Every finding on record at La Brea Rehabilitation Center

Based on interview and record review, the facility failed to ensure proper verification, documentation, and maintenance of legal power of attorney (a signed legal paper that lets you pick a trusted person to make choices or handle tasks for you if you cannot do them yourself) and advance directive (a legal document indicating resident preference on end-of-life treatment decisions) records for one of four sampled residents (Resident 1) when the Physician Orders for Life-Sustaining Treatment (POLST - a set of portable medical orders, executed by an adult patient [or legal surrogate] and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals) was listed a POA but no legal POA paperwork existed and no follow up was performed to obtain required documents. This failure resulted in uncertainty regarding the resident's authorized decision maker and risked inappropriate medical decision making.During a review of the admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), difficulty in walking, chronic atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and heart failure (a condition in which the heart does not pump blood as well as it should). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 5/31/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Advance Directive Acknowledgment Form (ADAF) dated 10/13/2026, the ADAF indicated, Resident 1 has not executed an Advance Directive and declined to execute an Advance Directive. The ADAF form was signed by Social Services Director with verbal consent from Resident 1's Emergency Contact #1. During a review of Resident 1's POLST dated 10/13/2025, the POLST indicated Resident 1 option opted to Do Not Attempt Resuscitation/DNR, with signature by SSD via verbal consent over the phone from Resident 1's Emergency Contact #1. The POLST was signed by the physician, but there was no date when it was signed by the physician. During a review of Resident 1's Progress Notes (PN), dated 10/13/2025, the PN indicated, Called resident's responsible parties, Emergency Contact #1 and Emergency Contact #2, Resident 1 was DNR per instructions, asked them to provide copy of POA and medical directive when they come by, they confirmed they would., written by SSD. During a concurrent interview and record review with SSD on 8/25/2026 at 12:21 p.m., SSD stated, he talked to Resident 1's Emergency Contact #1 upon admission and he was told that Resident 1 was DNR. SSD stated, I asked if they could bring Resident 1's Advance Directive and POA documentation but they never brought it. SSD stated that he never followed up with the POA documentation, therefore, he was unable to provide the legal documentation that Resident 1 has a POA. SSD stated, I should have followed up. During an interview with Director of Nursing (DON) on 8/25/2026 at 4:10 p.m., staff should have obtained Resident 1's legal POA documentation and Advance Directive to ensure that Resident 1's actual POLST was DNR. DON stated that they should have clarified that Resident 1 has a POA by verifying it through legal documentation. During a review of the facility's policy and procedure (P&P) titled, Resident Representative, revised on 1/2026, the P&P indicated that, The facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated by the resident or to the extent required by the court, in accordance with applicable law. The court appointed resident representative will exercise the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with state law. Documentation designating that the representative has been delegated the necessary authority to exercise the resident's rights for decision-making issues is obtained by the director of nursing or a designee. During a review of the facility's P&P titled, Advance Directive, revised on 1/2026, the P&P indicated that, Prior to or upon admission of a resident, the social services director or designee will inquire of the resident his/her family members and/or his or her legal representative, about the existence of any written advance directives. During a review of the facility's P&P titled, Do Not Resuscitate Order, revised on 1/2026, the P&P indicated that, A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record.

Based on interview and record review, the facility failed to ensure detailed skin assessments were accurate and completed upon admission for one of three sampled residents, (Resident 1). This deficient practice had the potential to delay the provision of necessary care and services and deterioration of residents' current wounds. During a review of the admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), difficulty in walking, chronic atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and heart failure (a condition in which the heart does not pump blood as well as it should). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 5/31/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated Resident 1 was not at risk of developing pressure ulcer injuries. During a review of General Acute Care Hospital 1 (GACH 1) Medical Record (MR), dated 4/22/2026, the MR indicated, Resident 1 had an active pressure ulcer/wound, the MR indicated, Resident 1 had an impaired skin integrity/wound moisture associated skin damage (a type of wound where the skin is torn or separated from the underlying tissues) in the sacrum (a triangular-shaped bone located at the base of spine). The Skin Assessment indicated the sacrum was, red, with skin/wound treatment used is a moisture barrier ointment and cover with foams. During a review of Resident 1's MR from Skilled Nursing Facility 2 (SNF 2), the MR indicated Resident 1 was transferred from SNF 2 on 10/10/2025. The MR indicated, Resident 1 had a physician's order to cleanse sacrococcyx (tailbone area) with normal saline (a gentle, clean saltwater rinse used to wash dirt and germs out of a cut or scrape without stinging or harming new healing), pat dry, apply zinc oxide (a safe, chalky white mineral paste or cream used on the skin) every day. During a review of Resident 1's admission Assessment, dated 5/27/2026, the admission Assessment indicated that Resident 1's skin was intact besides surgical site. During a review of Resident 1's Baseline Care Plan (BCP) dated 5/27/2026, the BCP for skin care needs were blank. The BCP for skin care needs does not have information if Resident 1's skin was intact or if there was any skin breakdown and/or pressure injury present. The BCP indicated that there were no interventions initiated for skin care needs for Resident 1. During a review of Resident 1's Braden Scale (for predicting pressure sore risk), dated 5/28/2026, Resident 1's Braden Scale score was 13 (moderate risk for developing pressure ulcers or skin breakdown). During a concurrent interview and record review with Treatment Nurse 1 (TXN 1) on 8/25/2026 at 1:13 p.m., TXN 1 stated, upon admission and readmission, treatment nurse must do their own skin assessment, aside from the admission assessment, so that they may do a detailed skin assessment. TXN 1 stated, they use a different skin assessment with detailed information, and they compare it to the admitting nurses' admission assessment. TXN 1 reviewed Resident 1's medical record and stated there was no detailed skin assessment conducted when Resident 1 was admitted . TXN 1 stated, Resident 1 has a moderate Braden scale score of 13, which they should have notify the physician and order for skin maintenance and initiate in the BCP and comprehensive care plan. During a concurrent interview and record review with TXN 1 on 5/5/2025 at 3:22 p.m., TXN 2 stated, Resident 5 had a scar tissue on her buttocks that has been resolved. Resident 5's sacral skin with TXN 1 and Resident 5's skin appeared open, yellowish, green in color, with some light fluid drainage. TXN 2 stated, it looked like it had a fissure (tear) on the left side of the wound. During a concurrent interview and record review with Director of Nursing (DON) on 8/25/2026 at 4:10 p.m., DON reviewed Resident 1's BCP which indicated Resident 1 did not have any skin care needs and the form was blank. DON reviewed Resident 1's medical record which indicated, there was no detailed skin assessment done upon admission which should have been done by treatment nurses. DON stated, since there was no detailed skin assessment done during admission, they could not identify if Resident 1 has any skin breakdown. DON further stated that they should have documented and initiated a care plan so that may have done interventions to prevent and/or manage skin breakdown. During a review of facility's policy and procedures (P&P), titled, Preventions of Pressure Injuries, revised on 1/2026, the P&P indicated, Assess the resident on admission (within 8 hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Skin Assessment: a. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs.: Identify any signs of developing pressure injuries. Moisturize dry skin daily; and Reposition resident as indicated on the care plan. Monitoring: evaluate, report and document potential changes in the skin; review the interventions and strategies for effectiveness on an ongoing basis.

Based on observation, interview, and record review, the facility failed to assess, notify the physician, and obtain medical orders for one of five residents (Resident 1) reviewed for changes in condition after Resident 1 sustained an injury while trying to move out of his wheelchair to his bed on 7/20/2026 at approximately 11 AM according to the facility's policies and procedures (P&P) titled Change of Condition dated January 2026, Accidents dated January 2026, and Charting and Documentation dated January 2026.Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 1 were aware Resident 1 reported hitting the resident's right leg during a transfer attempt and that Resident 1 had requested for ice to apply to the right leg. This failure resulted in delayed evaluation, treatment, and interventions to address Resident 1's complaint of pain to the right leg. Also, Resident 1 had developed a bruise (contusion - is skin discoloration from damaged, leaking blood vessels underneath the skin) and raised lump on the same leg.Findings include: During a review of Resident 1's admission Record, dated 7/20/2026, indicated Resident 1 was admitted to the facility on [DATE] with primary diagnosis of Lack of Coordination, and secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD- lung disease causing restricted airflow and breathing problems). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 6/22/2026, indicated Resident 1 had intact cognition (ability to think, remember and reason). The MDS indicated Resident 1 was dependent (Staff does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for chair to bed transfers, toilet transfer, and required maximal assistance (Staff does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to shower, upper and lower body dressing, putting on taking off footwear, roll left and right, sit to lying, and lying to sitting on side of bed. Resident 1 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for oral hygiene, and partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting. During a concurrent observation and interview on 7/20/2026 at 2:27 PM with Resident 1, in Resident 1's room, Resident 1 stated he was doing alright except for the awful pain on his right leg. Resident 1 stated that on 7/20/2026 at approximately 11 AM he was moving himself from his wheelchair onto his bed without staff assistance and struck his right leg on the bed frame. Resident 1 pointed to his right leg where a round, raised lump was observed. The surrounding area showed green-colored ecchymosis (bruising). The lump was palpable and elevated above the surrounding tissue. Resident 1 reported severe pain that had not resolved despite placing an ice pack that was brought to him by LVN1. During an interview on 7/20/2026 at 2:34 PM with CNA1, CNA1 stated he was assigned to care for Resident 1 and that Resident 1 did not notify staff about needing assistance to transfer from wheelchair to bed. CNA1 stated Resident 1 requested an ice pack on the morning of 7/20/2026 (unsure of the time), to place on the resident's right leg. CNA1 stated he reported to LVN1 about Resident 1's injury and request for an ice pack. CNA1 sated that LVN 1 went to get an ice pack to place on Resident 1's leg. During an interview on 7/20/2026 at 2:38 PM with LVN1, LVN 1 stated that on 7/20/2026 at approximately 12:30 PM, CNA1 reported to LVN1 that Resident 1 had requested an ice pack. LVN1 stated that LVN 1 went to get an ice pack and brought it back to Resident 1 in Resident 1's room. LVN1 stated Resident 1 reported hitting the right leg during the transfer attempt and requested ice. LVN 1 acknowledged providing ice but stated he did not complete a nursing assessment, did not ask Resident 1 what his pain level was, did not notify the physician, or obtain physician orders following the incident because Resident 1 was not assigned to him that day. The LVN1 stated he reported to LVN2 who was assigned to Resident 1 on 7/20/2026. The LVN 1 stated he did not go back to assess if the ice pack had been effective at reducing Resident 1's pain. During an interview on 7/20/2026 at 2:42 PM with LVN2, LVN2 stated no staff had reported to him that Resident 1 had sustained an injury, and verified that no documented nursing assessment of the injured extremity, including evaluation of pain, swelling, bruising, range of motion, or circulation had been done. The LVN2 verified that no documentation that the physician was notified of the injury and no physician orders were obtained for evaluation, monitoring, diagnostic testing, or treatment. The record lacked documentation of continued monitoring or follow-up of the resident's condition after the injury. During an interview on 7/20/2026 at 3:20 PM with the Director of Nursing (DON), the DON stated that the facility's policy requires licensed nurses to assess residents following an injury, notify the physician when there is a change in condition or injury with pain or swelling, document the assessment, and implement physician orders as indicated. The DON stated licensed nurses should ask residents how the incident happened, determine if there's an injury such as a fracture (break in the bone), determine if any medications such as blood thinners must be discontinued, and notify the physician to obtain medical orders for residents. The DON stated regardless of who's assigned to each resident, any licensed nurse must assess resident's immediately, and failure to do so places residents at risk for delayed treatment and worsening condition. During a review of the facility's policy and procedures (P&P) titled Change of Condition dated January 2026, indicated, the nurse will notify the resident's attending physician when there has been an accident or incident involving the resident, discovery of injuries of an unknown source, and gather relevant and pertinent information for the provider, including information prompted by the SBAR communication form. During a review of the facility's P&P titled Accidents dated January 2026, indicate, the nurse shall promptly initiate and document investigation of an accident or incident to include date and time the accident took place, nature of the injury/illness, where the accident took place, the circumstances surrounding the accident or incident, condition of the injured person, including his/her vital signs. During a review of the facility's policy and procedure titled Charting and Documentation dated January 2026, indicated, all services provided to the resident shall be documented in the medical record. The following information is to be documented in the resident medical record:Objective observationsMedications administeredTreatments administeredChanges in resident's conditionEvent, incidents, accidents involving the residentProgress toward or changes in the care plan goals and objectives.Documentation of procedures and treatments will include care-specific details, including:The date and time the procedure was providedName and title of the individual who provided careAssessment data and or any unusual findings obtained during the procedure and treatmentHow the resident tolerated the treatmentNotification of family, physicianSignature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice by failing to assess and evaluate one of five residents (Resident 1) following an injury sustained during an unassisted transfer attempt. Specifically, the facility failed to perform a nursing assessment after Resident 1 struck the right leg on the bed, despite the resident complaining of pain and developing a bruise and palpable lump to the right leg according to the facility's policy and procedures P&P) titled Comprehensive Assessments dated January 2026.Licensed Vocational Nurse (LVN) 1 was aware Resident 1 reported hitting the resident's right leg during the transfer attempt and requested ice. This failure had the potential to delay identification of an injury and appropriate treatment for Resident 1.Findings: During a review of Resident 1's admission Record, dated 7/20/2026, indicated Resident 1 was admitted to the facility on [DATE] with primary diagnosis of Lack of Coordination, and secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD- lung disease causing restricted airflow and breathing problems). During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 6/22/2026, indicated Resident 1 had intact cognition (ability to think, remember and reason). The MDS indicated Resident 1 was dependent (Staff does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for chair to bed transfers, toilet transfer, and required maximal assistance (Staff does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to shower, upper and lower body dressing, putting on taking off footwear, roll left and right, sit to lying, and lying to sitting on side of bed. Resident 1 required set up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating, supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for oral hygiene, and partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting. During a concurrent observation and interview on 7/20/2026 at 2:27 PM with Resident 1, in Resident 1's room, Resident 1 stated he was doing alright except for the awful pain on his right leg. Resident 1 stated that on 7/20/2026 at approximately 11 AM he was moving himself from his wheelchair onto his bed without staff assistance and struck his right leg on the bed frame. Resident 1 pointed to his right leg where a round, raised lump was observed. The surrounding area showed green-colored ecchymosis (bruising). The lump was palpable and elevated above the surrounding tissue. Resident 1 reported severe pain that had not resolved despite placing an ice pack that was brought to him by the LVN1. During an interview on 7/20/2026 at 2:34 PM with Certified Nursing Assistant (CNA) 1, CNA1 stated he was assigned to care for Resident 1 who did not notify staff about needing assistance to transfer from wheelchair to bed. CNA1 stated Resident 1 requested an ice pack on the morning of 7/20/2026 unsure of the time, to place on his right leg. CNA1 stated he reported to the LVN1 about Resident 1's injury and request for an ice pack, and LVN 1 went to get an ice pack to place on Resident 1' leg. During an interview on 7/20/2026 at 2:38 PM with LVN1, LVN 1 stated that on 7/20/2026 at approximately 12:30 PM, CNA1 reported that Resident 1 had requested an ice pack and LVN 1 went to get an ice pack and brought it back to Resident 1 in Resident 1's room. LVN1 stated Resident 1 reported hitting the right leg during the transfer attempt and requested ice. LVN 1 acknowledged providing ice but stated he did not complete a nursing assessment, did not ask Resident 1 what his pain level was, did not notify the physician, or obtain physician orders following the incident because Resident 1 was not assigned to him that day. The LVN1 stated he reported to LVN2 who was assigned Resident 1 on 7/20/2026. The LVN 1 stated he did not go back to assess if the ice pack had been effective at reducing Resident 1's pain. During an interview on 7/20/2026 at 2:42 PM with LVN2, LVN2 stated no staff had reported to him that Resident 1 had sustained an injury, and verified that no documented nursing assessment of the injured extremity, including evaluation of pain, swelling, bruising, range of motion, or circulation had been done. The LVN2 verified that no documentation that the physician was notified of the injury and no physician orders were obtained for evaluation, monitoring, diagnostic testing, or treatment. The record lacked documentation of continued monitoring or follow-up of the resident's condition after the injury. During an interview on 7/20/2026 at 3:20 PM with the Director of Nursing (DON), the DON stated facility policy requires licensed nurses to assess residents following an injury, notify the physician when there is a change in condition or injury with pain or swelling, document the assessment, and implement physician orders as indicated. The DON stated licensed nurses should ask residents how the incident happened, determine if there's an injury such as a fracture (break in the bone), determine if any medications such as blood thinners must be discontinued, and notify the physician to obtain medical orders for residents. The DON stated regardless of who's assigned to each resident, any licensed nurse must assess resident's immediately, and failure to do so places residents at risk for delayed treatment and worsening condition. During a review of the facility's policy and procedures titled Comprehensive Assessments dated January 2026, indicated licensed nurses will assess the individual to include What, Where, and When information to gather relevant information from multiple sources including:ObservationPhysical assessmentSymptom or condition related assessmentsResident interviewLab and diagnostic test resultsEvaluations from other disciplines.Information analysis should include how and why?Define issues including problems, risk factors, identify contributing factors such asMedicalPsychosocialEnvironmental and functional.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records for one of five sampled residents (Resident 2) by failing to accurately document Resident 2's transfer status after the resident was sent to the hospital on 7/14/26 according to the facility's policies and procedures (P&P) titled Transfer or Discharge Documentation dated January 2026, and Census Report dated April 2007. This failure resulted in Resident 2 remaining on the facility census during the survey despite no documentation supporting Resident 2's whereabouts or admission status, creating the potential for inaccurate resident accountability, continuity of care, and medical record documentation.Findings: During a review of Resident 2's admission Record, dated 7/20/2026, indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with primary diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue), and secondary diagnosis of neoplasm of prostate (tumor located just below the bladder and in front of the rectum). During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool), dated 6/23/2026, indicated Resident 2 had moderate impaired cognition (ability to think, remember and reason). The MDS indicated Resident 2 required partial assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for eating, maximal assistance (Staff does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for oral hygiene, and was dependent (Staff does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for toileting, showering, upper and lower body dressing, putting on taking off footwear, roll left and right, sit to lying, lying to sitting, sit to stand, and chair to bed transfers. During a review of the facility's Daily Census Report dated 7/20/2026, indicated Resident 2 was currently in the facility. During a review of Resident 2's Order Summary dated 7/8/2026 indicated Resident 2 had a scheduled appointment on 7/14/2026 with an outside oncologist (physician who specialized in cancer treatment). During a review of Resident 2's Progress Notes dated 7/14/2026, indicated Resident 2 left the faciity on 7/14/26 at 11:20 AM for a scheduled appointment to the oncologist. The Progress Notes indicated Resident 2 had not been back yet from doctor's appointment at 3:57 PM. The medical record did not contain documentation indicating the resident had been admitted to the hospital, transferred, discharged , placed on leave of absence, or otherwise explaining the resident's absence from the facility from 7/14/2026 through 7/20/2026. No progress notes were found after 7/14/2026 regarding Resident 2's status. During an observation on 7/20/26 at 11 AM Resident 2 was not present in the facility. During an interview on 7/20/2026 at 1:55 PM with Registered Nurse (RN) 1 Supervisor, stated that Resident 2 was not in the facility because the resident had not returned from an appointment since 7/14/2026. RN 1 Supervisor stated she knew Resident 2 had been admitted to a general acute care hospital (GACH) the same day the resident went out to a oncologist (a medical doctor who has special training in diagnosing and treating cancer) appointment, however, RN1 stated that RN1 did not document in any of the resident's progress notes on the resident's medical chart. During an interview on 7/20/2026 at 1:59 PM with the MDS nurse, the MDS nurse stated MDS nurse was unaware that Resident 2 had not returned from the oncologist appointment since 7/14/2026. The MDS nurse stated the business office is responsible for verifying if residents reside in the facility or have been discharged , and should be communicated during the facility's morning meetings with nursing. MDS nurse stated that the RN Supervisor should document resident's whereabouts, especially if the resident does not return to the facility, and the resident's progress notes and facility census should be updated daily. During an interview on 7/20/2026 at 3:18 PM with the Admissions Coordinator, the Admissions Coordinator stated she was unaware that Resident 2 was not in the facility, and that no staff had not communicated that Resident 2 had been admitted to a GACH following the resident's oncologist appointment on 7/14/2026. During an interview on 7/20/26 at 3:20 PM with the Director of Nursing (DON), the DON stated she (DON) took the opportunity to schedule Resident 2's appointment at the oncologist hoping Resident 2 would be admitted to a GACH. The DON acknowledged and stated that the facility did not follow its discharge planning process before sending Resident 2 out of the facility. The DON acknowledged and stated that documentation regarding Resident 2's transfer status was not completed. During a review of the facility's policy and procedures (P&P) titled Census Report dated April 2007, indicated, daily census reports must reflect the resident count at midnight each night and must include the names of all the residents admitted or discharged during the previous 24 hour period. During a review of the facility's P&P titled Transfer or Discharge Documentation dated January 2026, indicated, residents transferred or discharged from the facility are to have discharge planning completed and documentation maintained in the clinical record to ensure continuity of care and accurate resident status. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record:The basis for the transfer or dischargeIf resident's needs cannot be met in the facilitySpecific resident needs that cannot be metFacility's attempt to meet those needsReceiving facility's services that are available to meet those needsA summary of the resident's overall medical, physical, and mental condition.Date and time of transferNew location of the residentMode of transportation.

