out from the room to get the lift [device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone] that was outside the resident's door and I hear a patient screaming from room [number], I went to look really quick at her and when I came back, patient was on the floor.' Upon writer entering resident's room, resident was noted leaning forward with top of head on the floor mat that was placed by the wall (floor mat was placed by the wall in order to have space for the lift) patient was noted with more inclination towards left upper extremities, knees were down on floor. Upon assessment writer noted [Resident 7] with facial grimaces and raised bump to [left] side of head, abrasion to 3rd [left] finger, bruise to 2nd [left] finger and [left] metacarpal (finger). Writer asked patient is she was ok, [Resident 7] stated, ' I don't know . Writer and fell ow nurse noted increased in facial grimaces, episodes of moaning and an increase in [blood pressure] . per [Medical Doctor] to transfer resident to hospital for further evaluation . During a review of Resident 7's Fall Assessment-Post Incident (FAP), dated 8/31/23, the FAP indicated, (Resident 7) . Category: High Risk .Type: Initial Post Incident . Default Category: High Risk . 3. History of falls within last six months: 1 - 2 times . 9. Confined to a Chair: If resident cannot walk even when assisted by staff are they: 1. Confined to a chair and oriented . 11. Gait [the pattern that a person walks] Analysis: . 11. Not applicable- bed/chair bound . During a review of Resident 7's Progress Notes (PN), dated 9/6/23, the PN indicated, .Event being reviewed: .unwitnessed fall at resident's room on 8/31/23 at 3:15 p.m., . Root Cause Analysis for event: .Resident possibly fell asleep while sitting up in a wheelchair, then fell forward to the floor in the resident's room. Prior to the fall, resident was wheeled by the Certified Nursing Assistant to the resident's room to put her back to bed when CNA and licensed nurses noted resident sleepy while sitting up in a wheelchair in front of the nurse's station. Assigned CNA just stepped out outside the room by the resident's door to get the [brand name] lift (equipment to lift a resident who cannot support their own body weight), when CNA came back to the room resident was on the floor. Resident was noted in prone [lying face down] left side lying position with top of head touching the floor mat (floor mat was against the wall) .Interventions initiated and residents response/compliance with intervention: .Resident was on the floor- noted a raised bump to left side of head, abrasion (skin scrape) to third left finger, purplish discoloration to second left finger and left metacarpal (finger) .resident remains awake, conversant and with confusion .noted increased in facial grimaces, episodes of moaning when touching left hand and increased blood pressure of 166/85 mmHg (millimeters of mercury-unit of measurement) when resident was in bed . Ambulance was called immediately .Medical Doctor (MD) notified with new order to send out resident to emergency room for further evaluation .update was given at the facility that resident has a neck fracture .Resident was admitted due to ground level fall with odontoid fracture [break of the second bone in the neck]. During a review of Resident 7's Summary Report of Meeting: In-Service [training] (SRM), dated 8/31/23 and 9/1/23, the SRM indicated, .Meeting Notes: Method of Presentation: Lecture, Discussion . Subjects Covered: At-risk for fall residents .Summary and Conclusions: .Do not leave unattended in the room when up in wheelchair . During an interview on 9/8/23 at 12:50 p.m., with the Director of Nursing (DON), the DON stated on 8/31/23 Resident 7 was tired and sleepy in her wheelchair located at the nurse's station and CNA 2 took the resident back to her room. The DON stated when CNA 2 got back to Resident 7's room, she heard another resident yell from across the hall and went to that room to check on her leaving Resident 7 alone in the wheelchair. The DON stated CNA 2 left Resident 7 by herself for a minute or two and when she came back to Resident 7, she was lying face down on the floor. The DON stated Resident 7's safety was put at-risk when CNA 2 left Resident 7 up in the wheelchair and left the resident's room. The DON stated the fall was avoidable and CNA 2 should not have left Resident 7 unattended when Resident 7 was sleepy sitting in the wheelchair. The DON stated Resident 7's fall resulted in an injury and hospital admission. The DON stated Resident 7 had a history of falls at the facility including a prior fall on 4/16/23 where she fell forward in her wheelchair. The DON stated Resident 7 had a fall-risk score that resulted in being a high-risk for falls resident. The DON stated Resident 7 required extensive assistance (individual cannot perform any ADL or weight bearing without another person providing assistance) for all transfers. During an interview on 9/8/23 at 2:30 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was the CNA responsible for Resident 7's care when Resident 7 fell . CNA 2 stated she knew Resident 7 was a high fall-risk and had cared for her many times before. CNA 2 stated Resident 7 needed staff for basically everything and required extensive assistance. CNA 2 stated on 8/31/23 Resident 7 was leaning forward in her wheelchair and looked tired and uncomfortable at the nurse's station. CNA 2 stated she wheeled Resident 7 back to her room with the intention of putting her in bed. CNA 2 stated she parked Resident 7 in her room in front of the dresser facing her bed. CNA 2 stated Resident 7's feet were flat on the floor and she did not lock the wheelchair. CNA 2 stated she left Resident 7's room to get the lift to put her in bed when she heard a resident across the hall yell something. CNA 2 stated she left Resident 7 for around a minute. CNA 2 stated when she came back into Resident 7's room, she was face down on the floor and her face appeared to hit the floor. CNA 2 stated she should have never left Resident 7 up in the wheelchair by herself in the condition she was in. CNA 2 stated she did not meet the expectation of the facility which was to stay with Resident 7 and not leave her alone. CNA 2 stated Resident 7 fell because she left her unattended. During an interview on 9/8/23 at 4:45 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse responsible for Resident 7 at the time of the fall. LVN 1 stated Resident 7 had fallen before and was a high fall-risk resident. LVN 1 stated CNA 2 took Resident 7 to her room because she was tired. LVN 1 stated CNA 2 left Resident 7 by herself in her room, and she fell forward out of her wheelchair hitting the ground. LVN 1 stated when she came to the room Resident 7 had a big bump on her forehead with facial grimacing and appeared to be in pain. During an observation on 9/15/23 at 11:30 a.m., Resident 7 was sitting in her wheelchair, asleep, in front of the nurse's station. Resident 7 had black and purple under each eye and on both eye lids. Resident 7 had a grey neck brace on and a 1-inch (unit of measurement) circular bump on her forehead above her left eye. During a review of Resident 7's History and Physical (H&P), from Hospital 1, dated 8/31/23, the H&P indicated, .Chief Complaint: .Patient presents with Fall .Ground level fall unwitnessed at skilled nursing facility (SNF) .Mechanism of injury: .unable to provide history. Per Emergency Medical Systems deformity to wrist and hematoma [swelling that is filled with blood caused by a break in the wall of a blood vessel] to face .Per son SNF called says she fell from her chair was down for at most 15 minutes .Past medical history: .does not want any surgeries .Objective: Physical Exam- .Mental status: mumbling incoherent speech .Head: .hematoma to face .Face: hematoma to left forehead .Extremities: Left upper extremity [a part of the body, such as a hand or a foot]: Chronic deformity to left wrist, ecchymosis (type of bruise) to 2nd and 3rd finger and tender to palpation (a method of feeling with the fingers or hands during a physical examination) . Assessment/Plan: .Odontoid fracture [a broken bone in the neck] .Hematoma of scalp .large, to left forehead .Ground-level fall .Plan: Admit medicine and surgery to follow . During a review of Resident 7's Discharge Summary (DS), from Hospital 1, dated 9/8/23, the DS indicated, admitted : 8/31/23, discharge date : 9/8/23 .Chief complaint: Fall .Admission diagnosis: Odontoid fracture .Discharge Diagnoses: .(Principal) Odontoid Fracture, hematoma of scalp, confusion, Ground-level fall .Alzheimer's dementia with anxiety .Resolved Hospital Problems: No resolved problems to display . Images: .XR (X-Ray) Spine Cervical (neck) .Result date: 9/6/23 .stable transverse (lying across, crosswise or from left to right) odontoid process fracture .Computed Tomography (CT- diagnostic imaging procedure) Cervical (spine) with Contrast (a substance injected into an intravenous (in the vein) line that causes the particular organ/tissue/bone under study to be seen more clearly) result date: 8/31/23 .Impression: 1. There is a nondisplaced transverse (bone not moved far enough to be out of alignment) odontoid fracture .3. The bones are osteopenic (bone loss) .CT Head without Contrast, Result Date 8/31/23 . Impression: 1. Large area of soft tissue contusion (bruise to an area of the body that is not bone) with hematoma of the left forehead and frontal area extending cephalad (toward the head) . During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated July 2023, the P&P indicated, .Policy Statement: 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 . A fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force . when a resident is found on the floor, a fall is considered to have occurred .Fall Risk Factors: .Resident conditions that may contribute to the risk of falls include: .lower extremity weakness .functional impairments .Medical factors that contribute to the risk of falls include: .neurological disorders; and balance and gait disorders . Resident-Centered Approaches to Managing Falls and Fall Risk .The staff .will implement resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident or with a history of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .Monitoring Subsequent Falls and Fall Risk .The staff will monitor and document each resident's response to interventions intended to reduce falling or risk of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .

