Every finding on record at Knolls West Post Acute LLC

Based on interview and record review, the facility failed to protect one (1) of 3 sampled Residents (Resident 1) from misappropriation of property (the deliberate misplacement, exploitation, or wrongful use of a resident's money without their consent) when a Licensed Vocational Nurse 1 (LVN 1) allegedly withdrew funds from Resident 1's bank account without Resident 1's knowledge or permission. This failure had the potential to cause Resident 1 financial loss, emotional distress, and a loss of confidence in the facility's ability to safeguard their personal property.Findings: An unannounced visit was made to the facility on July 7, 2026, at 10 AM, to investigate a facility reported incident regarding an allegation of misappropriation of property. A review of Resident 1's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of December 16, 2025. Resident 1 had diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life). During an interview with the Assistant Administrator (AA) on July 7, 2026, at 10:07 AM, the AA stated she called the police and reported the allegation of misappropriation of property. The AA stated the police came on May 21, 2026, and interviewed Resident 1, and she was present during the interview. The AA stated the police officer asked what happened, and Resident 1 stated he went to the bank with the facility's [NAME] Assistant (BA) to check on his balance because when he had called the bank to check on his account, his balance was lower than expected. The AA stated that while at the bank, Resident 1 stated the bank informed him of several unauthorized withdrawals, and Resident 1 filed a fraud report with the bank. The AA stated Resident 1's bank statement with the unauthorized withdrawals indicated LVN 1's name, and she provided LVN 1's name and contact information to the police officer, who stated he would make contact with LVN 1. The AA stated the police officer called the facility and spoke with her on June 1, 2026, and stated the police department had made contact with and arrested LVN 1. The AA stated LVN 1's actual arrest occurred on May 28, 2026. The AA stated the facility terminated LVN 1's employment on June 15, 2026. During an interview with Resident 1 on July 7, 2026, at 12:06 PM, Resident 1 stated his bank card was in his drawer and it went missing and he reported it missing to the facility. Resident 1 stated a staff person from the facility helped him go to the bank to check on his money. Resident 1 stated it was at the bank where he found out someone had taken a lot of his money. Resident 1 stated he did not remember who had taken his money. Resident 1 stated he had received a new bank card from his bank, and it was now locked up with the facility for safety. A review of the facility's policy and procedure (P&P) titled, Resident Rights, dated August 22, 2017, indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, misappropriation of property, and exploitation .

Based on observation, interview, and record review, the facility failed to ensure the policy and procedure (P&P) for change of condition was followed for one (1) of three (3) sampled residents (Resident 1), when one License Vocational Nurse (LVN 1) did not notify the physician and Resident 1's family promptly after Resident 1 eloped (Resident leaves facility without being officially discharged ) on June 11, 2026. This failure resulted in delayed communication regarding a significant change in Resident 1's condition and location placing Resident 1 at risk for injury without timely medical evaluation and follow-up.Findings: During a review of Resident 1's face sheet (contains demographic and medical information), the face sheet indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (any brain disease, damage, or malfunction that alters how your brain works), and epilepsy (a brain condition that causes a person to have repeated, unexpected seizures). During a review of Resident 1's Change of Condition (COC) report, dated June 11, 2026, the COC report indicated, Resident [Resident 1] eloped from facility between the hours of 2:00 AM to 3:00 AM. Resident was picked up and taken to the hospital. [name of the hospital] called facility around 5:00 AM and spoke to Registered Nurse [RN]. RN supervisor informed charge nurse that hospital called and that he was there. Charge nurse called Daughter and notified daughter about situation. AM [morning] nurse notified. During a concurrent telephone interview and record review on June 12, 2026, at 12:20 PM, with LVN 1, Resident 1's COC report, dated June 11, 2026, was reviewed. The COC report indicated Resident 1 had eloped from facility between the hours of 2:00 AM to 3:00 AM. LVN 1 stated that at around 4:00 AM, a Certified Nurse Assistant (CNA) informed her Resident 1 could not be located. LVN 1 stated she completed the COC report and documented the estimated time Resident 1 eloped between the hours of 2:00 AM to 3:00 AM based on CNA's last contact. LVN 1 further stated the facility staff searched both inside and outside the facility after Resident 1 was discovered missing. LVN 1 stated, on June 11, 2026, after 5:00 AM, the RN Supervisor (RNS 1) informed her the hospital had called and reported Resident 1 had been found and transported there. LVN 1 stated she notified Resident 1's family regarding the elopement at approximately 6:30 AM, after receiving information from RNS 1 but she failed to communicate with the physician. LVN 1 stated failure to report to the physician was not acceptable and did not align with facility policy. During an interview on June 15, 2026, at 8:14 AM, with RNS 1, RNS 1 stated he instructed LVN 1 to complete the COC report and to inform Resident 1's family and the physician. RNS 1 stated he did not contact Resident 1's family or the physician himself because he had already directed LVN 1 to do so. During a concurrent telephone interview and record review on June 15, at 11:40 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Change of Condition, dated August 2017, was reviewed. The P&P indicated, .1. The licensed nurse in charge of resident's care shall be responsible for notification of resident (as applicable), resident's primary care physician, family member(s) and/or legal representatives of any change in a resident's status and condition as soon as possible. The DON stated LVN 1 did not comply with the policy by not informing Resident 1's family as soon as the resident was found to be missing and for forgetting to notify the physician.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one (1) of three (3) sampled residents (Resident 1), When one Licensed Vocational Nurse (LVN 1) mistakenly documented that the physician was notified of Resident 1's elopement (Resident leaves the facility without being officially discharged ). This failure resulted in an inaccurate medical record and had the potential to affect communication among healthcare providers and the delivery of resident care.Findings: During a review of Resident 1's face sheet (contains demographic and medical information), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (any brain disease, damage, or malfunction that alters how your brain works), and epilepsy (a brain condition that causes a person to have repeated, unexpected seizures) During a review of Resident 1's Change of Condition (COC) report, dated June 11, 2026, the COC report indicated, Resident 1 eloped from facility between the hours of 2:00AM to 3:00AM.Resident representative/family notified: June 11, 2026, at 00:00. Physician notified: June 11, 2026, at 00:00. During a concurrent telephone interview and record review on June 12, 2026, at 12:20 PM, with LVN 1, Resident 1's COC report, dated June 11, 2026, was reviewed. The COC report indicated that Resident 1's family and physician were notified on June 11, 2026, at 00:00. LVN 1 stated that she informed Resident 1's family about the elopement around 6:30 AM but in the COC report she did not document the time when Resident 1's family was notified, which is why it appeared as 00:00. LVN 1 also admitted that she did not inform the physician, she wrote the physician's name on the COC form but forgot to contact the physician. LVN 1 acknowledged that inaccurate documentation was not acceptable and did not align with facility policy. During a concurrent telephone interview and record review on June 15, 2026, at 3:37 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Documentation Principles, dated August 22, 2017, was reviewed. The P&P indicated, .4. Entries in the clinical record must be accurate, legible, clear and timely (recorded within the required time period) .11. Each entry in the clinical record must be dated with month, date and year. The DON stated in this case, LVN 1 was not compliance with the policy.

Based on interview and record review, the facility failed to ensure medical records were processed and released in accordance with facility policy and federal regulations for one of four residents (Resident 1). This failure had the potential to jeopardize Resident 1's authorized representative's access to medical records through lawful authorization requests, potentially adversely impacting legal matters related to the resident.During a review of Resident 1's face sheet (contains demographic and medical information), it indicated Resident 1 was admitted to facility on April 2, 2025, with diagnoses that included chronic obstructive pulmonary disease (lung condition that makes breathing difficult due to damaged), acute respiratory failure (life threatening sudden inability of the lungs to oxygenate blood or carbon dioxide), and type 2 diabetes mellitus (disorder characterized by high blood sugar). During a telephone interview with the Law Office Staff, on May 6, 2026, at 8:43 AM, she stated their law office had been requesting Resident's 1 medical records from the facility since January 28, 2026 (more than three months ago). She further stated they have re-submitted the request multiple times, but they still have not received the requested records for Resident 1. During a review of the facility provided document titled Fax Cover Sheet, sent by the Law Office Staff to the facility on April 2, 2026, at 3:19 PM, and received by the facility the same day at 3:20 PM, it indicated .Our office has made multiple attempts to obtain the requested medical records from your facility regarding the above-referenced patient. Despite repeated calls, we are consistently routed to voicemail and have not received any response . Further review of the facility provided document titled Fax Cover Sheet, dated April 2, 2026, it indicated a phone call was made by the facility to the Law Office Staff on May 7, 2026, at 2:00 PM (35 days after the fax was received). During a follow up telephone interview with the Law Office Staff, on May 8, 2026, at 10:38 AM, she stated the Administrator (Admin) contacted her on May 7, 2026, and informed her that the facility would mail Resident 1's medical records within 48 hours after receiving the payment. The Law Office Staff further stated this was the first time the facility had reached out to them. During a concurrent telephone interview and record review, on May 12, 2026, at 3:57 PM, with the Director of Nursing (DON), the DON reviewed and acknowledged the facility's policy and procedure (P&P) titled, Privacy, with a subject, Resident/Personal Representative Access to Protected Health Information, dated January 2026, which indicated, The facility will provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual (if it is readily producible in such form and format, including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) [CFR(s): 483.1 0(g)(2)(i)]. and the State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, concerning resident's right to access personal and medical records, the regulation specifies . The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility.

Based on interview and record review, the facility failed to ensure medical records were processed and released according to federal regulations for one of four residents (Resident 1).This failure had the potential to jeopardize Resident 1's authorized representative's access to medical records through lawful authorization requests, potentially adversely impacting legal matters related to the resident. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that includes encounter for surgical aftercare following surgery on the digestive system (focuses on pain management, wound care, and gradual dietary changes to avoid complications following operation), encounter for attention to ileostomy (maintenance of stoma [surgically created opening on the stomach that diverts waste]) , and benign neoplasm of transverse colon (non-cancerous, non-spreading growth on the large intestines).During a telephone interview with a staff from Resident 1's legal representative (Legal Staff) on March 30, 2026, at 12:19 PM, she stated as of March 26, 2026, the law office has not yet received the medical records requested from the facility. Legal Staff further stated the initial request was transmitted via fax on February 26, 2026.During a concurrent interview on record review on April 2, 2026, at 1:21 PM, the Medical Record Director (MRD) reviewed the documentation confirming that third-party services for the Law Offices requested medical records for Resident 1 on February 26, 2026. The MRD stated he submitted the requested documents to the Director of Nursing (DON) for review, over a month ago, but has not yet received them back to proceed with the release of medical records.During a concurrent interview and record review on April 2, 2026, at 1:45 PM, with the Assistant Director of Nursing (ADON), The State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, concerning resident's right to access personal and medical records, the regulation specifies . The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility. The ADON acknowledged that the regulation was not followed by the facility.