Based on observation, interview, and record review the facility failed to respect the residents' rights to dignity (the right to be valued and treated as a worthwhile human being) and respect for three out of three sampled residents (Resident 31, Resident 75, Resident 80, and Resident 126) by failing to: 1. Ensure residents' rights information was posted in an accessible area per the facility's policy and procedure (P&P) titled Resident Rights dated 1/2026.2. Ensure Certified Nursing Assistant 1 (CNA 1) wore the appropriate identification/employee badge and did not verbally abuse Resident 31 on 7/8/2026. Cross Reference: F6003. Provide privacy for Resident 75, whose buttock was left exposed to other residents, staff, and visitors.4. Provide Resident 80 and Resident 126 with a privacy cover for Resident 80's and Resident 126's foley catheter bag (a thin, flexible tube inserted through the tube into the bladder [A hollow, muscular, balloon-shaped organ that expands as it fills with urine] to drain urine continuously) flexible tube inserted directly into your bladder through a small cut in your lower belly used to drain urine into an external bag). This failure had the potential for residents (in general) not to know their rights and to cause emotional distress and affect the residents (Resident 31, Resident 75, Resident 80 and Resident 126) self-esteem (how much you value, respect, and like yourself) and cause a loss of dignity and psychosocial wellbeing (how you feel inside your mind and how well you interact with the people and world around you). During an interview on 7/9/2026 at 12:34PM with the Admissions and Marketing Director (AMD), the AMD stated copies of the residents' rights were provided only to residents as part of the admission packet to ensure the residents were informed when making decisions. The AMD stated that copies of the residents' rights needed to also be posted so that all individuals, including staff, were aware of them. During an interview on 7/9/2026 at 1:08 PM with the Director of Nursing (DON), the DON stated that copies of the residents' rights needed to be posted in the prominent areas of the facility so families of the residents were also well informed if they (residents and/or families) had any grievance and everyone in the facility can see and read residents rights. During a concurrent observation and interview on 7/9/2026 at 2:46 PM with the Social Services Director (SSD), copies of the residents' rights were not observed to be posted or displayed in any prominent areas of the facility. The SSD stated that there were no copies of the residents' rights posted in the areas where most residents and families were staying and it was beneficial from a compliance-related standpoint when residents' rights were highly visible in all these accessible areas of the facility, allowing residents and families including the staff to review the residents' rights at all times. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 1/2026, the P&P indicated federal and state laws guaranteed certain basic rights to all residents of the facility. The facility policy stated that copies of the residents' rights were to be posted throughout the facility. During a review of Resident 75's admission Record, the admission Record indicated the facility admitted the resident on 5/15/25, with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 75's MDS dated [DATE], the MDS indicated the resident required moderate assistance (helper does less than half the effort) from facility staff to complete activities of daily living (ADLS, activities a person performs daily such as bathing, dressing, and toileting). During a review of Resident 75's H&P dated 5/10/26, the H&P indicated Resident 75 lacked the capacity to make decisions. During a concurrent observation and interview on 7/6/26 at 11:55 a.m. with Certified Nursing Assistant (CNA) 5, in the hallway, Resident 75 was observed side lying in bed with her (Resident 75) buttock exposed. CNA 5 stated facility residents were not to be left exposed. CNA 5 stated privacy had to be provided by either covering the residents with a blanket or by pulling the curtains back to ensure residents were not exposed. During an interview on 7/8/26 at 12:06 p.m., with Licensed Vocational Nurse (LVN) 6, LVN 6 stated residents' dignity and privacy are violated when their private body parts, such as breasts or buttocks, are exposed to people in the hallway. LVN 6 stated privacy should have been provided by covering the exposed body part or by pulling the curtains to cover the resident. During a concurrent interview and record review on 7/9/26 at 10:56 a.m., the facility's policy and procedure (P&P) titled Dignity revised January 2026, was reviewed with the DON. The DON reviewed the P&P and stated the P&P was not followed. The DON stated that even when staff could not physically cover the buttock, like during diaper changes, staff had to draw the curtain to ensure privacy and to protect the resident's dignity. During a review of the facility's P&P titled Dignity, revised January 2026, the P&P indicated for staff to promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. During a review of Resident 126's admission Record, the admission Record indicated the facility admitted the resident on 3/4/2026 with diagnoses that included Urinary Tract Infection (UTI, an infection in the bladder/urinary tract), Fournier disease (a bacterial infection of the genitals), stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral region (tailbone area), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure). During a review of Resident 126's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 3/5/2026 that indicated the resident was to receive foley catheter care every shift. During a review of Resident 126's MDS dated [DATE], the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 126 required partial/moderate assistance (helper does less than half the effort) from facility staff with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 12 required substantial/maximal assistance (helper does more than half the effort) from facility staff with toileting hygiene, showering/bathing herself, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 126 had an indwelling catheter (foley catheter). During a concurrent interview and record review on 7/06/2026 at 12:06 PM with Restorative Nursing Assistant 1 (RNA 1), in Resident 126's room, the resident was observed with a foley catheter. Resident 126's foley catheter bag was observed without a privacy cover. RNA 1 stated Resident 126 should have had a privacy cover for the resident's foley catheter bag. RNA 1 stated that the privacy cover was supposed to protect Resident 126's foley catheter bag from being exposed. RNA 1 stated there was potential for Resident 126's dignity to be affected if the resident did not have a privacy cover for the resident's foley catheter bag. During an interview on 7/8/2026 at 9:15 AM with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident 126 had a foley catheter. LVN 5 stated that there should have been a privacy cover on Resident 126's foley catheter bag to prevent exposure and maintain the resident's dignity. During an interview on 7/09/2026 at 2:12 PM with the Director of Nursing (DON), the DON stated Resident 126 had a foley catheter. The DON stated there should have been a privacy cover over Resident 126's foley catheter bag. The DON stated there was potential for Resident 126's dignity to be affected without a privacy cover over the resident's foley catheter bag. The DON stated Resident 126 had to have their (Resident 126) dignity maintained. During a review of the facility's Policy and Procedure (P&P) titled Dignity dated 1/2026 the P&P indicated Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered. Findings: 2.During a review of Resident 31's admission Record, the admission Record indicated the facility originally admitted Resident 31 on 8/16/2024 and readmitted Resident 31 on 10/16/2025 with diagnoses that included metabolic encephalopathy (a temporary, generalized malfunction of the brain caused by a chemical imbalance in the body, rather than a direct physical injury or disease in the brain itself), dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 31's History and Physical (H&P - the most formal and complete assessment of the patient and the problem) dated 10/17/2025, the H&P indicated Resident 31 had no capacity (a person does not have the mental ability to understand their medical condition, weigh the risks and benefits of treatment, and make a reasoned healthcare decision). During a review of Resident 31's Minimum Data Set (MDS – a resident assessment tool), dated 5/30/2026, the MDS indicated Resident 31 usually had the ability to understand others and usually had the ability to make himself understood. The MDS indicated Resident 31 required substantial/maximal assistance (helper does more than half the effort) from facility staff for oral hygiene (ability to clean teeth), personal hygiene (combing hair, shaving, washing/drying face and hands), and for toileting. The MDS indicated Resident 31 was dependent (helper does all of the work) on facility staff for shower/bathing. During a concurrent observation and interview on 7/8/2026 at 6:04 AM with CNA 1 in the hallway outside of Resident 31's room, CNA 1 was observed telling Resident 31 to shut up. Resident 31 was observed yelling back to CNA 1 telling (Resident 31) CNA 1 you shut up! Resident 31 was observed to become more agitated after he (Resident 31) was told to shut up by CNA 1. CNA 1 was asked to confirm that she (CNA 1) told Resident 31 to shut up, CNA 1 answered yes. CNA 1 stated she was sorry. CNA 1 stated she (CNA 1) should not have told Resident 31 or any other resident (in general) to shut up. During the same observation on 7/8/2026 at 6:04 AM with CNA 1 in the hallway outside of Resident 31's room, CNA 1 was observed not wearing an identification/employee badge. CNA 1 was asked to produce her badge and could not produce the badge. CNA 1 was then asked to go to the nursing station to verify her (CNA 1's) identity. During an interview on 7/8/2026 at 6:10 AM with Licensed Vocational Nurse 1 (LVN 1), Registered Nurse 1 (RN 1) and CNA 1. RN 1 was asked to identify CNA 1. RN 1 verified the identify of CNA 1. A photo of the night shift roster was taken. CNA 1 admitted she (CNA 1) did not have her badge and stated she (CNA 1) lost her badge. LVN 1 and RN 1 stated staff (in general) were not to tell any residents (in general) to shut up. LVN 1 and RN 1 stated telling a resident (in general) to shut up was a form of verbal abuse. RN 1 stated staff (in general) had to wear badges so that residents (in general) could know who they (residents in general) were dealing with (staff). During an interview on 7/8/2026 at 7:05 AM with the Administrator (ADM), the ADM stated CNA 1 was taken off the floor and away from Resident 31. The ADM stated he (ADM) would report the incident between CNA 1 and Resident 31 according to the facility's abuse reporting policy. During a follow up interview on 7/8/2026 at 8:00 AM in the ADM office, CNA 1 stated she could not explain why she told Resident 31 to shut up. During an interview attempt on 7/8/2026 at 8:05 AM, an attempt was made to speak with Resident 31. Resident 31 yelled back, what do you want and refused to answer any questions. During a review of CNA 1's employee file on 7/8/2026 at 8:45 AM, CNA 1's employee file indicated the facility hired CNA 1 on 11/18/2025. The employee file indicated CNA 1 received abuse training on 11/18/2025. During a concurrent interview and record review on 7/8/2026 at 9:26 AM with the DSD, CNA 1's abuse in-service dated 5/29/2026 (education or coaching that an employer provides to you while you are already employed to help you stay good at your job) was reviewed. The DSD stated the in-service CNA 1 received on 5/29/2026 included a lesson plan about verbal abuse training. During an interview on 7/8/2026 at 10:19 AM with the ADM, the ADM stated CNA 1 was placed on suspension pending the results of the facility's investigation regarding CNA 1's verbal abuse on Resident 31. During a concurrent interview and record review on 7/9/2026 at 3:36 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Abuse and Neglect – Clinical Protocol (a standardized set of rules or step-by-step instructions that dictate how something should be done), dated 1/2026, was reviewed, the P&P indicated verbal abuse was a form of abuse. The DON stated CNA 1 did not follow the facility's P&P when she told Resident 31 to shut up. The DON stated CNA 1 should not have told Resident 31 to shut up because it could provoke (to do or say something that intentionally makes someone mad, annoyed, or eager to fight) Resident 31. The DON stated Resident 31's dignity could have been affected. During a review of the facility's P&P titled, Identifying Types of Abuse, dated 6/2022, the P&P indicated staff (in general) are expected to be able to identify different types of abuse. The P&P indicated verbal abuse was considered a type of mental abuse that included written, gestured communication (the use of body language—primarily hand, arm, and facial movements—to express a message, feeling, or idea with or without spoken word) or sounds to residents (in general) within hearing distance. The P&P indicated examples of verbal abuse included harassing a resident (in general), mocking, insulting, ridiculing (making fun of), yelling, intimidating, threatening or isolating a resident (in general) from social interactions or activities. The P&P indicated mental abuse included agitating a resident to solicit a response (to ask for an answer, reply, or feedback). During a review of the facility's P&P titled, Dignity, dated 1/2026, the P&P indicated the facility would care for each resident (in general) in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated staff had to speak respectfully to residents at all times. 4.During a review of Resident 80's admission Record, the admission Record indicated the facility originally admitted Resident 80 on 8/5/2024 and readmitted Resident 80 on 6/19/2026 with diagnoses that included acute respiratory failure with hypoxia (the lungs suddenly stopped working well enough to move oxygen into your bloodstream, causing dangerously low oxygen levels in the body), dysphagia (difficulty swallowing), epilepsy (a brain condition that causes repeated, unprovoked seizures), homelessness, muscle weakness, and unspecified psychosis (a temporary, significant disconnect from reality, but the symptoms don't perfectly fit a specific mental health diagnosis). During a review of Resident 80's Minimum Data Set (MDS – a resident assessment tool), dated 5/13/2026, the MDS indicated Resident 80 sometimes could make herself (Resident 80) understood and sometimes had the ability to understand others. During a review of Resident 80's History and Physical (H&P - the most formal and complete assessment of the patient and the problem) dated 7/10/2026, the H&P indicated Resident 80 did not have the capacity (ability) to understand and make decisions. The H&P indicated Resident 80 had dementia (a progressive state of decline in mental abilities). The H&P indicated Resident 80 was s/p (status post meaning after) nephrostomy (a procedure that creates an outside drain for your urine). The H&P indicated Resident 80 had a foley catheter. During a concurrent observation and interview on 7/6/2026 with Certified Nursing Assistant 2 in Resident 80's room, Resident 80's foley catheter bag was observed without a privacy bag covering it (Resident 80's foley catheter bag). CNA 2 stated Resident 80's foley catheter bag had to have a privacy cover. During a concurrent observation and interview on 7/6/2026 at 11:41 AM with Licensed Vocational Nurse 3 (LVN 3) in Resident 80's room, Resident 80's foley catheter bag was observed without a privacy bag covering it (Resident 80's foley catheter bag). LVN 3 stated Resident 80's foley catheter bag had to be covered to preserve Resident 80's dignity. During an interview on 7/9/2026 at 3:38 PM with the Director of Nursing (DON), the DON stated Resident 80's dignity was affected when staff (in general) failed to place a privacy cover over Resident 80's foley catheter bag. The DON stated the staff (in general) had to cover Resident 80's foley catheter bag with a privacy cover to preserve Resident 80's dignity. During a review of the facility's P&P title Dignity dated 1/2026, the P&P indicated the facility would care for each resident (in general) in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated staff (in general) would promote, maintain, and protect resident (in general) privacy, including bodily privacy during assistance with personal care and during treatment procedures. The P&P indicated staff (in general) were expected to promote dignity by helping the resident to keep urinary catheter bags covered.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 133) reviewed for unnecessary medications such as psychotropic (any drug that affects the mental function, behavior, and mood) received the appropriate care by failing to ensure to:-Limit Resident 133's order for PRN (as needed) clonazepam (a medication used to treat mental illness) to 14 days or provide documentation of clinical justification for extending the duration.-Define Resident 133's specific behavior manifestation of depression (a mental illness characterized by sad mood, lack of interest in activities and social isolation) related to the use of Wellbutrin (a medication used to treat depression).These failures increased the risk that Resident 133 could have experienced adverse effects (a harmful, unintended result) related to psychotropic medication therapy, such as drowsiness, dizziness, constipation (a problem with passing stool), or increased risk of fall, possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial (combines your inner mental world with your social environment) status.Findings:During a review of Resident 133's admission Record (a document containing a resident's diagnostic and demographic information) dated 7/8/2026, the admission Record indicated the facility admitted Resident 133 on 8/25/2020 and most recently readmitted the resident on 2/14/2025 with diagnoses including anxiety disorder (a mental illness characterized by excessive worry or panic strong enough to interfere with daily activities) and depression. During a review of Resident 133's History and Physical (H&P - a record of a comprehensive physician's assessment) dated 2/17/2025, the H&P indicated Resident 133 had the capacity to understand and make decisions. During a review of Resident 33's Medication Administration Record (MAR - a record of all medications administered, and monitoring completed for a resident) for May 2026, the MAR indicated nursing staff (in general) were only to monitor for sadness as the behavioral manifestation of depression related to treatment with Wellbutrin. During a review of Resident 133's Care Plan Report for depression revised 6/23/2026, the Care Plan Report indicated Resident 133's depression was manifested by sadness but did not provide any specific behavioral manifestations (e.g. self-isolation, lack of interest in activities, crying, etc.) During a review of Resident 133's Order Summary Report (a summary of all active physician orders) dated 7/8/2026, the Order Summary Report indicated Resident 133's attending physician prescribed the following medications:-Wellbutrin XL 150 milligrams (mg - a unit of measure for mass) one tablet by mouth every morning for depression manifested by sadness.-Clonazepam 0.5 mg one tablet by mouth every 12 hours as needed for anxiety for 30 days. During a review of Resident 133's available clinical record, the clinical record indicated there was no documented clinical justification provided for extending her PRN order for clonazepam from 14 days to 30 days.During a review of Resident 133's available clinical record, the clinical record indicated there were no other specific behavioral manifestations of depression identified or defined for the purpose of monitoring the effectiveness of Resident 133's treatment with Wellbutrin. During an interview on 7/08/2026 at 10:20 AM with the Director of Nursing (DON), the DON stated Resident 133's order for clonazepam was not limited to 14 days. The DON stated there was no documentation in Resident 133's medical record to justify exceeding the 14-day limit on PRN clonazepam. The DON stated this increased the risk that Resident 133 may experience falls with injury due to adverse effects such as drowsiness, dizziness, or instability when walking. The DON stated Resident 133's order for Wellbutrin did not list a specific behavioral manifestation for depression. The DON stated sadness was too general and impossible to objectively monitor for as it does not specify specific manifestations such as self-isolation, lack of interest in activities, crying, or verbalization of sadness. The DON stated this made it difficult to monitor the effectiveness of Wellbutrin and may contribute to untreated depression or adverse effects which could decrease her quality of life. During a review of the facility's policy Psychotropic Medication Use, revised January 2026, the policy indicated PRN orders for psychotropic medications are limited to 14 days. for psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Psychotropic medication management includes: .adequate monitoring for efficacy and adverse consequences.