Based on observation, interview and record review, the facility failed to ensure residents' right to receive written notice, including the reason for the change, before the resident's room or roommate was changed, was not supported for 16 of 26 sampled residents (Resident 1,2,3,4,5,7,8,9,11,12,13,14,15,16,18,22) when Resident 1, Resident 2, Resident 3, Resident, 4, Resident 5, Resident 7, Resident 8, Resident 9, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 18 and Resident 22 were moved from their assigned room to another room in the facility without first receiving written notice. Resident 1 was moved to another room on [DATE] without first receiving written notice, including the reason for the room change and 15 other residents were moved without first providing residents' written notice and reason for the room change. These failures resulted in a system-wide situation where the residents' rights were not protected and honored. Subsequent to the room change, Resident 1 experienced sadness, periods of uncontrollable crying, not wanting to participate in facility activities and mental anguish. Resident 2 on [DATE] (date of room change), experienced sadness and uncontrollable crying and on [DATE] stated he did not want to live. Resident 4 was moved rooms on [DATE] and experienced feeling twisted around and angry. Resident 4 stated it affected her physically by causing upset stomach and digestive issues. Resident 11 experienced feeling ignored and insulted like she didn't have a mouth or a brain. This facility practice placed 14 residents (Resident 3, Resident 4, Resident 5, Resident 7, Resident 8, Resident 9, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 18, Resident 22) at a potential to experience feelings of anxiety and insecurity and could lead to emotional distress and decline in their well-being. Because of the serious actual harm to Residents 1 and 2 mental and emotional health and the serious potential harm to all residents' well-being related to not ensuring the residents' right to receive written notice and the reason for the room change and the systematic facility practice of not protecting residents' rights, an Immediate Jeopardy (IJ- a condition where the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on [DATE] at 4:53 p.m. under Code of Federal Regulations (CFR) S483.10(e)(6) The right to receive written notice (F559) with Administrator (ADM 1), Director of Nursing (DON), Regional Director of Operations (RDO), Director of Clinical Operations (DCO) and [NAME] President of Clinical Services (VPCS) in attendance. The Centers for Medicare & Medicaid Services (CMS, a federal agency which administers the nation's major healthcare programs) IJ template was provided to ADM 1 on [DATE] at 5:00 p.m., with an expectation for the facility to submit a written Plan of Removal based on the need for immediate actions as listed on the IJ Template (Centers for Medicare and Medicaid Services worksheet to document evidence of each component of IJ). The facility submitted an acceptable IJ Plan of Removal (POR), Version 4.2 on [DATE] at 12:16 p.m. the Plan of Removal included but was not limited to the following: 1) On [DATE], Qualified Activities Director (QAD) completed the form of psychosocial assessment to Resident 1 which contains the following: 1. Cognitive Patterns (recurring templates that humans use during problem solving/reasoning activities) 2. Memory 3. Memory Recall (the mental process or retrieval of information from the past) 4. Daily Decisions Cognitive Skills (Choosing items of clothing, knowing when to eat meals) 5. Signs and Symptoms of Delirium (a disturbed state of mind or consciousness) 6. Psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality) 7. Wandering (traveling aimlessly from place to place) Presence and Frequency 8. Change in Behavior or other symptoms 9. Psychosocial (of, affecting, or arising in the mind; related to the mental and emotional state of a person) well-being (construct that includes emotional or psychological well-being, as well as social and collective well-being) 10. Unsettled (lacking stability) Relationships 11. Past roles 12. Behavior/Mood (a temporary state of mind or feeling) 13. Medications 14. Discharge Planning (the process of identifying and preparing for a patient's anticipated health care needs after they leave the facility) 15. Abbreviated PCL-C (Evaluate how much the resident has been bothered by each problem on the list below in the past month) Total Score of questions 1 to 6 above (An individual is considered to have screen positive if the sum of these items is 14 or greater) For Positive screen (score 14 or greater) inquire about and enter triggers as well as any special cultural considerations the resident may have. 2) On [DATE] Care Plan has been updated by DON to reflect needs/special considerations 3) On [DATE] Social Services Director (SSD) conducted Psychosocial Assessment to Resident 1 with the same Psychosocial Assessment Outcome 4) On [DATE] a elNTERACT (a set of dashboards, checklists, and automatic triggers designed to work together to assist care teams) Change of Condition Evaluation V4.2 was completed by Licensed Nurse for room change of Resident 1. 5) On [DATE] Per Resident 1 requested to go back to her old room (41-B) to Admission Coordinator and on [DATE] Resident 1 was notified with a written room change notification dated [DATE] by the Admission Coordinator, Resident signed and dated the document 6) On [DATE] Resident 1 was provided a copy of the written notification room change by the Admission Coordinator. Before moving to her room on [DATE]. 7) On [DATE] elNTERACT Change of Condition Evaluation V4.2 was completed by LN (Licensed Nurses) with primary physician notification on actual room change to resident 1. It was done after the DON & Administrator that a Change of Condition needs to be done for Resident 1 8) On [DATE] Resident 1 continue on alert charting for 72 hours by LN per DON's directives, short term plan of care was done by LN and Resident 1 stated I'm happy to be back in my old room. 9) On [DATE] the primary physician was notified by LN and got an order for Psychological Evaluation by a Psychologist as recommended by the Interdisciplinary Team (cross functional team) headed by Administrator and DON. 10) On [DATE] the Interdisciplinary Team (IDT - DON, Administrator, Qualified Activities Director, Admission Coordinator, Director of Rehab and Dietary Manager) conducted meeting regarding the elNTERACT Change of Condition and room change policy and process to validate that Resident 1 was comfortable and satisfied by the interventions done by facility staff. Resident roommate will be evaluated and monitor for room compatibility for 72 hours LNs will document in the eMAR Monitoring, if noted, physician will be notified. 11) On [DATE] a patient (resident) centered comprehensive (complete, including all or nearly all aspects of something) care plan was done by the Director of Nursing (DON) during the IDT meeting. 12) Resident 1 was placed on alert charting for 72 hours starting [DATE] to [DATE] to ensure and monitor and documented in the electronic Medical Record (eMAR) to prevent any resident suffered serious actual harm such as tearfulness, sadness, isolation, and withdrawal from social interactions with other residents, decreased interest and participation in daily activities, and resulted in her refusal to eat her meals in the dining room, any identified issue(s) physician will be notified, resident/and or resident representative using the elNTERACT COC with short-term care plan will be develop by LN's and validated by the IDT led by DON during the 5 days Clinical meeting. lssue(s) identified will be corrected immediately to include safety, the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. 13) On [DATE] Completed the form in point click care (PCC) titled psychosocial assessment by Activity Director (AD) using an interpreter app to conduct a form psychosocial assessment to Resident 2. Resident 2 Total Score is 6 = Not Applicable 14) On [DATE] Resident was monitored for emotional distress related to previous room change by LNs. 15) On [DATE] DON used the interpreter app and met with Resident 2 to discuss residents' current room and stated I am happy here, I have been here for almost 7 years, If I could say one thing that could be changed it would be to have better activities. In the past the activities were much better. DON ask Resident 2 if he still like to attend activities, resident stated Yes, just want them how they used to be. They are just okay, just so, so. DON asked if resident 2 if he is comfortable here, he stated Yes, yes this is my home. 16) On [DATE] Resident 2 was place on alert charting for 72 hours by LNs. 17) On [DATE] LN called resident representative, left a voice mail to call the facility regarding recommendation for Psychologist evaluation, awaiting call back from resident representative. On [DATE] DON called resident representative to inform her regarding recommendation for Resident 2 to seen by a psychologist and stated she is coming to the facility. Daughter will personally see first resident before giving her consent, and stated that she is sick and cannot come at this time verbal notification and mailed a copy of the written notice of room change as stated by DON 18) On [DATE] DON using the interpreter app visited Resident 2 to evaluate his psychosocial status pertaining to room change Resident 2 stated to the DON that he was comfortable and satisfied in his current room. On [DATE] IDT meet and discussed Resident's 2 responses to validate that Resident 2 was satisfied in his current room. DON resolved short term care plan for previous room change. A patient (resident) comprehensive care plan was developed by DON and with additional input by the IDT to monitor psychosocial well-being in this current room and environment. 19) On [DATE] IDT led by DON and inform the MDS (Minimum Data Set) Coordinator to conduct Modification for Section C- Cognition BIMS Score based on the DON's conversation with Resident 2 that he is alert and oriented X4. Residents 4, 5, 7, 9, 11, 12 13, 15, 16, 17, 18, 19, and 22 were provided a copy of the written room change notification by the Admission Coordinator on ,d+[DATE], ,d+[DATE] to ensure resident's rights are not violated, prevent the potential to result in changes in interactions with peers and interest and participation with education to prevent psychosocial harm. 20) Resident 3 deceased on [DATE], Resident 8 deceased on [DATE], Resident 14 deceased [DATE], Resident 20 deceased on [DATE], Resident 21 deceased , Resident 23 deceased [DATE]. Resident 6 discharge to home on [DATE] and Resident 10 was discharged to home on [DATE] 3) Residents 1, 2, 4, 5, 7, 9, 11, 12 13, 15, 16, 17, 18, 19, and 22 will be put again in alert charting by LNs starting [DATE] to ensure: 1. Resident's rights are not violated, 2. Prevent the potential to result in changes in interactions with peers and 3. Interest and participation in activities with education to prevent psychosocial harm 4. Resident(s) and/or Resident Representative were provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator and audited by MRD five days a week 5. If LNs identified any of changes such as tearfulness, sadness, isolation, and withdrawal from social interactions with other residents, decreased interest and participation in daily activities, and resulted in her refusal to eat her meals in the dining room, then the LNs will report to the physician and will obtain an order for Psychologist referral/consult 6. IDT team meeting when appropriate to identify and ensure any deficient practice, immediate resolution to honor resident rights, prevent psychosocial harm, Resident(s) and/or Resident Representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator, resident(s) and/or resident representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator, notification of primary physician, referral to Psychologist as approved by primary physician and/or Medical Director when there is an identified changes such as tearfulness, sadness, isolation, and withdrawal from social interactions with other residents, decreased interest and participation in daily activities, and resulted in any issues with meal intake, resident his/her meal refusal to eat meals. All residents are potentially affected by the identified deficient practice. Twenty-two (22) out of twenty-two (22) residents were not provided a copy of the written room changed notification. 