Based on observation, interview, and record review, the facility failed to maintain food safety practices in the kitchen as required by facility's policy and procedure (P&P). The facility did not ensure food preparation areas, equipment, and storage were kept clean, labeled, and safe and failed to prevent cross-contamination, improper thawing and unsanitary conditions when: 1. One kitchen staff was not wearing a hairnet in the food prep area. 2. The juice machine nuzzle, and black rubber ring had dark grime, old stains, and residue. 3. Six red colored drink pitchers were left on a counter without date labels. 4. A large blue plastic container labeled ICE ONLY was found uncovered and filled with ice on a metal prep table. 5. Two dented cans (6 lbs.) of pears in light syrup were found in the kitchen ready to use. 6. About 20 packages of raw meat were thawing in stacked plastic container under running water in the sanitizing compartment of the three-compartment sink; the meat was not labeled with thawing dates and temperature measured 62.4 F. 7. Four trays of uncovered deserts bowls were found in the refrigerator. 8. Two ovens had heavy grease, burnt food particles, and dark residue of interior walls racks and the oven floor; two loose screws were also found inside the bottom of one of the non-working ovens. The ovens contained heavy greasy, burnt food particles, dark residue on the interior walls, and debris on the oven floor. 9. The stove burners were covered in thick black greased and crumbled food debris 10. The flat top griddle had layers of grease stains and dark discoloration with a dirty spatula resting on its edged. 11. Personal beverages and food items belonging to staff were stored inside the refrigerator designated for resident food. These failures have the potential to result in foodborne illness(caused by eating food or drinking water contaminated with harmful germs such as bacteria, parasites, or viruses) for 100 of 103 residents who rely on the kitchen for their meals and beverages. Findings: 1. During a concurrent observation and interview on May 19, 2025, at 8:32 AM with the Dietary Aid 1 (DA 1), the DA 1 was working inside the kitchen food preparation area without wearing a hairnet. DA 1 acknowledged the requirement and stated Yes, I will put one on. During a concurrent interview and record review on May 19, 2025, at 8:42 AM with the Dietary Supervisor (DSS)the facility's policy and procedure (P&P) titled Food Preparation and Service, dated August 22, 2017, was reviewed. The P&P indicated, Food and nutrition services staff swear hair restraints (hair net, hat beard restrain, etc.) so that hair does not contact food. The DSS stated that it was the facility's expectation for staff to wear proper hairnets while working inside the kitchen areas and that the staff did not follow the P&P. 2. During a concurrent observation and interview on May 19, 2025, at 8:35 AM with DA 1, during a juice machine inspection, the juice machine was observed with a juice nozzle and surrounding black rubber ring. It was observed to be visible dirty and stained and covered with old residue and grime buildup. The clear plastic dispenser handle had yellow and red residue trapped inside and appeared discolored. The DA 1 acknowledged the condition and stated the equipment should be clean. During a concurrent interview and record review on May 22, 2025, at 8:35 AM with the Dietary Supervisor (DSS) the facility's policy and procedure (P&P) titled, Sanitation, dated August 22, 2017, was reviewed. The P&P indicated, All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. The DSS stated that the expectation was for staff to clean and sanitize the juice machine regularly as part of daily cleaning routines and confirmed that the policy was not followed by staff. 3. During an concurrent observation and interview on May 19, 2025, at 8:36 AM with Dietary Aid 1 (DA 1), six drink pitchers were observed on a metal preparation table filled with dark red liquid. The pitchers were unlabeled with the date indicating when they were prepared. The DA 1 confirmed the six pitchers should have been labeled with the preparation date, to track when they were prepared. During a concurrent interview and record review on May 22, 2025, at 8:44 AM with the Dietary Services supervisor (DSS), the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated Revised January 2020 was reviewed. The P&P indicated, 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). The DSS stated that the expectation for staff was to label the drink pitchers with the preparation date. The DSS confirmed that the P&P was not follow by the staff. 4. During a concurrent observation and interview on May 19, 2025, at 8:37 AM with Dietary Supervisor Assistant 1(DSSA 1), a large blue plastic container labeled ICE ONLY was observed uncovered and filled with ice on top of a metal preparation table. The container was open to the air and left uncovered. DSSA 1 confirmed the ice container should have been covered and not left open to air. During a concurrent interview and record review on May 22, 2025, at 8:46 AM with the Dietary Services Supervisor (DSS) the facility's policy and procedure (P&P) titled, Food Preparation and services, dated August 2017, was reviewed. The P&P indicated, 5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food bone illness. The DSS stated that ice is considered food and confirmed that the ice container should be covered when not in use to protect it from contamination. The DSS acknowledged that the P&P was not followed by staff. 5. During a concurrent observation and interview on May 19, 2025, at 8:39 AM with Dietary Aide 1 (DA 1), two dented 6 - lbs. (six, pounds measure of weight) were found on the bottom area of a metal car in the kitchen's ready to use section. The DA 1 confirmed that dented cans should not be used and acknowledged they were incorrectly placed in the ready to use section. During a concurrent interview wand record review on May 22, 2025, at 8:51 AM with Dietary Services Supervisor (DSS), the facility's policy and procedure (P&P) titled, Food Receiving and Storage. Dated Revised January 2020 was reviewed. The P&P indicated, Food that are prepared off site will only be accepted from institutions that are subject to federal, state or local inspection. The food and nutrition services manager shall verify the latest approved inspection and also monitor food quality of the supplier. The DSS stated that dented cans should be removed and discarded. The DSS acknowledged that the policy was not follow by staff. 6. During a concurrent observation and interview on May 19, 2025, at 8:40 AM with Dietary services Supervisor 1 (DSSA 1) approximately 20 packages of raw meat were observed thawing inside two stacked clear plastic containers under running water in the sanitize compartment off the three-compartment sink. DSSA 1 confirmed the packages were unlabeled and acknowledged that the facility did not maintain a thawing log. During a follow up observation and interview on May 19, 2025, at 9:38 AM with [NAME] 1 and DSSA 1, meat temperature was measured the temperature of the raw meat was found at 62.4 F and the [NAME] 1 stated that the meat had been thawing since 6:00 AM. [NAME] 1 further stated the meat would need to be discarded because the temperature exceeded the safe limit (above 41 F) increasing the risk of foodborne illness. DSSA 1 confirmed the meat should be kept at or below 41 F to remain safe. During an interview on May 19, 2025, at 4:46 PM with the Registered Dietitian (RD), the RD stated the facility standard procedure is to thaw meat in the refrigerator over approximately three days and that using the running water method is only acceptable if done correctly and for less than two hours. The RD confirmed the observed practice of thawing meat in the sanitize sink under running water was not the preferred method and acknowledged that no thawing log was maintained. The RD further stated that the staff education is needed to ensure proper thawing methods. During a concurrent interview and record review on May 22, 2025, at 8:55 AM with the Dietary Services Supervisor (DSS), the facility's policy and procedure (P&P) titled, Food Preparation and Service, dated August 22, 2017, was reviewed. The P&P indicted, Thawing Frozen Food, 1. Foods will not be thawed at room temperature. Thawing procedures include a. Thawing the refrigerator in a drip-proof container; b. completely submerging the item in cold running water (70 F or below) that is running fast enough to agitate and remove loose ice particles . The DSS stated the expectation was for staff to follow the proper thawing procedures, explaining that correct thawing is important to avoid foodborne hazards, and confirmed that the policy was not follow by staff. 7. During a concurrent observation and interview on May 19, 2025, at 8:54 AM with Dietary Services Supervisor Assistant 1 (DSSA 1) the walking refrigerator was inspected and there were four trays with bowls of uncovered resident desserts were observed stored inside the refrigerator. The trays were not covered, leaving the food exposed to the air. DSSA 1 acknowledged that the desserts should have been covered to prevent contamination. During a concurrent interview and record review on May 22, 2025, at 8:56 AM with the Dietary Services supervisor (DSS), the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated Revised January 2020, was reviewed. The P&P indicated, 8. All foods stored in the refrigerator or freezer will be covered . The DSS stated all foods should be covered while inside the refrigerator. The DSS confirmed the P&P was not follow by the staff. 8. During a concurrent observation and interview on May 19, 2025, at 9:05 AM with Dietary Supervisor Assistant 1 (DSSA 1), two out of five ovens were inspected inside the kitchen. Oven 2 was observed with heavy grease and burned food suck on the inside walls and racks and floor pan. Rust was noted on the oven racks, and no signs of recent cleaning or sanitization were evident. The DSSA 1 confirmed that the oven should have been cleaned regularly even if not in use. During a concurrent observation and interview on May 19, 2025, at 9:06 AM with Dietary Supervisor Assistant 1(DSSA 1). Oven 3 was inspected inside the kitchen. The oven was visibly dirty with thick layers of burnt food particles, dark grease stains, and heavy discoloration across the interior surfaces, including the walls, racks, and bottom pan. Two loose screws were noted inside the oven bottom. DSSA 1 stated although the oven was reported as out of order, it should still have been cleaned by staff. During a concurrent interview and record review on May 22, 2025, at 9:08 AM with the Dietary Services Supervisor (DSS), the facility's policy and procedure (P&P) titled, Sanitation, dated August 17, 2017, was reviewed. The P&P indicated, 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fastener will be kept in good repair .17. The food services manage will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness thought their work areas during all tasks, and to clean after task before proceeding to the next assignment. The DSS stated that staff are expected to follow the sanitation policy, ensuring all equipment including nonfunctional ovens, is kept clean. The DSS acknowledged that the P&P was not followed by the staff. 9. During a concurrent observation and interview on May 19, 2025, at 9:07 AM with Dietary Supervisor Assistant 1(DSSA 1), the kitchen stove burners were inspected and found with a thick layer of blackened grease, burned food residue, and crumbled food debris across the top surface and burners. DSSA 1 stated the stove should have been regularly cleaned and confirmed that the equipment was not found in a clean condition. During a concurrent interview and record review on May 22, 2025 , at 9:09 AM with the Dietary Services Supervisor (DSS), the facility policy and procedure (P&P) titled, Sanitization dated August 17, 2017, was reviewed. The P&P indicated, 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fastener will be kept in good repair .17. The food services manage will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness thought their work areas during all tasks, and to clean after task before proceeding to the next assignment. The DSS acknowledged the P&P was not followed by staff. 10. During a concurrent observation and interview on May 19, 2025, at 9:12 AM with Dietary Supervisor Assistant 1 (DSSA 1) the flat top griddle inside the kitchen was inspected and found with thick layers of dark grease stains, burnt food residues, and heavy discoloration across the surface. A dirty spatula was resting on the edge of the griddle. DSSA 1 stated that the griddle should have been cleaned regularly after each use and confirmed that it was found unclean. During a concurrent interview and record review on May 22, 2025, at 9:12 AM with the Dietary Services Supervisor (DSS), the facility's policy and procedure (P&P) titled, Sanitization, dated August 17, 2017, was reviewed. The P&P indicated, 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fastener will be kept in good repair The DSS stated that staff are expected to clean the griddle regularly, have cleaning logs and deep cleaning rotations, and acknowledged the staff did not follow the P&P. 11. During a concurrent observation and interview won May 19, 2025, at 9:14 AM with the with Dietary supervisor assistant (DSSA 1), personal food and beverage items were found stored inside the refrigerator designated for residents' food. These included three opened bottles of water, two canned drinks, multiple condiments cups containing left over food, and a grocery store plastic bag (labeled with name of an employee). DSSA 1 confirmed that staff are not allowed to store their personal items in the resident designated refrigerator and acknowledged the refrigerator should be kept free of non-resident items to avoid cross contamination. During an concurrent interview and record review on May 22, 2025, at 9:18 AM with the Dietary Services Supervisor (DSS), the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised January 2020, was reviewed. The P&P indicated, 14 d. Beverages must be dated, when opened and discarded after twenty-four (24 ) hours .f. Partially eaten food may not be kept in the refrigerator. The DSS stated the staff should not place personal items in the resident designated refrigerator to avoid cross - contamination and confirmed that the P&P was not follow by staff.

Based on observation, interview, and record review, the facility failed to maintain essential kitchen equipment in safety operating condition when: 1. Two ovens located in the kitchen were observed to be non-functional not in use, yet they remained accessible and unmarked as out of order. This failure has the potential to result in limited cooking capacity, delays, and disruption in the kitchen's ability to deliver timely meals and maintain appropriate sanitation. Findings: During a concurrent observation and interview on May 19, 2025, at 9:06 AM with the Dietary Services Supervisor Assistant 1 (DSSA 1) inside the kitchen, during and inspection two of five ovens were to be visible nonfunctional. The second oven (Oven 2) had heavy blackened residue, grease build up, burned on grease and buildup from old food spills, along with rust on the interior walls, racks and bottom tray. The oven was grimy and clearly nonoperational, with no signage or markings indicating it was out of order. DSSA 1 stated the oven should be cleaned and kept in working condition and further confirmed that oven had been out of order for some time and, although maintenance had been notified, no repairs had been completed. During a concurrent observation and interview on May 19, 2025, at 9:10 AM with the DSSA 1, a third oven (Oven 3) was inspected and found to be nonfunctional and contained two loose screws on their interior bottom surface. DSSA 1 confirmed that Oven 3 was also out of order and had been reported to maintenance but was not labeled or marked as out of service. DSSA 1 acknowledged that even nonworking equipment should have been kept clean. During a concurrent interview and record review on May 21, 2025, at 9:21 AM with the Dietary Services Supervisor (DSS), the facility's policy and procedure (P&P) titled, Sanitation, dated August 22, 2017, was reviewed. The P&P indicated, 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair .16, Kitchen and .surfaces not in contact with food shall be cleaned on a regular scheduled and frequently enough to prevent accumulation of grime. The DSS stated that the two nonfunctional ovens (Oven 2 and Oven 3) had been out of order since February 2025 (approximately 1.5 to 2 months) and that maintenance had been notified. The DSS acknowledged that the equipment should have been labeled as out of order and kept clean even when not in use. The DSS further confirmed that although maintenance had been contacted and follow up was expected, no repairs had yet been made. The DSS also stated that staff are expected to clean equipment daily, including items like grills and top burners, even if the equipment is not currently operational The DSS explained that the pilot lights on the ovens would not stay lit, and [NAME] ovens were not currently in use, the staff had not followed the facility's sanitation P&P.

Based on interview, and record review, the facility did not ensure physician's visits were conducted or physician's orders were signed in a timely manner when: 1. Two of eight sampled residents (Residents 19 and 22) were missing required physician's visits for their Medicare Part A&B (Government hospital insurance and medical insurance) stay. This failure had the potential to result in transcription errors for Resident 19 and 22. 2. Four of eight sampled residents (Resident 14, 44, 56, and 43) had unsigned physician's orders in their chart. This failure had the potential to result in medical errors, and increased risk to resident's safety for Resident 14, 44, 56, and 43. Findings: 1. A review of Resident 19's face sheet (demographic information) indicates Resident 19 is an [AGE] year-old female, admitted from the hospital on March 12, 2025, with diagnoses which include arthritis (redness, painful, swollen joint), atrial fibrillation (irregular rhythm that disrupts the normal flow of blood through the heart), hyperlipidemia (having too much fat in the blood), dementia (group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), nutritional deficiency (occurs when someone doesn't get enough of the essential nutrients their body needs to function properly, like vitamins, minerals, or protein), fracture of left femur (a break in the femur, the largest and strongest bone in the human body). Resident 19 was admitted to the facility under a short term stay with Medicare coverage part A&B. During a review on May 20, 2025, of Resident 19's medical chart, it was noted that all physician's orders since Resident 19 admission on March 12, 2025, are red flagged for physician's signature. A record review of Resident 19's physician's orders (written instructions from a doctor outlining what should be done for a Resident 19 care and treatment) indicates the physician's orders were received via phone and there are no physician's signatures for the months of March 2025, April 2025, and May 2025 physician orders. A record review of Resident 22's face sheet (demographic information) indicates the resident is a [AGE] year-old female, admitted from the hospital on April 8th, 2025, with diagnoses which include end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), diabetes mellitus (high blood sugars), morbid obesity (a complex chronic disease in which you have a body mass index (BMI) of 40 or higher), dependence on renal dialysis (Dialysis acts as a substitute for the kidneys, filtering the blood and removing waste products), hypertension (high blood pressure), muscle weakness, major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), history of falling. Resident 22 was admitted to the facility under a short term stay with Medicare coverage part A&B. During a review on May 20, 2025, of Resident 22's medical chart, it was noted that all physician's orders since Resident 22 admission on April 8th, 2025, are red flagged for physician's signature. A record review of Resident 22's physician's orders indicates the physician's orders were received via phone and there are no physician signatures for the months of April 2025 and May 2025 physician's orders. In an interview with the Assistant Director of Nursing 1 (ADON 1) on May 22, 2025, at 12:10 PM, the ADON 1 acknowledged that in a skilled nursing facility the first physician visit (this includes the initial comprehensive visit) must be conducted within the first 30 days after admission, and then at 30-day intervals up until 90 days after the admitted . The ADON 1 stated that the facility notified the physician several times via fax of the overdue visit. During a concurrent interview and record review on May 22, 2025, at 12:18 PM with the ADON 1, the facility's Policy and Procedure (P&P) titled, Physician Visits, dated August 22, 2017, was reviewed. The P&P states, 1. The attending physician will visit residents in a timely fashion, consistent with applicable State and Federal requirements . 2. The attending physician must visit his/her patients within 72 hours of admission, at least once every 30 days for the first 90 days following the resident's admission, and then at least every 60 days thereafter . 6. a physician visit is considered timely if it occurs no later than 10 days after the date the visit was required . The ADON 1 stated that the physicians were reminded by fax that their visits are overdue on several occasions. The ADON 1 stated the physicians responded to facility phone calls, provided verbal orders, and visited the facility during this timeframe and does not know as of why the documentation is not completed and orders are not signed. The ADON 1 recognized that as of May 22, 2025, all physician Orders for Residents 19 and 22 are not signed and dated by the physicians. ADON 1 acknowledged that the facility's P&P was not followed. 51099 2. During a record review on May 20, 2025, at 9:15 AM, Resident 14's medical chart was reviewed. The physician order dated March 31, 2025, indicated, .D/C [discontinue] Benadryl [a medication used for allergies]. Alprazolam [a medication used for anxiety] 0.5 MG [milligram- a unit of measurement] tab [tablet] PO [by mouth] BID [twice a day] PRN [as needed] x [times] 30 days; Dx anxiety m/b [manifested by] inability to relax. Continue all monitors . The order was not signed by the physician. During a record review on May 20, 2025, at 9:23 AM, Resident 44's medical chart was reviewed. The physician order dated February 2, 2025, indicated, .0.1 MG Clonidine [a medication used for blood pressure] PO Q 6 H [hours] PRN for SBP [systolic blood pressure] > [greater than] 160. Monitor for BP [blood pressure] Q 6 H for PRN Clonidine use . The physician order dated February 27, 2025, indicated, .Rebels [a medication for high blood sugar] 7 MG tab PO QD [every day] AC [before] Breakfast; Dx [diagnoses]; DM . The orders were not signed by the physician. During a record review on May 20, 2025, at 9:30 AM, Resident 56's medical chart was reviewed. The physician order dated March 20, 2025, indicated, .Discontinue D 5 NS [dextrose in normal saline- a type of fluid given through the veins of the resident]; discontinue norepinephrine [a medication that helps regulates heart rate, blood pressure, attention, memory, and emotion]; discontinue dilaudid [a pain medication]; discontinue morphine [a pain medication] . The physician order dated April 8, 2025, indicated, .Flagyl [an antibiotics] 500 MG PO TID [three times a day] x 10 days; Dx: C-diff [an infection of the gut] . The orders were not signed by the physician. During a record review on May 20, 2025, at 9:39 AM, Resident 43's medical chart was reviewed. The physician order dated April 14, 2025, indicated, .D/C contact isolation precautions . The order was not signed by the physician. During a concurrent interview and record review on May 20, 2025, at 11:50 AM, with the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, Telephone Orders, revised 2017, was reviewed. The P&P indicated, .Telephone orders must be countersigned by the physician during his or her next visit . The ADON stated facility did not follow the P&P.