Based on observation, interview, and record review, the facility failed to accurately assess three of 27 sampled residents (Resident 2, Resident 10, and Resident 7) on the Minimum Data Set (MDS- a resident assessment tool) by failing to ensure to: 1. Include Resident 2's diagnosis of depression (a mental illness characterized by depressed mood, insomnia, and lack of energy or interest in usually enjoyable activities) on the MDS dated [DATE]. 2. Identify Resident 2's multiple falls and the use of a Merry [NAME] (adaptive equipment that combines walker and chair to allow a person to walk independently and safely) as a physical restraint on the MDS dated [DATE]. 3. Assess Resident 10's range of motion ([ROM] full movement potential of a joint) limitations on the right arm on the MDS dated [DATE]. 4. Assess Resident 7's use of tobacco on the MDS dated [DATE]. These failures had the potential to affect the provision of care to address Resident 2, Resident 7 and Resident 10's needs. Findings: 1. During a review of Resident 2's admission Record (a record containing diagnostic and demographic resident information) dated 7/8/2026, the admission Record indicated the facility admitted Resident 2 on 9/6/2023 and most recently readmitted Resident 2 on 6/3/2025 with diagnoses including schizophrenia (a mental illness characterized by hearing or seeing things that are not there). During a review of Resident 2's History and Physical (H&P – a record of a physician's comprehensive medical assessment and plan) dated 1/4/2026, the H&P indicated Resident 2 did not have capacity to understand and make medical decisions. During a review of Resident 2's MDS assessment Section I dated 3/16/2026, the MDS indicated Resident 2 did not have a diagnosis of depression. During a review of Resident 2's MDS assessment Section N (medications) dated 3/16/2026, the MDS indicated Resident 2 was taking an antidepressant (mirtazapine) seven out of seven days in the look back period. During a review of Resident 2's Care Plan Report related to the use of mirtazapine, last revised 6/18/2026, indicated Resident 2 used mirtazapine for depression manifested by poor oral intake. During a review of Resident 2's Order Summary Report (a summary of all current physician orders), dated 7/8/2026, the Order Summary Report indicated Resident 2's attending physician prescribed mirtazapine (antidepressant medication) 7.5 milligrams (mg – a unit of measure for mass) to take one tablet at bedtime for depression manifested by poor oral intake. During an interview on 7/08/2026 at 9:59 AM with the Director of Nursing (DON), the DON stated the 3/16/2026 quarterly MDS assessment for Resident 2 was incorrect. The DON stated Section I indicated that Resident 2 did not have depression when it was clear from Resident 2's medical record and section N of the same assessment that Resident 2 had depression. The DON stated inaccurate assessments increased the risk that care was not planned appropriately and increased the risk that Resident 2's depression would not be care-planned specifically to her (Resident 2) needs possibly resulting in a decline in her (Resident 2) quality of life. During a review of the facility's policy Charting and Documentation, revised January 2026, indicated .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 2.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had clear speech, had difficulty communicating some words or finishing thoughts, understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 2 did not have any ROM limitations in both arms and legs. The MDS Section I indicated Resident 2 did not have a diagnosis of depression. The MDS Section J indicated Resident 2 had two falls without injury and two falls with injury (except major) since admission/reentry or the prior assessment. The MDS Section P indicated Resident 2 did not use any physical restraints while in or out of bed. During a review of Resident 2's SBAR ([Situation, Background, Assessment, Recommendation] a communication tool used by healthcare workers when the resident experiences a change of condition) Communication Form, dated 3/15/2026, the SBAR Communication Form indicated Resident 2 had an unwitnessed fall when found sitting on the floor next to the wheelchair during routine rounds. During a review of Resident 2's SBAR Communication Form, dated 4/11/2026, the SBAR Communication Form indicated Resident 2 had an unwitnessed fall on 4/7/2026 when Resident 2 was found lying on the floor mat next to the bed. During a review of Resident 2's SBAR Communication Form, dated 5/4/2026, the SBAR Communication Form indicated Resident 2 slid off from the wheelchair onto the floor hallway near Resident 2's room. During a review of Resident 2's MDS dated [DATE], the MDS Section J indicated Resident 2 did not have any falls since admission/reentry or the prior assessment. During a concurrent interview and record review on 7/9/2026 at 11:58 PM with the Director of Nursing (DON) and the MDS Coordinator (MDS 1), the DON and MDS 1 reviewed Resident 2's SBAR Communication Forms and stated Resident 2 fell on 3/15/2026, 4/7/2026, and 5/4/2026. During a concurrent interview and record review on 7/9/2026 at 2:15 PM with the MDS Coordinator (MDS 1) and MDS Coordinator 2 (MDS 2), Resident 2's MDS, dated [DATE], was reviewed. MDS 2 stated the MDS (in general) was the full assessment of a resident which needs to be accurate to determine the care plan. MDS 1 stated signing each section for the completed MDS (in general) indicated the resident's MDS was accurate. MDS 1 reviewed Section J of Resident 2's MDS which indicated Resident 2 did not have any falls since admission/reentry or the prior assessment. MDS 1 stated Resident 2's MDS for falls was inaccurate. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, revised 1/2026, the P&P indicated any person completing the portion of the MDS must sign and certify the accuracy of that portion of the assessment. During a review of Resident 2's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 2 required CGA for ambulating 60 feet without an assistive device. The PT Discharge recommendations indicated to transition Resident 2 to the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) for ambulation (the act of walking) with the Merry Walker. During a review of Resident 2's MDS, dated [DATE], the MDS Section P indicated Resident 2 did not use any physical restraints while in or out of bed. During a concurrent observation and interview on 7/6/2026 at 12:19 PM in the activity/dining room, Resident 2 was sitting on a seat in a wheeled device with multiple metal bars connected in a square shape around Resident 2. The metal bars extended above the height of Resident 2's head while seated. The device had blue padding attached to the metal bars. Restorative Nursing Aide 1 (RNA 1) initially stated Resident 2 was sitting in a wheelchair. RNA 1 then stated Resident 2 was seated in a Merry [NAME] after checking the physician's order for RNA. RNA 1 stated Resident 2 had a physician's order to place Resident 2 in the Merry [NAME] and had to check the resident's position every two hours. During a concurrent observation and interview on 7/7/2026 at 9:35 PM in the resident's room, Resident 2's transfer into the Merry [NAME] was observed. RNA 1 stated two people were required to transfer Resident 2 to the chair, referring to the Merry Walker. Restorative Nursing Aide 2 (RNA 2) removed the rear metal bar from the Merry Walker. Resident 2 required physical assistance to transfer from sit-to-stand. RNA 2 stood in front of the Merry [NAME] while assisting Resident 2 to remain standing. RNA 1 was behind Resident 2 to adjust Merry Walker's seat. Resident 2 sat on the seat while RNA 1 reattached the Merry Walker's rear metal bar. RNA 2 wheeled Resident 2, who also used both feet to propel forward while seated in the Merry Walker, into the activity/dining room down the hallway. Resident 2's Merry [NAME] was observed with two front wheels and four rear wheels. RNA 2 stated Resident 2's Merry [NAME] had six brakes since each wheel had a separate brake. During an interview on 7/8/2026 at 2:12 PM with Physical Therapist 1 (PT 1) and the Director of Rehabilitation (DOR), PT 1 described the Merry [NAME] as a walker with a chair that Resident 2 could not freely get out of to prevent Resident 2 from falling. During a concurrent observation and interview on 7/9/2026 at 11:17 PM in the activity/dining room with the DON, Resident 2 was observed sitting in the Merry [NAME] with all six brakes activated on each wheel. Resident 2 was asked to unlock the brakes. The DON stated Resident 2 was unable to unlock the Merry Walker's brakes. The DON stated the staff needed to activate the Merry Walker's brakes while Resident 2 was seated to prevent Resident 2 from moving. During an interview on 7/9/2026 at 12:44 PM with the DON and the DOR, the DON stated the Merry [NAME] was a physical restraint if the brakes prevented Resident 2 from moving. The DOR stated Resident 2 could not get out of the Merry [NAME] without assistance and did not know it was considered a physical restraint. During an interview on 7/9/2026 at 2:15 PM with the MDS 1 and MDS 2, MDS 2 stated the MDS (in general) was the full assessment of a resident which needs to be accurate to determine the care plan. MDS 1 stated signing each section for the completed MDS (in general) indicated the resident's MDS was accurate. During a concurrent interview and record review on 7/9/2026 at 2:26 PM with MDS 1, MDS 1 reviewed Section P of Resident 2's MDS, dated [DATE], which indicated Resident 2 did not have physical restraints. MDS 1 stated the Merry [NAME] prevented Resident 2 from moving and was considered a physical restraint. MDS 1 stated the facility did not know the Merry [NAME] was a physical restraint and did not indicate the physical restraint on the MDS assessment. During a review of the facility's P&P titled, Certifying Accuracy of the Resident Assessment, revised 1/2026, the P&P indicated any person completing the portion of the MDS must sign and certify the accuracy of that portion of the assessment. 3. During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted Resident 10 on 1/13/2026 and readmitted on [DATE] with diagnoses including dementia (progressive state of decline in mental abilities), muscle weakness, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and dysarthria (difficulty speaking due to weak speech muscles). During a review of Resident 10's Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in each joint of both arms and legs) dated 2/1/2026, the JMA indicated Resident 10 had minimal (25-50 percent [%] joint limitation) ROM limitation in the right shoulder, moderate (50-75% joint limitation) ROM limitation in the right elbow, moderate ROM limitation in the left knee, and severe (75-100% joint limitation) ROM limitation in the right knee. During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had clear speech, had difficulty communicating some words or finishing thoughts, usually understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 10 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for toileting, dressing, hygiene, rolling from lying on back to either side in bed, transferring from lying to sitting on the side of the bed, and chair/bed-to-chair transfers. The MDS indicated Resident 10 did not have any ROM in both arms but had ROM limitations in both legs. During a review of Resident 10's physician's orders dated 6/29/2026, the physician's orders indicated for Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both arms, five times per week as tolerated. Another physician's order, dated 6/29/2026, indicated for the RNA to apply the right-hand splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and right elbow splint. During a concurrent observation and interview on 7/6/2026 at 12:50 PM in Resident 10's room, Resident 10 was lying in bed and turned toward the right side with both hips and knees also turned toward the right side. Resident 10 raised the left arm up from under the blankets without ROM limitations. Resident 10 stated she was unable to move the right arm. During an observation on 7/7/2026 at 10:18 PM in Resident 10's room, Resident 10 was awake while lying in bed. Resident 10's right arm was positioned in internal rotation (shoulder joint rotated toward the body), elbow flexion (bent), wrist flexion (bent downward), and the fingers positioned in extension. Resident 10 allowed RNA 2 to provide limited PROM to the right shoulder, elbow, wrist, and hand. During an observation on 7/7/2026 at 2:27 PM in Resident 10's room, Resident 10 had the elbow extension splint and hand splint applied to the right arm. During an interview on 7/9/2026 at 2:15 PM with the MDS 1 and MDS 2, MDS 2 stated the MDS (in general) was the full assessment of a resident which needed to be accurate to determine the care plan. MDS 1 stated signing each section for the completed MDS (in general) indicated the resident's MDS was accurate. During a concurrent interview and record review on 7/9/2026 at 2:26 PM with MDS 1, MDS 1 reviewed Section GG of Resident 10's MDS, dated [DATE], which indicated Resident 10 did not have any ROM limitations in both arms. MDS 1 stated Resident 10 has had a physician's order for the right hand and elbow splint which indicated Resident 10 had contractures in the right arm. MDS 1 stated Resident 10's MDS should have indicated Resident 10 had an impairment in one arm. During a review of the facility's P&P titled, Certifying Accuracy of the Resident Assessment, revised 1/2026, the P&P indicated any person completing the portion of the MDS must sign and certify the accuracy of that portion of the assessment. 4.During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 4/28/2026 with diagnoses that included other toxic encephalopathy (brain malfunction or damage caused by exposure to poisonous substances, excluding the most common or well-known toxins), anemia (a condition where the body does not have enough healthy red blood cells), morbid obesity due to excess calories (your body stores far more fat than is healthy because you consistently take in more energy through food and drinks than your body uses), dependence on renal dialysis (your kidneys have stopped working well enough to keep you alive, and you require a medical machine or process to filter toxins and extra fluid out of your blood), and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 7's Smoking Assessment (a safety check to determine if a resident can smoke independently without posing a fire hazard), dated 4/28/2026 indicated Resident 7 had the ability to independently go to the facility's smoking area. The Smoking Assessment indicated Resident 7 had the ability to smoke safely. During a review of Resident 7's H&P dated 5/1/2026, the H&P indicated Resident 7 had the capacity (ability) to understand and make medical decisions. During an observation on 7/8/2026 Resident 7 was observed smoking in the facility's designated smoking area. During a concurrent interview and record review on 7/8/2026 at 11:54 AM with Registered Nurse 2 (RN 2), Resident 7's care plan titled, Resident Care Plan: Smoking, dated 4/28/2026 was reviewed. The care plan indicated Resident 7 was a smoker. RN 2 stated Resident 2's smoking care plan was not in the EMR (a digital version of a patient's paper chart) but was able to locate the care plan in Resident 7's physical chart. RN 2 stated Resident 7's care plan indicated Resident 7 smoked. During a concurrent interview and record review on 7/8/2026 at 11:57 AM with the Minimum Data Set (MDS – a resident assessment tool) Registered Nurse Coordinator (MDS 1) and the MDS Licensed Vocational Nurse Coordinator (MDS 2), Resident 7's MDS accepted by CMS (Centers for Medicare and Medicaid Services is the federal agency that runs government health insurance programs in the United Stated) on 5/18/2026 was reviewed. The MDS section J indicated the box for tobacco use (plant whose dried leaves are used to make products that people smoke, chew, or sniff such as cigarettes, cigars, vapes) was checked no. MDS 1 and MDS 2 verified the box in section J for tobacco use was clicked no indicating on the MDS assessment that Resident 7 did not use tobacco. MDS 1 stated she (MDS 1) would get information to fill out the MDS from the resident activities. MDS 2 stated Resident 7 should have a smoking assessment. MDS 1 and MDS 2 stated Resident 7 had a smoking care plan and stated the MDS dated [DATE] was not accurate. MDS 1 and MDS 2 stated an inaccurate MDS could have affected Resident 7's care plan. During a concurrent interview and record review on 7/9/2026 at 4:13 PM, the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment, dated 1/2026 was reviewed. The P&P indicated any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment. The DON stated the facility did not follow their policy and should have ensured the accuracy of the MDS for the purpose of care planning.