2. A On [DATE] the following were identified 6 out of 22 were deceased , and 2 discharged to home. 4) Residents 1, 2, 4, 5, 7, 8, 11, 12, 13, 15, 16, 17, 18, and 22 will be put again in alert charting by LNs starting [DATE] to validate residents if there is any other issue regarding: 1. Resident's rights are not violated, 2. Prevent the potential to result in changes in interactions with peers and 3. Interest and participation in activities with education to prevent psychosocial harm 4. Resident(s) and/or Resident Representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator 5. Refer to Psychologist when there is an identified changes such as tearfulness, sadness, isolation, and withdrawal from social interactions with other residents, decreased interest and participation in daily activities, and resulted in her refusal to eat her meals in the dining room 6. IDT meeting to identify and ensure any deficient practice, immediate resolution to honor resident rights, prevent psychosocial harm, Resident(s) and/or Resident Representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator, resident(s) and/or resident representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator, notification of primary physician, referral to Psychologist as approved by primary physician and/or Medical Director when there is an identified changes such as tearfulness, sadness, isolation, and withdrawal from social interactions with other residents, decreased interest and participation in daily activities, and resulted in her refusal to eat her meals in the dining room and monitoring the roommate compatibility. 7. Resident 19 was admitted on [DATE] and was not move to other room from the time of admit nothing before [DATE]. 5) On [DATE] DON and Administrator received training and education regarding facility policy and procedure by the Regional Nurse Consultant. On [DATE] Corporate/HR Administrator was relieved by an outsource interim Administrator. - Training and education conducted on [DATE] by contracted Director of Staff Development {DSD) to Administrator, DON, SSD, DRS, DSD, Director of Dietary Services, Maintenance Director/Housekeeping, Director of Rehabilitation (DOR - Physical Therapist), Occupational Therapist (OT), Speech Language Pathologist (SLP), PT Aide, Certified Occupational Therapy Aide {COTA), Registered Dietician, Admission Coordinator, Licensed Nurses regarding facility policy and procedures Room Change/Roommate Assignment and Roommate to and regarding responsibility during resident room change to make resident belongings move to the new room, after the room change CNA to report tearful on sad facial expression, negative statements about new room, changes in eating habits, activity participation and changes in participation in ADLs and to report to LNs. - On ,d+[DATE]/ 22 Corporate SSD, DON, Administrator and Medical Records Designee (MRD) will ensure resident and/or resident representative received a copy of written notice within 24 hours prior to room change, including the reason for the change, before the resident's room or roommate in the facility is changed and following the facility policy, issue(s) identified immediate action will be reported to the administrator and/or DON & will be corrected immediately by Administrator and a written audit conducted by MRD & will be reported during the five days Department managers meeting and on the weekends the Licensed Nurses will report to DON and Administrator to ensure that the deficient practice will not recur. If the facility has an outbreak, resident to resident altercation and for any other reason to ensure resident safety then the facility will follow its policy. On [DATE] CNAs training and education regarding responsibility during resident room change to make resident belongings move to the new room, after the room change CNA to report tearful on sad facial expression, negative statements about new room, changes in eating habits, activity participation and changes in participation in ADLs and to report to LNs. - Residents 1, 2, 4, 5, 7, 9, 11, 12 13, 15, 16, 17, 18, 19, and 22 will be put again in alert charting by LNs starting [DATE] to ensure 1. Resident's rights are not violated, 2. Prevent the potential to result in changes in interactions with peers and initiate elNTERACT Change of Condition 3. Administrator has the ultimate responsibility, ensuring resident right was not violated, the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. SSD, Qualified Activities Director Recreational and Admission Coordinator will be the back-up and responsible for resident change of room and following facility policy 4. Interest and participation in activities with education to prevent psychosocial harm 5. Resident(s) and/or Resident Representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator 6. IDT meeting to identify and ensure any deficient practice, immediate resolution to honor resident rights, prevent psychosocial harm, Resident(s) and/or Resident Representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator, resident(s) and/or resident representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator, notification of primary physician, referral to Psychologist as approved by primary physician and/or Medical Director when there is an identified changes such as tearfulness, sadness, isolation, and withdrawal from social interactions with other residents, decreased interest and participation in daily activities, and resulted in her refusal to eat her meals in the dining room 7. A short-term care plan will be developed by the IDT Team and a patient (resident) comprehensive care plan will be developed and an MDS Assessment to ensure consistency in facility assessment and documentation, this will be reviewed by the IDT five days Clinical Meeting led by DON. 8. Monitoring and documentation in the eMAR for 72 hours will be done by resident and resident roommate Corporate SSD, MDS Coordinator, DSD, Director of Dietary Services, MRD, Director of Recreational Services led by DON will review facility assessment during the five days clinical meeting to ensure accuracy of resident psychosocial health and well-being, written room change notification and a copy was provided to resident and/or resident representative by the Admission Coordinator. New hired LNs, MDS Coordinator, DSD, Director of Dietary Services, Medical record director, Director of Recreational Services, Administrator, Maintenance Director, and DON will be train and educate regarding facility policy focusing on resident's rights and for room change notification during their orientation period. 1. ADHOC QAPI Committee will meet on [DATE] with Medical Director to review and update facility policy and guidelines regarding immediate resolution to honor resident rights, prevent psychosocial harm, Resident(s) and/or Resident Representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator, resident(s) and/or resident representative was provided a copy of the written room change notification 24 hours prior to the change of room with approval from resident(s) or resident representative by the Admission Coordinator, notification of primary physician, referral to Psychologist as approved by primary physician and/or Medical Director when there is an identified changes such as tearfulness, sadness, isolation, and withdrawal from social interactions with other residents, decreased interest and participation in daily activities, and resulted in her refusal to eat her meals in the dining room. The components of the IJ Plan Of Removal - (CFR) S483.10(e)(6) Version 4.2 were validated through observations, interviews, and record review. The facility was determined to have implemented its POR. The IJ was removed onsite, on [DATE] at 5:05 p.m., with the ADM 2, DON, VPCS and President of Operations in attendance. Findings: During an interview on [DATE], at 12:46 p.m., with the Activities Assistant (AA), the AA stated, the ADM and the AC had been moving residents in the facility without their consent. The AA stated they were moving long term residents to new rooms. The AA stated, Resident 1 was moved to another room on [DATE]. The AA stated, Resident 1 had been refusing to transfer rooms, so staff were directed to move her belongings to a new room while Resident 1 was out of the room. The AA stated, residents at the facility had the right to refuse room changes. The AA stated, he had told the ADM that residents had the right to refuse room changes. The AA stated, the ADM told him he was going have the staff start charting negative behaviors to provide a reason for changing a resident's room. During a phone interview on [DATE], at 6:30 p.m., with the Administrator (ADM) 1, ADM 1 was made aware Resident 1 suffered harm caused by moving resident to another room. The ADM 1 stated he did not know how changing residents' rooms could cause harm to the residents. During an interview on [DATE] at 12:22 p.m., with the Admission Coordinator (AC), the AC stated, he started working as the AC on [DATE]. The AC stated he had been assisting with room changes since the Social Services Director (SSD) 1 left the facility at the end of November. The AC stated the process for room changes at the facility should have been that the SSD, MDS Coordinator and the ADM 1 would meet for an Interdisciplinary Team (IDT) meeting and discuss resident room changes. The AC stated the facility's process for room changes was not followed due to the facility not having an SSD. The AC stated the SSD would document what was discussed in a care conference note and document the room changes in the Electronic Medical Record (EMR). The AC stated he had not attended any IDT meetings regarding room changes. The AC stated he had not read the facility's policy and procedure for room changes. The AC stated that he was documenting notes in the Electronic Medical Record (EMR) regarding resident room changes. The AC stated the facility had hired a new SSD on [DATE]. The AC stated the new SSD had not been involved in room changes. The AC stated the new SSD had not been working with him on resident room changes. The AC stated moving a resident from one room to another to take an admission was not an acceptable reason for a room change. The AC stated the residents' rooms at the facility were their home. The AC stated he had not ever provided a written notice with reason for room change to residents or Responsible Party's (RP, a person that is responsible for making decisions for another person) for residents that moved to new rooms. During an interview, on [DATE], at 1:30 p.m., with ADM 1, ADM 1 stated, This facility had been a long-term care (LTC) skilled facility for many years. The residents and staff had been here for years. I would like for this facility to grow and have a Short Term Unit more Medicare . Rehabilitation (Physical Therapy, Occupational Therapy). ADM 1 stated, Room changes were, and are being made and many staff don't like change. ADM 1 stated, Resident 1 is very manipulative . She makes false allegations, throws urine in her roommate's bed, water on the floor, and turns on the television too loud . We had to move her to another room. The reason she does these acts . she wants to be in one bed-bedroom, alone, no roommates. During a concurrent interview and record review on [DATE], at 1:35 p.m., with ADM 1, ADM 1 stated the Policy and Procedure (P& P) for Room Changes was revised on [DATE]. ADM 