Based on observation, interview, and record review, the facility failed to ensure it followed its infection control program when: 1. A Registered nurse Supervisor 3 (RNS 3) did not perform hand hygiene (hand washing or the use of alcohol based hand sanitizer) after performing a blood glucose check (procedure done to check the level of sugar in the blood and requires a pinprick blood sample). This failure had the potential for the spread of infectious blood borne pathogens (bacteria and viruses which can cause disease and illness) and the spread of infectious microorganisms from one patient to another in a vulnerable population of 106 patients. 2. There was a bag of intravenous antibiotics (antibiotics administered into the veins) and IV tubing set (disposable IV set used to administer medication intravenously) dated [DATE] and [DATE], left at Patient 33 bedside on [DATE] (23 days after it was used). This failure had the potential for inadvertent use of an expired IV tubing set or antibiotic bag which was past its expiration date placing the resident at increased risk of infection. Findings: 1. During an observation on [DATE], at 5:37 AM, with Registered Nurse Supervisor 3 (RNS 3), RNS 3 used a lancet (a device used to pinprick a finger and create a drop of blood) to test Resident 69's blood sugar (amount of sugar in the blood). After RNS 3 obtained a blood sample from Resident 69 and tested the resident's blood sugar, RNS 3 took off his gloves and began documenting in the Medication Administration Record (a document used to record the administration of medications). During continued observation on [DATE], at 5:51 AM, with RNS 3, RNS 3 completed medication administration for Resident 69 and began preparing the medications for administration to his next resident. RNS 3 still had not performed hand hygiene after performing a blood glucose test on Resident 69. During an interview on [DATE], at 5:56 AM, with RNS 3, RNS 3 stated he didn't perform hand hygiene after removing the gloves he used to check Resident 69's blood sugar because he forgot. RNS 3 further stated he was supposed to use hand sanitizer immediately after removing his gloves and prior to preparing another patients medications but he didn't. RNS 3 stated the Licensed Vocational Nurse who was supposed to work the current shift had called off and that was why he had to administer medications. The RNS 3 stated it had been a while since he had to administer medications. During an interview on [DATE], at 8:37 AM, with the Infection Preventionist (IP), the IP stated staff were supposed to perform hand hygiene immediately after removing their gloves. The IP further stated staff should also be doing hand hygiene before and after performing a blood glucose check on a resident. The IP stated it was important to perform hand hygiene to help prevent the spread of infectious microorganisms. During an interview on [DATE], at 11:51 AM, with the Assistant Director of Nursing 2 (ADON 2), the ADON 2 stated staff should be performing hand hygiene after removing gloves and after using a glucometer (device used to check blood sugar) because it was important to prevent cross contamination (the spread of micro-organisms from one person or object to another) between patients for infection control. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated [DATE], the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before and after handling an invasive device .l. After removing gloves .8. Hand hygiene is the final step after removing and disposing of personal protective equipment [i.e. gloves] . 51361 2. During a review of Resident 33's clinical record, the Admission Record (a document that gives a summary of residents information) indicated Resident 33 was admitted to the facility on [DATE] with the diagnoses of Cellulitis (a kin infection that causes swelling and redness), Acute Respiratory Failure with Hypoxia, Essential Hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During an observation on [DATE] at 10:23 AM, Resident 33 was found to have two intravenous (IV) pole was found next to Resident 33 bed with two empty IV medication bags with tubing, labeled Ceftriaxone (medication used to treat infection) 2 gm into 100 ML of Normal Saline with attached tubing dated [DATE], (32 days later) and the second labeled Ceftriaxone (medication used to treat infection) 2 gm into 100 ML of Normal Saline with tubing labeled with an expiration date of [DATE] (31 days). During a concurrent observation and interview on [DATE] at 4:06 PM, with the Director of Nursing (DON), the DON confirmed that the medication bags were dated [DATE] and [DATE] and further stated that the medication bag should have been removed following the administration completion. During a concurrent interview and record review on [DATE] at 1:08 PM with the DON, the facility's policy and procedure (P&P) titled, Infection Control Universal Precautions was reviewed. The P&P indicated .All personnel involved with administering IV therapy will comply with universal precaution guidelines on all patients during any and all IV therapy procedures. The DON confirmed the P&P was not followed.

Based on observation, interview, and record review, the facility failed to maintain resident dignity for one of seven sampled residents (Resident 311) reviewed for dignity practices by not providing a dignity bag (a cover placed over a urine collection bag so others cannot see the urine) for the foley catheter bag (a thin tube place in the bladder to drain urine into a bag) which exposed the urine contents to public view. This failure has the potential to cause Resident 311 embarrassment, and emotional distress (Feeling upset, anxious or humiliated), and loss of dignity (feeling disrespected or devaluated as a person). Findings: During a review of Resident 311's Admission Record (contains demographic and medical information) indicated Resident 311 was admitted to the facility on [DATE], with the admitted diagnosis of hemiplegia and hemiparesis following cerebral infarction (weakness on one side of the body (left side) after a stroke making it hard to move), Acute and Chronic Respiratory failure ( the lungs don't work properly, causing breathing problems that make them weak, and unable to get enough oxygen), and congestive heart failure (the heart isn't pumping blood well, which can cause swelling and tiredness). During an observation on May 19, 2025, at 11:55 AM inside Resident 311's room, Resident 311 was observed lying down in bed with head of the bed elevated, awake, alert and oriented to name, time and place. On the left side of the bed, a urine collection bag was visibly hanging, filled with yellow urine and attached to a catheter tubing. The bag was uncovered, with no dignity cover or privacy bag in place. During an interview on May 19, 2025, at 11:56 AM with Resident 311, the Resident 311 stated that he uses the urine bag because he cannot urinate on his own and that the nurses take care of it. During an interview on May 19, 2025, at 11:59 AM with Certified Nurse Assistant 3 (CNA 3), CNA 3 confirmed that the urine bag should have been place inside a dignity bag to protect the resident's privacy. During an interview on May 19, 2025, at 12:01 PM inside Resident 311's room with the Assistant Director of Nursing (ADON), the ADON acknowledge and stated that the urine collection bag should be place inside a dignity cover (privacy bag) to ensure resident privacy and for infection control. During a review of Resident 311's Physician Orders dated May 7, 2025 indicated, Foley catheter (a thin, flexible tube inserted into the bladder to drain urine into a bag when someone cannot pee on their own), FR # 16 x 10 cc (the catheter size is French size 16, which is the tube width and 10 cc balloon refers to a mall balloon at the tip that is filled with 10 milliliters of water to hold the catheter in place) to gravity drainage (the urine drains down naturally from the bladder into a collection using gravity) Dx (diagnosis) Neurogenic bladder (the bladder doesn't work properly, the person cannot fully control when or how they urinate) . During a review of Resident 311's Care Plan dated May 8, 2025, indicated, suprapubic catheter (a thin, flexible tube placed through the lower belly directly into the bladder to drain urine when someone cannot urinate thought on their own) .risk: infection / irritation at Suprapubic Site, Goals, suprapubic site will be free from infection QD (daily), Intervention .,provide privacy, promote dignity . During a concurrent interview and record review on May 22, 2025, at 10:48 AM with ADON, the facility's P&P titled, Dignity Dignity, dated August 22, 2017, was review. The P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents: for example: a. helping the resident to keep urinary catheter bags covered . The ADON confirmed that the staff did not follow the facility's P&P.

Based on interview, and record review, the facility failed to ensure a copy of the notice of transfer or discharge were sent to the Ombudsman for one of two sampled residents (Resident 106) reviewed for hospitalization when Resident 106 was sent to the hospital on February 9, 2025, and there was no copy of notice of transfer or discharge sent to the Ombudsman. This failure had the potential for Resident 106 to be inappropriately transferred or discharged . Findings: During a review of Resident 106's clinical record, the Admission Record (a document that gives a summary of resident's information) indicated Resident 106 was admitted to the facility on [DATE] for cellulitis (infection of the skin) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review Resident 106's physician order (a set of instructions written by a doctor for the care of the resident) dated February 9, 2025, the physician's order indicated, Send patient to Desert Valley Hospital related to: left 4th toe infection. During a subsequent review of Resident 106's hospitalization paperwork, dated February 9, 2025, there was no record of the notice of transfer or discharge sent to the Ombudsman. During a concurrent interview and record review on May 21, 2025, at 9:30 AM with the Director of Nursing (DON) the regulation F-623 was reviewed. It stated, Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The DON stated that the notification of the ombudsman is done by the social worker. During a concurrent interview and record review on May 21, 2025, at 9:57 AM with the Social Services, Resident 106's hospitalization paperwork, dated February 9,2025, was reviewed. The Social Services stated the notification to the Ombudsman is only done for planned discharges that are sent home, board and care or other skilled nursing facilities. The Social Worker further stated that there is no notification sent when the resident is sent to the hospital. During a subsequent interview and record review on May 21, 2025, at 10:00 AM with the Medical Records, Residents 106's chart was reviewed. The Medical Record stated when residents are sent out to he hospital, duplicate transfer sheets are used for resident information, however there is no record sent from medical records to the ombudsman, that task is handled by the social worker. During an interview and record review with the DON and the Administrator on May 21, 2025, at 1:56 PM, the Administrator stated that there is no process, policy or procedure for notification for transfers. The Administrator stated there was no process in place to notify the ombudsman for residents sent to the hospital. The DON further stated this process was not a nursing issue but was an issue for the social services, and there is no notification sent for residents being discharged or transferred to a hospital setting.

Based on interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for two sampled residents (Resident 84 and Resident 99) when: 1. For Resident 84's RAI-MDS assessment was not coded to indicate she had a diagnosis of schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves). 2. For Resident 99's RAI-MDS assessment was not coded to indicate she had a stage 1 pressure ulcer (bed sore). These failures resulted in the MDS assessments for Resident's 84 and 99 to inaccurately reflect their current medical status which had the potential to result in unmet care needs for the residents. Findings: 1. During a review of Resident 84's Admission Record, (contains medical and demographic information), the Admission Record, indicated Resident 84 was initially admitted on [DATE], with admitting diagnoses which included schizophrenia, hemiplegia and hemiparesis (weakness and paralysis on one side of the body), altered mental status, and dementia (term for loss of memory, language, problem-solving and other thinking abilities. During a review of Resident 84's RAI-MDS assessment dated [DATE], the assessment indicated, Section I - Active Diagnoses - Psychiatric/Mood Disorder was not coded to indicate Resident 84 had the diagnosis of schizophrenia as the checkbox I6000 Schizophrenia, was left unchecked. During a concurrent interview and record review on May 22, 2025, at 10:37 AM, with the Assistant Director of Nursing 1 (ADON 1), Resident 84's RAI-MDS assessment dated [DATE], was reviewed. The ADON 1 stated Resident 84 had a diagnosis of schizophrenia and the MDS assessment should have indicated that but it did not. The ADON 1 further stated the facility used the current version of the RAI manual as their policy and procedure. During an interview on May 22, 2025, at 10:55 AM, with the Minimum Data Set Nurse (MDS Nurse), the MDS nurse stated the facility incorrectly coded Resident 84's MDS assessment dated [DATE], because it did not include Resident 84's diagnosis of schizophrenia. The MDS Nurse further stated it was an oversight. During a review of current version of the RAI Manual titled, Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Dated October 2024, the manual indicated, .Section I: Active Diagnoses .Intent: the items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status .One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status . 2. During a review of Resident 99's Admission Record, (contains medical and demographic information), the Admission Record, indicated Resident 99 was admitted on [DATE], with diagnoses which included obesity (excess weight), muscle wasting and atrophy (loss or shrinking of muscle tissue), and cellulitis (skin infection) of left toe. During a review of Resident 99's Comprehensive Resident Admission Assessment (an assessment done upon the resident's admission into the facility), dated April 27, 2025, the assessment indicated Resident 99 had a scratch/redness to the sacrococcyx area (tailbone area) upon admit. During a review of Resident 99's physician's orders, an order dated April 28, 2025, indicated, sacrococcyx stage 1 [pressure sore in the tailbone region] cleanse with soap and h20 [water] pat dry apply zinc oxide oint/cream [ointment/cream] QD [every day] & PRN [and as needed] x 21 days [for 21 days] . During a concurrent interview and record review on May 21, 2025, at 7:58 AM, with the Assistant Director of Nursing 1 (ADON 1), the ADON 1 stated Resident 99 was admitted to the facility with a Stage 1 pressure ulcer. Resident 99's RAI-MDS assessment dated [DATE], was reviewed and the ADON 1 stated the assessment was coded incorrectly and should have indicated Resident 99 had a pressure ulcer upon admit but it did not. The ADON 1 stated the facility used the current version of the RAI manual as their policy and procedure. During a review of current version of the RAI Manual titled, Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Dated October 2024, the manual indicated, Section M: Skin Conditions .Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries .A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program .

Based on observation, interview, and record review, the facility failed to ensure secure storage of medications when: 1. One Medication Storage room and one Medication Refrigerator located at Nursing station 4 was found unlocked, and 2. One medication refrigerator located at Nursing station 1 was found unlocked. This failure has the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 103 residents. Findings: 1. During a concurrent observation and interview on May 19, 2025, at 8:44 AM, the Medication Storage room located at the Nursing station 4 was accessed without a key by Licensed Vocational Nurse 1 (LVN 1). Inside the Medication Storage room, the Medication Refrigerator displays lock latches in place and no padlock. The unlocked medication refrigerator contains vials of injectable Ativan (a medication used to treat anxiety) and Haldol (a medication used to treat mental disorders), several Insulin (a medication used to treat high blood sugar) pens, and one Emergency Kit. The LVN 1 stated that he started working at the facility at the end of April 2025, and that the medication room and the medication refrigerator are always unlocked. The LVN 1 added that he never noticed a padlock on the medication refrigerator, and he has no key to the Medication Storage Room and has no key to the medication refrigerator. During a secondary observation on May 19, 2025, at 12:12 PM, the Medication Storage room and the Medication refrigerator at Nursing station 4 were rechecked in the presence of the Assistant Director of Nursing 1 (ADON 1). The ADON 1 opened the Medication Storage room without using a key and found the medication refrigerator still unlocked. The ADON 1 stated that the facility's policies require all medication storage areas and the medication refrigerator to be locked at all times and accessible by licensed nurses only. The ADON 1 called the RN Supervisor 1 (RNS 1). The supervisor confirmed that the medication room should be locked and accessible by key and the medication refrigerator should be locked with a padlock. 2. During a concurrent observation and interview on May 19, 2025, at 12:21 PM, the second Medication Storage room located at the Nursing station 1 was inspected. The ADON 1 unlocked the door using a key. Inside this Medication Storage room, the Medication Refrigerator was unlocked. The medication refrigerator contains resident's medications that need to be refrigerated. The ADON 1 acknowledged this is a security problem with the medication storage areas, stating that many new nurses received online training during COVID ( a lung disease caused by a virus). The RNS 1 suggested staff retraining and refresher courses regarding medication storage safety and enforcement of consequences for staff who fail to follow medication security protocols. During a concurrent interview and record review on May 21, 2025, at 3:18 PM with the ADON 1, the facility's Policy and Procedure (P&P) titled, Storage of Medications dated August 22, 2017, was reviewed. The P&P indicated, 1). Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .6). Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use .7). Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secure location . The ADON 1 stated the facility's P&P was not followed.