Based on observation, interview, and record review, the facility failed to provide services to two of three sampled residents (Resident 2 and Resident 10) who had limited range of motion (ROM- full movement potential of a joint) and mobility (ability to move) by failing to: -Assess and develop goals for the use of Resident 2's Merry [NAME] (adaptive equipment that combines walker and chair to allow a person to walk independently and safely) prior to discharge from Physical Therapy (PT-profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 5/26/2026. -Indicate the distance for the Restorative Nursing Aide (RNA- nursing aide program that helps residents to maintain their function and joint mobility) to ambulate (walk) in the Merry [NAME] to maintain Resident 2's ability to walk 60 feet (unit of measure) after discharge from PT on 5/26/2026. -Provide Resident 2 with ambulation (the act of walking) using the Merry [NAME] on 7/7/2026 in accordance with the physician's order, dated 5/26/2026. -Apply both knee extension (straightening) splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to both knees on 7/7/2026 for Resident 10. These failures had the potential to result in Resident 2's decline in the ability to ambulate and worsening contractures (stiffening/shortening at any joint that reduces the joint's range of motion) in Resident 10's knees, which could cause skin integrity (health and condition of the skin) issues and interfere with providing activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence). Cross reference F604.Findings:a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 9/6/2023 and readmitted on [DATE] with diagnoses including encephalopathy (disease that affects the brain, causing changes in its function), difficulty in walking, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and lack of coordination (functioning of muscle groups or body systems to perform smooth, efficient movements). During a review of Resident 2's PT Evaluation and Plan of Treatment dated 5/6/2026, the PT Evaluation indicated nursing referred Resident 2 to PT after a fall. The PT Evaluation indicated Resident 2 had ROM within normal limits (WNL- normal joint movement) in both legs.The PT Evaluation indicated Resident 2 required stand-by assistance ([SBA] required verbal cues and no physical assistance to perform the activity) for bed mobility and contact guard assistance ([CGA] required steadying assistance or less than 25 percent [%] physical assistance to perform the task) for transfers and walking 50 feet with hand-held assistance.The PT Evaluation indicated a short-term goal to ambulate 100 feet on level surfaces without an assistive device and a long-term goal to ambulate 175 feet on level surfaces without an assistive device. During a review of Resident 2's PT Treatment Encounter Notes dated 5/26/2026, the PT Treatment Encounter Note indicated Resident 2 walked 60 feet using the Merry Walker. The PT Treatment Encounter Note indicated caregiver training was provided for transfers into and out of the Merry [NAME] from the wheelchair. During a review of Resident 2's PT Discharge summary dated [DATE], the PT Discharge Summary indicated Resident 2 required CGA for ambulating 60 feet without an assistive device. Resident 2's PT Discharge recommendations included RNA for ambulation in the Merry Walker. During a review of Resident 2's physician's orders dated 5/26/2026, the physician's orders indicated for RNA to ambulate Resident 2 in the Merry Walker, every day, five times per week as tolerated. Another physician's order, dated 5/26/2026, indicated for the RNA to provide active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) exercises to both of Resident 2's arms, five times per week. During a review of Resident 2's care plan titled, RNA Care Plan, updated 6/5/2026, Resident 2's RNA Care Plan indicated for the RNA to provide AAROM to both arms, five times per week, and to ambulate the resident using the Merry Walker, five times per week as tolerated. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 6/18/2026, the MDS indicated Resident 2 had clear speech, had difficulty communicating some words or finishing thoughts, understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 2 did not have any ROM limitations in both arms and legs and required partial/moderate assistance (helper does less than half the effort) for upper body dressing, rolling from lying on bed to either side in bed, transferring from lying to sitting on the side of the bed, sit-to-stand transfers, chair/bed-to-chair transfers, and walking 10 feet. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) for toileting and lower body dressing. During an interview on 7/6/2026 at 8:53 AM with the Director of Rehabilitation (DOR), the DOR stated the purpose of PT included improving a resident's ability to perform transfers, gait (manner of walking), and other mobility needs. The DOR stated RNA was a maintenance program provided to residents (in general) to maintain gains the residents achieved during therapy and to decrease the risk for ROM and mobility decline. During a concurrent observation and interview on 7/6/2026 at 12:19 PM in the activity/dining room, Resident 2 was sitting on a seat in a wheeled device with multiple metal bars connected in a square shape around Resident 2. The metal bars extended above the height of Resident 2's head while seated. The device had blue padding attached to the metal bars. Restorative Nursing Aide 1 (RNA 1) initially stated Resident 2 was sitting in a wheelchair. RNA 1 then stated Resident 2 was seated in a Merry [NAME] after checking the physician's order for RNA. RNA 1 stated Resident 2 had a physician's order to place Resident 2 in the Merry [NAME] and had to check the resident's position every two hours. During a concurrent observation and interview on 7/7/2026 at 9:35 AM in the resident's room, Resident 2's RNA session was observed. Resident 2 was observed with both arms and legs crossed while lying in bed. RNA 1 provided ROM exercises to the right ankle and attempted to provide ROM exercises to the right knee when Resident 2 became agitated and extended the right leg. RNA 1 performed ROM exercises to the left ankle, but Resident 2 refused additional left leg exercises. Resident 2 followed RNA 1's demonstration to raise both arms overhead but refused to perform additional arm exercises. Resident 2 rolled the entire body to the left side with Resident 2's back facing RNA 1. RNA 1 stated two people were required to transfer Resident 2 to the chair, referring to the Merry Walker. Restorative Nursing Aide 2 (RNA 2) removed the rear metal bar from the Merry Walker. Resident 2 rolled toward the right side of the bed and required physical assistance to transfer from lying to sitting on the side of the bed. Resident 2 required physical assistance to transfer from sit-to-stand. RNA 1 adjusted the seat behind Resident 1 while RNA 2 stood in front of the Merry [NAME] to assist Resident 2 to remain standing. RNA 1 assisted Resident 2 to sit once the seat was secured and then reattached the Merry Walker's rear metal bar. RNA 2 proceeded to push Resident 2, who also used both feet to propel forward while seated in the Merry Walker, into the activity/dining room down the hallway. Resident 2 took small steps for approximately two feet while seated in Merry [NAME] without assistance. Resident 2 was not observed walking upright in the Merry Walker. During an interview on 7/7/2026 at 9:53 AM with RNA 1, RNA 1 stated Resident 2 received AAROM to both arms and legs. RNA 1 stated Resident 2 was also transferred to the Merry Walker. RNA 1 stated Resident 2 walked slowly in the Merry [NAME] and did not need RNA 1's assistance to walk while using the Merry Walker. RNA 1 stated Resident 2's position was checked every two hours while in the Merry Walker. During an observation on 7/7/2026 at 10:07 AM in the resident's room, Resident 2 was seated in the Merry [NAME] and used small steps to propel forward. During an observation on 7/7/2026 at 12:35 PM in the activity/dining room, Resident 2 was seated in the Merry Walker. Resident 2 attempted but was unable to propel forward while seated in the Merry Walker. During a concurrent interview and record review on 7/8/2026 at 2:12 PM with Physical Therapist 1 (PT 1) and the DOR, Resident 2's PT Evaluation, dated 5/6/2026, PT Treatment Encounter Notes, dated 5/6/2026 to 5/26/2026, and PT Discharge summary, dated [DATE], were reviewed. PT 1 stated Resident 2 required CGA to walk which meant a person needed to be physically guiding Resident 2 for safety. PT 1 stated the PT Discharge Summary indicated Resident 2 walked with CGA for 60 feet without an assistive device. PT 1 stated the PT Discharge Summary indicated recommendations for the RNA to ambulate with Resident 2 using a Merry Walker. PT 1 stated PT 1 did not recommend Resident 2's Merry Walker. The DOR stated a physician (unknown) recommended Resident 2's Merry [NAME] during a Quality Assurance and Performance Improvement ([QAPI] a proactive, data-driven framework that combines quality checks with continuous process improvement to enhance patient outcomes, care quality, and overall quality of life) meeting (unknown date) due to frequent falls. PT 1 described the Merry [NAME] as a walker with a chair that Resident 2 could not freely get out of to prevent Resident 2 from falling. PT 1 stated it was PT's responsibility to assess and train Resident 2 on the use of the Merry Walker. PT 1 stated the PT Treatment Encounter Notes from 5/6/2026 to 5/25/2026 did not include an assessment or Resident 2's use of the Merry [NAME] during PT treatment sessions.PT 1 stated The PT Treatment Encounter Note, dated 5/26/2026, was the only documentation indicating Resident 2 walked 60 feet with CGA using the Merry [NAME] prior to Resident 2's discharge on the same day (5/26/2026). PT 1 stated Resident 2 walked upright while holding onto the handlebars of the Merry Walker. PT 1 stated the RNAs were trained to assist Resident 2 with walking upright using the Merry [NAME] prior to Resident 2's discharge from PT services. PT 1 stated Resident 2's physician's order for RNA, dated 5/26/2026, did not include the distance for RNA to walk with Resident 2 using the Merry [NAME] because the RNAs verbally received a baseline understanding of Resident 2's ability to walk during RNA training. During an interview on 7/9/2026 at 7:29 AM with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 2 was confused and used to walk in the facility's hallways until about four months ago. CNA 4 stated Resident 2 could sit at the side of the bed but could not stand and walk anymore. CNA 4 stated Resident 2 was usually in Merry [NAME] and walked very slow while seated in the Merry Walker. During an interview on 7/9/2026 at 7:47 AM with RNA 1, RNA 1 stated Resident 2 used to walk without assistance about two months ago. RNA 1 stated Resident 2 could stand and walk while seated and upright in the Merry Walker. During a telephone interview on 7/9/2026 at 8:21 AM with Resident 2's responsible party (RP 1), RP 1 stated Resident 2 used to walk and has gotten weaker in the past six months. RP 1 did not know if Resident 2's weakness was due to mental or physical decline. RP 1 stated the facility reported to RP 1 that Resident 2 needed the Merry [NAME] because Resident 2 could not sit upright, had difficulty standing and walking, and had falls. During a concurrent interview and record review on 7/9/2026 at 8:56 AM with Physical Therapist Assistant 1 (PTA 1), Resident 2's PT Treatment Encounter Notes, dated 5/6/2026 to 5/26/2026, were reviewed. PTA 1 stated Resident 2's PT Treatment Encounter Notes did not include intervention using Resident 2's Merry [NAME] until 5/26/2026. PTA 1 stated Resident 2 stood and walked while holding onto the Merry Walker's handlebars. PTA 1 reviewed Resident 2's PT Treatment Encounter Note, dated 5/26/2026, and stated RNA 1 and RNA 2 were educated in transferring Resident 2 from a wheelchair to the Merry Walker. PTA 1 stated the PT Treatment session on 5/26/2026 was the only documented session Resident 2 walked using the Merry Walker. During an interview on 7/9/2026 at 10:30 AM with the Director of Nursing (DON), the DON stated Resident 2 used a Merry [NAME] after a QAPI discussion regarding Resident 2's frequent falls. The DON stated one (unknown) of the five physicians present during the QAPI meeting suggested using the Merry [NAME] since the facility was running out of ideas to prevent Resident 2 from falling. During a concurrent observation and interview on 7/9/2026 at 10:39 AM with the DON in Resident 2's room, RNA 1 and RNA 2 were observed assisting Resident 2 with transferring from sitting on the side of the bed to standing in the Merry Walker. RNA 2 was observed to assist Resident 2 to stand while RNA 1 adjusted the seat behind Resident 2. RNA 1 and RNA 2 were observed to assist Resident 2 to sit on the seat after RNA 1 secured its position in the Merry Walker. RNA 1 reattached the rear metal bar on the Merry [NAME] behind Resident 2. Resident 2 sat in the Merry [NAME] and used both feet to propel approximately five feet from the bed toward the bedroom doorway. RNA 1 was observed to assist Resident 2 to transfer from sit-to-stand in the Merry [NAME] and encouraged Resident 2 to walk. Resident 2 was observed walking three steps while upright in the Merry [NAME] prior to sitting down with RNA 1's assistance. Resident 2 stated, I cannot walk. The DON stated Resident 2 walked two to three steps in the Merry Walker. During a concurrent interview and record review on 7/9/2026 at 12:44 PM with the DON and the DOR, Resident 2's physician's order for RNA, dated 5/26/2026, was reviewed. The DON stated the purpose of RNA (in general) was to maintain or improve a resident's mobility from resident's gains made with therapy. The DON stated Resident 2's physician's orders for RNA did not include the distance Resident 2 walked with therapy to maintain Resident 2's mobility. During a concurrent observation and interview on 7/9/2026 at 1:11 PM with Physical Therapist 2 (PT 2), PT 2 performed a screen of Resident 2's mobility while Resident 2 was seated in the Merry Walker. PT 2 assessed Resident 2's legs and stated Resident 2 had within functional limits (WFL- sufficient joint movement without significant limitation) ROM in both legs. During a concurrent observation and interview on 7/9/226 at 1:20 PM with PT 2, Resident 2 was transferred from the Merry [NAME] to a wheelchair with the assistance of three additional therapists. PT 2 placed a front wheeled walker (FWW- an assistive device with two front wheels used for stability when walking) in front of Resident 2 who proceeded to stand and walk down two partial hallways prior to sitting back down into the wheelchair. PT 2 stated Resident 2 walked 60 feet with minimal assistance (required less than 25% physical assistance to perform the task) using the FWW. During a concurrent observation and interview on 7/9/2026 at 1:32 PM with PT 2, Resident 2 was observed walking upright with PT 2 using the Merry Walker. Resident 2 was observed walking slowly using the Merry [NAME] and declined further attempts to walk with the Merry Walker. PT 1 stated Resident 2 walked 10 feet using the Merry Walker. PT 2 stated Resident 2 had a more reciprocal gait pattern (natural, alternating rhythm of walking) using the FWW and had more difficulty walking with the Merry Walker. During a concurrent interview and record review on 7/9/2026 at 2:05PM with the DOR and PT 2, Resident 2's PT Evaluation, dated 5/6/2026, and PT Discharge summary, dated [DATE], were reviewed. PT 2 stated Resident 2's PT Evaluation and Discharge Summary did not include a goal for walking using the Merry Walker. PT 2 stated (in general) a new assistive device should not be used just one time during PT treatment as it required practice with a resident prior to discharge from PT services. The DOR stated there was no documented evidence Resident 2 used the Merry [NAME] more than one time (on 5/26/2026) during PT treatment sessions.The DOR stated Resident 2 walked 60 feet without an assistive device when discharged from therapy. PT 2 and the DOR stated Resident 2's Merry [NAME] should not have been part of the RNA program to maintain Resident 2's mobility since Resident 2 could walk 60 feet without an assistive device and the Merry [NAME] was not part of the PT treatment goal. During a review of the facility policy and procedure (P&P) titled, Resident Mobility and Range of Motion, the P&P indicated Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The P&P also indicated the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. b. During a review of Resident 10's admission Record, the admission Record indicated the facility originally admitted Resident 10 on 1/13/2026 and readmitted on [DATE] with diagnoses including dementia (progressive state of decline in mental abilities), muscle weakness, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and dysarthria (difficulty speaking due to weak speech muscles). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had clear speech, had difficulty communicating some words or finishing thoughts, usually understood verbal content, and was severely impaired for daily decision making.The MDS indicated Resident 10 required substantial/maximal assistance (helper does more than half the effort) for eating and dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for toileting, dressing, hygiene, rolling from lying on back to either side in bed, transferring from lying to sitting on the side of the bed, and chair/bed-to-chair transfers. During a review of Resident 10's Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in each joint of both arms and legs), dated 6/17/2026, the JMA indicated Resident 10 had between minimal (25-50% joint limitation) ROM limitation and WFL ROM for right shoulder flexion (lifting the arm overhead) and moderate (50-75% joint limitation) ROM limitation in the right elbow, right wrist, and right hand. The JMA also indicated Resident 10 had between minimal and moderate ROM limitation in both hips and knees and minimal ROM in the right ankle. During a review of Resident 10's PT Evaluation and Plan of Treatment, dated 6/17/2026, the PT Evaluation indicated Resident 10's both knees and the right ankle ROM were impaired (unspecified). The PT Evaluation indicated Resident 10 had (unspecified) contractures. The PT Evaluation indicated Resident 10 had knee extension (straightening) splints and a foot drop splint (also known as an ankle foot orthosis [AFO] which is a brace to hold the foot and ankle in a 90-degree position). During a review of Resident 10's PT Discharge summary dated [DATE], the PT Discharge Summary indicated Resident 3 tolerated both knee extension splints for 30 minutes. The PT Discharge recommendations included RNA for passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both legs and application of both knee extension splints. During a review of Resident 10's physician's orders dated 6/29/2026, the physician's orders indicated for RNA to provide PROM to both arms, five times per week as tolerated. Another physician's order, dated 6/29/2026, indicated for the RNA to apply the right hand splint and right elbow splint. During a review of Resident 10's physician orders dated 7/1/2026, the physician's orders indicated for RNA to provide PROM to both legs and to apply both knee extension splints for up to six hours, five times per week as tolerated. During a concurrent observation and interview on 7/6/2026 at 12:50 PM in the resident's room, Resident 10 was lying in bed with the foot of the bed elevated above the upper body. Resident 10 was turned toward the right side with both hips and knees also turned toward the right side. Resident 10 raised the 0left arm up from under the blankets without ROM limitations. Resident 10 stated she was unable to move the right arm. During an observation on 7/7/2026 at 10:18 AM with RNA 2, Resident 10's RNA session was observed. Resident 10 was awake while lying in bed. RNA 2 performed ROM to the left shoulder, elbow, wrist, and fingers. RNA 2 went to the right side of the bed, and Resident 10 initially refused for RNA 2 to move the right arm. Resident 10's right arm was positioned in internal rotation (shoulder joint rotated toward the body), elbow flexion (bent), wrist flexion (bent downward), and the fingers positioned in extension. Resident 10 allowed RNA 2 to provide limited PROM to the right shoulder, elbow, wrist, and hand. RNA 2 uncovered Resident 10's legs from underneath the blanket. Resident 10's hips and knees were bent and rotated toward the right side. RNA 2 rotated both legs to the left toward the midline of Resident 10's body. Resident immediately screamed when RNA 2 attempted to extend the right hip and knee. During an interview on 7/7/2026 at 10:30 AM in Resident 10's room with RNA 2, RNA 2 stated Resident 10 usually did not have pain during ROM exercises but could have pain in the legs since Resident 10 was yelling. RNA 2 stated the nurse would be informed of Resident 10's pain and will return later for the ROM exercises to both legs. During an observation on 7/7/2026 at 2:27 PM with RNA 2 in Resident 10's room, Resident 10 had the elbow extension splint and hand splint applied to the right arm. RNA 2 stated the splints were applied at approximately noontime. RNA 2 removed the blanket over both legs and performed PROM to both hips, knees, and ankles. During an interview on 7/7/2026 at 2:34 PM with RNA 2, RNA 2 stated Resident 10 received PROM exercises to both arms and legs and application of the right hand and elbow splints. RNA 2 stated Resident 10 did not have any splints for both legs. During a concurrent interview and record review on 7/8/2026 at 1:44 PM with PT 1, Resident 10's PT Evaluation, dated 6/29/2026, PT Discharge summary, dated [DATE], and physician's orders for RNA, dated 7/1/2026, were reviewed. PT 1 stated Resident 10 had contractures in both knees. PT 1 stated Resident 10's Discharge recommendations and the physician's order for RNA indicated to provide PROM to both legs and apply both knee splints. PT 1 stated the RNA was supposed to apply both knee splints to prevent further contractures in Resident 10's knees, which could cause skin issues in the folds behind the knees and could interfere with ADLs including cleaning. During a concurrent interview and record review on 7/8/2026 at 3:16 PM with RNA 2, RNA 2 reviewed Resident 10's RNA orders, dated 7/1/2026. RNA 2 stated Resident 10 did not have any physician's order to apply splints to both knees. RNA 2 reviewed the physician's order and stated both knee splints were not applied. RNA 2 stated Resident 10 had knee splints in the room from prior RNA sessions but did not know there was a physician's order to apply them. During a review of the facility's P&P titled, Resident Mobility and Range of Motion, the P&P indicated Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 37, Resident 85, Resident 135) reviewed for respiratory care, received the necessary respiratory care and services by failing to:1. Ensure Resident 37's oxygen (invisible, odorless, and tasteless gas in the air we breathe) tank (a metal cylinder that holds purified oxygen under high pressure) did not run empty while in use.2. Provide Resident 85 with two liters per minute ([2 LPM] measure of volume of a gas passing through in one minute) of oxygen as per physician orders, dated 6/13/2025.3. Connect Resident 135's nasal canula (a lightweight, flexible plastic tube that delivers extra oxygen directly into to the nose) to an oxygen tank or oxygen concentrator (a machine that pulls in regular room air, removes the nitrogen, and delivers concentrated, medical-grade oxygen to help you breathe easier) to ensure the delivery of prescribed oxygen. This failure resulted in Resident 37, Resident 85, and Resident 135 not receiving oxygen as prescribed and had the potential for the residents to have an insufficient amount of oxygen to the body. Cross reference: F658 Findings: During a review of Resident 37's admission Record, the admission Record indicated the facility admitted the resident on 6/2/2026 with diagnoses that included Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), malignant neoplasm of prostate (prostate cancer, uncontrolled growth of abnormal cells in the prostate gland) and benign prostatic hyperplasia (enlargement of the prostate gland). During a review of Resident 37's Minimum Data Set (MDS, a resident assessment tool) dated 6/23/2026, the MDS indicated the resident had moderately impaired cognition (a slight decline in the ability to think, understand, and reason). The MDS indicated Resident 37 required set up or clean up assistance (helper sets up or cleans up) from facility staff with eating. The MDS indicated Resident 37 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from facility staff with oral hygiene. The MDS indicated Resident 37 required partial/moderate assistance (helper does less than half the effort) from facility staff with upper body dressing, lower body dressing, toileting hygiene, personal hygiene, and putting on/taking off footwear. The MDS indicated Resident 37 was dependent on help (helper does all the effort) from facility staff with showering/bathing himself. The MDS indicated Resident 37 was not on oxygen therapy. During a review of Resident 37's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 7/6/2026 for oxygen at 3 Liters Per Minute (LPM, measures the volume of supplemental oxygen delivered to a resident per minute) via nasal to maintain the resident's oxygen saturation (O2 sat, a measurement of how much oxygen the blood is carrying as a percentage, typically between 95% and 100%) at 92% for shortness of breath. The physician order indicated to notify Resident 37's physician if the resident's oxygen saturation was below 90% every shift. During a concurrent observation and interview on 7/06/2026 at 12:20 PM, with Registered Nurse 4 (RN 4), in Resident 37's room, Resident 37 was observed lying in bed wearing a nasal cannula that was connected to an oxygen tank at the resident's bedside. The oxygen tank indicated the oxygen tank was empty and needed to be refilled. RN 4 stated Resident 37's oxygen tank needed to be changed because the oxygen tank was empty. RN 4 stated Resident 37 was supposed to be on 2 to 4 liters of oxygen continuously. RN 4 checked Resident 37's oxygen saturation. Resident 37's oxygen saturation was 82%. RN 4 was observed changing Resident 37's oxygen tank. Resident 37 stated he did not feel short of breath. RN 4 stated Resident 37's oxygen tank should have been changed before the oxygen tank needed to be refilled so the resident could receive the oxygen continuously. RN 4 stated there was potential for Resident 37 to become short of breath if the oxygen tank was empty. During an interview on 7/9/2026 at 2:16 PM with the Director of Nursing (DON), the DON stated licensed nursing staff (in general) should have been checking Resident 37's oxygen tank. The DON stated there should have been a standby oxygen tank for Resident 37 when needed. The DON stated the licensed nursing staff (in general) should not have waited until Resident 37's oxygen tank was empty before the oxygen tank was changed. The DON stated Resident 37's oxygen tank should be changed prior to the oxygen tank becoming empty, especially if the resident was on continuous oxygen. The DON stated there was potential for Resident 37 to have respiratory distress and shortness of breath if the resident's oxygen tank was empty and the resident was not receiving oxygen. During a review of the facility's Policy and Procedure (P&P) titled Oxygen Administration dated 1/2026, the P&P indicated The following equipment and supplies will be necessary when performing this procedure.Portable oxygen cylinder (strapped to the stand).Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. Place appropriate oxygen device on the resident (i.e. mask, nasal cannula and/or nasal catheter). Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. 2. During a review of Resident 85's admission Record, the admission Record indicated the facility originally admitted Resident 85 on 4/6/2021 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] long-term lung disease causing difficulty in breathing), difficulty walking, and dementia (progressive state of decline in mental abilities). During a review of the physician's order, dated 6/13/2025, the physician's order indicated to administer oxygen at 2 LPM to maintain oxygen saturation (measurement as a percentage [%] of how much oxygen the blood is carrying) at 92% and notify the physician if oxygen saturation is below 90%. During a review of Resident 85's MDS dated [DATE], the MDS indicated Resident 85 had clear speech, understood verbal content, expressed ideas and wants, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 85 required supervision or touching assistance from facility staff for eating, upper body dressing, sit-to-stand transfers, and chair/bed-to-chair transfers. The MDS indicated Resident 85 required partial/moderate assistance from facility staff for toileting, lower body dressing, and walking 150 feet (unit of measure). During a review of Resident 85's physician's orders dated 4/29/2026, the physician's order indicated for the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to provide ambulation (the act of walking) with a front wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking), five times per week as tolerated. During an observation on 7/6/2026 at 11:11 a.m. in the hallway next to the nursing station, Resident 85 was sitting up in a wheelchair with an oxygen tank inserted in a compartment on the rear of the wheelchair. Resident 85 was not wearing a nasal cannula. During a concurrent observation and interview on 7/7/2026 at 10:39 a.m. with RNA 1 and RNA 2 in the hallway, Resident 85's RNA session for ambulation was observed. Resident 85 was wearing a nasal cannula with an oxygen tank inserted into the rear of the wheelchair. RNA 2 stated Resident 85 oxygen tank was empty. RNA 1 went down the hall to exchange the oxygen tank. During a concurrent observation and interview on 7/7/2026 at 10:42 a.m., RNA 1 returned with a full oxygen tank. RNA 1 was observed connecting Resident 85's nasal cannula directly to the oxygen tank. RNA 1 initially administered 2 LPM of oxygen. RNA 2 stated Resident 85 did not like having the oxygen administered at 2 LPM and requested for RNA 1 to adjust the oxygen to 1 LPM. RNA 1 was observed turning down the oxygen to 1 LPM. RNA 2 provided physical assistance to transfer Resident 85 from sitting in the wheelchair to standing using the FWW. RNA 2 walked next to Resident 85 as RNA 1 pushed the wheelchair containing the oxygen tank behind Resident 85. Resident 85 walked using the FWW approximately 50 feet prior to sitting in the wheelchair for a rest break. Resident 85 was observed slightly out of breath while receiving oxygen at 1 LPM. RNA 2 stated Resident 85 was tired. During a concurrent interview and record review with the Director of Nursing (DON), the DON reviewed Resident 85's physician's order for oxygen, dated 6/13/2025. The DON stated Resident 85 had a physician's order to administer oxygen at 2 LPM. The DON stated the oxygen should have been administered in accordance with the physician's order because that was the amount determined as effective for the resident. The DON stated Resident 85 could have experienced desaturation (when the amount of oxygen in the body is lower than normal levels) while walking and could have been out of breath without the adequate amount of oxygen administered. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 1/2026, the P&P indicated to verify and review the physician's order for oxygen administration in preparation for safe oxygen administration. 3. During a review of Resident 135's admission Record, the admission Record indicated the facility admitted Resident 135 on 4/23/2026 with diagnoses that included acute respiratory failure with hypoxia (the lungs suddenly stopped working well enough to get enough oxygen into your bloodstream), anemia (a condition where the body does not have enough healthy red blood cells), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 135's Care Plan Report dated 4/23/2026, the Care Plan Report indicated Resident 135 was to receive O2 (oxygen) at 2 liters per minute (2LPM - your medical device delivers exactly two liters of concentrated oxygen into your lungs over the course of 60 seconds). The Care Plan Report indicated an intervention (any action a nurse takes to help a patient heal, feel comfortable, or stay safe) to maintain Resident 135's oxygen saturation level above 92%. During a review of Resident 135's H&P dated 4/25/2026, the H&P indicated Resident 135 had the capacity to understand and make decisions. During a review of Resident 135's MDS dated [DATE], the MDS indicated Resident 135 usually had the ability to understand others and usually had the ability to make herself (Resident 135) understood. The MDS indicated Resident 135 was receiving oxygen therapy. During a review of Resident 135's Order Summary Report, dated 7/10/2026, the Order Summary Report indicated a physician order for Resident 135 to receive O2 at 2 LPM via nasal cannula (a lightweight, flexible plastic tube that delivers extra oxygen right into your nose) continuously to maintain O2 sat at 92% and to notify Resident 135's physician is below 90% every shift. During a concurrent observation and interview on 7/6/2026 at 12:24 PM with Licensed Vocational Nurse 4 (LVN 4) in Resident 135's room, Resident 135's nasal cannula tubing was observed to not be connected to an oxygen tank or oxygen concentrator with Resident 135's O2 sat showing between 84 and 85%. LVN 4 stated she would place Resident 135 back on oxygen at 2 LPM. LVN 4 stated she (LVN 4) would document a change in condition (any change in a person's physical, mental, or functional health status that differs from their normal status) and would recheck Resident 135's O2 sat after Resident 135 was once again receiving oxygen. During a follow up interview on 7/6/2026 at 12:40 PM with LVN 4, LVN 4 stated Resident 135's O2 sat was 96% on oxygen at 2 LPM. During a concurrent interview and record review on 7/9/2026 with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Oxygen Administration, revised 1/2026, the P&P indicated the facility's staff needed to check the nasal canula tubing to ensure the tubing was connected to the oxygen cylinder and that the tubing was free from kinks (a sharp bend or fold in a flexible tube). The P&P indicated the staff had to check the oxygen tank was in good working order and securely fastened. The P&P indicated the facility staff had to observe the resident upon set up and periodically (from time to time) thereafter to be sure oxygen is being tolerated). The DON stated Resident 135's nurse (in general) should have ensured Resident 135's oxygen was connected. The DON stated Resident 135's nurse (in general) should have checked Resident 135's O2 sat.