1 presented a binder titled, QAPI (Quality Assurance/Performance Improvement) 2022. The QAPI dated ,d+[DATE] did not indicate the Quality Assurance members (including the Medical Director, ADM 1, Director of Nurses, Department Heads) had reviewed nor approved the P & P for Room Changes. When asked who made decisions to change the resident's rooms, ADM 1 stated, The Interdisciplinary Team (IDT) does but if emergency move/room transfers are needed, the Licensed Nurses will initiate the move and report up . we use Notice for room changes. During an interview on [DATE], at 9:35 a.m., with the SSD 2, SSD 2 stated she started working at the facility on [DATE]. SSD 2 stated she had worked as an SSD for 8 years at a different facility. SSD 2 stated she had not been involved in room changes at the facility. SSD 2 stated she had not seen the facility's policy and procedure for room changes. SSD 2 stated the process for room changes based on her professional work experience, was for the IDT to meet and discuss why the room change was necessary. SSD 2 stated if the resident requested a room change and there were no beds available or if there was no available room at the facility, the facility must provide resident with options. SSD 2 stated an example of options would be to wait for a bed to become empty or come up with other interventions. During an interview on [DATE], at 4:41 p.m., with ADM 1, ADM 1 stated ultimately, he was responsible for resident's room changes. During an interview, on [DATE], at 2:10 p.m. to 3:22 p.m., with the DON, the DON stated, From when I started in [DATE], I know of 22 resident room change . I was not involved in initiating nor had any knowledge until after the 21 room changes had been completed. The administrator (ADM 1) and the admissions coordinator were the ones who made decisions for room changes. DON stated, I am only aware of Resident 1's room changes . Resident 1 was moved to prevent altercation between her and her roommate. Resident 1 threw urine toward roommate (urine did not get to the roommate). DON stated, The facility did not provide a copy of the room change notice to the residents and their responsible parties (RP), for all 22 residents. DON stated, Residents have rights to refuse room transfers . If the resident or RP refuses the room change, then we must respect the resident's right to refuse and document their refusal. DON stated, ADM 1 had the ultimate responsibility to run the facility and ensure the rights of all residents are respected . right to be treated with dignity and respect and/or right to refuse room transfers. During an interview, on [DATE], at 9:56 a.m., with Director of Rehabilitation (DOR), DOR stated he had been employed at this facility since [DATE]. The DOR stated, There are many facility- specific changes. We are transitioning from Long Term Care (LTC) Skilled Nursing Facility (SNF, a facility that provides 24-hour skilled nursing care) to Short-Term (Medicare/Rehab) facility. The DOR stated, During a stand-up (meetings that are regularly held to provide status reports) back in ,d+[DATE], ADM told us there would be many room/bed changes to be made to support filling up/admit and build census up with Medicare/Short term residents. During a review of Resident 1's Admission Record (AR), dated [DATE], the AR indicated Resident 1 was admitted to the facility on [DATE]. The AR indicated Resident 1 had diagnoses of Anxiety Disorder (mental condition characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension), Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long term loss of pleasure or interest in life), recurrent (the experience of additional episodes of depression after periods of time without symptoms), Unspecified Dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), unspecified severity, without behavioral disturbance, Psychotic (related to or affected with a psychosis) Disturbance, Mood Disturbance, and anxiety, Schizoaffective Disorder (a combination of symptoms of schizophrenia [a disorder that affects a person's ability to think, feel and behave clearly] and mood disorder). During a review of Resident 1's Minimum Data Set (MDS - a comprehensive, standardized assessment of each residents' functional capabilities and health needs), dated [DATE], the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status) of 14 (a score of ,d+[DATE] suggests severe impairment, ,d+[DATE] suggests moderately impaired, ,d+[DATE] suggests cognitively intact). During a review of the facility's document Census, (undated), the Census indicated Resident 1 was in room [ROOM NUMBER] B from [DATE] to [DATE]. Resident 1 was moved on [DATE] from room [ROOM NUMBER] B to 30 B. Resident 1 was moved on [DATE] from room [ROOM NUMBER] B to room [ROOM NUMBER] B. Resident 1 was moved on [DATE] from room [ROOM NUMBER] B to room [ROOM NUMBER] B. During an interview on [DATE], at 2:06 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she had worked at the facility for 5 years. CNA 2 stated, she was familiar with Resident 1. CNA 2 stated, Resident 1 was moved to a new room (29 B) without her consent. CNA 2 stated, when Resident 1 was in her old room (41 B), she was out of her room all the time and would eat her meals in the dining room. CNA 2 stated, since Resident 1 was moved to the new room, Resident 1 no longer ate her meals in the dining room. CNA 2 stated, after Resident 1 was moved to the new room she had not seen Resident 1 leave the room. During an interview on [DATE], at 2:09 p.m., with CNA 3, CNA 3 stated she had worked at the facility for 4 years. CNA 3 stated, she was familiar with Resident 1. CNA 3 stated, Resident 1 had been moved multiple times in the facility. CNA 3 stated, when Resident 1 was in her old room she used to participate in activities and ate in the dining area. CNA 3 stated, after Resident 1 was moved to the new room she had stopped participating in activities and no longer ate in dining room. During an interview on [DATE], at 2:15 p.m. with CNA 5, CNA 5 stated she had worked at the facility for [AGE] years. CNA 5[TRUNCATED]

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to prevent falls, for one of five sampled residents (Resident 27), when Resident 27 had known behavior of getting up unassisted from bed, was assessed as being a high fall risk, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 27 getting out of bed unassisted on 4/11/22. Resident 27 fell and sustained a displaced right intertrochanteric fracture (broken hip bone that have moved out of their normal position) and right anterolateral (in front and to the side) second, third, fourth, fifth, sixth and seventh rib fractures and experienced pain. Resident 27 required surgical intervention and required hospitalization at the acute care hospital from 4/12/22 to 4/16/22 (four days). Resident 27 experienced severe pain and a change of mobility and ability to perform activities of daily living due to the fall with injury. Findings: During a review of Resident 27's, Admission Record (a document with personal and medical information), dated 4/21/22, the Admission Record indicated Resident 27 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 27's, Minimum Data Set (MDS assessment of healthcare and functional needs) assessment, dated 2/4/22, the MDS assessment indicated Resident 27's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score was five out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment) indicating Resident 27 had severe cognitive impairment in decision making. During a review of Resident 27's MDS Assessment Section G, dated 2/4/22 (prior to fall on 4/11/22), the MDS assessment indicated, A. Bed mobility- how resident moves to and from lying position, turns side to side, and positions body while in bed .2. Limited assistance .2. One person physical assist .B. Transfers- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position .2. Limited assistance .2. One person physical assist . C. Walk in room-how resident walks between locations in his/her room .7. Activity occurred only once or twice .1. Setup help only . E. Locomotion on unit- how resident moves between locations in his/her room and adjacent corridor on the same floor .1. Supervision .1. Setup help only .F. Locomotion off unit- how resident moves to and returns from off-unit locations .1. Supervision .1. Setup help only .G. Dressing- how resident puts on fastens and takes off all items of clothing .2. Limited assistance .2. One person physical assist .I. Toilet use- how resident uses the toilet room .3. Extensive assistance .2. One person physical assist .J. Personal hygiene- how resident maintains personal hygiene .2. Limited assistance .2. One person physical assist . During a review of Resident 27's MDS Assessment Section G, dated 4/27/22 (post fall on 4/11/22), the MDS assessment indicated, A. Bed mobility- how resident moves to and from lying position, turns side to side, and positions body while in bed .3. Extensive assistance .2. One person physical assist .B. Transfers- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position .3. Extensive assistance .2. One person physical assist . C. Walk in room-how resident walks between locations in his/her room .8. Activity did not occur .8. ADL activity itself did not occur . E. Locomotion on unit- how resident moves between locations in his/her room and adjacent corridor on the same floor .3. Extensive assistance .2. One person physical assist .F. Locomotion off unit- how resident moves to and returns from off-unit locations .3. Extensive assistance .2. One person physical assist .G. Dressing- how resident puts on fastens and takes off all items of clothing .3. Extensive assistance .2. One person physical assist .I. Toilet use- how resident uses the toilet room .4. Total dependence .2. One person physical assist .J. Personal hygiene- how resident maintains personal hygiene .3. Extensive assistance .2. One person physical assist . During an interview on 4/21/22, at 9:22 a.m., with Certified Nursing Assistant (CNA) 4, she stated she had worked in the facility for nine months and had taken care of Resident 27 prior to resident 27's fall on 4/11/22. CNA 4 stated Resident 27 had episodes of confusion and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA 4 stated Resident 27 did not like using her call light and tried to do everything herself. During an interview on 4/21/22 at 10 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she was an LVN employed through a Registry/Agency (employees that can be hired out for temporary or long-term work) utilized by the facility as needed for staffing needs. LVN 5 stated she was assigned to work the morning shift (7 a.m. to 3 p.m.) and was assigned to Resident 27 today (4/21/22). LVN 5 stated she had worked with Resident 27 once, prior to Resident 27's fall on 4/11/22 and twice since Resident 27 returned from the General Acute Care Hospital (GACH) (4/16/22). LVN 5 stated Resident 27 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 4/21/22, at 10:57 a.m., with the Physical Therapist (PT), the PT stated PT worked with Resident 27 on 4/4/22 and Resident 27 was discharged from PT services on 4/11/22 because Resident 27 had a fall on 4/11/22 and was sent out to GACH. The PT stated Resident 27 was very high-risk for fall. The PT stated Resident 27 was impulsive (act suddenly), had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The PT stated she attended Interdisciplinary Team (IDT) meetings and she remembered discussing during an IDT meeting to keep Resident 27 in a wheelchair in a supervised area has worked and recommended to have one on one (referring to one staff and one resident) care. The PT stated she did not know if the facility followed her recommendation to provide one on one supervision. During a telephone interview on 7/6/22, at 4:14 p.m., with CNA 5, CNA 5 stated she was assigned to work the afternoon shift (2:30 p.m. to 11 p.m.) on 4/11/22 and was assigned to Resident 27. CNA 5 