Based on interview, and record review, the facility failed to update Resident 84's Pre-admission Screening and Resident Review (PASRR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness [SMI], intellectual or developmental disability [I/DD] are not inappropriately placed in nursing homes for long term care) when Resident 84 did not have her diagnosis of schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves) included in the PASRR assessment used to admit Resident 84 into the skilled nursing facility. This failure had the potential to result in Resident 84 to not be accurately assessed regarding the need for treatment and services in alternate care settings to better suite the needs of Resident 84. Findings: During a review of Resident 84's Admission Record (contains medical and demographic information), the Admission Record indicated Resident 84 was initially admitted on [DATE]. Further review of the face sheet indicated Resident 84 had a diagnosis of schizophrenia with an onset date which indicated December 2, 2024 (date of admission). Other diagnoses Resident 84 had upon admission included altered mental status, and dementia (a general term for a decline in mental ability, including memory, thinking and social abilities, severe enough to interfere with daily life). During a review of Resident 84's Preadmission Screening and Resident Review (PASRR) Level I screening (a level 1 screening includes assessment of the resident's medical diagnoses to determine if the resident has or is suspected of having a PASRR condition [i.e. SMI, or I/DD]), dated December 2, 2024, the PASRR Level 1 screening indicated in section III for Serious Mental Illness .9. diagnosed Serious Mental Illness. Does the individual have a serious diagnoses mental disorder such as .Schizophrenia .? This question was marked NO. Further review of the PASRR indicated the resolution status was LII - not required (Level 2 assessment is not required [level 2 assessment is done when the resident is positive for possible SMI and/or I/DD]). During an interview on May 21, 2025, at 10 AM, with the Minimum Data Set Nurse (MDS Nurse), the MDS Nurse stated Resident 84's PASRR dated December 2, 2024, was inaccurate and did not include Resident 84's diagnosis of schizophrenia. The MDS Nurse further stated the PASRR assessment dated [DATE], was completed by the hospital for admission to the skilled nursing facility and the skilled nursing should have reviewed the PASRR when Resident 84 was admitted and identified the discrepancy (omission of schizophrenia diagnosis) but the discrepancy was not identified. The MDS Nurse further stated the skilled nursing facility updated the PASRR. During a review of Resident 84's revised PASRR level 1 screening, dated May 20, 2025, the revised PASRR indicated, .Status Change .9. diagnosed Serious Mental Illness. Does the individual have a serious diagnosis mental disorder such as .Schizophrenia .? This question was marked YES. Further review of the revised PASRR indicated the resolution status was [NAME] Categorical Review (this means the resident was positive for a categorical condition, the resident is pending a review for possible level 2 screening and should not be admitted to a skilled nursing facility until acceptable resolution is obtained. During an interview on May 21, 2025, at 10:20 AM, with the Assistant Director of Nursing 1 (ADON 1), the ADON 1 stated the facility did not have a policy and procedure (P&P) specific to the PASRR process and stated they followed the guidance provided on the document titled, Preadmission Screening and Resident Review (PASRR) Level I Screening Assessment Guide, updated October 2024. During an interview on May 22, 2025, at 8:52 AM, with the Quality Assurance Director (QA), the QA stated her expectation was that staff review PASRR assessments received from the hospital and ensure it was accurately completed and to complete a new one if needed. During a concurrent interview and record review on May 22, 2025, at 11:42 AM, with the Assistant Director of Nursing 2 (ADON 2), the ADON 2 stated Resident 84 had the diagnosis of schizophrenia upon admission into the skilled nursing facility. The ADON 2 further stated the hospital usually performed the PASRR level I assessment and skilled nursing facility staff were supposed to review it (PASRR Level 1) upon Resident 84's admission to ensure it was accurately completed. The ADON 2 stated if the PASRR was not accurate upon resident admit, the Minimum Data Set Nurse (MDS Nurse) was supposed to create an amendment to the PASRR. The ADON 2 stated the purpose of the PASRR is to ensure it is appropriate for the resident to be placed in a skilled nursing facility. The ADON 2 then reviewed Resident 84's PASRR dated May 20, 2025 (the amended PASRR which now reflected Resident 84 had schizophrenia), and acknowledged the PASRR indicated [NAME] Categorical review. During a concurrent interview and record review on May 22, 2025, at 11:43 AM, with the ADON 2, the facility document titled, Preadmission Screening and Resident Review (PASRR) Level I Screening Assessment Guide, dated October 2024, was reviewed. The document indicated, Level I Screening Corrections. The Level I screening must always reflect the individual's current condition .Submitted Screenings: Cannot be edited .For major demographic and/or clinical errors, such as entering the wrong last name or selecting the wrong option for the clinical questions, the hospital must submit a new Pre-Admission Screening (PAS) and the SNF must submit a new Resident Review (RR) to update the previous screening .Unacceptable PASRR Resolutions and Letters .The following PASRR resolutions are not valid PASRR resolutions and are unacceptable for admission to a Medicaid-Certified SNF: -[NAME] - Categorical Review .Here are explanations for each unacceptable resolution: [NAME] - Categorical Review: The Level 1 Screening was positive for a Categorical condition and is pending review by the Level II Evaluation contractor to confirm the Categorical condition. SNF admission must be deferred until an acceptable resolution is obtained .Reviewing the PASRR: .the admitting facility must accept the case and review the PASRR for the following: 1. Ensure the responses to the PASRR clinical questions were submitted accurately .

Based on observation, interview, and record review, the facility failed to ensure physical therapy services were provided to one of three residents (Resident 59) sampled for rehabilitative and restorative services when Resident 59 did not receive physical therapy five times a week as ordered by the physician. This failure had the potential to cause a decrease in Resident 59 overall functioning or the inability for Resident 59 to reach his/her highest level of functioning. Findings: During a review of Resident 59's face sheet (contains medical and demographic information), the face sheet indicated Resident 59 was admitted on [DATE], with diagnoses which included polyneuropathy (condition in which multiple nerves are damaged or dysfunctional on both sides of the body, often leading to symptoms like weakness, numbness, and burning pain), generalized osteoarthritis (breakdown of cartilage in multiple joints, leading to pain, stiffness, and decreased joint function), heart failure (the heart not being able to fill with and pump blood), obesity (excess weight), and low back pain. During a concurrent observation and interview on May 19, 2025, at 10:56 AM, Resident 59 was lying in her bed and when asked how she was doing, Resident 59 stated she wanted to leave the facility but couldn't leave until she was able to walk again. Resident 59 further stated she was supposed to receive physical therapy daily but stated she did not receive it (physical therapy) as often as she thinks she was supposed to. During a review of Resident 59's physician's orders, an order dated April 30, 2025, indicated, Physical therapy .PT [physical therapy] eval [evaluation], and treatment. See patient QD [every day] 5 x/wk [five times a week] x 4 wks [for four weeks]. TX [treatment] approved may include .gait training [walking training] .manual PT [physical therapy] .wheelchair mobility and training . During a review of Resident 59's medical record a document titled, PT Evaluation & Plan of Treatment (an initial evaluation by the physical therapy department and an individualized rehabilitative treatment plan) dated April 30, 2025, indicated, frequency 5 times(s)/week 4 weeks, daily . During a review of Resident 59's care plan (individualized plan for the medical care of a resident), a care plan dated April 30, 2025, indicated, encourage mobility/activity as tolerated. Assist with ADL functioning & monitor for decline. During a review of Resident 59's Physical Therapy Treatment Encounter Note(s) (documentation of physical therapy sessions) dated all of May 2025, Resident 59 only received 3 physical therapy sessions for the week of May 14, 2025 to May 21, 2025. During a concurrent interview and record review on May 21, 2025, at 9:24 AM, with the Rehab director (RHD), the RHD reviewed Resident 59's clinical record and stated the rehab week starts on the day of the evaluation and treatment plan which for Resident 59 was on Wednesday April 30, 2025. The RHD stated Resident 59 was supposed to receive physical therapy services 5 days a week. The RHD acknowledged Resident 59 did not receive physical therapy 5 days a week for the week of May 14, 2025 to May 21, 2025. The RHD stated Resident 59 was supposed to receive physical therapy on May 16, 2025, but did not because he thought there may have been a scheduling error because Resident 59 was not assigned to a rehab staff for services. The RHD further stated Resident 59 did not receive services on May 20, 2025, because the physical therapy assistant who was assigned to work with Resident 59 called off and there was no documentation that Resident 59 received services on that day either. During an interview on May 22, 2025, at 12:52 PM, with the Assistant Director of Nursing 2 (ADON 2), the ADON 2 stated it was important for Resident 59 to receive therapy services to ensure the resident maintains functional ability and is able to reach their highest functioning level possible. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, dated October 2014, the policy indicated, Policy - It shall be this facility's policy to provide care and services to the resident in accordance with physician orders . During a review of the facility's P&P titled, Care Plan, dated August 22, 2017, the policy indicated, Consistent with the facility's policy of providing appropriate care & services to residents admitted to the facility, the facility shall ensure development of a comprehensive care plan for each resident to meet his/her medical, nursing, and mental and psychosocial needs .5. Services that are to be furnished for resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well being are to be included in the plan of care .

Based on observation, interview, and record review, the facility failed to follow the physician's orders for heel protector boots for one of seven sampled residents (Resident 64) reviewed for skin integrity when Resident 64 was observed without the ordered heel protectors and was documented to have develop a deep tissue injury (DTI). This failure has the potential to contribute to Resident 64 delayed wound healing (slower recovery of injured skin and tissue), pain (physical discomfort), and further skin breakdown (worsening skin condition leading to open wounds). Findings: During a review Resident 64's Admission Record (contains demographic and medical information) indicated Resident 64 was admitted to the facility on [DATE], with the admitted diagnosis of peripheral vascular disease (poor blood circulation), stiffness of right ankle (limited movement), stiffness of left ankle (limited movement). During an observation on May 19, 2025, at 10:50 AM inside Resident 64's room, Resident 64 was lying down on her back in bed with the head of the bed elevated. A pair of heel protectors was observed place on top of her nightstand. During an interview on May 19, 2025, at 11:25 AM with the Assistant Director, ADON 1, the ADON 1 confirmed that the heel protectors were found on top of the nightstand. The ADON 1 further stated after checking with the wound treatment nurse, Resident 64 should have been wearing the heel protector boots as ordered by the physician. During a review of Resident 64's Physician Orders dated May 12, 2025, indicated, heel protectors when in bed (for skin maintenance). During review of Resident 64's Braden Scale (a standardized clinical tool used to assess a resident's risk for developing pressure injuries or bedsores), dated February 20, 2025. The Braden assessment indicated a total score of 12. (Braden Scoring a total score of 12 or less = high, 13-14=Moderate risk; 15-16 = low risk. The Braden Scale indicates six areas: sensory perception (how well the resident feels discomfort or pain), moisture (How often the skin is wet) activity (how much the resident moves), mobility (How well the resident can change positions), nutrition (how well the resident eats), and friction / Shear (how much the skin rubs or slides when moving.) A high score (the resident requires specific interventions to protect skin integrity and prevent development of wounds). During a review of Resident 64's care plan titled, Pressure Ulcer / Skin Integrity dated November 22, 2024, the care plan indicated, .related to manifested by pressure ulcers/ skin breakdown, delayed/poor wound healing related to: impaired mobility, impaired condition urinary incontinence, chairfast/bedfast most of the time, impaired cognition .goals Maintain intact skin integrity ., interventions, Assist in turning and repositioning, Use pressure reducing devise such as gel cushion . During a second observation on May 21, 2025, at 5:35 AM, Resident 64 was lying on bed on her back with the head of the bed elevated. On top of her bedside table, a pair of purple heel protectors were resting alongside a stack of folded blue disposable under pads and linens. The heel protectors were visibly place aside on the table and not applied to Resident 64's heels as ordered by the physician. During an interview on May 21, 2025, at 5:45 AM with Certified Nursing Assistant 4 (CNA 4), the CNA 4 stated that when she started her shift at 10:00 PM in May 2025, the heel protectors were already place on the bedside table. The CNA 4 confirmed that the heel protectors remained there through her shift and that she did not notify the nurse. The CNA 4 further stated that she chose not to apply the protectors because Resident 64 did not have a dressing on her left ankle. During an interview on May 21, 2025, at 5:50 AM with License Vocational Nurse 4, ( LVN 4), LVN 4 stated that it was her first time working with Resident 64 and that she had not assessed Resident 64's skin during her shift. LVN 4 admitted she missed that step due to being unfamiliar with Resident 64. The LVN 4 further stated that her last rounding was at 5:00 AM, and she did not notice that the heel protectors were not being worn. During a review of Resident 64's nursing documents titled, License Progress Notes, dated May 21, 2025, at 7:15 AM, the license progress notes indicated, Noted resident left lateral ankle-deep tissue injury (DTI) with open area measuring 3.1 cm x 2 cm, with redness, purplish red discoloration, irregular surrounding skin and dark skin center . During a concurrent interview and record review on May 22, 2025, at 3:08 PM, the facility's policy and procedure (P&P) titled, Physician Orders, dated October 2014, was reviewed. The P&P indicated, It shall be this facility's policy to provide care and services to the resident in accordance with physician orders. Procedure. 1. All aspect of resident's care, including but not limited to the following shall only be provided if ordered by the physician .treatments . The ADON 1 acknowledged and confirmed that the staff should have followed the policy, but they did not.

Based on observation, interview, and record review, the facility failed to ensure the attending physician conducted an initial comprehensive visit within the first 30 days after admission, for two sampled residents under a Medicare Part A&B stay (Resident 19 and 22). This failure has the potential to place Residents 19 and 22 at risk for serious harm or death. Findings: 1. A review of Resident 19's face sheet (demographic information) indicates Resident 19 is an [AGE] year-old female, admitted from the hospital on March 12, 2025, with diagnoses which include arthritis (redness, painful, swollen joint), atrial fibrillation (irregular rhythm that disrupts the normal flow of blood through the heart), hyperlipidemia (having too much fat in the blood), dementia (group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), nutritional deficiency (occurs when someone doesn't get enough of the essential nutrients their body needs to function properly, like vitamins, minerals, or protein), fracture of left femur (a break in the femur, the largest and strongest bone in the human body). Resident 19 was admitted to the facility under a short term stay with Medicare coverage part A&B. During a concurrent observation and record review on May 20, 2025, Resident 19 chart was noted to have a blank History and Physical (H&P) [a comprehensive assessment where a healthcare provider gathers information about a patient's health history and performs a physical examination] page. As of May 20, 2025, the H&P was not completed by the physician and was red flagged for his/her attention. 2. A review of Resident 22's face sheet (demographic information) indicates Resident 22 is a [AGE] year-old female, admitted from the hospital on April 8th, 2025, with diagnoses which include end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), diabetes mellitus (a disease where the body has trouble regulating blood sugar levels, either because it doesn't produce enough insulin, or the body can't properly use the insulin it does produce), morbid obesity (a complex chronic disease in which you have a body mass index (BMI) of 40 or higher), dependence on renal dialysis (Dialysis acts as a substitute for the kidneys, filtering the blood and removing waste products), hypertension (high blood pressure), muscle weakness, major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), history of falling. Resident 22 was admitted to the facility under a short term stay with Medicare coverage part A&B. During a concurrent observation and record review on May 20, 2025, Resident 22's chart was noted to have a blank History and Physical (H&P) [a comprehensive assessment where a healthcare provider gathers information about a patient's health history and performs a physical examination] page. As of May 20, 2025, the H&P was not completed by the physician and was red flagged for his/her attention. In an interview with the Assistant Director of Nurses 1 (ADON 1) on May 22, 2025, at 12:10 PM, the ADON 1 acknowledged that in a skilled nursing facility the first physician visit (this includes the initial comprehensive visit) must be conducted within the first 30 days after admission, and then at 30-day intervals up until 90 days after the admitted . The ADON 1 stated that the facility notified the physician several times via fax of the overdue visit. During a concurrent interview and record review on May 22, 2025, at 12:18 PM with the ADON 1, the facility's Policy and Procedure (P&P) titled, Physician Visits dated August 22, 2017, was reviewed. The P&P states, 1). The attending physician will visit residents in a timely fashion, consistent with applicable State and Federal requirements . 2). The attending physician must visit his/her patients within 72 hours of admission, at least once every 30 days for the first 90 days following the resident's admission, and then at least every 60 days thereafter . 6) a physician visit is considered timely if it occurs no later than 10 days after the date the visit was required . The ADON 1 stated that the physicians were reminded by fax that their visits are overdue on several occasions. The ADON 1 stated the physicians responded to facility phone calls, provided verbal orders, and visited the facility during this timeframe and does not know as of why the documentation is not completed and orders are not signed. The ADON 1 recognized that as of May 22, 2025, Resident 19 and 22 History and Physical Examinations are not completed, not signed, and not dated by the Physician. The ADON 1 acknowledged that the facility's P&P was not followed.

Based on observation, interview, and record review, the facility did not ensure staff signed the narcotic reconciliation log when discrepancies were found in two of four narcotic reconciliation logbooks. This failure had the potential to result in improper administration of medication and dosage, increasing risk of adverse drug reactions, and possible harm to 106 vulnerable patients. Findings: During a concurrent observation and interview with Registered Nurse Supervisor 3 (RNS 3), on May 21, 2025, at 5:07 AM, in the hallway, the narcotic reconciliation logbook in station 4 was inspected. The dates: March 7, 18, 19, 26; April 13, 17, 24; May 14, 20, 21, 2025 were missing signatures. RNS 3 confirmed the dates were missing signatures. During a concurrent observation and interview with Licensed Vocational Nurse 5 (LVN 5), on May 21, 2025, at 1:04 PM, in the hallway, the narcotic reconciliation logbook in station 1 was inspected. The dates: March 9, 10, 11, 12, 16, 22, 25, 26, 29; May 19, 20, 21, 2025 were missing signatures. LVN 5 confirmed the dates were missing signatures. During a concurrent interview and record review on May 21, 2025, at 1:10 PM, with the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, Controlled Drug Reconciliation, revised 2020, was reviewed. The P&P indicated, .At the completion of each nursing shift, the on-coming and off-going nurses will count and reconcile controlled drugs subject to regulations and/or facility policies for individual counts . The ADON stated the facility staff should have followed the P&P.