Based on observation, interview, and record review, the facility failed to: 1. Maintain accountability of two doses of controlled medications (medications with a high risk for abuse or diversion [any use other than that intended by the prescriber]) on the controlled substance accountability record affecting Residents 29 and 108 in one of three inspected medication carts (Station A Cart 2.)2. Create a controlled substance accountability record for 15 tablets of lorazepam (a controlled medication used to treat mental illness) and include the accountability record in the narcotic log for six tablets of lorazepam affecting Resident 59 in one of three inspected medication carts (Station A Cart 2.)3. Remove five discontinued controlled medications affecting Residents 73 and 159 from one of three inspected medication carts (Station A Cart 2.) These failures increased the risk of diversion of controlled mediations (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber), misappropriation of resident property (illegal use of the property or funds of another person for unauthorized purpose), and the risk that residents could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.Findings:During an observation and concurrent interview of Station A Cart 2 on 7/7/26 at 10:44 AM with the Licensed Vocational Nurse 3 (LVN 3), the following discrepancies were found between the Narcotic/Controlled Substance Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): Resident 29's Narcotic/Controlled Substance Record for Pregabalin (a medication used to treat nerve pain) 50 milligrams (mg - a unit of measure for mass) indicated there were 48 doses left; however, the medication card contained 47 doses.Resident 108's Narcotic/Controlled Substance Record for hydrocodone/apap (a medication used to treat pain) 5/325 mg indicated there were 3 doses left; however, the medication card contained 2 doses.Further observation of Station A Cart 2 indicated there was a supply of 15 tablets of lorazepam 1 mg for Resident 59 that did not have a corresponding Narcotic/Controlled Substance Record and a supply of six tablets of lorazepam 1mg for Resident 59 for which the Narcotic/Controlled Substance Record was not included in the controlled medication log used to periodically reconcile medication counts. Further observation of Station A Cart 2 indicated the following discontinued controlled medications were present in the medication cart:Nineteen (19) tablets of hydrocodone/apap 10/325 mg for Resident 73Thirteen (13) tablets of oxycodone (a medication used to treat pain) 30 mg for Resident 159Eleven (11) tablets of lorazepam 1 mg for Resident 159Twenty-one (21) tablets of hydrocodone/apap 5/325 mg for Resident 159Twenty-seven and one-half (27.5) milliliters (ml - a unit of measure for volume) of morphine sulfate (a medication used to treat pain) 100 mg/5 ml solutionA review of Resident 73's clinical record indicated he was discharged from the facility on 6/27/26. A review of Resident 159's clinical record indicated the resident was discharged from the facility on 6/24/26. During the same observation and concurrent interview of Station A Cart 2 on 7/7/26 at 10:44 AM, LVN 3 stated she gave the missing pregabalin dose for Resident 29 and the missing dose of hydrocodone/apap for Resident 108 earlier that morning (7/7/2026) and failed to sign the Narcotic/Controlled Substance Record at that time. LVN 3 stated the accountability record had to be signed immediately after the medication was administered. LVN 3 stated documented at time given helped prevent diversion and ensured that medications were not given too often. LVN 3 stated if pregabalin or hydrocodone/apap 5/325 were given too often it could lead to medical complications for Resident 29 and 108. LVN 3 stated there was no accountability record for one supply of Resident 59's lorazepam containing 15 tablets and another one with six tablets was not included in the narcotic logbook despite being an active order. LVN 3 stated that without the accountability record, the quantity of lorazepam for Resident 59 would not get counted between nurses when changing shifts and that could lead to a greater chance of diversion and misappropriation of resident property. LVN 3 stated the hydrocodone/apap 10/325 for Resident 73 and the oxycodone, lorazepam, hydrocodone/apap and morphine sulfate for Resident 159 had been discontinued for several days and should have been removed from the cart and turned over to the Director of Nursing (DON) for secure storage as soon as possible after the resident left or the order was discontinued. LVN 3 stated Resident 73 was discharged on 6/27/26 and Resident 159 was discharged on 6/24/26 and so the facility had failed to remove their discontinued controlled medications from the cart for several days after they were discharged . LVN 3 stated not removing discontinued narcotics from the medication cart increased the risk of diversion and misappropriation of resident property. A review of the facility's policy Controlled Substances, revised January 2026, indicated Upon receipt: .an individual resident controlled substance record is made for each resident who is receiving a controlled substance. Upon administration: The nurse administering the medication is responsible for recording. time of administration. signature of nurse administering medications. At the End of Each Shift: Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. A review of the facility's policy Storage of Medications, revised January 2026, indicated .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to ensure staff followed fortified diet (diet enhanced to increase caloric content of food) and the Controlled Carbohydrate Diet (CCHO- diet for blood sugar control) according to the spreadsheet (food portioning and serving guide) instructions on 7/6/2026 during the lunch service when:1. Four trays requiring fortified diet did not receive fortified foods and the Dietary Aide (DA1) did not read out the orders for cooks (Cook1) and (Cook 2) to serve.2. Consistent Carbohydrate diet (CCHO diet) trays received 1/2 cup of mashed potato instead of 1/3 cup per menu. These failures had the potential to result in decreased caloric intake and lead to undesirable weight loss for residents on the fortified diet and result in increased blood sugar levels for 47 out of 124 residents who were on CCHO diet.Findings:1.During an observation of the kitchen tray line service for lunch (tray line- a system of food preparation, in which trays move along an assembly line) on 7/6/2026 at 11:50AM, trays requiring fortified diets received same food as trays that did not have fortified diet orders. Dietary Aide (DA1) did not communicate the fortified diet orders written on the resident tray cards (a printed sheet that includes resident diet order, preferences for food and dislikes) during tray line for lunch service. A review of tray cards on the meal carts indicated the orders for fortified diet. However, DA1 did not read out loud the fortified diet and cook 1 and cook 2 did not add any additional food items. During an interview with DA1 and [NAME] 2 on 7/6/2026 at 1:00PM, DA1 stated fortified diets we served fortified mashed potatoes and did not realize mashed potatoes were on the regular menu. DA1 stated fortified diets were for residents who had weight loss issues and it was important to have extra calories. [NAME] 2 stated it was important for DA1 to communicate residents' diets correctly so cooks could serve the required food items. Cook2 stated fortified trays were to receive something extra such as melted margarine and they did not receive the extra food item because DA1 did not communicate the diets correctly. [NAME] 2 stated fortified diet was for residents who lost weight and extra margarine was added and when residents didn't receive the fortified diet, they could weight loss. During an interview with the Registered Dietitian (RD) on 7/7/2026 at 12:30PM, the RD stated the facility did not offer fortified mashed potatoes some days for the fortified diets. The RD stated it was important for Dietary Aide to read out the fortified diets so the cook could add additional calories to meal trays. The RD stated fortified diets were for residents who were not eating as much food and needed dense calories to avoid weight loss. 2. During a review of the facility lunch menu for regular and CCHO diets dated 7/6/2026, the menu indicated the following items were to be served: Old Fashioned Meatloaf 4 ounces (oz); herb mashed potatoes 1/2 cup; seasoned fresh vegetables 1/2 cup; parsley garnish; pan biscuit 1; margarine; ice cream and milk 1/2 cup. During an observation of the tray line service for lunch (a system of food preparation, in which trays move along an assembly line) on 7/6/2026, at 11:50AM, observed both regular and CCHO diets received 1/2 cup of mashed potatoes and pan biscuit. During a review of the facility's Cooks spreadsheet for 7/6/2026 (food portioning and serving guide), the spreadsheet indicated CCHO diet trays were to receive 1/3 cup mashed potatoes instead of 1/2 and should receive a wheat roll. During the same observation of the tray line service for lunch on 7/6/2026, at 11:50AM, DA1 and DA2 did not communicate CCHO diets to the cooks (cook 1 and [NAME] 2). During a concurrent observation and interview with DA1and DA2 on 7/6/2026 at 1:00 PM, DA1 and DA2 stated they did not communicate to the cooks the CCHO diet. DA1 stated CCHO diets were for residents with blood sugar concerns and were to get less starches. DA1 stated kitchen staff served regular bread instead of wheat and 1/2 mashed potato instead of 1/3 cup. DA1 stated the meal could make the residents' blood sugar go high. During an interview with Dietary Supervisor (DS) on 7/6/2026, at 2:00PM, the DS stated DA1 and DA2 should have read the tray ticket and the cooks should have followed the menu. The DS said the residents on CCHO diet should have received 1/3 cup of potatoes and they received 1/2 cup which could have potentially affected the blood sugar. During an interview with the RD on 7/7/2026 at 12:30PM, the RD stated there were always different scoop sizes available to serve the starches and that was why it was important for the Dietary aides to read the diet orders in full and not just the diet textures so the cook could serve the correct diet and portions. CCHO diets were for residents who had blood sugar control problems and were served less starch such as bread, potatoes, pasta, etc. During a review of facility policy and procedures (P & P) titled, Menus (revised 1/2026) the P & P indicated, Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. During a review of facility policy titled, Fortified Diet (revised 2026) the policy indicated, the fortified diet is designed for residents who cannot consume adequate amounts of calories and or protein to maintain their weight or nutritional status. The goal is to increase the calorie density of foods commonly consumed by the residents. Examples of adding calories may include Extra margarine or butter to food items such as vegetables, potatoes etc.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Resident dish cover had holes with food stuck in the hole and one can opener blade was not clean with dried brown residue, and the blade was worn and dented with the potential to harbor harmful bacteria and metal shavings around it. 2. Kitchen towels used to wipe food contact surfaces were not stored in the sanitizer solution bucket and the sanitizer solution level was not in range. 3.Cook1 did not wash hands after removing soiled gloves from preparing raw chicken and proceeded to prepare vegetables and pasta. 4. Food brought to residents from outside of the facility was stored in the resident refrigerator located in the utility room on the 3rd floor with no date and was not monitored for the expiration date. The refrigerator temperature log was missing for the month of July 2026. There were bags with resident food inside the refrigerator not dated, one expired Greek yogurt and one expired half and half stored in the resident refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (infectious organisms or their toxins are the most common cause of food poisoning symptoms may include cramping, nausea, vomiting, or diarrhea) for 124 out of 137 residents who received food from the facility and including residents who had food stored in the resident refrigerator.Findings:During a concurrent observation and interview in the dishwashing area with the Dietary Supervisor (DS) and the Dishwasher (DW) on 7/6/2026 at 9:00AM, the DW was observed removing resident trays, a plate and plate holders from the dishwashing machine and storing them away to air dry. One plate holder had a hole (Resident plates are placed in between a plate holder and plate cover (dome) to maintain temperature during service) and orange color food particles were stuck inside the hole. The DW was removing the plate holder from the dish machine with visible solid waste and stored the plate holder on the rack to air dry. During a concurrent observation and interview with the DS and the DW on 7/6/2026 at 9:00AM, the DS stated there was a hole in the cover, the plate cover was probably left on the stove and melted from the heat. The DS said dishes that were broken and not smooth could not be cleaned and sanitized effectively. The DS stated kitchen staff had to discard broken and melted plates and covers. The DW stated the DW saw the hole on the cover but did not know the cover needed to be discarded. The DW stated dishes had to be clean and sanitized to avoid contaminating food. During a review of facility's policy and Procedure (P&P) titled Sanitation (Dated 2026) the P & P indicated, 11. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks, and chipped areas. 12. Plastic ware, china and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. During a review of facility's policy and procedures (P & P) titled Kitchen Safety (dated 2023) the P & P indicated, All chipped or cracked dishes should also be discarded when found. During a review of the 2002 U.S. Food and Drug Administration Food Code, code 3-304.11 titled Food Contact with Equipment and Utensils code indicated, Food shall only contact surfaces of: (A) Equipment and utensils that are cleaned and sanitized.Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. During an observation in the kitchen food preparation area on 7/6/2026 at 9:10AM, one can opener blade was noted to be not clean, dull and worn out. The blade was not smooth to the touch and was stained and covered with brown residue. The plastic can opener holder that was mounted on the counter was also covered with brown residue. During a concurrent observation and interview with the DS on 7/6/2026 at 9:10AM, the DS verified that there were residues on the blade and the can opener was not clean. The DS stated the can opener needed to be washed to prevent cross contamination. During a review of facility policy and procedures (P & P) titled Can opener and Base (dated 2023) the p & p indicated, Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade. The can opener must be thoroughly cleaned on each work shift and, when necessary, more frequently. Replace blade on can opener, as needed. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Good Repair and proper Adjustment Code # 4-501.11(C), indicated, Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. During a review of 2022 Food Code titled, Can Openers Code# 4-202.15 indicated, Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. 2. During an observation in the kitchen cooks' food preparation area on 7/6/2026 at 9:15AM, Cook1 wiped food contact surfaces and counters with a kitchen towel, then stored the kitchen towel on the counter. During the same observation in the cook's food preparation area on 7/6/2026 at 9:15AM there was a red bucket with sanitizer solution on a shelf below the cook's food preparation sink. Cook1 stated the bucket was filled with sanitizer solution and the towels should have been in the bucket. Cook1 said the towels were not stored in the sanitizer solution and the surfaces did not get sanitized. Cook1 stated it was important to clean and sanitize the surfaces before and after work to not have contamination of food and make residents sick. The DS stated kitchen towels had to be stored in the sanitizer solution in the red bucket. The DS stated the sanitizer solution was changed every 2 hours. When Cook1 was asked to check the sanitizer solution effectiveness, cook 1 immersed a test strip in the sanitizer solution and the result was not in range. The DS stated the sanitizer was prepared in the morning and should have been changed. During a concurrent interview with DS and review of the facility log titled Sanitizer Log dated (July 2026), on 7/6/2026 at 9:20AM the sanitizer log was missing documentation on 7/6/2026. The DS stated the log was not checked that day (7/6/2026) and it was a problem because it was important to make sure the sanitizer was effective in sanitizing the surfaces. A review of the 2022 U.S. Food and Drug Administration Food Code, Code 3-304.14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; 3.During an observation in the food preparation area on 7/6/2026 at 9:30AM, Cook1 was observed opening a package of raw chicken and then adding the chicken to a large stainless-steel bowl that was on the food preparation counter. Cook1 had gloves on, Cook1 left the food preparation area to grab seasoning from the dry storage room, returned and started adding seasonings to the raw chicken. Cook1 was then observed mixing the chicken using hands with gloves. After finishing with the chicken preparation, cook 1 removed the soiled gloves and returned to the food preparation area, replacing gloves without washing hands. Cook1 proceeded to prepare and mix vegetables and pasta that was on the stove with gloves. During a concurrent observation and interview with cook1 on 7/6/2026 at 9:30AM, cook1 stated that cook 1 forgot to wash hands after removing the gloves. Cook1 confirmed having dirty hands and could have contaminated everything that cook1 touched during the chicken preparation. Cook1 stated that cross contamination of the counters and handles of spoons and seasonings with raw chicken during the food preparation could make residents sick. During a review of facility policy and procedures (P & P) titled Handwashing/Hand Hygiene (revised 1/2026), the P&P indicated, The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognizes as the best practice for preventing healthcare-associated infections. During a review of facility policy and procedures (P & P) titled Personal Protective Equipment-Using Gloves (revised 1/2026) the p & p indicated, Wash hands after removing gloves. (Note: Gloves do not replace handwashing). A review of the 2022 U.S. Food and Drug Administration Food Code, Code 2-301.14 When to Wash. Indicated, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and E) After handling soiled EQUIPMENT or UTENSILS. (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD. (H) Before donning gloves to initiate a task that involves working with FOOD. 4. During an observation in the resident refrigerator located in the facility's utility room on the 3rd floor on 7/7/2026 at 9:00AM, the refrigerator temperature log for July 2026 was missing. During a concurrent observation and interview with LVN 8 on 7/7/2026 at 9:00AM, LVN8 stated that when residents' families brought in food, nurses would check the food for diet accuracy and if there were leftovers nurses were to label and date the leftover food before storing in the refrigerator and the food was discarded within 2 days. LVN 8 looked inside the resident refrigerator and stated there were several food bags in the refrigerator with no dates, one container of yogurt with best by date 7/4/2026 and one container of half and half cream with a date 6/21/2026 expired and stored in the resident refrigerator. LVN 8 stated when there were no dates on the bags of food and facility staff would not know when to discard the food and the food could potentially be expired and make residents sick. LVN8 stated that the yogurt and creamer expired had to be discarded. During an interview with the Infection Prevention Nurse (IPN) on 7/7/2026 at 10:00 AM, the IPN stated nursing checked the food brought by visitors, nurses label and date the food and was stored in the refrigerator for 48 hours. The IPN stated labeling and dating food was important so facility staff knew when to discard and not have expired food that could make residents sick. The IPN stated it was important to check the temperature of the refrigerator to make sure food was stored safely. The IPN stated housekeeping was responsible for discarding food that was in the refrigerator by the use by date. The IPN stated if there was no date on the food the housekeeping would not know when to discard the food. The IPN did not know what happened to the July 2026 resident refrigerator temperature log. During a review of facility policy and procedures (P & P) titled, Food Brought by Family/Visitors (revised 1/2026) indicated, Food brought by family/visitors that is left with the resident to consume later will be labeled and stored.Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator container will be labeled with residents name, the item and the use by date. The nursing staff will discard perishable foods on or before the Use By date.