stated Resident 27 ate dinner in her room and she helped her to bed. CNA 5 stated Resident 27 tried to get out of bed unassisted and not calling for assistance prior to Resident 27's fall. CNA 5 stated she was charting in the hallway, when she heard Resident 27 calling out for help. CNA 5 stated she responded to Resident 27 and found Resident 27 sitting on the floor next to her bed. CNA 5 stated Resident 27 complained of pain to the charge nurse while the nurse performed Resident 27's body assessment. CNA 5 stated she was not sure where resident 27 complained of pain. CNA 5 stated Resident 27 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent telephone interview and record review on 7/6/22, at 4:38 p.m., with LVN 1, Resident 27's medical records were reviewed. LVN 1 stated he worked on 4/11/22, the afternoon shift (2 pm-11:30 p.m.). LVN 1 stated prior to Resident 27's fall on 4/11/22, Resident 27 was alert with confusion and forgetfulness. LVN 1 stated after Resident 27's fall on 4/11/22, Resident 27 was more confused. LVN 1 stated on the day of the fall, he did not remember where Resident 27 was, but Resident 27 was usually up in her wheelchair, in the hallway, near the nurse station. LVN 1 reviewed Resident 27's medical record, specific to his note titled, Event Initial Note dated 4/11/22 at 8:30 p.m. LVN 1 stated he walked down the hallway, then he heard Resident 27 calling out in Spanish, Help me, help me. LVN 1 stated he ran towards Resident 27's room and found Resident 27 sitting on the floor between her bed and wheelchair. LVN 1 stated Resident 27 stated she tried to transfer herself from the wheelchair to bed unassisted and lost her balance and ended on the floor. LVN 1 stated Resident 27 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 reviewed Resident 27's fall care plan dated 2/7/22, LVN 1 stated the interventions were, .Monitor for post fall injuries . Neurochecks (evaluation of a person's nervous system) to be performed . Therapy to screen post fall . LVN 1 reviewed Resident 27's fall care plan dated 2/27/22, LVN 1 stated the interventions were: .Check range of motion . Monitor/document/report PRN (as needed) X 72h (seventy two hours) to MD (Medical Doctor) for s/sx (signs and symptoms) Pain, bruises, change in mental status . Neuro-checks x24 hours. LVN 1 reviewed Resident 27's fall care plan dated 4/2/22, LVN 1 stated the interventions were: .Monitor for 72hrs (hours) for delayed injuries . Monitor for pain Qshift (every shift) .Neurochecks for 72 hrs . LVN 1 stated the interventions were not patient-centered and did not prevent Resident 27 from falling again. During a concurrent observation and interview on 8/1/22, at 10:22 a.m., in Resident 27's room, Resident 27 sat at the edge of the bed, there was a floor mat (floor covering that is placed on the floor) on the floor. Resident 27 was unable to be interviewed. During a concurrent interview and record review on 8/5/22, at 9:35 a.m., with the Infection Preventionist (IP)/Minimum Data Set Nurse (MDS), Resident 27's medical records were reviewed. The IP/MDS stated Resident 27 was considered high risk for falls and all four of Resident 27's falls (2/6/22, 2/27/22, 4/2/22 and 4/11/22) were due to Resident 27 transferring self-unassisted and not asking for assistance. The IP/MDS reviewed Resident 27's fall care plan dated 2/7/22, which indicated, .Focus: At risk for injuries due to recent fall on 2/6/22 due to poor safety awareness and wanting to take self to the bathroom . Interventions: Monitor for post fall injuries for 72 hours . Neurochecks to be performed . Therapy to screen post fall . The IP/MDS reviewed Resident 27's fall care plan dated 2/27/22, which indicated, .Focus: Resident had a claimed fall with no injury . Interventions: Check range of motion (Specify #) times daily . Monitor/document/report PRN X 72 h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture (position), agitation . Neuro-checks x24 hours . The IP/MDS reviewed Resident 27's fall care plan dated 4/2/22, which indicated, .Focus: unwitnessed fall . Interventions: Monitor for 72 hrs for delayed injuries . Monitor for pain Q shift . Neuro checks for 72 hrs . The IP/MDS reviewed Resident 27's fall care plan dated 4/11/22, which indicated, .Focus: Fall 4/11/22 due to attempting self transfer . Interventions: Assess for pain every shift and during routine rounds . Bed in low position . Call light placed within reach and instruction given to press on the button if she needs to get up or needs any assistance . Inform resident about the importance of locking wheelchair before transferring . Neurocheck started . Pharmacy to review medications . Resident was having pain and sent out to ER (emergency room ) for further evaluation . The IP/MDS stated, .The interventions were not appropriate and not resident-centered, the interventions did not address the causes of falls, the facility should have tried to do more . The IP/MDS reviewed Resident 27's medical record titled, Risk for falls, dated 7/24/18, which indicated, .Score: 14 Category: Resident at risk . A. Risk for falls 1. LOC (level of consciousness- term used to describe a person's awareness and understanding of what is happening in their surroundings)/MENTAL STATUS/COGNITIVE SKILLS . 4. Intermittent confusion .3. Ambulation (ability to walk)/Elimination Status . 2. Chair bound-requires assist with elimination . 7. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Takes 3-4 of these medications currently and/or within last 7 days . The IP/MDS stated Resident 27's fall risk score was 14, which meant Resident 27 was high risk for falls. The IP/MDS stated Resident 27 was at risk for falls since she was admitted in the facility on 7/24/18. During a review of Resident 27's Medical Record titled, Fall Assessment-Post Incident, dated 4/2/22, the Fall Assessment -Post Incident, indicated, .Category: High Risk . 3. History of falls within last six months . Multiple Falls 4. Medication Use . [CONDITION(S)] (condition in which your blood sugar level is lower than the standard range) . Antihypertensive . NSAID's (non-steriodal anti [CONDITION(S)] drug- drug class to reduce pain, decreases inflammation, decreases fever, and prevents blood clots) . Psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) . Sedatives/Hypnotic's chemical substance used to reduce tension and anxiety and induce calm or to induce sleep) 9. Confined to a chair: .Confined to a chair and disoriented . 11. Gait (walk) Analysis . Unable to independently come to a standing position. Exhibits loss of balance while standing . Requires hands-o assistance to move from place to place . Uses an assistive device, e.g. cane, walker . During a concurrent interview and record review on 8/5/22, at 1:14 p.m., with the Director of Nursing (DON), the DON reviewed Resident 27's fall care plans dated 2/7/22, 2/27/22, 4/2/22 and 4/11/22 and stated the care plans for Resident 27 were not resident specific and the interventions did not help to prevent additional falls. The DON stated the care plan interventions should have been more resident specific to address the cause of each fall. During a review of Resident 27's Event Initial Note, dated 4/11/22 at 20:30 [8:30p.m.] the Event Initial Note indicated, .Event Type: S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Detailed description of event . Writer heard 'Ayuda me cai [speaking in Spanish].' Help I fell . resident sitting on the floor next to her bed and wheelchair . Patients description of event: Resident verbally stated she was trying to transfer from the wheelchair to her bed when she lost her balance and fell on her bottom . New Interventions initiated (should address any abnormal assessment findings): Neurochecks . During a review of Resident 27's Event follow up note, dated 4/12/22 at 7:56 a.m. the Event follow up note indicated, .Event Type: S/P unwitnessed fall .Full Range of Motion Assessment findings (i.e. [example] wnl [within normal limit] for resident, or describe abnormal findings): .Severe pain to right lower extremity . Describe any new injuries or complaints of new pain or enter none: Severe pain to right lower extremity . treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .at around 7:30 a.m. while receiving care resident started c/o [complained of] severe pain to right lower extremity, refused to be turned d/t [due to] pain. Resident was noted to be touching right hip area with two hands while grunting with a tense body posture . New orders received/New treatments initiated: Sent out to [name of general acute care hospital] for further evaluation, to rule out fx [fracture] r/t severe pain . During a review of Resident 27's medical record titled, Transfers/Discharge Report, dated 4/12/22, the reported indicated, . Chief Complaint (reason for transfer) Severe pain to right hip s/p Fall ibuprofen (type of pain medication) at 700 a.m. During a review of Resident 27's medical record titled, Acute Care Surgery Service Discharge Summary, dated 4/16/22, the record indicated, .admitted : 4/12/22, discharge date : 4/16/22 . Injuries: R (right) intertrochanteric femur (thigh bone) fracture (s/p IMN [intramedullary nail- metal rod that is inserted into the cavity of a bone and across the fracture] with orthopedics (medicine dealing with the correction of deformities of bones or muscles) 4/13). Right rib fractures 2-7 (two to seven) . Admission Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Displaced right intertrochanteric fracture is demonstrated .Right anterolateral second, third, fourth, fifth, sixth and seventh rib fractures .Proximal right femoral shaft intertrochanteric fracture . During a review of facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered dated 2018, the P&P indicated, Policy Statement .A comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. Policy Interpretation and Implementation .1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .7. The comprehensive, person-centered care plan will .a. Include measurable objectives and timeframes .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems . k. Reflect treatment goals, timetables and objectives in measurable outcomes .m. Aid in preventing or reducing decline in the resident's function status and/or functional levels .o. Reflect currently recognized standards of practice for problem areas and conditions .8. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan .9. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . During a review of the facility's P&P titled, Falls and fall Risk, Managing, dated 2018, the P&P indicated, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications . will implement a resident-centered fall prevention plan to reduce specific factors of falls . Staff will monitor and document each resident's response to interventions intended to reduce falling . If resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . During a review of the facility's P&P titled, Assessing Falls and Their Causes, dated 2018, the P&P indicated, .provide guidelines for evaluating/gathering data on a resident after a fall and to assist staff in identifying causes of the fall .Review the resident's care plan to assess for any special needs of the resident . Refer to resident-specific evidence including medical history, known functional impairment . During a review of the facility's P&P titled, Falls-Clinical Protocol, dated 2018, the P&P indicated, .Assessment and Recognition .While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause .the nurse shall assess and document/report .All current medications, especially those associated with dizziness or lethargy .Cause Identification .For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall .Often, multiple factors contribute to a falling problem .Treatment/Management .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .Monitoring and Follow-Up .If the individual continues to fall, the staff .will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions .

Based on observation, interview and record review, the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 45), when Resident 45 was identified as being at risk for falls with a history of multiple falls in the facility and the care plan intervention to place the bed in the low position was not implemented on 12/27/21. This failure resulted in Resident 45 experiencing an unwitnessed fall from the bed on 12/27/21 onto the floor. After the fall, Resident 45 experienced left side pain and was sent to the general acute care hospital (GACH) for evaluation. Resident 45 was diagnosed with a left femur fracture (broken thighbone) and required surgical repair and was hospitalized from 12/27/21 to 1/4/22 (eight days). After the fall, Resident 45 experienced a decline in mobility and pain due to the fall and injury. Findings: During a review of Resident 45's Admission Record (document containing resident demographic information and medical diagnosis), dated 1/5/22, the admission record indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnosis included .ALZHEIMER'S (progressive disease that destroys memory and other important mental functions) .PULMONARY EMBOLISM (condition in which one or more arteries in the lungs become blocked by a blood clot) .ACUTE EMBOLISM AND [CONDITION(S)] OF UNSPECIFIED DEEP VEINS OF LOWER EXTREMITY BILATERAL (blood clot forms in one or more of the deep veins in the body) .DEMENTIA (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) .MAJOR DEPRESSIVE DISORDER (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) . (MORBID (SEVERE) OBESITY (commonly defined as being 100 pounds over ideal body weight) .FRACTURE OF LEFT FEMUR MUSCLE WEAKNESS .DIFFICULTY WALKING . During a review of Resident 45's Care Plan (CP) dated 10/26/21, the CP indicated, .At risk for falls related [disease] of Alzheimer's Dementia, Major Depressive Disorder, Obesity, Pulmonary Embolism, DVT (deep vein [CONDITION(S)]), LE (lower extremity) muscle weakness; not steady and requiring assistance by staff with walking, toileting, and sit to stand, and poor safety awareness .Resident slid from bed while sitting at the edge of bed on 12/12/2020; [status post] unwitnessed on 12/22/2020 in room; on 1/21/21 CNA (Certified Nursing Assistant) was assisting resident with the walker to the bathroom and he just stopped walking and kneeled down by the doorway to the bathroom-CNA helped lower him to the floor. 2/8/2021, resident as noted laying on the floor. On 5/25/2021 resident rollover from bed. Unwitnessed fall on 8/29/2021 with a redden area to left side of thigh. Unwitnessed fall on 12/04/2021 self-transfer from bed to wheelchair. Unwitnessed fall on 12/11/21 self-transfer from wheelchair to bed. Date initiated: 10/14/2020 .Goal Minimize risk for falls and fall related injuries. Date Initiated: 10/14/2020 .Target Date: 1/24/2022 .Interventions .Assess for pain and medicate as needed .Bed in low position . During a review of Resident 45's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 10/21/21, the MDS indicated Resident 45's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation and memory recall) score of 4 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 4 had severe cognitive impairment. During a review of Resident 45's Progress Note (PN), dated 12/27/21, the PN indicated, .[status post] Unwitnessed fall Date of Event: 12/27/21 Time of Event: [8:15 p.m.] . Writer heard resident verbally yelling for help upon entering residents room writer noticed resident laying on his left side next to his bed. Resident [45] [complained of] pain to [left] hip. Writer administered [as needed] Medication. Resident [45] was lifted with lyft [sic] and placed in bed. No delayed injuries noted except [complaints of left] hip .Resident verbally stated [h]e just fell down .Patients description of event: Resident verbally stated He just fell down .If Fall note-injury how patient was found, environment footwear, last toileted, [Fasting Blood Sugar-amount of sugar in the blood overnight] if diabetic (a person who's body cannot turn sugar into energy): Resident was found in a side laying position to [left] side, resident was wearing non-skid socks, last time toileted was one hour ago .Author [Licensed Vocational Nurse1] . During a review of Resident 45's Neuro Check (an evaluation of person's nervous system), dated 12/27/21, the Neuro Check indicated, .Was there any injury sustained .Yes .If yes, explain .Resident [complains of] [left] hip pain .Change in range of motion .Yes .If yes, explain .unable to move [left lower] Body extremity .Is resident experiencing any pain .Yes .If yes, explain in detail .[blank] . During a review of Resident 45's Fall Assessment-Post Incident, dated 12/27/21, the Fall Assessment-Post Incident indicated, .History of falls within last six months .1-2 times . During a review of Resident 45's Pain Assessment-Post Incident, dated 12/27/21, Pain Assessment-Post Incident indicated, .Pain location and characteristics .Based on appropriate pain scale for Resident, what is the current level of pain? .0 .If able to verbalize what is the Residents acceptable level of pain? .0 .What appears to increase the resident's pain? . Moving resident [left] hip .What is most likely cause of pain? .Resident fell on [left]side and hurts to [left] hip . During an observation in 1/5/22, at 2:05 p.m., in Resident 45's room, Resident 45 was asleep in bed, snore like sounds were heard. Resident 45 was unable to be interviewed. During a concurrent observation and interview on 1/5/22, at 2:45 p.m., with Registered Nurse (RN) 1, at the nurse's station, Resident 45 was observed calling out for assistance in the room. RN 1 stated, Resident 45 had returned to the facility from a GACH today (1/5/22) and Resident 45 was non weight bearing (when an area of the body cannot withstand pressure from body weight) on his left side. RN 1 stated, Physical Therapy (PT) needed to assess him in order to determine the assistance Resident 45 needed. RN 1 stated, prior to Resident 45's fall on 12/27/21. RN 1 stated Resident 45 was able to get up and use the bathroom prior to his 12/27/21 fall with assistance and post fall (1/5/22) Resident 45 could not get up, he needed to use a urinal (a vessel into which a bedridden person urinates) at his bedside. During an interview on 1/5/22, a 2:57 p.m., with RN 2, RN 2 stated, Resident 45 did not complain of pain prior to his fall on 12/27/21. RN 2 stated, after the fall Resident 45 complained of left sided pain. RN 2 stated, Certified Nursing Assistance (CNA) 3 found Resident 45 on the floor on 12/27/21. During an interview on 1/5/22, at 3:10 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, he entered Resident 45's room on 12/27/21, when Resident 45 was on the floor. LVN 1 stated, CNA 3 called out for assistance with Resident 45. LVN 1 stated, Resident 45 was on the floor next to his bed. LVN 1 stated, Resident 45 wanted to be placed back into bed after the initial fall assessment was completed and that Resident 45 had no visible injuries and Resident 45 said he was ok. LVN 1 stated after placing Resident 45 back into bed, Resident 45 complained of pain to the left side of his body. LVN 1 stated he called an ambulance to transfer Resident 45 to a GACH. During a review of Resident 45's Care Conference Summary v2.0 (Care Conference), dated 1/14/22, the Care Conference indicated, .Nursing .Summary of Nursing Services/Concerns .[Resident 45] does [complain of] pain to the left leg due to recent fracture of the femur that was a result of a fall. [Status post open reduction and internal fixation (ORIF- a type of surgery that is used to repair broken bones that need to be put back together) to [his] left femur .At this time requires extensive to total assist with [Activities of Daily Living-ADLs] such as bed mobility, toileting, personal hygiene and bathing. Resident [45] does not transfer at this time per [Doctors] orders due to being toe touch weight bearing (resident can place their toe on the ground for very subtle balance) on the left leg only but unable to tolerate .Medication Changes/Concerns .none .Falls/Accidents .Briefly describe any falls/accidents. If none, Enter none .none .Signed By .MDS Coordinator .Signed Date .01/27/2022 .Therapy/Restorative .Summary of Therapy/Restorative Services or Concerns .[Resident 45] presents with [left] hip [fracture with] new ORIF from acute .and has been currently on therapy services to address pain, functional mobility, [lower extremity strength, activity tolerance .Signed By .