Based on interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set, (MDS- a federally required resident assessment tool used to plan care and track clinical status) for one of seven sampled residents (Resident 64) reviewed for MDS coding accuracy when the facility inaccurately, documented Resident 64 received antibiotics in February 2025, despite no physician's orders showing antibiotic use. This failure has the potential to cause poor care planning and inaccurate understanding of Resident 64's health, increasing the risk Resident 64's needs will not be met. Findings: During a review Resident 64's Admission Record (contains demographic and medical information) indicated Resident 64 was admitted to the facility on [DATE], with the admitted diagnosis of peripheral vascular disease (poor blood circulation), stiffness of right ankle (limited movement), stiffness of left ankle (limited movement) During a review of Resident 64's MDS (Minimum Data Set) Section N0300-Medications, dated February 20, 2025, the MDS indicated, this section is used to record how many days in the last 7 days Resident 64 received injections or specific medications, such as antibiotics or insulin. This section indicated Resident 64 was coded as receiving antibiotics. During a concurrent interview and record review on May 22, 2025, at 11:22 AM with MDS Nurse, the Resident 64's Physician Orders dated February 1, 2025, was reviewed. The physician's orders, indicated, there was no documented evidence that Resident 64 was on antibiotics. The MDS nurse confirmed there was no indication or supporting documentation showing antibiotic administration and identified as an oversight and coding discrepancy on his part. During a concurrent interview and record review on May 22, 2025, at 11:36 AM with the MDS nurse, Resident 64's MDS Section N - medications, dated February 20, 2025, was reviewed. The MDS nurse acknowledged Resident 64 was inaccurately coded under F (antibiotics) and further stated that the accuracy of the MDS is very important because it directly affects resident care planning. During a concurrent interview and record review on May 22, 2025, at 11:50 AM, the Centers for Medicare & Medicaid Services, CMS (U.S. Federal agency that oversees Medicare and Medicaid, and regulatory compliance for health care facilities, including nursing homes), Resident assessment Instrument, RAI (is an assessment system used in nursing homes) Version 3.0 Manual Section N: Medications was reviewed. The manual indicated, Intent: the intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and / or select medications were received by the resident. The MDS nurse acknowledged that the documentation for Resident 64 under MDS section N was inaccurate.

Based on interview, and record review, the facility failed to ensure quarterly (every 3 months) Payroll Based Journal (PBJ) Staffing Data (data combining census and staffing information) report required by Centers of Medicare and Medicaid Services (CMS), was transmitted (submitted) to CMS in accordance with federal submissions timeframes, for quarter 2 (January 1 through March 31 of 2024. This failure resulted in inadequate monitoring of staffing information to be transmitted to CMS. Findings: During a record review of the PBJ Staffing data report for quarter 2 of 2024 for January 1 through March 31, 2024, no PBJ data was submitted (due May 15, 2024). On May 22 at 2:00 PM a policy and procedure (P&P) was requested from the facility, the Director of Nursing (DON) stated I don't have one. During a phone interview on May 22, 2025 at 2:21 PM with the Administration resource, the Administration Resource stated one of her roles was ensuring the PBJ Staffing Data report is submitted on a timely basis. The Administration Resource verified and stated quarter 2 of 2024 was not submitted. The Administration Resource stated timely submission of the PBJ Data is important to ensure staffing is adequate and as needed for patient care.

Based on observation, interview, and record review, the facility failed to ensure the prevention of avoidable accidents for one of three sampled residents (Resident 1), when a Certified Nursing Assistant 1 (CNA 1) failed to perform a two-person transfer while using a Hoyer Lift (a mechanical lift used to transfer residents from their bed to a chair, or wheelchair, etc.) with Resident 1, and failed to use the appropriate Hoyer Lift sling with Resident 1 during a transfer from a bed to a wheelchair. These failures resulted in Resident 1 falling to the floor and sustaining a laceration (a break in the skin caused by blunt force trauma) to the back of the head, requiring evaluation and treatment at a hospital. Findings: During a review of Resident 1's Admission Record (contains Resident 1's medical and demographic information), undated, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included quadriplegia (paralysis of the arms and legs), altered mental status, muscle weakness, and cachexia (weakness and wasting of the body due to severe chronic illness) and severe protein-calorie malnutrition (inadequate intake of calories from proteins, vitamins, and minerals). During a review of Resident 1's fall assessment titled, [name of facility] Fall Risk Evaluation, (a scored assessment of Resident 1's fall risk) dated March 3, 2023, the fall assessment indicated, Resident 1 was identified to be at high-risk for falls, with a score of 12. The document further indicated, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls . During a concurrent observation and interview on May 4, 2023, at 2:38 PM, with Resident 1, in Resident 1's room, Resident 1 was observed to be unable to move his arms and legs. Resident 1 appeared thin and frail (weak and delicate), and did not verbalize anything when spoken to, but when asked if he fell from a Hoyer Lift recently, Resident 1 nodded his head up and down. During an interview on May 23, 2023, at 2:25 PM, with the Assistant Director of Nursing (ADON), the ADON stated, she was working at the facility on April 20, 2023, at the time when Resident 1 fell from the Hoyer Lift. The ADON stated, she responded to the incident after Resident 1 had fallen to the floor, and because of the fall, Resident 1 sustained a laceration to the rear of his head, which bled and required evaluation at a hospital. The ADON further stated, Resident 1 fell from the Hoyer Lift sling, because CNA 1 had used the incorrect sling to transfer Resident 1 with the Hoyer Lift. The ADON further stated, CNA 1 had used the sling intended to be used with the sit-to-stand lift (a mechanical lift used to aid residents to rise from the seated position but does not support the resident's entire body weight) but should have instead used the full body sling meant to be used with the Hoyer Lift. The ADON further stated, the sit-to-stand sling was not supposed to be used at all with the Hoyer Lift. The ADON further stated, Resident 1 required the assistance of two staff members when the Hoyer Lift was used, but CNA 1 did not get the assistance of another staff member to assist with the transfer, and instead attempted the transfer by herself. During an interview on May 23, 2023, at 2:44 PM, with CNA 1, CNA 1 stated, on April 20, 2023, she attempted to transfer Resident 1 by herself from their bed to a wheelchair using the Hoyer Lift. CNA 1 further stated, she was aware Resident 1 required the assistance of two staff during transfers with the Hoyer Lift but stated Resident 1 was not very heavy, so she thought she could attempt to perform the transfer alone. CNA 1 further stated, she used the sit-to-stand sling instead of the Hoyer full body sling when she used the Hoyer device to transfer Resident 1, and at the time she performed the transfer, she was not aware that she was using the wrong sling. During a follow up interview on May 23, 2023, at 2:54 PM, with the ADON, the ADON stated, two staff members were required to transfer any resident when using the Hoyer Lift, because one person was supposed to stand by the Hoyer Lift while the other staff member was supposed to be by the resident in the sling, to guide the resident and make sure they don't bump their head or fall. During a concurrent interview and record review, on May 30, 2023, at 4:30 PM, with the Director of Nurses (DON), the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, was reviewed. The P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents . Individualized, Resident-Centered Approach to Safety . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: . d. Ensuring that interventions are implemented . The DON stated, Resident 1 required two staff members during transfers with the Hoyer Lift, but the resident only had the supervision of one staff member at the time the resident fell . During a review of Resident 1's physician's orders, dated April 20, 2023, the physician ' s orders indicated the following: 1) Amoxicillin (An antibiotic used to treat bacterial infections) 875 mg (milligrams-a unit of measurements) - potassium clavulanate (an antibiotic used to treat bacterial infections) 125 mg 1 tablet by mouth every 12 hours x (times) 7 days .2) Sulfamethoxazole (an antibiotic used to treat bacterial infections) 800 mg-trimethoprim (an antibiotic used to treat bacterial infections) 160 mg 1 tablet by mouth every 12 hours x 7 days - head laceration/prophylaxis-(a medication or a treatment designed and used to prevent a disease or illness from occurring) .3. Back of head laceration treatment cleanse with normal saline wound cleanser, pat dry, cover with dry dressing wrap with kerlix (a type of gauze dressing), secure with tape daily & reevaluate in 7 days . During a review of the facility's Hoyer Lift [name of manufacturer] operator's manual titled, Owner's Operator and Maintenance Manual Electric Portable Patient Lift, undated, the manual indicated, Warning . [name of manufacturer] products are specifically designed and manufactured for use in conjunction with [name of manufacturer] accessories. Accessories designed by other manufacturers have not been tested by [name of manufacturer] and are not recommended for use with [name of manufacturer] products . Operating the Patient Lift . [name of manufacturer] slings and patient lift accessories are specifically designed to be used in conjunction with [name of manufacturer] patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of [name of manufacturer] ' s patient lift system . for the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers. Warranty will be voided . Operating the Patient Lift . [name of manufacturer] recommends that two assistants be used for all lifting preparation and transferring to/from procedures . WARNING . DO NOT use slings and patient lifts of different manufacturers . Injury or damage may occur . During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment of the resident's functional capabilities), dated March 1, 2023, the MDS Section G (functional status) indicated, Resident 1 was total dependence (totally dependent on staff) for transfers [to and from bed, wheelchair etc.] and bed mobility. The MDS further indicated, Resident 1 required the assistance of two staff members during transfers. During a review of Resident 1's Physical Therapy Recertification and Updated Plan of Treatment (a summary assessment and plan of treatment for the resident), signed on April 20, 2023, the plan indicated, . Patient will safely perform functional transfers with TD [total dependence] . Comments: Hoyer transfers recommended for safety . During a review of Resident 1's care plan titled, ADL [activities of daily living] - care plan, dated January 23, 2023, the care plan indicated, Needs assistance with ADLs: Transfers - Total Assist Support . 2-3 staff assist . with interventions including, Assist with transfers, request extra help as needed . During a review of the facility's P&P titled, Policy and Procedure on Hoyer Lift Usage, dated August 2017, the P&P indicated, It is this facility ' s policy to help move, lift, and transfer heavy residents who are unable to assist mover . 1. Assess physical characteristics of the resident (i.e. weight size, height, age, physical limitations and abilities) and determine if assistance is needed from another caregiver . 5. DO NOT use Hoyer Lift equipment if unfamiliar with procedure . 7. Provide reassurance that precaution will be taken to prevent falls . During a review of the facility's P&P titled, Policy and Procedure on Fall Prevention and Reduction, dated October 2014, the P&P indicated, Policy. It is this facility ' s policy to prevent falls to the extent possible and within the control of the facility . 1. Residents, Upon admission, shall be assessed and evaluated for risk for falls or further falls. 2. Residents identified to be at risk for falls or further falls shall have plans of care developed to minimize or reduce risk factors for falls or further falls. 3. Plans of care shall include interventions on the following . Provision of monitoring and supervision to resident to prevent fall incident . During a review of the facility's job description for Certified Nursing Assistant titled, Certified Nursing Assistant, undated, the job description indicated, . Purpose of your job position. The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident ' s assessment and care plan, and as may be directed by your supervisors . Delegation of Authority. As a Certified Nursing Assistant you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties . Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors . Follow established safety precautions in the performance of all duties . Operate all equipment in a safe manner .

Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure titled Policy and Procedure on Pressure Ulcers (wounds caused by prolonged pressure on a bony prominence that may be superficial (Stage 1) to involving damage which includes all layers of skin down to the bone (Stage IV), dated August 22, 2017, for two of two sampled residents (Residents 3 and 44) was followed when: 1. The facility did not provide documented evidence for Resident 3 who had a Stage 4 pressure (involves all layers of skin down to the bone) ulcer on the sacrum (located above the tailbone) and a Stage 3 pressure (Involves all layers of skin down to the muscle) ulcer on the left hip to show the resident had been repositioned at least every two hours to prevent further pressure on the wounds. 2. For Resident 44: the facility did not conduct a full assessment (includes: Type of Ulcer, Location, Stage of Pressure Ulcer, Measurements, Non-viable tissue, Odor, Amount of Exudate [fluid], Type of Exudate, Wound bed, Description of surrounding skin/tissue, Description of wound edges, Progress towards healing, Nature and frequency of Pain and Signs of Infection) of a Deep Tissue Injury (DTI- a form of pressure ulcer. Pressure ulcers are localized areas of tissue damage that develop because of prolonged pressure on areas of bone that are close to the skin's surface) on Resident 44's right heel at admission; the facility did not follow the physician's treatment order for the DTI for 64 days, the facility did not inform the wound care doctor of Resident 44's DTI for 40 days; the facility did not conduct weekly wound assessments for nine weeks and the Registered Dietician (RD) did not include the DTI in Resident 44's Nutritional Assessments from admission through to November 9, 2022. These failures had the potential to cause Residents 3 and 44, to suffer an increased risk of mortality (the state of being subject to death), infection, decline in function (a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living), and pain. Findings: 1. During a review of Resident 3's Admission Record (contains demographic and medical information), undated, indicated Resident 3 was initially admitted to the facility on [DATE], and readmitted [DATE], with diagnoses that included metabolic encephalopathy (chemical imbalance in the brain), hemiplegia and hemiparesis following cerebral infarction (muscle weakness, inability to move one side of body as a result of blocked blood flow to the brain), dementia (a group of conditions affecting the ability to remember, think or make decisions), contracture of left and right knee (stiffening of the knee and inability to move the knee), blindness (inability to see), pressure ulcer of sacral region and pressure ulcer of left hip (localized damage to the skin on the hip). During a concurrent observation and interview on December 13, 2022, at 8:48 AM, with Resident 3, who was lying in bed covered up with her legs turned to the right, Resident 3 stated she did not know how her wound developed or when it occurred, and the facility staff had not explained that to her. Resident 3 stated the treatment nurse puts a dressing on her wound, and she did not know if they [wounds] are getting better. Resident 3 stated the certified nursing assistant (CNA) would come twice a day to check the dressing on her wound. Resident 3 stated that she did not have pain in the wounds, but the wounds would sometimes itch and I know I shouldn't scratch them. Resident 3 stated the certified nursing aides did not come in every two hours to assist with repositioning and that they used to come in more often but not so much anymore. Resident 3 was observed three times on December 13, 2022, at 8:48 AM, 10:30 AM, and 12:25 PM lying in her bed, in the same position, on her back with legs turned to the right and under her blanket. During a review of Resident 3's Braden Scale - For predicting pressure sore risk (Braden scale), dated October 21, 2022, the Braden Scale indicated Resident 3 was at high risk for pressure sore development with a score of 9 out of 23. The lower the score, indicated the increased risk for pressure sore development. During a review Resident 3's Long term care plan, Impaired skin/tissue integrity, chronic wound (care plan) dated October 21, 2022, indicated the plan/approach included assist with and/or encourage turning/repositioning at least every 2 hours and as needed. During a review of Resident 3's MDS (minimum data set, a clinical assessment of all residents in nursing homes) 3.0 Section G (MDS) dated [DATE], indicated Resident 3 required total assistance (full staff performance every time) with one-person physical assist for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). During a review of Resident 3's IDT (interdisciplinary team- a group of clinical staff such as nursing, dietary, and activities), wound care committee (IDT notes), dated November 11, 2022, the IDT notes under IDT recommendations was to reposition/turn every 2 hours. During an interview with a Certified Nursing Assistant (CNA 2) on December 13, 2022, at 3:20 PM, CNA 2 stated documentation for certified nursing assistants was written on the facility's nurse assistant additional notes. CNA 2 stated this documentation would include every 2-hour turning or those cares that are completed outside of the ADL (Activities of daily living such as eating, bathing, and walking) charting. During a review of Resident 3's Nurse assistant additional notes, dated October 25, 2022, through November 27, 2022, the notes indicated zero documentation of every 2-hour turning or repositioning of Resident 3. During a review of the facility's policy and procedure titled, Policy and Procedure on pressure ulcers (P&P), dated August 22, 2017, the P&P indicated, in section 1.8 If bedbound, reposition every two hours; if chairbound reposition every hour. Section 5.3 indicated, A resident who is dependent on staff for repositioning should have repositioning schedule to maintain skin integrity. Repositioning schedule may range from every 2 hours or more frequently depending on tissue tolerance. Section 5.7, indicated Document implementation of repositioning schedule in the resident's medical chart, e.g., licensed progress notes, ADLS charting or medication administration record (MAR). During an interview on December 13, 2022, at 5:06 PM, with the Director of Nursing (DON), the DON stated the intervention for pressure ulcers was expected to be every 2-hour turning and/or repositioning, which was not documented. The DON stated she made observations of residents' positions while lying in bed, throughout the day to ensure they were repositioned every two hours. The DON stated staff used a badge card to tell staff which way a resident should be facing at various times during the day while in bed. The DON stated that the CNAs and all staff have the same badge. The DON stated only observations were completed, there was no paper documentation to show that repositioning and/or every 2-hour turning was completed. 35183 2. A review of Resident 44's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 44 was admitted to the facility on [DATE], with diagnoses of 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), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), difficulty with walking, muscle weakness and lack of coordination. During an observation and interview with Resident 44 and Resident 44's family member on December 5, 2022, at 11:23 AM, Resident 44 was in a wheelchair positioned beside her bed in her room. Sitting on Resident 44's bed was her family member. The family member stated she found out today Resident 44 had a blister on her right heel. Resident 44's right ankle had a cushion fastened around the ankle and there was a sock on the right foot. Resident 44's family member stated she was upset because it seemed Resident 44 had gone downhill since being admitted to the facility. Resident 44's family member stated Resident 44 could no longer use the bathroom on her own, wore a diaper and had a sore on her right foot. Resident 44 began to speak to her family member however Resident 44's sentences did not make sense and did not relate to the subject being discussed. A review of Resident 44's Comprehensive Resident Admission Assessment, dated September 27, 2022, indicated Resident 44's skin was intact. Resident 44's Body Reassessment, dated September 28, 2022, indicated Resident 44 had a DTI to her right heel. The Body Reassessment, did not indicate measurements of the DTI, condition, or appearance of the skin in and around the DTI, presence of pain or signs of infection if any. A review of Resident 44's ADL [Activities of Daily Living] Care Plan, dated September 28, 2022, indicated, Bed Mobility: extensive assist, Transfers: extensive assist, Walk in Room/Corridor: extensive assist and Locomotion On/Off Unit: extensive assist. Pressure Ulcer/Skin Integrity Care Plan, dated September 28, 2022, indicated, Pressure ulcers/skin breakdown, delayed/poor wound healing related to impaired mobility, impaired cognition, urinary incontinence and chairfast/bedfast most of the time. A review of Resident 44's Long Term Care Plan titled, Impaired Skin/Tissue Integrity, Chronic Wound, dated September 28, 2022, indicated, Related to: DTI (R) [right] heel . Plan/Approach: . Assess and Document wound characteristics/dimensions initially, q [every] week and PRN [as needed] decline, Monitor wound progress; reevaluate wound Tx [treatment]/interventions q week and PRN, Use proper infection control procedures @ [at] all times to prevent cross contamination, Assess infection risk. Monitor for s/s [signs and symptoms] of wound infection and notify Dr. [doctor] . Assess for pain [secondary] to wound or its treatment and manage appropriately, . Monitor those dressings remain clean and intact between changes, replace PRN, . Avoid pressure, friction, and shear to involved area(s) @ all times, . Suspend Feet/Heels(s) off bed surface w/ [with] pillow under calf as tolerated, . A review of Resident 44's treatment orders for the DTI indicated: a. September 28, 2022, (R) heel DTI clnse [cleanse] c [with] NS [normal saline], pat dry, paint c iodine [antiseptic], cover c dry drsg [dressing], Qday [every day], x [times] 21 days, reeval [reevaluate] PRN [as needed]. b. November 4, 2022, (R) heel blood filled blister. Cleanse c N/S [normal saline] pat to dry. Apply betadine [an antiseptic], ABD [abdominal] pad & [and] wrap c kerlix [brand name] wrap. Then re-eval x 21 days . c. December 5, 2022, D/C [discontinue] previous orders to R [right] heel . [change] in etiology [the cause of the condition]. R heel st [stage] 3 [three-full thickness skin loss involving damage or necrosis (dead tissue) of subcutaneous tissue (innermost layer of skin) that may extend down to, but not through, underlying fascia (connective tissue)] PR [pressure] injury clnse [cleanse] c [with] NS [normal saline], pat dry, apply Medi Honey [a brand name for an ointment that supports autolytic (destruction of cells by their own enzymes) debridement (removal of damaged tissue) and a moist wound healing environment], cover c dry drsg [dressing], Qday [every day] & [and] PRN [as needed] x [times] 21 days, then reeval [reevaluate]. A review of Resident 44's Treatment Administration Record (TAR) from September 28, 2022, to November 3, 2022, indicated Resident 44's right heel DTI was being treated by cleanse with normal saline, pat dry, apply Medi Honey, cover with dry dressing every day and as needed. Not with the order dated September 28, 2022, (R) heel DTI clnse c NS, pat dry, paint c iodine, cover c dry drsg, Qday, x 21 days, reeval PRN. A review of Resident 44's physician's orders did not indicate a Medi Honey treatment during this time period. Thirty-seven days had passed without following the correct physician's order for wound treatment. A review of Resident 44's Treatment Administration Record (TAR) from November 4, 2022, to November 30, 2022, indicated Resident 44's right heel DTI was being treated by cleanse with normal saline, pat dry, apply Medi Honey, cover with dry dressing every day and as needed. Not with the order dated November 4, 2022, (R) heel blood filled blister. Cleanse c N/S pat to dry. Apply betadine, ABD pad & wrap c kerlix wrap. Then re-eval x 21 days . A review of Resident 44's physician's orders did not indicate a Medi Honey treatment during this time period. Twenty-seven days had passed without following the correct physician's order for wound treatment. A review of Resident 44's Wound Care Doctor's Progress Notes was conducted. There was no documented evidence to show the Wound Care doctor had assessed Resident 4's DTI from September 27, 2022, to November 6, 2022, for a total of 40 days. A review of Resident 44's Weekly Wound Assessments from September 27, 2022, to December 4, 2022, was conducted. There was no documented evidence to show weekly wound assessments had been conducted, for a total of nine weeks. A review of Resident 44's Nutritional Assessments dated October 5, 2022, October 12, 2022, October 19, 2022, and November 9, 2022, indicated Resident 44's skin was clear and intact, and no breakdown documented. During an interview and record review with a Registered Dietician (RD) on December 13, 2022, at 10:56 AM, a review of Resident 44's weights from September 27, 2022 (weight 124 pounds) to October 24, 2022 (weight 117 pounds) was conducted. The RD verified Resident 44 lost 7 pounds in one month, a negative 5.65% [percent] significant weight change, which impacted the body's ability to heal. During an observation of Resident 44's wound on December 13, 2022, at 5:20 PM with a Treatment Nurse (TN 1), Resident 44's right and left heels were floated (pressure is relieved by not having the heel touch any surface) on pillows. Resident 44's right heel was wrapped in gauze. TN 1 stated Resident 44's stage III pressure sore measured 3 (three).9 (nine) cm (centimeters-a unit of measurement) x (by) 4 (four).9 cm about the size of a baseball. TN 1 cut the dressing away. Resident 44 became agitated stating be careful, be careful, no, no, no, Resident 44 reached toward her right foot in a protective gesture. TN 1 reassured Resident 44 and was very gentle with Resident 44's right foot. Resident 44 relaxed back onto her pillow. Resident 44's stage III pressure ulcer looked like hard, black necrotic (dead) tissue covering the entire wound's surface with one very small open area to the lower right corner of the wound. No oozing or weeping was observed coming from the wound. There was no odor. During a concurrent interview with the Wound Care Doctor (WCD) on December 13, 2022, at 5:42 PM, in the presence of TN 1, the WCD stated he came to the facility every Monday and evaluated all the residents with wounds. The WCD stated he was not told about Resident 44's wound until November 7, 2022. The WCD reviewed Resident 44's TARS from September 28, 2022, to November 3, 2022. The WCD stated he would not have ordered a Medi Honey treatment for a DTI and the treatment nurses knew this. TN 1 stated she would not have used the Medi Honey because she knew the WCD liked the betadine treatment for DTIs. The WCD stated Resident 44's wound was covered by a scab which was eschar (dead tissue). The WCD stated the wound was stable at this time and he was monitoring it for signs of infection. The WCD stated if the wound started oozing pus, he would debride (removal of dead tissue with a scalpel) the scab. The WCD stated he was hopeful the scab would eventually fall off and healthy tissue would be underneath. The WCD stated Resident 44 could not turn or reposition herself and it was very important that the staff kept the pressure off the resident's heels. The doctor stated he recommended a boot, but the facility did not want the boot they liked floating the heels with pillows. During a continued concurrent interview on December 13, 2022, at 6:07 PM with TN 1 and in the presence of the WCD, TN 1 stated she had not been informed about Resident 44's wound until November 4, 2022. TN 1 stated the Charge Nurses would let her know about resident wounds. TN 1 stated she used the betadine treatment in November 2022 and did not start the Medi Honey treatment until December 5, 2022. TN 1 reviewed Resident 44's TARs for September 2022, October 2022, and November 2022. TN 1 stated her initials on the TARS were made by someone else, because she had not documented her initials on the September 2022, October 2022, and November 2022 TARS presented to her. TN 1 stated she did not know where the TAR was which indicated the treatment she had provided. TN 1 stated the charge nurses were responsible for conducting the weekly wound assessments and she filled out the wound progress report with the WCD on his Monday visits. During an interview with the RD on December 13, 2022, at 6:35 PM, the RD stated she reviewed the residents' admission assessments to obtain information on the residents and check for the presence of wounds. The RD stated Resident 44's admission assessment indicated Resident 44's skin was clear and intact. The RD stated she had missed the Body Reassessment, that indicated the right heel DTI. The RD stated Resident 44's Nutritional Assessments dated October 5, 2022, October 12, 2022, October 19, 2022, and November 9, 2022, did not include considerations for the right heel DTI. During an interview with the Director of Nursing (DON) on December 13, 2022, at 7:41 PM, the DON verified a full assessment of Resident 44's DTI was not documented at admission and should have been. The DON verified there was no physician's order for the Medi Honey treatment indicated on Resident 44's TARs dated September 2022, October 2022, and November 2022. The DON stated a Treatment Nurse conducted the recapitulation (orders are reviewed and verified as accurate against the physician's initial orders, subsequent telephone orders and compared to the medication and treatment administration records monthly) of wound care orders and should have caught the error and did not. The DON stated the nurses should have followed the physician's treatment orders dated September 28, 2022, and November 4, 2022, and did not. The DON stated a Treatment Nurse should have informed the WCD of Resident 44's DTI on October 3, 2022 (the first weekly WCD visit following admission) and did not. The DON verified weekly wound assessments had not been documented and Resident 44's nutritional assessments should have included the right heel DTI and did not. A review of the facility's policy and procedure titled, Policy and Procedure on Pressure Ulcers, dated August 22, 2017, indicated, Policy: .A resident, who enters the facility with pressure ulcer and/or develops unavoidable pressure ulcers being in the facility, must receive treatment and services necessary to promote healing, prevent infection and prevent new ulcers from developing. Procedures: .All residents shall be assessed on admission or readmission of their skin condition and integrity, using the prescribed Nursing Admission Assessment form. Licensed nurse must also refer resident to the Registered Dietitian at the new onset of a pressure ulcer for possible adjustments in his/her nutritional needs (caloric, protein and fluid) .Physician and other healthcare professional .shall have inputs in the assessment and identification of the type of ulcer. Assessments of Pressure Ulcers: Licensed charge nurse or treatment nurse shall conduct basic assessment and data collection on the following: Type of Ulcer . Location .Stage of Pressure Ulcer . Measurements . Non-viable tissue . Odor . Amount of Exudate [fluid] . Type of Exudate . Wound bed . Description of surrounding skin/tissue . Description of wound edges . Progress towards healing . Nature and frequency of Pain . Signs of Infection. Assessment of pressure ulcers shall be done at least once every week or as wound condition changes. Document general findings in the weekly skin and wound progress report. Choice of treatment and dressings should be based on the characteristics of the wound, relevance of the specific product to the identified pressure ulcer, treatment goals and manufacturer's recommendations for use. Pressure ulcer treatment orders shall be evaluated for effectiveness every 2 [two] - [to] 4 [four] weeks . The licensed nurse or treatment nurse shall also evaluate treatment plan, documenting whether or not to continue or modify the current interventions. Weekly/Monthly Special Skin Care Report - report containing progress on each resident identified with pressure ulcer, whether in-house or community acquired, shall be completed by the licensed nurse or treatment nurse on a weekly basis. A review of the facility's policy and procedure titled, Policy and Procedure on ReCapping of Physician Orders, dated August 22, 2017, indicated, Policy: It is the policy of this facility to review and provide recapitulation of physician's orders on a monthly basis. Physician Order Sheets will be reviewed and recapped to include necessary changes, corrections and updates made via telephone orders.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident A) was provided the necessary care and psychosocial support when Resident A verbalized he wanted to go home upon discharge and not be transferred to an assisted living facility. This failure negatively affected the mental health and well being of Resident A, which resulted in Resident A's death. Findings: An unannounced visit was made to the facility on [DATE] at 1:45 PM, to investigate a facility reported incident (FRI) regarding a resident's (Resident A) death. A review of the clinical record for Resident A revealed the admission record, dated [DATE] at 8:20 PM, indicated that Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident A's care plan titled Depression dated [DATE], indicated Resident A had depression. The interventions listed included: social services to interact as needed, listen attentively and attempt resolve or discuss a real of upset, and monitor episodes of depression. A review of Resident A's clinical record from the general acute care hospital (GACH) revealed when Resident A was admitted to the GACH, Resident A had a [DIAGNOSES REDACTED]. A review of Resident A's ancillary and nursing transfer orders from the GACH, dated [DATE], indicated Resident A had a one to one staff member at the bedside due to suicidal ideation during Resident A's admission at the GACH. Further review of the ancillary and nursing transfer orders discharge revealed, Patient depressed and does not want to live . A review of Resident A's discharge Home medication from the GACH, dated [DATE], indicated Resident A had an order to continue to take [MEDICATION NAME] (antidepressant medication used for sadness) 50 mg (a unit of measurement) by mouth every day. A review of the SNF physician's admission orders [REDACTED]. A review of Resident A's antidepressant medication form, undated and untimed, signed by the doctor, indicated a check mark in the box to monitor behaviors to include crying, inability to sleep, and [MEDICAL CONDITION]. A review of Resident A's antidepressant medication form clarification, dated [DATE] at 9 AM signed by the doctor, indicated a check mark in the box to monitor behaviors of withdrawal and verbalization of depression. The behaviors to include crying, inability to sleep, and suicidal ideation indicated were discontinued. A review of the licensed nurses' progress notes dated [DATE] at 9 AM, indicated, Clarification of [MEDICATION NAME] order and depression manifestations . There was no documented evidence to show the reason for the discontinuation of behaviors to include crying, inability to sleep and suicidal ideation. During an interview with the Director of nursing (DON) on [DATE] at 2:10 PM, the DON reviewed the licensed nurses' progress notes dated [DATE] at 9 AM, and the DON confirmed there was no documented evidence to show the reason for the discontinuing the behaviors of crying, inability to sleep, and suicidal ideation. The DON stated, The nurse should have documented why those behavior monitoring were discontinued. A review of the Skilled Nursing Facility's (SNF) physician's history and physical for Resident A, completed on [DATE], indicated Resident A does have the capacity to understand and make his own decisions. The history and physical did not show documented evidence by the SNF physician that Resident A had a [DIAGNOSES REDACTED]. During a telephone interview with the Certified Nursing Assistant (CNA 1), on [DATE] at 10:30 AM, she stated, On [DATE], I went into the room at approximately 4 AM to provide care for the resident in Bed A (Resident A's roommate), and while I was providing care, that is when I found him (Resident A) on the floor. He (Resident A) had the call light tightly tied around his neck. I tried to loosen it but it was really tight. I pulled the call light from the wall. I immediately called the charge nurse. He came and we started CPR (cardiopulmonary resuscitation.) During a review of the clinical record for Resident A, the licensed nurses' progress notes dated [DATE] at 4:10 AM, indicated the Licensed Vocational Nurse (LVN 1) documented, Called to room by CNA, patient found on the floor with call light tied around his neck with a knot, patient facing the floor unresponsive, unplugged call light right away to be able to remove call light quickly from his neck, unable to feel pulse per forearm, CPR code blue paged to the building, called paramedics for help, and further evaluation while performing CPR with RN (registered nurse). During a telephone interview with the LVN 1 on [DATE] at 1:27 PM, the LVN 1 stated, The resident tied the call light around his neck. We started CPR immediately and called 911. He was still very warm but no pulse. A review of the licensed nurses' progress notes dated [DATE] at 4:25 AM, revealed Resident A was transported out of the facility via 911 (ambulance). A review of Resident A's Preadmission Screening and Resident Review (PASRR- a tool used to screen the mental health status of a resident) dated, [DATE], under section V-mental illness, indicated Resident A did not have a [DIAGNOSES REDACTED]. A review of Resident A's care plan titled Psychosocial dated [DATE], indicated Resident A had depression and anxiety. The intervention listed included: Explain all care, validate feelings and demonstrate empathy (the ability to understand other's feelings). During an interview with the DON on [DATE] at 5:30 PM, the DON reviewed Resident A's PASRR and confirmed the PASRR was not done correctly. The facility failed to included [DIAGNOSES REDACTED]. During a review of the clinical record for Resident A, the IDT (interdisciplinary team- a team meeting of staff members discuss a resident care) conference review, dated [DATE], indicated a care coordinator, social services, physical therapy assistant and Resident A's family members were in attendance. Further review of the IDT conference review indicated the family did not want Resident A to be discharged to home. The family wanted Resident A to be discharged to an assisted living facility. A review of the written statement by the Physical Therapy Assistant (PTA) who attended the IDT conference and interpreted for Resident A and Resident A's family on [DATE], documented, The patient's daughter stated they would like him to go to an assisting living facility since all the daughters work and are unable to help with his care. The patient expressed not being satisfied with this decision multiple times, and he stated he preferred to go home with a caregiver during the day .The patient continued to express not wanting to discharge anywhere else but home. During an interview with the Care Coordinator (CC), on [DATE] at 5:10 PM, the CC stated, I did not know what the resident and the PTA were talking about because I do not speak Spanish. The CC further stated, I do not remember if it was communicated to the team that the resident did not want to be discharged to an assisted living facility. I do not know what was done about resident not wanting to be discharged to an assisted living facility. A review of the GACH's discharge summary, dated [DATE] from the GACH discharging physician, revealed Resident A should follow up with a psychiatrist. A review of Resident A's physician's orders [REDACTED]. A review of Resident A's neuropsychological consultation executive summary, dated [DATE], indicated Resident A felt depressed, hopeless, and helpless. It indicated Resident A's family and his returning to house motivated him to rehabilitate. Further review of Resident A's neuropsychological consultation executive summary indicated Resident A was reporting significant depressive and anxiety symptoms. The recommendation listed included anticipate and prevent fear producing stimuli (an event that triggers behaviors). A review of the licensed nurses' progress notes from [DATE] through [DATE], indicated no documented evidence that Resident A's physician was notified that Resident A was feeling depressed, hopeless, and helpless. A review of the Nurse Practitioner Notes dated [DATE] and [DATE], indicated there is no documented evidence that Resident A's Nurse Practitioner was aware Resident A was feeling depressed, hopeless, and helpless. During an interview with the DON on [DATE] at 3:10 PM, the DON reviewed the licensed nurse's progress notes from [DATE] through [DATE] and the Nurse Practitioner notes dated [DATE] and [DATE]. The DON confirmed there was no documented evidence to show Resident A's Physician or Nurse Practitioner were notified about the results of the neuropsychological consultation executive summary which indicated, Resident A was feeling depressed, hopeless, and helpless. The DON stated, The consultation reports are put in the medical record chart under the consultation tab. When the doctor comes in, it is up to the doctor to look at the consultation report. The DON further stated, The Doctor or the Nurse Practitioner should have been notified about the results and documented. A review of social services notes dated [DATE] indicated, Social Services returned call from daughter {name of daughter}regarding anticipated discharge date stated father could not come home due to being unable to take care of him. Requested assisted living placement. Further review of the Social Services notes, indicated no documented evidence to show any interventions were done for Resident A's expressed feelings of dissatisfaction with the family decision of being discharged to an assisted living facility. The social worker was not available for interview During an interview with the DON on [DATE] at 5 PM, the DON reviewed the Social Services notes for the months of [DATE] and [DATE], and confirmed there was no documented evidence to show interventions for Resident A's expressed feelings of dissatisfaction with the family decision of being discharged to an assisted living facility. The DON stated, The Social Worker should have been working with the resident to cope with his feelings of not wanting to go to an assisted living facility. The DON further stated, It is about what the resident wants. There should have been interventions. During a review of the policy and procedure titled, Social Services Responsibilities dated [DATE], indicated under the section titled [MEDICAL CONDITION]'s/behavior management: lead the IDT to identify possible medical, environmental, and psychosocial causal factors of behaviors. The facility failed to ensure that one of three sampled residents (Resident A) was provided necessary care and psychosocial support when Resident A verbalized he wanted to go home upon discharge and not be transferred to an assisted living facility. This failure negatively affected the mental health and well being of Resident A which resulted in Resident's A death. On [DATE] at 7:35 PM, after interviews, and records reviews, an Immediate Jeopardy (IJ, a situation that had threatened the health and safety of a resident) was called in the presence of the Administrator and Director of Nursing. The corrective action plan provided by the facility included: A. The facility began the immediate correction on [DATE] by assessing all residents in the facility to identify any residents that have thoughts of harming self, depression, and anxiety. On [DATE] at 6:00 PM, one resident (Resident B) was identified with suicidal ideation, stating, When he first arrived he wished he had a gun to shoot himself. Resident B was immediately placed on one to one supervision, his attending physician was called immediately. The physician returned the call at 9:00 PM and the physician gave an order to monitor closely and to transfer the Resident B to the acute care hospital for a psychiatric evaluation. Resident B was transferred to (name of the hospital) at 10:00 PM. Resident B returned on [DATE] at 1:20 AM. B. The one resident (Resident B) that was identified during the assessment to be at risk for harming self has had a Patient Care Conference on [DATE]. Resident B stated, that he was talking past tense on his intent to harm himself back when he was getting a divorce and that he was happy now that he had a new truck, apartment and a cat that talks. C. IDT (inter disciplinary team- Nursing, Social Services Designee, Activities, dietary, and Therapy) members were in-serviced on [DATE] and on going on the new care conference process and communication. Beginning [DATE] all care conference will be reviewed by the IDT. Any concerns regarding to harm self, depression and/or anxiety will be brought to the attention of the director of nursing/ Registered Nurse (RN) immediately. D. In services for all departments were immediately initiated on [DATE] and ongoing to staff on the identification of depression, anxiety and suicidal ideation and will be contingent on those employees as they report to work or return from any leaves. E. Facility will receive complete patient information from transferring facility in order to accurately assess each patient for proper placement and accurate completion of PASRR (preadmission screening and resident review) prior to review and acceptance of the patient by the director of nursing and or nursing home administrator beginning [DATE]. F. In servicing to Patient Care Coordinators/MDS (Minimal data sheet- a assessment tool) was initiated on [DATE] and ongoing to staff responsible for completing the PASRR no later than on admission to assure accuracy and inclusion of [DIAGNOSES REDACTED]. G. All current PASRR's will be audited by Patient Care Coordinator/MDS for accuracy and correction will be made as deemed necessary beginning on [DATE]. H. Physicians will promptly be notified once requested psychology/neuropsych consultant reports are received by the facility and will be monitored by DON/administrator. All executive mental Health Consultation from the last 5 months were faxed to Physician's or reviewed by the Physician in the facility immediately on [DATE]. All psychological/neuropsych consultations will be reviewed by the IDT (inter disciplinary team-Nursing,SSD, ACT, Dietary and Therapy) for appropriate follow up recommendation on [DATE]. During an interview with the DON on [DATE] at 7:20 PM, the DON stated the following: A. All residents in the facility were assessed to identify any residents that have thoughts of harming self, depression and anxiety. B. The interdisciplinary team members were inserviced on the new care conferences process. C. In services for all departments were initiated to staff on identification of depression, anxiety, and suicidal ideation. D. The facility will receive complete patient information from the transferring facility in order to accurately assess each patient for proper placement. E. Inservice's to patient care coordinators/ MDS responsible for completing the PASRR, all current PASRR were audited by patient care coordinator for accuracy. F. The physician will be promptly notified once psychology/neuropsychological consultant reports are received by the facility. On [DATE] at 7:30 PM, for the purpose of compliance with the corrective action plan, a record review and interviews with the staff were conducted. It was revealed the staff are assessing the residents for thoughts of suicide ideations, the staff are being inserviced on signs and symptoms of suicide ideations, the interdisciplinary team members are being inserviced on the new care conference process, and the PASRR audit sheets were reviewed and they indicated compliance with the facility's corrective action plan. The corrective action plan was reviewed and accepted on [DATE] at 7:45 PM, in the presence of the Administrator, and Director of Nurses. The IJ was lifted on [DATE] at 7:45 PM , in the presence of the Administrator, Director of Staff Development, Director of Staff Development from Resource, Registered Nurse (RN 1), the nurse from Resource and Director of Nurses (DON).