Based on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections when: 1. Certified Nursing Assistant (CNA) 6 failed to remove his gloves and perform hand hygiene after leaving a resident room on enhanced barrier precautions (EBP, the use of gown and gloves during high-contact resident care activities to reduce multidrug resistant organism [MDRO] transmission). CNA 6 used the same gloves to enter and provide care in a room that was not on EBP.2. Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) 1 (RNA 1) failed to wear appropriate personal protective equipment (PPE-mask, gown, eye protection, gloves); a gown when providing ROM exercises to Resident 11 who was on EBP.3. CNA 3 failed to wear gloves while setting up the lunch tray for a resident in a room designated for residents with Candida auris ([C. auris] a fungus that can cause severe multidrug resistant infections) with contact isolation (used for infections spread through direct or indirect physical contact, requiring mandatory use of a gown and gloves), and then disposed the gown in a trash can across the hallway in the shower room.4. Licensed vocational nurse 9 (LVN 9) did not wear a gown while flushing Resident 134's gastrostomy (G-tube, a tube inserted through the belly that delivers food directly to the stomach).5. Signage for transmission-based precautions (TBP, used to help stop the spread of germs from one person to another) on four of five rooms did not clearly indicate the appropriate PPE needed. These failures had the potential to result in the spread of pathogens (harmful microorganisms) to residents, visitors, and staff throughout the facility.Findings: 1. During a concurrent observation and interview on 7/08/2026 at 6:24 AM CNA 6 was observed in room [ROOM NUMBER] wearing a gown and gloves. CNA 6 was observed assisting a resident in bed A to be repositioned in bed. Signage for Enhanced Barrier Precautions (EBP, infection-control practices used in nursing homes to prevent the spread of multidrug-resistant organisms (MDROs), that require healthcare staff to wear a gown and gloves during high contact tasks) were observed posted at the entrance to room [ROOM NUMBER]. CNA 6 was observed exiting room [ROOM NUMBER] without doffing (taking off) the gown and gloves. CNA 6 then entered the neighboring room, room [ROOM NUMBER]. CNA 6 was observed wearing the same gown and gloves used in room [ROOM NUMBER]. CNA 6 was observed assisting another resident in room [ROOM NUMBER] to reposition in bed. There was no signage that indicated room [ROOM NUMBER] was on transmission-based precaution. CNA 6 stated that he (CNA 6) did not remove the gown and gloves prior to leaving room [ROOM NUMBER] because he (CNA 6) was going to be quick. CNA 6 stated room [ROOM NUMBER] was on EBP and room [ROOM NUMBER] was not on any transmission-based precaution (infection-control measures used in healthcare for patients known or suspected to be infection with highly transmissible pathogens). CNA 6 stated he (CNA 6) was supposed to have removed the gown and gloves before exiting room [ROOM NUMBER]. CNA 6 stated that because he (CNA 6) did not remove the gown and gloves before exiting room [ROOM NUMBER] there was potential for the spread of infection. During an interview on 7/9/2026 at 3:27 PM with the Infection Prevention Nurse (IPN), the IPN stated staff were expected to wear a gown and gloves when working with a resident (in general) who was on EBP. The IPN stated staff (in general) were expected to remove the gown and gloves prior to leaving a room on EBP. The IPN stated there was potential for infection to spread if the gown and gloves were not removed prior to leaving a room on EBP. The IPN stated there was potential for infection to spread from one resident to another when CNA 6 went from one room to another wearing the same gown and gloves. During an interview on 7/09/2026 at 2:24 PM with the Director of Nursing (DON), the DON stated staff (in general) were expected to wear a gown and gloves when working with a resident on EBP. The DON stated staff (in general) were supposed to remove the gown and gloves prior to leaving a room on EBP. The DON stated staff (in general) were not to go from one room to another wearing the same gown and gloves. The DON stated there was potential for the transmission of infection. The DON stated there was potential to put another resident (in general) at risk for developing an infection when PPE was not used appropriately. During a review of the facility's Policy and Procedure (P&P) titled Enhanced Barrier Precaution (EBP) Policy dated 1/2026, the EBP indicated .shall implement Enhanced Barrier Precautions for residents who are at increased risk for transmitting MDROs during high-contact care activities.Staff shall wear gloves and isolation gown.after completion of care remove gown and gloves appropriately, perform hand hygiene immediately, clean and disinfect reusable equipment before use with another resident. 2. During a review of Resident 11's admission Records, the admission Records indicated the facility originally admitted Resident 11 on 4/18/2024 and readmitted on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), kidney failure, osteomyelitis (inflammation of bone or bone marrow, usually due to infection) in the right ankle and foot, and chronic ulcer (a small open sore or wound generally found in the stomach or on the skin) of the right ankle. During a review of Resident 11's physician's orders, dated 9/25/2025, the physician's orders indicated the RNA was to provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both legs followed by application of multipodus boots (also known as pressure relief ankle foot orthoses [PRAFO] which is a device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) for up to two hours as tolerated. During a review of Resident 11's physician's orders, dated 11/24/2025, the physician's orders indicated Resident 11 had EBP due to the wound on the right ankle and the presence of a Foley catheter (flexible tube passed through the urethra and into the bladder to drain urine). During an observation on 7/7/2026 at 2:07 p.m. with RNA 1 in Resident 11's room, Resident 11's RNA session was observed. Resident 11 was observed lying awake in bed with the Foley catheter present. RNA 1 wore disposable gloves and did not wear a disposable gown. Resident 11 was observed to have both PRAFOs already applied to both feet. RNA 1 removed the PRAFOs to perform PROM exercises to both hips, knees, and ankle. Once completed with PROM exercises, RNA 1 re-applied both PRAFOs. During a concurrent observation and interview on 7/7/2026 at 2:47 p.m. with RNA 1, RNA 1 observed the orange-colored EBP sign prior to entering Resident 11's room. RNA 1 stated Resident 11 was on EBP because of the Foley catheter which means a face mask and gloves should be worn. RNA 1 stated a disposable gown was not worn during Resident 11's ROM exercises because RNA 1 did not provide direct care like changing Resident 11's incontinence brief. During an interview on 7/8/2026 at 12:06 p.m. with the IPN, the IPN stated residents with EBP (in general) were at risk for infection due to an opening in their body including a Foley catheter, feeding tube, and wounds. The IPN stated the staff had to wear a gown and gloves when performing high contact activities with residents on EBP including exercises in the bed. The IPN stated infection could transfer to a resident on EBP without wearing the proper PPE. During an interview on 7/8/2026 at 12:22 p.m. with the IPN, the IPN stated Resident 11 had EBP due to the Foley catheter and wounds. The IPN stated disposable gloves and gown should be worn to prevent Resident 11 from contracting an infection. During a review of the facility's P&P titled, Enhanced Barrier Precaution (EBP) Policy, dated 1/2026, the P&P indicated staff shall wear gloves and isolation gown during high-contact care activities including any activity involving extensive contact with the resident or immediate environment. 3. During an interview on 7/6/2026 at 12:45 p.m. prior to entering room [ROOM NUMBER], Certified Nursing Assistant (CNA) 4 and CNA 5 stated room [ROOM NUMBER] was an isolation room. During an observation on 7/6/26 at 2:16 p.m. in front of room [ROOM NUMBER], a stop signage was posted. The sign had 6 pictures with a checkbox. Pictures with checkmarks in the checkboxes showed hand hygiene, gloves, a surgical mask, a disposable gown, and a red container bin. During a concurrent observation and interview on 7/7/2026 at 1:08 p.m. in room [ROOM NUMBER], CNA 3 was observed placing a tray on a resident's bedside table, CNA 3 removed the cover from the plate, and set up the resident's utensils while wearing a disposable gown without wearing gloves. CNA 3 confirmed by stating gloves were not reapplied in between delivering the trays to residents in room [ROOM NUMBER]. CNA 3 was observed removing a disposable gown while exiting the room, CAN 3 exited the room with the disposable gown in both hands and then walked down the hallway. CNA 3 returned without the disposable gown and stated the disposable gown was thrown into a trash can in the shower room. During an interview on 7/7/2026 at 12:22 p.m. with the IPN, the IPN stated the residents in room [ROOM NUMBER] had contact isolation precautions for C. auris. The IPN stated staff (in general) had to wear a disposable gown and gloves prior to entering the room since the residents had an active infection. The IPN stated room [ROOM NUMBER] had two canisters inside the room labeled trash and linen. The IPN stated the staff (in general) had to dispose of the gown and gloves inside the room to prevent spreading the infection into the hallway since the residents and staff walk around the hallways. During a review of the facility's P&P titled, Isolation – Categories of Transmission-Based Precautions, revised 1/2026, the P&P indicated staff wear gloves and a disposable gown when entering the room and remove before leaving the room. 4. During a review of Resident 134's admission Records, the admission Record indicated the facility readmitted the resident on 2/1/25, with diagnoses that included extended spectrum beta lactamase (ESBL, enzymes produced by certain bacteria that make them highly resistant to many common antibiotics), dysphagia (difficulty swallowing), and methicillin resistant staphylococcus aureus (MRSA, a bacteria that does not respond to antibiotics). During a review of Resident 134's Minimum Data Set (MDS, a standardized assessment tool) dated 6/23/26, the MDS indicated the resident was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on facility staff to complete activities of daily living (ADLs, activities a person performs daily such as bathing, dressing, and toileting). During a review of Resident 134's History and Physical (H&P), dated 1/9/26, the H&P indicated the resident lacked capacity to make and understand decisions. During a review of Resident 134's Order Summary Report, dated 11/24/25, the Order Summary Report indicated the resident was on EBP due to wound and G-tube. During a concurrent observation and interview on 7/6/26 at 12:18 p.m. with Licensed Vocational Nurse (LVN) 9, in Resident 134's room, LVN 6 was observed flushing (pushing a small amount of water through the feeding tube with a syringe) Resident 134's G-tube. LVN 6 wore gloves but was not wearing a gown. LVN 6 stated staff were supposed to wear a gown and gloves while providing G-tube care. LVN 6 stated the purpose of PPE was for infection control and protection in case of backsplash from the G-tube fluids. During an interview on 7/9/26 at 10:19 a.m. with the Infection Prevention Nurse (IPN), the IPN stated staff had to wear a gown and gloves when providing close contact care for residents on EBP. The IPN stated residents with G-tube were at greater risk for infection due to the skin opening, so staff had to correctly follow PPE to prevent staff-to-resident bacteria transfer. During an interview on 7/9/26 at 11:05 a.m. with the Director of Nursing (DON), the DON stated PPE were a safety measure to prevent the spread of infection. The DON stated staff had to wear the proper PPE for infection prevention and control. During a review of the facility's P&P titled, Enhanced Barrier Precautions (EBP Policy dated January 2026, the P&P indicated residents were to be placed on EBP if they had a feeding tube. The P&P indicated staff had to wear gloves and an isolation gown during high-contact care activities such as device care. 5. During an observation on 7/6/26 at 2:16 p.m. in front of room [ROOM NUMBER], a stop sign was posted. The sign indicated to report to the nursing station prior to entering the room. The sign had 6 pictures with a checkbox. Pictures with checkmarks in the checkboxes showed hand hygiene, gloves, a surgical mask, a disposable gown, and a red container bin. The checkbox for the goggle was filled with black marker. During an observation on 7/8/26 at 8:49 a.m. in front of room [ROOM NUMBER], a stop was posted. The sign indicated to report to the nursing station prior to entering the room. The sign had 6 pictures with a checkbox. Pictures with checkmarks in the checkboxes showed hand hygiene, gloves, a disposable gown, and a red container bin. Pictures with a X symbol in the checkboxes showed a surgical mask and goggles. During an observation on 7/8/26 at 8:50 a.m. in front of room [ROOM NUMBER], a stop signage was posted. The sign indicated to report to the nursing station prior to entering the room. The sign had 6 pictures with a checkbox. Pictures with checkmarks in the checkboxes showed hand hygiene, gloves, a surgical mask, a disposable down, and a red container bin. The checkbox for the goggle was blank. During an observation on 7/8/26 at 8:51 a.m. in front of room [ROOM NUMBER], a stop was posted. The sign indicated to report to the nursing station prior to entering the room. The sign had 6 pictures with a checkbox. Pictures with checkmarks in the checkboxes showed hand hygiene, gloves, a surgical mask, a disposable down, and a red container bin. The checkbox for the goggle was blank. During a concurrent interview and record review on 7/8/26 at 8:58 a.m. with Certified Nursing Assistant (CNA) 7, rooms [ROOM NUMBER] stop signs, undated, were reviewed. The signage for room [ROOM NUMBER] indicated an X in the goggle checkbox. CNA 7 stated that because the goggles were marked, staff had to wear goggles while providing care for residents in room [ROOM NUMBER]. For room [ROOM NUMBER]'s signage, the checkbox for the goggle was filled in with black marker. CNA 7 stated she (CNA 7) did not know how to interpret that and was unsure if goggles were supposed to be worn while providing care for residents in room [ROOM NUMBER]. The signage for room [ROOM NUMBER] had checkmarks in the checkboxes for all the pictures, except for the goggle. CNA 7 stated that based on the signage, staff did not have to wear goggles while providing care for residents in room [ROOM NUMBER]. CNA 7 stated the posted signages were confusing and unclear. CNA 7 stated that rooms [ROOM NUMBER] were all on contact isolation, and the signage should have been marked the same to reduce confusion amongst staff and visitors about what PPE to use. During a concurrent interview and record review on 7/8/26 at 11:48 a.m. with Licensed Vocational Nurse (LVN) 5, rooms [ROOM NUMBERS] stop signage, undated, was reviewed. LVN 5 stated that because there was an X in the goggle checkbox, that meant goggles were not needed when providing care for residents in room [ROOM NUMBER]. LVN stated that for the checkboxes, checkmarks meant yes and X meant no. Observed room [ROOM NUMBER] signage with checkmarks on all pictures except for goggles. LVN 5 stated residents in both rooms [ROOM NUMBERS] were on contact isolation for c. auris. LVN 5 stated contact isolation required use of gloves and gown, but if there were splash risk, goggles or face shield was also needed. LVN 5 stated the signage could be misinterpreted because they were marked differently. LVN 5 stated the signage was confusing. During an interview on 7/9/26 at 9:57 a.m. with the Infection Prevention Nurse (IPN), the IPN stated the contact isolation signs should have been filled out the same to avoid confusion. The IPN stated that unclear signage for TBP could lead to staff or visitors' misinterpretation and incorrect PPE used. The IPN stated that when incorrect PPE were used, germs could easily spread from staff to residents and onto other surfaces. During a concurrent interview and record review on 7/9/26 at 11:09 a.m. with the Director of Nursing (DON), photos of the signage posted in front of rooms 39, 50, 51, and 53 were reviewed. The DON stated TBP signs should have been consistent for contact isolation room. The DON stated unclear TBP signs were ineffective for infection prevention. During a review of the facility's P&P titled, Isolation – Notices of Transmission-Based Precautions, revised January 2026, the P&P indicated when transmission-based precautions were implemented. the appropriate notification was to be placed on the room entrance door. so that personnel and visitors were aware of the need for and type of precautions.