[Physical Therapy] .Date .01/14/22 . During a review of Resident 45's Care Plan, dated 4/22/22, Resident 45's Care Plan indicated, .Resident [45] has physical functioning deficit related to: Total dependency with Mobility impairment, [status post Open Reduction Internal Fixation for Broken (surgery to fix a severely broken bone)] to left femur . Date Initiated: 01/06/2022 . During a review of Resident 45's Section G Functional Status (Section G) (prior to fall on 12/27/21), dated 12/27/21, Section G indicated, .Activities of Daily Living (ADL) Assistance (term used in healthcare to refer to person daily self-care activities ability) .ADL Self Performance .Coding .2. Limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance .C. Walk in room-how resident walks between locations in his/her room .2 .D. Walk in corridor-how resident walks in corridor on unit .2 .F. Locomotion off unit-how resident moves to and returns from off-unit locations .2 . During a review of Resident 45's Section G Functional Status (Section G) (post fall 12/27/21) dated 7/14/22, the Section G indicated, .Activities of Daily Living (ADL) Assistance .ADL Self Performance .Coding .8. Activity did not occur .C. Walk in room-how resident walks between locations in his/her room .8 .D. Walk in corridor-how resident walks in corridor on unit .8 . F. Locomotion off unit-how resident moves to and returns from off-unit locations .8 . During an interview on 7/28/22, at 3 p.m., with CNA 3, CNA 3 stated, on 12/27/21, he had placed Resident 45 in his wheelchair at approximately 6 p.m. CNA 3 stated, he was not Resident 45's assigned CNA for the shift. CNA 3 stated, when he walked by Resident 45's room at approximately 7:45 p.m., Resident 45 was in his bed. CNA 3 stated, he had not placed Resident 45 in his bed and the bed was not in the lowest position from the floor. CNA 3 stated, after he passed Resident 45's room and turned the corner, he heard Resident 45 yell out for help and when CNA 3 returned to Resident 45's room, Resident 45 was on the floor. CNA 3 stated, it was important that Resident 45's bed be placed in the lowest position because he was considered a fall risk. During a concurrent observation and interview on 8/4/22, at 3:52 p.m., with CNA 3, in Resident 45's room, Resident 45 was in his bed. Resident 45's bed was observed at a height that was not in the lowest position. CNA 3 stated, when Resident 45 had fallen out of bed on 12/27/21, Resident 45's bed was raised slightly higher. CNA 3 raised the height of Resident 45's bed. CNA 3 was observed with a measuring tape. CNA 3 measured the height of Resident 45's bed, the height of Residents 45 bed was 22 inches (unit of measurement) from the bottom of the mattress to the floor. CNA 3 stated, Resident 45 was a fall risk, and the bed should always be at the lowest height. CNA 3 lowered Resident 45's bed to the lowest position and measured the height from the bottom of the mattress to the floor, the height measurement was 14 inches (a difference of 8 inches). CNA 3 stated, before Resident 45's fall on 12/27/21, Resident 45 was able to assist with transfers, however Resident 45 is a two person transfer now (post fall). During an interview on 8/4/22, at 4:05 p.m., with LVN 1, LVN 1 stated, Resident 45 was more mobile prior to his fall on 12/27/21 than he was on 1/5/22. LVN 1 stated, prior to Resident 45's fall on 12/27/21 fall, Resident 45 could assist with moving himself in his bed. LVN 1 stated, Resident 45 post fall on 12/27/21 was a two-person transfer. During an interview on 8/5/22, at 10:03 a.m., with the Director of Physical Therapy (DPT), the DPT stated, prior to 12/27/21, Resident 45 was a sit to stand mid assist (when a resident needs minimal assistance to move from sitting to standing) and had a higher level of function. The DPT stated, Resident 45 post fall on 12/27/21 is a two-person transfer with a mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone). During a review of Resident 45's [X-Ray] (picture through the body to see bones) Femur Left Final Result (XR femur), dated 12/28/21, the XR femur indicated, .REASON FOR EXAM .Fall .Pain .FINDINGS/IMPRESSION .Comminuted (bone that is broken in at least two places), mildly displaced fracture of the subtrochanteric (below the femur) left femur with 1.4 [centimeter-cm unit of measurement] displacement . During a review of Resident 45's [X-Ray] Hip Left Complete (XR hip), dated 12/28/21, the XR hip indicated, .REASON FOR EXAM .Fall .Pain .FINDINGS/IMPRESSION .Comminuted oblique (incline) fracture of the proximal (near center) femur just below the intertochanteric (area of femur where angle changes) region. There is a 9 [millimeter-mm unit of measurement] displacement . During a review of Resident 45's, Patient Care Timeline 12/27/21 to 12/30/21 (PCT), the PCT indicated, .12/27/2021 .[10:26 p.m.] . Patient arrived in the [Emergency Department (ED)] .[10:33 p.m.] Pain Assessment Pain Scale Used: Faces Wong-Baker Faces Scale (patients are not able to understand the standard 0-10 pain scale): 2-Hurts a little bit .[10:35 p.m.] ED Fall Risk .Fall Risk: High Risk .12/28/2021 .[1:05 a.m.] [MEDICATION(S)] (powerful drug used in the treatment of severe pain) .injection 25mcg (micrograms-unit of measurement) .[3:00 a.m.] .[MEDICATION(S)] .injection 25 mcg .[3:10 a.m.] .[Patient] was placed in bucks traction (used for fractures in the lower body) .[6:33 a.m.] [MEDICATION(S)] (drug used to relieve pain) injection 4 mg (milligrams- unit of measurement) .[6:38 a.m.] Pain Assessment .Pain Scale Used: Faces .Wong Baker Faces Scale: 8-Hurts a whole lot .Pain Type: Acute pain .Pain Location: Leg .Pain Orientation: Bilateral (both sides) .Pain Quality 1: Aching .Patients Acceptable Level of Pain: No Pain .Pain Intervention(s): Medication .[9:50 a.m.] .Pain Assessment .Pain Assessment Pain Scale Used: 0-10 .Rank your current pain where 0 is no pain and 10 is severe pain: 10 .Pain Type: Acute pain .Pain Intervention(s): Medication .[9:54 a.m.] [MEDICATION(S)] injection 4 mg .[2:15 p.m.] . Pain Assessment .Pain Assessment Pain Scale Used: 0-10 .Rank your current pain where 0 is no pain and 10 is severe pain: 10 .Pain Type: Acute pain .Pain Location: Leg .Pain Intervention(s): Medication .[2:24 p.m.] .[MEDICATION(S)] injection 4 mg .12/29/2021 .[11:40 a.m.] . Pain Assessment .Pain Assessment Pain Scale Used: 0-10 .Rank your current pain where 0 is no pain and 10 is severe pain: 6 .Pain Type: Acute pain .Pain Intervention(s): Medication .[11:58 a.m.] .[MEDICATION(S)] (drug used to relieve severe pain) .injection 1 mg . During a review of Resident 45's Operative Report, dated 1/1/22, the Operative Report indicated, .DATE OF OPERATION: 12/30/2021 .POSTOPERATIVE DIAGNOSIS: Left subtrochanteric hip fracture .OPERATIVE PROCEDURE: Intramedullary nailing (a permanent nail or rod is placed into the center of the bone), left hip fracture . During a review of Resident 45's Discharge Summary (from the acute care hospital), dated 1/4/22, the Discharge Summary indicated, .the patient took a fall before his presentation, suffering left hip pain. Workup significant for left hip fracture requiring ORIF . During a review of the facility's policy and procedure (P&P) titled, Assessing Falls and Their Causes, dated 2018, the P&P indicated, .Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors Appropriate interventions taken to prevent future falls . During a review of the facility's P&P titled, Falls-Clinical Protocol, dated 2018, the P&P indicated, .Assessment and Recognition .While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause .Often, multiple factors contribute to a falling problem .Treatment/Management .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .Monitoring and Follow-Up .If the individual continues to fall, the staff .will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions . During a review of the facility's P&P titled, Falls and Fall Risk, Managing, dated March 2018, the P&P indicated, .Based on previous evaluations and current date, 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 .Resident-Centered Approaches to Managing Falls and Fall Risk .The staff .will implement resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident or with a history of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .Monitoring Subsequent Falls and Fall Risk .The staff will monitor and document each resident's response to interventions intended to reduce falling or risk of falling .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .

Based on observation, interview and record review, the facility failed to ensure residents' environment remained free of accident hazards (potential to cause injury or illness) to prevent accidents for one of three sampled residents (Resident 1), when an extra walker (an assistive device used for support and stability when walking) was left at the end of Resident 1's bed. This failure resulted in Resident 1 tripping over an extra walker on 6/23/21, causing Resident 1 to fall onto the floor, which resulted in a left patella (kneecap) fracture (break in the bone). Resident 1 experienced a decline in mobility (the ability to move with ease) of her left leg, had a decrease in her ability to participate in activities of daily living (ADL- term used in healthcare to refer to people's daily self-care activities such as grooming/personal hygiene, dressing, toileting/continence), and experienced pain associated with physical therapy for the fractured patella. Findings: During a review of Resident 1's Admission Record (document containing resident personal information), dated 6/24/21, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included, . wedge compression fracture (a type of break in the bone) of first lumbar vertebra (a bone in the lower back protecting the spinal cord) .muscle weakness .difficulty in walking .unspecified [CONDITION(S)] (degeneration of joint cartilage) . During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 6/14/21, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 13 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 1 had no cognitive deficit. During an observation on 7/12/21, at 11:10 a.m., in Resident 1's room, the area around Resident 1's bed was observed. Resident 1 laid in bed; the room was dark with the lights turned off. The area around Residents 1's bed contained a wheelchair that was placed against the wall, a four-wheeled walker (4WW-designed to assist in the ability to stabilize and balance during walking), a bedside commode (portable toilet), a front wheeled walker (FWW- an assistive device used to provide extra stability and can help individuals move) and an overbed table (an adjustable rectangular, narrow table). During a concurrent observation and interview on 7/12/21, at 11:12 a.m., with Resident 1, Resident 1 stated she had a fall, but could not remember the date. Resident 1 was alert and oriented to person and place, but was confused regarding time. Resident 1 stated she was independent (not depending on others) of getting out of bed before her fall. Resident 1 stated since the fall, she has to call for help and the staff would assist Resident 1 by transferring her to the bedside commode. Resident 1 stated she had a wrap on her leg. Resident 1 pulled back her blanket and exposed an immobilizer brace (a brace to hold a bone or joint into place) on her left leg. During an interview on 7/12/21, at 12 p.m., with the Director of Rehabilitation (DOR), the DOR stated before Resident 1's fall on 6/23/21, Resident 1 was more confident in walking and was able to ambulate (walk) short distances without her walker. The DOR stated Resident 1 was able to walk to the bathroom on her own with the assistance of a front wheeled walker. The DOR stated after Resident 1's fall on 6/23/21, Resident 1 needed staff to assist her out of bed to the bedside commode. The DOR stated he had an in-service (training) with the nursing staff on how to care for Resident 1 after her injury (fall on 6/23/21). The DOR stated he showed the staff how to use the immobilizer brace, explained why the immobilizer brace needed to remain in a locked position, the important to not bend the resident's knee and weight bearing precautions (how much weight a person puts through an injured body part). The DOR stated after Resident 1's fall, she (Resident 1) had an increase in pain, therefore he (DOR) requested the nurses to administer pain medication to Resident 1 prior to physical therapy (aims to help patients maintain, recover or improve physical ability that may be impaired due to a condition or injury). During a review of Resident 1's Physical Therapy (PT) Recert (recertification), Progress Report & Updated Therapy Plan dated 6/28/21, the Physical Therapy PT Recert, Progress Report & Updated Therapy Plan indicated, .Summary of Functional Progress Since Last Certification .Lying to sitting on the side of bed .(6/8/2021) Partial/moderate assistance .(6/21/2021) Supervision or touching assistance .(6/25/2021) [post fall] partial/moderate assistance .Sit to stand .(6/8/2021) Supervision or touching assistance . (6/21/2021) Supervision or touching assistance . (6/25/2021) [post fall] Dependent (requiring assistance) . Chair/bed-to-chair transfer . (6/8/2021) Supervision or touching assistance . (6/21/2021) Supervision or touching assistance . (6/25/2021) [post fall] Dependent . Gait (a person's manner of walking) . (6/8/2021) Supervision or touching assistance . (6/21/2021) Supervision or touching assistance . (6/25/2021) [post fall] Dependent . Precautions: fall risk, s/p (status post) kyphoplasty (surgical filling of an injured vertebrae [small bones forming the backbone]), L (left) patella fx (fracture) with associated pain-knee immobilizer . Weight Bearing LE (lower extremity [limbs of the body]) Weight Bearing Status =Weight Bearing as Tolerated (with L knee fully extended with immobilization splint) . Functional Skills Assessment . Transfers . toilet transfer = Dependent . Ambulation . Walk 10 feet (unit of measurement) = Not attempted due to medical conditions or safety concerns . Assessment and Summary of Skilled Services . Patient Progress . Progress & Response to Treatment: Pt (patient) was making excellent progress over the past couple weeks with increase in LE strength . independence with functional transfers . ambulation . sustained a fall on 6/23/21 . Radiograph (image) revealed patella fracture .Goals were downgraded (reduce to lower grade or level of importance) for modified (changes) transfers with the L knee immobilized as well as pain management to improve independence with mobility . BSC (bedside commode) will be recommended when pt is read[y] for transfers . Pt will be premedicated (using medication before some type of therapy) with nursing about 1 hour prior to PT Tx (treatment) . During a concurrent observation and interview on 7/12/21, at 12:52 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, Resident 1's bed area was observed. Resident 1's room was dark with the blinds closed. LVN 1 stated Resident 1 preferred to keep the room dark. LVN 1 stated Resident 1 had a four wheeled walker, a front wheeled walker, a wheelchair, bedside commode, and a bedside table around her bed. LVN 1 stated Resident 1's room was cluttered and was a fall hazard. During a concurrent interview and record review on 8/12/21, at 12:58 p.m., with LVN 1, Resident 1's fall risk (increased susceptibility to falling that may cause physical harm) care plan (plan, document, and accomplish individualized care goals) dated 6/7/21 was reviewed. Resident 1's fall risk care plan indicated, .Focus . At risk for falls related to: fell in the past 30 days, poor safety awareness (lack of safety knowledge), generalized weakness, unsteady gait (persons manner of walking), poor balance . Resident is non-compliant with the use of FWW in the room despite cueing (reminder) and encouragement . Goal . Minimize risk for fall and fall related injuries . Interventions . Keep environment well-lit and free of clutter . remove extra walker in the room (s/p fall 6/23/2021) . LVN 1 stated care plans were necessary because they were the instructions on how to keep residents safe and improve their health. During an interview on 7/12/21, at 1:15 p.m., with LVN 2, LVN 2 stated, she was the LVN assigned to Resident 1 the day of Resident 1's fall. LVN 2 stated on the evening shift of 6/23/21, she (LVN 2) stood in the doorway to Resident 1's room. LVN 2 stated Resident 1 walked out of the bathroom without her FWW, she (LVN 2) asked Resident 1 if she needed a pain pill and turned her (LVN 2) back to Resident 1 where she (LVN) faced the medication cart and her back faced Resident 1. LVN 2 stated she heard the walker that was propped (positioned) at the foot of Resident 1's bed hit against the footboard (board or platform which support the foot or feet). LVN 2 stated she turned around and witnessed Resident 1's fall. LVN 2 stated she witnessed Resident 1 grab the walker that was at the foot of her bed as she fell on to the floor and landed on her left knee. LVN 2 stated Resident 1 verbalized she was mad the walker was left at the foot of her bed. LVN 2 stated the walker that was propped up against the footboard of Resident 1's bed was an extra walker Resident 1 did not use. LVN 2 stated Resident 1 already had a 4WW and a FWW in her room and LVN 2 was unsure where the third walker came from or why it was left at the foot of the bed. LVN 2 stated the third walker was left in Resident 1's path from the bathroom and caused Resident 1 to trip and fall. During a concurrent interview and record review on 7/12/21, at 2 p.m., with the Director of Nurses (DON), Resident 1's MDS Assessment, Section G (Function Status) dated 6/14/21 (prior to fall on 6/23/21), was reviewed. Resident 1's MDS Assessment Section G indicated, . B. Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . code 2 (one-person physical assist) . C. Walk in room-how resident walks between locations in his/her room Code 2 . D. Walk in corridor-how resident walks in corridor on unit . code 1 (Set up help only) . I. Toilet use-how resident uses the toilet room, commode . code 2 . The DON stated the MDS Section G indicated Resident 1 required one-person physical assistance to walk in room, bed mobility and transfers. The DON stated Resident 1 needed another person to safely ambulate in the room. The DON stated Resident 1 already had a walker in her room assigned to her by physical therapy. The DON stated Resident 1's fall was avoidable, the fall was caused by Resident 1 tripping on an extra walker left in her room by the Occupational Therapist (OT- work with patients to build or restore their abilities to perform the daily tasks of life). During a review of Resident 1's MDS Assessment, Section G, dated 6/14/21 (prior to Resident 1's fall on 6/23/21), the MDS Assessment, Section G indicated, .C. walk in room . code 2 (one person physical assist) . D. Walk in corridor . code 1 (Setup help only) . E. Locomotion (movement or the ability to move from one place to another) on unit . code 2 (One person physical assist) . F. Locomotion off unit . code 1 (Setup help only) . During a review of Resident 1's MDS Assessment, Section G, dated 6/30/21 (after Resident 1's fall on 6/23/21), the MDS Assessment, Section G indicated, .C. walk in room . code 8 (ADL activity itself did not occur) . D. Walk in corridor . code 8 (ADL activity itself did not occur) . E. Locomotion on unit . code 8 (ADL activity itself did not occur) . F. Locomotion off unit . code 8 (ADL activity itself did not occur) . During a review of the facility document titled, IDT (Interdisciplinary Team- group of health care professionals with various areas of expertise who work together toward the goals of their patient) Review, dated 6/24/21, at 1:15 p.m., the IDT Review indicated .on 6/23/21 at 2000 (8:00 p.m.), LVN witnessed the fall, resident was ambulating without the use of assistive device (FWW) from the bathroom to the bed, tripped on the walker by the foot part of the bed, lost her balance and landed on her left knee .resident is at risk for fracture and risk for falling r/t (related to) h/o (history of) multiple falls, non-compliant with the use of FWW, poor safety awareness . During an interview on 7/13/21, at 12:20 p.m., with the OT, the OT stated before Resident 1's fall on 6/23/21, Resident 1 had worked on becoming independent with the goal of moving to an assisted living facility (for people who need help with daily care, but not as much help as a nursing home provides). The OT stated the day Resident 1 fell , he (the OT) went into Resident 1's room and she wanted to walk, so he went out to get a walker for Resident 1 and brought it into Resident 1's room. The OT stated when he returned with a FWW, he did not realize Resident 1 already had a FWW from physical therapy in her room, so he folded up the one he had brought into the room and left it propped against the footboard of the bed. The OT stated he forgot about the FWW in Resident 1's room after therapy. During a concurrent phone interview and record review on 9/3/21, at 12:20 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 1's Admission & baseline careplan/summary, dated 6/7/21 was reviewed. The Admission & baseline careplan/summary indicated, .Fall Risk Assessment . 2. Falls- past three months . 1-2 falls in past 3 months . 5. Gait Balance . Balance problem while walking . Fall Risk Score . Greater than 10 . The MDSC stated Resident 1's fall risk score was 11 and stated Resident 1 was at high risk for falls. During a review of Resident 1's Event Initial Note, dated 6/23/21, at 10:06 p.m., the Event Initial Note indicated, . Event Type: S/P witnessed fall . Date of Event: 6/23/21 . Time of event: 2000 (8:00 p.m.) . Detailed description of event . Res (Resident) AMB (ambulated) out of BR (bathroom) walking towards bed. Tripped on closed walker @ (at) end of bed. Landing on left knee . Patients description of event: 'I tripped on walker' . New Interventions initiated (should address any abnormal assessment findings): Ice pack applied. Order for left knee x-ray (creates pictures of the inside of your body) in am (morning) . During a review of Resident 1's Radiology Report, dated 6/24/21, the Radiology Report indicated, .Knee . Left . Results: There is an acute (severe and sudden onset) fracture of the patella . During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 2018, the P&P indicated, .Fall Risk Factors . 1. Environmental factors that contribute to the risk of falls include . b. poor lighting . obstacles in the footpath . Resident-Centered Approaches to Managing Falls and Fall Risk . 3. Examples of initial approaches might include . a rearrangement of room furniture . changing the lighting .