Based on observation, interview, and record review, the facility failed to obtain a significant medication order for [MEDICATION NAME] ([MEDICATION NAME] - a prescription anticoagulant medicine used to prevent [MEDICAL CONDITIONS], and blood clots in veins and arteries) for one of 22 sampled residents, (Resident 10). This failure resulted in Resident 10's blood levels to decrease significantly placing the Resident at risk for developing blood clots which could result in a stroke, [MEDICAL CONDITION], or death. Findings: During a review of the clinical record for Resident 10, the face sheet indicated Resident 10 was readmitted to the facility on [DATE], with an admitting [DIAGNOSES REDACTED]. blood vessels outside of the heart and brain) and a right [MEDICAL CONDITION] (BKA). A review of Resident 10's admission orders [REDACTED]. A review of Resident 10's physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of Resident 10's laboratory results for PT/INR drawn on March 31, 2016, indicated the results were abnormal, PT/INR of 18.2/1.60, (reference range 11.0 - 13.6 and therapeutic range 2.0 -3.0). An abnormally high PT/INR placed Resident 10 who had a history of [REDACTED]. A review of Resident 10's physician orders [REDACTED]. A review of the MAR indicated [REDACTED]. During review of a physician's orders [REDACTED]. A review of the MAR indicated [REDACTED]. Further review of Resident 10's laboratory results indicated a PT/INR was done on April 5, 2016 and reflected a significant drop from 18.2/1.60 on March 31, 2016, to 10.0/0.90 (below therapeutic level) on April 5, 2016. A second PT/INR done on April 7, 2016 (after Resident 10 had received [MEDICATION NAME] for three days) indicated the level had increased to 11.2/1.0. (This level indicated the PT was in the therapeutic range, but the INR remained low, Resident 10 remained at risk for blood clots). A review of Resident 10's physician order [REDACTED]. On April 15, 2016 at 9:30 AM, during a concurrent interview and record review with the Director of Nursing (DON), the DON stated, Yes, there was an order to hold it ([MEDICATION NAME]) for two days, there should have been an order on the 31st (March 31, 2016). When asked who wrote on the lab results, [MEDICATION NAME] 2 mg tab x 3 days, recheck on Thursday, c/o (call out) to physician, the DON stated the handwriting belonged to the Licensed Vocational Nurse (LVN 3) who worked the afternoon shift on March 31, 2016. The DON stated that there was no documentation of [MEDICATION NAME] administration on the MAR's from March 31, 2016 through April 4, 2016, that a telephone order had not been received from the doctor, there was no nurse's notes, and there was no indication the doctor had been notified of the lab results of March 31, 2016. During an interview on April 15, 2016 at 11:00 AM with the DON, when asked if she knew that Resident 10 had not received [MEDICATION NAME] for 4 days, the DON replied, I did not know prior (to now). During an telephone interview on April 15, 2016 at 11:15 AM, with the Supervisor Registered Nurse (RN 3), who worked March 31, 2016, afternoon shift, when asked if she remembered receiving the PT/INR laboratory results for Resident 10 and had been made aware LVN 3 did not receive new orders for [MEDICATION NAME], RN 3 stated she did not remember and was not aware LVN 3 did not receive orders. RN 3 replied, When the lab results come in, it is the Charge Nurse's responsibility (LVN 3 was the charge nurse). During an telephone interview on April 15, 2016 at 4:00 PM, with LVN 3 regarding laboratory results for Resident 10 received March 31, 2016. LVN stated, the results were faxed to the resident's physician around 6 PM or 7 PM on March 31, 2016. Since there had been no response from Resident 10's attending physician, a call was made to the facility's Medical Director the following day, on April 1, 2016. On orders of the Medical Director, Resident 10's alternate physician was called on April 2, 2016, and the new order for [MEDICATION NAME] was received. LVN 3 was unable to explain the delay from receiving the order on April 2, 2016, to faxing the order to the pharmacy on April 3, 2016. When LVN 3 was asked if she had informed another nurse, or documented her attempts to reach the physician, or asked anyone to follow-up to get the physician's orders [REDACTED]. I did not write anything to follow-up or tell it to another nurse. I know it was my mistake on that. When asked if the Nursing Supervisor and/or the DON were notified, she replied, I told a Registered Nurse (RN) that the [MEDICATION NAME] order was late and he (RN Supervisor) said to try to get a hold of the doctor. I did not document it. LVN 3 stated she did not know if the DON was notified. During an interview on April 15, 2016 at 3:00 PM, with the Pharmacist for the facility, regarding [MEDICATION NAME] administration for Resident 10, the Pharmacist replied, that they did not receive the PT/INR laboratory results of March 31, 2016 until April 3, 2016, and on the bottom of the laboratory results was handwritten, [MEDICATION NAME] 2 mg PO (by mouth) x 3 days, PT/INR on Thursday (the pharmacy would have assured there was no lapse in coverage with the corrected [MEDICATION NAME] dose based on the laboratory results). When asked when the order for [MEDICATION NAME] 2 mg tablets was sent to the facility, the pharmacist replied, We did not dispense anything until we got the new order (telephone order slip) on April 3rd, we dispensed (the [MEDICATION NAME]) on April 4, 2016. When asked if the pharmacy had been made aware that Resident 10 had not received [MEDICATION NAME] for four days, she replied, When we got the new order (April 3, 2016), it might not have been immediately apparent that it (the [MEDICATION NAME]) was held prior (to the order being obtained). We don't monitor [MEDICATION NAME] dosage for this facility. We will look at the labs to make sure dosages are ok. During an interview on April 15, 2016 at 4:20 PM, with the facility's Pharmacy Consultant, the pharmacist stated, I was not aware that this Resident didn't receive [MEDICATION NAME] for four days, but they (facility staff) would only contact the physician, since I don't monitor (lab results). When asked the Pharmacy Consultant's role in [MEDICATION NAME] administration, the pharmacist stated, I double check periodically that PT/INR results are done. During an interview on April 15, 2016 at 5:00 PM, with the Medical Director (MD), when asked was he aware that Resident 10 did not receive [MEDICATION NAME] from March 31, 2016 through April 3, 2016, he replied, Yes, and that they (the facility) had a QA (Quality Assurance) meeting on April 4, 2016. We discussed a system to make sure that we follow-up with [MEDICATION NAME], PT/INR results, and that the physician is notified of the results. When asked if other residents (besides Resident 10) were discussed, the MD replied, I do not recall. The MD gave a list of names of who was present at the QA meeting, which included the facility administrator and the DON. The MD was asked if he was contacted by LVN 3 when she was unable to reach Resident 10's physician on April 1, 2016, with the abnormal laboratory results and he responded, I do not recall, so many things, I am not sure if she asked me. During an interview on April 15, 2016 at 6:00 PM, with the DON regarding the Quality Assurance meeting on April 4, 2016, when asked if the medication [MEDICATION NAME] was discussed, the DON replied, Not specifically [MEDICATION NAME]. The DON stated that laboratory results were mentioned, but did not specify which laboratory results. The DON then stated that PT/INR lab results were discussed, but not Resident 10. When the DON was asked about the MD's statement that the QA Committee discussed Resident 10 at the meeting on April 4, 2016, the DON stated, I don't have anything else. During a review of the facility's Drug Regimen Review (DRR) done by the Pharmacy Consultant for outcomes entered between April 1, 2016 and April 12, 2016, the abnormal PT/INR results and the missed [MEDICATION NAME] doses for Resident 10 were not identified by the Pharmacist Consultant. A review of the facility's Pharmacy Policies and Procedures (not dated) ,Appendix R-[MEDICATION NAME] Administration indicated, The facility nursing staff will receive and report the serum monitoring for administration of [MEDICATION NAME] such as [MEDICATION NAME] (PT or International Normalized Ratio (INR). The report will be called or faxed to the prescriber immediately. Documentation of physician notification of the results and prescriber's response will be made in the Nurses Notes, including the date and time. Laboratory target range for [MEDICAL CONDITION] Fibrillation 1.75-3.0. A review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised September 2012, indicates 1. A nurse will review all results. a. If the staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. A review of the facility's policy titled Test Results revised April 2007, indicates, The resident's Attending Physician will be notified of the results of diagnostic tests. 3. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results. A review of the facility's job description titled Charge Nurse dated 2003, indicated, Duties and Responsibilities . Report all discrepancies noted concerning physician's orders [REDACTED].to the Nurse Supervisor. Perform routine charting duties as required and in accordance with established procedures. Order prescribed medications .Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift . Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary. A review of the facility's job description titled Nurse Supervisor dated 2003, indicated, Duties and Responsibilities . Meet with your shift on a regularly scheduled basis to assist in identifying and correcting problem areas and/or to assist in the improvement of services. Review nurses' notes to ensure that they are information and descriptive of the nursing care being provided. Report problem areas to the Director. Assist in developing and implementing corrective action. Assist the Charge Nurse in monitoring seriously ill residents. A review of the facility's job description titled Medical Director dated 2003, indicated, Duties and Responsibilities .Monitor adherence of medical staff to rules and policies governing the medical care of residents. Assist in assessing and assuring quality, timeliness, and appropriateness of services rendered to residents, as well as the appropriate documentation and maintenance of quality records. Provide medical coverage for emergency situations of all individual residents.

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident A) from potential emotional abuse by a staff member when a certified nursing assistant (CNA 1) continued grasping Resident A's hand as she clung to the side-rail during personal care. Resident A repeatedly told CNA 1 to stop grasping her hand, because the grasp was tight and it was hurting her hand. CNA 1's failure to respond to Resident A's request to let go of her hand, and telling CNA 1, You're going to break it, caused physical pain and potential emotional distress for Resident A. Finding: On October 30, 2015 at 11:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of physical abuse. During a review of Resident A's clinical record, the face sheet (contains resident demographics) indicated Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The face sheet indicated Resident A was primarily Spanish speaking and that she understood and could speak some English. During an observation of Resident A on October 30, 2015 at 12:00 PM, the resident was observed sitting in a wheelchair awaiting lunch in the dining room. Review of the assignment list dated October 28, 2015, indicated CNA 1 was the CNA assigned to care for Resident A. During an interview with Resident A on October 30, 2015 at 12:05 PM, with Employee 1 providing interpretive services (Resident A was primarily Spanish speaking), Resident A stated CNA 1, who spoke Spanish, had not responded to her repeated requests to stop grasping her hand so tightly. Resident A stated she was in her room, in bed, holding on to the bed side-rail for support as CNA 1 was attempting to change her brief during the early morning hours of October 28, 2015 at approximately 4 AM. Resident A stated, I yelled at him (CNA 1) to please, please, let my hand go or you are going to break it. When asked if CNA 1 stopped what he was doing, Resident A stated, Not for a long time .It hurt very bad when he was grabbing it (her right hand) .my fingers were numb for a while he wanted to show me how strong he was I do not want to see him (CNA 1) anymore. Resident A appeared to be physically shaking as she stated this. During a review of the facility's, Resident Abuse Investigation Report Form, dated October 29, 2015, Resident A had stated to the Spanish speaking Activities Supervisor (AS), that CNA 1 was rough when turning her on her side. Resident A told the AS that she likes to hold on to the side-rails for support because she feels as if she is going to fall. Resident A told this to CNA 1, and CNA 1 told her she was not going to fall, and he proceeded to grab her hand that was holding onto the side-rail, and with both hands, took her hand off the side-rail. Resident A told the AS she yelled out because it hurt her and CNA 1 told her she yells too much and she exaggerated too much when yelling. During a review of the employee file for CNA 1, with the Facility Administrator (FA), the file indicated CNA 1 received Elder Abuse training on April 14, 2015. CNA 1 was suspended during the investigation of the allegation on October 28, 2015. The Employee Separation Report, dated October 30, 2015, indicated CNA 1 was terminated that day. Suspected allegation of resident abuse was indicated as the reason for separation. During a concurrent record review of the Resident Abuse Investigation Report Form completed by the FA dated October 29, 2015, under Summary of Investigator's findings, .if resident indicated she was being hurt this CNA (CNA 1) should have stopped immediately and sought assistance from another co-worker. The FA stated that had CNA 1 stopped what he was doing and sought assistance, that his termination could have potentially been avoided. Review of the facility policy and procedure titled, Resident Abuse/Rights/Reporting/Investigation, dated June 2007, indicated, Policy-General .2. The facility will enforce a policy of non-tolerance of any form of behavior that might be construed as abuse by any resident, family member, staff member, visitor, volunteer, student, or other persons.

Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure when there was no documented evidence for one of 22 sampled residents (Resident 11), the physician was notified of changes in Resident 11's condition when: 1. Following a fall on December 4, 2013, Resident 11 continued to complain of pain in the right ankle and experienced a decline in the ability to transfer and ambulate (walk). An xray was obtained seven days after Resident 11's fall which indicated Resident 11 sustained acute fractures to the lower end of both bones in the right lower leg (Where it joins with the ankle). 2. Resident 11 reported changes to licensed staff including a cough, with minimal amounts of blood (hemoptysis), for two days and "feeling weaker than usual." These failures delayed interventions and treatment, and placed Resident 11 at serious risk for complications including damaging surrounding tissues, tendons, or ligaments and the possibility of throwing a blood clot to the lungs which could have resulted in death. Findings: 1. During a review of Resident 11's clinical record on June 24, 2014, the face sheet (contains resident's demographic information) and the physician history and physical indicated Resident 11 was admitted on [DATE], and had [DIAGNOSES REDACTED]. The nurses notes, dated December 4, 2013 at 2:30 PM, indicated, Resident 11 "slid to floor during PT (physical therapy)." A nurses notes entry dated, December 4, 2013 at 10 PM, indicated that Resident 11 had "pain to (left) foot and ankle;" pain medication was administered. The nurses notes, dated December 5, 2013 at 7:15 AM, indicated Resident 11 refused to go to [MEDICAL TREATMENT] (the process wherein waste products and excess fluid are removed from the body) because of the presence of pain on the right knee and right ankle; pain medication was given. A review of the nurses notes, dated December 5, 2013 at 3:15 PM, indicated the physician examined Resident 11, was made aware of the X-ray (procedure used to view the structures inside the body) result of the right knee dated December 3, 2013 (a day prior to Resident 11's December 4, 2014 fall). During an interview with a licensed vocational nurse (LVN 4), and a concurrent review of the clinical record on June 24, 2014 at 12:40 PM, LVN 4 confirmed the X-ray result that the physician was made aware of and reviewed during the physician's visit on December 5, 2013, was that of a previously ordered right knee X-ray dated December 3, 2013, (performed one day prior to the December 4, 2013 fall) which indicated, "Modest [MEDICAL CONDITION] (a decline in the joints or bones) of the right knee." The subsequent nurses note indicated Resident 11 had "right ankle pain" on December 6, 2013, at 1 PM. The Medication Administration Record [REDACTED] a. December 4, 2013 at 2:30 PM, Tylenol #3 1 tablet (Tylenol with [MEDICATION NAME] - medication used to relieve pain) for pain on the right knee b. December 5, 2013 at 1 PM, Tylenol #3 1 tablet, for pain on the right ankle and right knee c. December 6, 2013 at 12 PM, Tylenol #3 1 tablet, for pain on the right ankle d. December 7, 2013 at 12:30 AM, Tylenol #3 1 tablet, for pain on the right ankle and the right knee e. December 10, 2013 at 11 AM, Tylenol #3 1 tablet, for pain on the right ankle. A review of the physical therapy (PT) daily treatment note, dated December 4, 2013, indicated the therapists lowered Resident 11 to the floor, and (the therapists) "unbent feet out from under (Resident 11)." Resident 11 reported increased pain to right knee and right ankle with a pain level of 8/10 (a scale used to determine the intensity of pain; from 0 to 10; a "0" would indicate no pain) after being transferred back into bed by the therapists. During an interview with the physical therapy assistant (PTA), and a concurrent review of the clinical record on June 24, 2014 at 1:25 PM, PTA confirmed that during the physical therapy daily treatment on December 4, 2013, he lowered (Resident 11) down on the floor because Resident 11's "knees buckled." The PT daily treatment notes from December 4, 2013 through December 11, 2013 indicated Resident 11 continued with physical therapy treatments after the fall on December 4, 2013. The notes indicated the changes in Resident 11's status as follows: a. December 5, 2013, Resident 11 was "too unstable to attempt functional transfer" from bed to wheelchair secondary to increased weakness and right ankle pain of 9-10/10. Resident 11 was unable to perform return demonstration of exercises because of compromised safety levels secondary to increased weakness and right ankle pain. b. December 6, 2013, Resident 11 was unable to transfer-train today secondary to increased instability, with increased risk of fall secondary to right ankle pain. c. December 9, 2013, Resident 11 participated in supine (laying on one's back) and rolling side to side exercises, and required rest breaks to regain energy and reduce right ankle pain. Resident 11 reported right ankle pain of 8/10 "limiting activity tolerance." d. December 10, 2013, continued with supine and sit bed mobility (from laying to sitting position exercises in bed) with moderate assistance and rolling side to side with minimal assistance. When sitting at the edge of bed, Resident 11 was unable to scoot forward without moderate to maximum assistance. Resident 11 reported right ankle pain of 8/10 limiting activity tolerance. e. December 11, 2013, Resident 11 completed "pre-gait standing (standing before walking) EOB (edge of bed)" three times for 40 seconds with moderate to maximum assistance. The note also indicated Resident 11 was able to take small side steps to the right to move up the bed for better positioning. Resident 11 reported weakness in (both) knees at the end of each standing, with increased fear of falling, necessitating Resident 11 to sit down. The note further indicated Resident 11 reported continued fatigue, and bilateral lower extremity weakness limiting activity tolerance. A physician progress notes [REDACTED]. The note indicated "strain R/O (rule out) fx (fracture) - will obtain xray..." The nurses note, dated December 11, 2013 at 1:30 PM, indicated the physician came in to see Resident 11 and ordered, "1. to xray (right) ankle AP/Lat (side and front view) (secondary to pain) 2. right akle - ace wrap (to wrap the affected limb with a bandage) with moderate pressure (secondary to pain) 3. ice pack to right ankle TID (three times a day) x (for) 14 days (secondary to) pain." A review of the nurses notes from December 4, 2013 through December 11, 2013 did not reflect Resident 11 had been assessed for the presence of a bruise on the ankle and shin areas. A review of the right ankle X-ray result dated December 11, 2013 revealed "...Acute distal fibular and anterior distal tibial (lower leg bones) fractures as above." The nurses note, dated December 11, 2013 at 7:46 PM, indicated a call was placed to the physician "(secondary to) xray of right ankle" and the nurse awaiting the physician to call. At 8:15 PM, the physician called and was advised of the xray results. The physician ordered to send Resident 11 to the general acute care hospital. During further interview with PTA, and a concurrent review of the PT daily treatment notes on June 25, 2014 at 4:15 PM, PTA confirmed there was a change and a decline in Resident 11's level of functioning after the December 4, 2013 incident, and "nursing" was made aware. Prior to the fall incident, Resident 11 was able to transfer with one-person standby (staff does not touch or provide any assistance, but may need to be close-by for safety) assistance during transfers with front wheel walker. Resident 11 was also able to walk using the parallel bars (a pair of long bars on post that are used to support resident when walking) approximately eight feet x three with contact guard assist (staff have one or two hands on your body to help with balance). PTA further confirmed Resident 11 continued with PT treatments performing "bed exercises" after the fall and there were no changes with the PT treatment orders. During further interview with PTA, and a concurrent review of the clinical record on June 26, 2014 at 3:10 PM, in the presence PT 1, PTA stated on December 11, 2013, Resident 11 performed the pre-gait standing and small side steps because Resident 11 was not complaining of pain that day. During a concurrent interview, PT 1 confirmed there was no documented evidence of a physician notification that Resident 11 had declined in both the ability to stand and ambulate, or that Resident 11 had decreased activity tolerance with continued pain during PT treatment. PT 1 stated "nursing" was informed of changes in Resident 11's pain level and decline in physical functioning. During an interview with the director of nurses (DON) on June 26, 2013 at 10 AM, and a concurrent review of the clinical record, she verified based on the facility's policy for change in a resident's condition or status, Resident 11 should have been immediately and continuously assessed for the character of the pain in the right ankle, as well as, for swelling and bruising to the affected area. The DON stated there should have been ongoing communication between the nursing and therapy departments, of Resident 11's clinical status. The physician also should have been kept informed of Resident 11's status so a determination could have been made to hold, make changes in, or discontinue physical therapy treatments, until resolution of the pain in the right ankle. The DON confirmed that after the physician's visit on December 5, 2013, there was no documented evidence that the physician was notified of Resident 11's continued episodes of pain to the right ankle or of Resident 11's decline in ability to stand and ambulate that followed. During an interview on June 27, 2014 at 8:30 AM, Resident 11 stated after the fall on December 4, 2013, "I went for a week or 2 with pain (on the right ankle). I didn't know it was broken. I kept walking on it after I fell because I didn't know. It was hurting when I stepped on it (right ankle)." During further interview, Resident 11 stated, "It (the right ankle) was swollen and hurting until I couldn't stand it no more and I had to tell the staff." Resident 11 further stated that the xray was then performed on December 11, 2013. Resident 11 explained that the pain on the right ankle was constant and that the pain medication would only decrease the level of the pain, but not relieve it. A review of the facility's policy and procedure titled, "Change in a Resident's Condition or Status," revised February 2014, indicated, "...The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there has been: ...d. A significant change in the resident's physical/emotional/mental condition ...g. A need to alter the resident's medical treatment significantly ..." A review of the facility's policy and procedure titled, "Fall - Clinical Protocol," revised April 2013, indicated under assessment and recognition, "...2. In addition, the nurse shall assess and document/report the following:...c. musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.;..f. pain..." The policy further indicated under monitoring and follow-up, "1. The staff, with the physician's guidance, will follow up on any falls with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved..." 2. During a review of the clinical record on June 24, 2014, the face sheet and the physician's history and physical indicated Resident 11 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The note indicated that Resident 11 received [MEDICAL TREATMENT] (process wherein waste products and excess fluid are removed from the body) treatments. A review of the nurses notes, dated June 3, 2014 9:30 PM indicated Resident 11 reported to the licensed nurse about having been coughing for two days, feeling like there was, "mucus in the back of (Resident 11's) throat and of feeling, and being "weaker than usual." The nurses notes further indicated Resident 11 had slight "crackles" (an abnormal lung sound) noted at the bases of the lungs, and was coughing up minimal amounts of blood. A review of the nurses notes, dated June 3, 2014 through June 10, 2014 indicated there was no documented evidence that the physician was notified of these changes in the resident's condition. During an interview with a licensed vocational nurse (LVN 4) and a concurrent review of the clinical record on June 26, 2014 at 10:20 AM, LVN 4 confirmed that the symptoms reported by Resident 11 was a change in Resident 11's usual condition. LVN 4 stated the physician should have been notified promptly of these changes. She stated, "I don't see that; it's not documented that they called." A review of the facility's policy and procedure titled, "Change in a Resident's Condition or Status," revised February 2014, indicated "...1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: ...d. A significant change in the resident's physical/emotional/mental condition; ......g. A need to alter the resident's medical treatment significantly..." During an interview with the Director of Nurses (DON), and a concurrent review of the clinical record on June 26, 2014 at 10:35 AM, the DON stated physician should have been notified of the changes in Resident 11's condition. She confirmed there was no documented evidence that the physician was notified of the changes in Resident 11's condition.