Based on interviews, and record review, the facility failed to maintain ongoing competency for restorative nursing assistants (RNAs) by failing to ensure a restorative nursing assistants training program was developed and implemented as per facility policy and procedures (P&P) titled Staff Development Program dated 1/2026. This failure had the potential to compromise nursing competence among restorative nursing assistants which could negatively affect the quality and safety of care provided to residents.Findings:During a review of the facility's Annual Staff Development Education calendar for 2025 and 2026, the calendars indicated that the monthly topics provided by the Director of Staff Development (DSD) to the staff did not include topics on weight assessment. During a review of the Restorative Nursing Assistant job description, the job description indicated that the RNA general duties included other related duties necessary and appropriate or as directed by the Charge Nurse, Supervisor, or Director of Nursing. During a review of the Restorative Nursing Assistant annual skills competency checklist, the competency checklist indicated there were no performance skill checks for weight assessment. During an interview on 7/8/2026 at 10:25 PM with Certified Nursing Assistant (CNA)5, CNA 5 stated that the CNAs were given individual assignments every shift, but Restorative Nursing Assistants (RNA) were responsible to weigh the residents per instruction from the Director of Staff Development (DSD) and the Director of Nursing (DON). CNA 5 stated that skills competency and education were important for the provision of quality care. During an interview on 7/8/2026 at 1:37 PM with Restorative Nursing Assistant (RNA)3, RNA 3 stated that the RNAs tasks include weighing the residents and participating in the feeding program meetings with the Dietary, Supervisor, the DSD, and the DON to review and discuss residents' weight and nutritional status. During an interview on 7/9/2026 at 12:31 PM with Director of Staff Development (DSD), DSD stated that restorative nursing assistants weigh the residents as part of their job description and daily assignments. The DSD stated that all in-service education provided to the staff were written and posted on the facility's Annual Staff Development Education calendar. During an interview on 7/9/2026 at 1:08 PM with the Director of Nursing (DON), the DON stated that restorative nursing assistants had to receive appropriate training to ensure competence and skills in performing their RNA duties including weight assessment among residents. The DON stated that if continuing education was not provided, RNA competence would be compromised resulting in poor resident care. During a review of the facility's policy and procedures (P&P) titled, Restorative Nursing Services dated 1/2026, the P&P indicated that restorative nursing care consisted of nursing interventions that could or could not be accompanied by formalized rehabilitative services. During a review of the facility's P&P titled Staff Development Program dated 1/2026, the P&P indicated that the primary objective of the facility's staff development program was to ensure that staff had the knowledge, skills and critical thinking necessary to provide excellent resident care.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled residents (Resident 98) by failing to ensure Resident 98's call light (a device with a button or touchpad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach as indicated in the facility's Policy and Procedures (P&P) titled Answering the Call Light, dated 1/2026. This failure had the potential for Resident 1 not to receive emergency care or to have a delay in care and services that could result in a fall or accident.Findings:During a review of Resident 98's admission Record, the admission Record indicated the facility originally admitted Resident 98 on 4/17/2017 and readmitted Resident 98 on 2/5/2024 with diagnoses that included type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, primary open angle glaucoma (an eye condition where fluid drains too slowly out of the eye, causing a slow, painless buildup of internal pressure that can lead to irreversible blind spots), need for assistance with personal care, lack of coordination, and age related cataracts (a natural clouding of your eye's lens that happens as you get older). During a review of Resident 98's Minimum Data Set (MDS - a resident assessment tool), dated 4/23/2026, the MDS indicated Resident 98 had the ability to make himself (Resident 98) understood and had the ability to understand others. The MDS indicated Resident 1's vision was impaired (able to see large print but not regular print in newspapers/books). During a review of Resident 98's (H&P - the most formal and complete assessment of the patient and the problem) dated 6/19/2026, the H&P indicated Resident 98 had capacity to understand and make decisions. The H&P indicated Resident 98 had deconditioning (the physical and mental decline that happens when you are inactive for a long time) and gait (refers to any problem with the way you walk, such as shuffling, dragging your feet, or staggering) and balance disorder (makes it hard to stay upright, leaving you feeling dizzy, wobbly, or like the room is spinning). The H&P indicated Resident 98 had impaired vision with severe vision loss. During a review of Resident 98's Internal Medicine Progress Note, dated 6/29/2026, the Internal Medicine Progress Note indicated Resident 98 had physical debility (chronic physical weakness or a lack of strength). The Internal Medicine Progress Note indicated Resident 98 had fall precautions (a set of rules and safety measures designed to prevent a resident from falling) and delirium precautions (a set of daily routines used to keep vulnerable residents safe and mentally sharp). During an observation on 7/6/2026 at 11:15 AM in Resident 98's room, Resident 98's call light was observed resting on the floor out of Resident 98's reach. During a concurrent observation and interview on 7/6/2026 at 11:21 AM with Licensed Vocational Nurse 3 (LVN 3) in Resident 98's room, Resident 98's call light was observed resting on the floor out of Resident 98's reach. LVN 3 stated Resident 98's call light was on the floor and could cause an infection control issue. LVN 3 stated she (LVN 3) would sanitize the call light and place it where Resident 3 could reach the call light to call for help if needed. During a concurrent interview and record review on 7/9/2026 at 4:04 PM with the Director of Nursing, the facility's policy and procedure (P&P) titled Answering the Call Light, dated 1/2026, was reviewed. The P&P indicated the purpose of the P&P was to ensure timely responses to resident's (in general) requests and needs. The P&P indicated the call light should be within easy reach of the resident (in general). The DON stated the facility did not follow the Answering the Call Light Policy. The DON stated Resident 98's call light had to have been within reach for Resident 98 to be able to call for help.

Based on interview and record review the facility failed to ensure the Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) Acknowledgment was completed and updated annually for one of five sampled residents (Resident 13) as indicated in the facility's Policy and Procedure titled Advance Directives dated 1/2026. This failure had the potential for Resident 13's wishes for care not to be honored in the event of an emergency. Findings: During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 3/17/2023 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities). During a review of Resident 13's Advance Directive Acknowledgement dated 1/24/2025, the Advance Directive Acknowledgement indicated the resident had executed an advance directive. The Advance Directive Acknowledgement indicated Resident 13's daughter signed the Advance Directive Acknowledgement because the resident did not have decision making capacity. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 5/15/2026, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 13 required set up or clean up assistance (helper sets up or cleans up, resident completes activity) with eating. The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from facility staff for oral hygiene. The MDS indicated Resident 13 required partial/moderate assistance (helper does less than half the effort) from facility staff for showering/bathing herself, upper body dressing, and personal hygiene. The MDS indicated Resident 13 required substantial/maximal assistance (helper does more than half the effort) from facility staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. During an interview on 7/08/2026 at 11:20 AM with the Social Services Director (SSD), the SSD stated Resident 13's Advance Directive Acknowledgement needed to be redone because there was confusion about whether the resident had an advance directive. During an interview on 7/09/2026 at 11:26 AM with Resident 13, Resident 13 stated she did not have an advance directive. Resident 13 stated she (Resident 13) had not been informed of what an advance directive was prior to 7/8/2026. Resident 13 stated she (Resident 13) would like help to make an advance directive. During a concurrent interview and record review on 7/09/2026 at 11:34 AM with the Social Services Director (SSD), Resident 13's Advance Directive Acknowledgement dated 1/24/2025 was reviewed. The SSD stated Resident 13's Advance Directive Acknowledgement indicated the resident had executed an advance directive. The SSD stated the Advance Directive Acknowledgement dated 1/24/2025 was not correct. The SSD stated Resident 13 did not have an advance directive. The SSD stated that the Advance Directive Acknowledgement had not been updated since 1/24/2025. The SSD stated the Advance Directive Acknowledgement was to be reviewed upon admission and re-evaluated quarterly and upon re-admission to the facility. The SSD stated that if the Advance Directive Acknowledgement for Resident 13 was not correct or reevaluated upon admission and/or quarterly there was potential for the resident's wishes about her (Resident 13) care to not be honored. During a concurrent interview and record review on 7/9/2026 at 2:19 PM with the Director of Nursing (DON), Resident 13's Advance Directive Acknowledgement dated 1/24/2025 was reviewed. The DON stated the Advance Directive Acknowledgement was to be reviewed and completed on admission and quarterly. The DON stated an advance directive was supposed to inform the staff (in general) of the care Resident 13 wanted in the event of an emergency. The DON stated the Advance Directive Acknowledgement was used to ensure Resident 13 was provided with information on what an advanced directive was, assessed if the resident had an advanced directive, or if the resident wanted help to create an advanced directive. The DON stated the Advance Directive Acknowledgment for Resident 13 should have been reassessed quarterly. The DON stated that if Resident 13 was not reassessed for an advance directive there was potential for Resident 13 to not have their (Resident 13) wishes about care honored during an emergency. During a review of the facility's Policy and Procedure (P&P) titled Advance Directives dated 1/2026, the P&P indicated Upon admission, the resident will be provided with written information concerns the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if he or her legal representative has already been given the information.Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS).

Based on observation, interview, and record review the facility failed to protect one of one sampled resident (Resident 31) from verbal abuse (using spoken, written, or gestured language to threaten, humiliate, or cause emotional pain to a resident) when on 7/8/2026 at 6:04 AM Certified Nursing Assistant 1 (CNA 1) told Resident 31 to shut up. This failure resulted in Resident 31 to be agitated (feeling very worried, upset, or restless) and placed Resident 31 and other residents (unidentified) at risk of further abuse and emotional harm. Cross Reference F550 Findings: During a review of Resident 31's admission Record, the admission Record indicated the facility originally admitted Resident 31 on 8/16/2024 and readmitted Resident 31 on 10/16/2025 with diagnoses that included metabolic encephalopathy (a temporary, generalized malfunction of the brain caused by a chemical imbalance in the body, rather than a direct physical injury or disease in the brain itself), dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 31's History and Physical (H&P) dated 10/17/2025, the H&P indicated Resident 31 did not have the capacity (a person does not have the mental ability to understand their medical condition, weigh the risks and benefits of treatment, and make a reasoned healthcare decision) to make decisions. During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool), dated 5/30/2026, the MDS indicated Resident 31 usually had the ability to understand others and usually had the ability to make himself understood. The MDS indicated Resident 31 required substantial/maximal assistance (helper does more than half the effort) for oral hygiene (ability to clean teeth), personal hygiene (combing hair, shaving, washing/drying face and hands), and for toileting. The MDS indicated Resident 31 was dependent (helper does all of the work) for shower/bathing. During a review of CNA 1's employee file, the employee file indicated the facility hired CNA 1 on 11/18/2025 and that CNA 1 received abuse training on 11/18/2025. During a concurrent observation and interview on 7/8/2026 at 6:04 AM with CNA 1 in the hallway outside of Resident 31's room, CNA 1 was observed telling Resident 31 to shut up. Resident 31 was observed yelling back to CNA 1 you shut up! Resident 31 was observed to become more agitated after he (Resident 31) was told to shut up by CNA 1. CNA 1 was asked to confirm that she (CNA 1) told Resident 31 to shut up, CNA 1 answered yes. CNA 1 stated she (CNA1) was sorry. CNA 1 stated she (CNA 1) should not have told Resident 31 or any other resident (in general) to shut up. During an interview on 7/8/2026 at 6:10 AM with Licensed Vocational Nurse 1 (LVN 1), Registered Nurse 1 (RN 1) and CNA 1. LVN 1 and RN 1 stated staff (in general) could not tell any residents (in general) to shut up. LVN 1 and RN 1 stated telling a resident (in general) to shut up was a form of verbal abuse. During an interview on 7/8/2026 at 7:05 AM with the Administrator (ADM), the ADM stated the facility's Human Resources Director (HR) and Director of Staff Development (DSD) were on the way to speak with CNA 1. The ADM stated CNA 1 was taken off the floor and away from Resident 31. The ADM stated he (ADM) would report the incident between CNA 1 and Resident 31 according to the facility's abuse reporting policy. During a follow up interview on 7/8/2026 at 8:00 AM in the ADM office with CNA 1, CNA1 stated she (CNA1) stated she (CNA1) could not explain why she (CNA 1) told Resident 31 to shut up. During an interview on 7/8/2026 at 8:05 AM, an attempt was made to speak with Resident 31. Resident 31 yelled back what do you want. Resident 31 refused to answer any questions. During a concurrent interview and record review on 7/8/2026 at 9:26 AM with the DSD, CNA 1's abuse in-service dated 5/29/2026 (education or coaching that an employer provides to you while you are already employed to help you stay good at your job) was reviewed. The DSD stated the in-service CNA 1 received on 5/29/2026 included a lesson plan included verbal abuse training. During an interview on 7/8/2026 at 10:19 AM with the ADM, the ADM stated CNA 1 was placed on suspension pending the results of the facility's investigation regarding CNA 1's verbal abuse to Resident 31. During a concurrent interview and record review on 7/9/2026 at 3:36 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Abuse and Neglect - Clinical Protocol [a standardized set of rules or step-by-step instructions that dictate how something should be done] dated 1/2026 was reviewed. The P&P indicated verbal abuse was a form of abuse. The DON stated CNA 1 did not follow the facility's P&P when CNA 1 told Resident 31 to shut up. The DON stated CNA 1 should not have told Resident 31 to shut up because it could provoke (to do or say something that intentionally makes someone mad, annoyed, or eager to fight) Resident 31. The DON stated Resident 31's dignity could have been affected. During a review of the facility's P&P titled Identifying Types of Abuse dated 6/2022, the P&P indicated staff (in general) were expected to be able to identify different types of abuse. The P&P indicated verbal abuse would be considered a type of mental abuse that included written, gestured communication (the use of body language-primarily hand, arm, and facial movements-to express a message, feeling, or idea with or without spoken word) or sounds to residents (in general) within hearing distance. The P&P indicated examples of verbal abuse included harassing a resident (in general), mocking, insulting, ridiculing (making fun of), yelling, intimidating, threatening or isolating a resident (in general) from social interactions or activities. The P&P indicated mental abuse could include agitating a resident to solicit a response (to ask for an answer, reply, or feedback). During a review of the facility's P&P titled Dignity dated 1/2026, the P&P indicated the facility would care for each resident (in general) in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated staff had to speak respectfully to residents at all times.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 2) reviewed for restraints was free from a physical restraint (any manual method, physical or mechanical device/equipment or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) by failing to:1. Document the Quality Assurance Performance Improvement ([QAPI] a proactive, data-driven framework that combines quality checks with continuous process improvement to enhance patient outcomes, care quality, and overall quality of life) meeting with the physician's recommendation for the use of Resident 2's Merry [NAME] (adaptive equipment that combines walker and chair to allow a person to walk independently and safely).2. Obtain a physician's order for Resident 2's Merry Walker.3. Obtain a consent for the Merry [NAME] from Resident 2's responsible party.4. Assess Resident 2's Merry [NAME] prior to use. These failures resulted in the use of a physical restraint which had the potential to negatively affect Resident 2's psychosocial (thoughts, emotions, and mental well-being) health and mobility (ability to move). Cross reference F641, F656, F688, F689 Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 9/6/2023 and readmitted on [DATE] with diagnoses including encephalopathy (disease that affects the brain, causing changes in its function), difficulty in walking, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and lack of coordination (functioning of muscle groups or body systems to perform smooth, efficient movements). During a review of Resident 2's SBAR ([Situation, Background, Assessment, Recommendation] a communication tool used by healthcare workers when the resident experiences a change of condition) Communication Form, dated 12/30/2025, the SBAR Communication Form indicated Resident 2 had an unwitnessed fall and was found on the floor with a headache, a bump on the back of the head, and neck pain. Resident 2 was sent to the hospital for further evaluation. During a review of Resident 2's History and Physical (H&P) dated 1/9/2026, the H&P indicated Resident 2 was admitted to the hospital on [DATE] due to an unwitnessed fall after the staff found Resident 2 on the floor with a hematoma (collection of blood outside of a blood vessel caused by a broken blood vessel) on the back of the head. The H&P indicated Resident 2 had fluctuating (unpredictable changes) capacity to understand and make medical decisions. During a review of Resident 2's SBAR Communication Form, dated 3/15/2026, the SBAR Communication Form indicated Resident 2 had an unwitnessed fall when found sitting on the floor next to the wheelchair during routine rounds. During a review of Resident 2's SBAR Communication Form dated 4/11/2026, the SBAR Communication Form indicated Resident 2 had an unwitnessed fall on 4/7/2026 when Resident 2 was found lying on the floor mat next to the bed. During a review of Resident 2's SBAR Communication Form dated 5/4/2026, the SBAR Communication Form indicated Resident 2 slid off from the wheelchair onto the floor hallway near Resident 2's room. During a review of Resident 2's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 5/6/2026, the PT Evaluation indicated nursing referred Resident 2 to PT after a fall. The PT Evaluation indicated Resident 2 had range of motion ([ROM] full movement potential of a joint) within normal limits ([WNL] normal joint movement) in both legs. The PT Evaluation indicated Resident 2 required stand-by assistance ([SBA] required verbal cues and no physical assistance to perform the activity) for bed mobility and contact guard assistance ([CGA] required steadying assistance or less than 25 percent [%] physical assistance to perform the task) for transfers and walking 50 feet (unit of measure) with hand-held assistance. The PT Evaluation indicated a short-term goal to ambulate 100 feet on level surfaces without an assistive device and a long-term goal to ambulate 175 feet on level surfaces without an assistive device. During a review of Resident 2's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 2 required CGA for ambulating 60 feet without an assistive device. The PT Discharge recommendations indicated to transition Resident 2 to the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) for ambulation with the Merry Walker. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 6/18/2026, the MDS indicated Resident 2 had clear speech, had difficulty communicating some words or finishing thoughts, understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 2 did not have any ROM limitations in both arms and legs and required partial/moderate assistance (helper does less than half the effort) for upper body dressing, rolling from lying on bed to either side in bed, transferring from lying to sitting on the side of the bed, sit-to-stand transfers, chair/bed-to-chair transfers, and walking 10 feet. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) for toileting and lower body dressing. During a concurrent observation and interview on 7/6/2026 at 12:19 p.m. in the activity/dining room, Resident 2 was sitting on a seat in a wheeled device with multiple metal bars connected in a square shape around Resident 2. The metal bars extended above the height of Resident 2's head while seated. The device had blue padding attached to the metal bars. Restorative Nursing Aide 1 (RNA 1) initially stated Resident 2 was sitting in a wheelchair. RNA 1 then stated Resident 2 was seated in a Merry [NAME] after checking the physician's order for RNA. RNA 1 stated Resident 2 had a physician's order to place Resident 2 in the Merry [NAME] and had to check the resident's position every two hours. During a concurrent observation and interview on 7/7/2026 at 9:35 a.m. in the resident's room, Resident 2's transfer into the Merry [NAME] was observed. RNA 1 stated two people were required to transfer Resident 2 to the chair, referring to the Merry Walker. Restorative Nursing Aide 2 (RNA 2) removed the rear metal bar from the Merry Walker. Resident 2 required physical assistance to transfer from sit-to-stand. RNA 2 stood in front of the Merry [NAME] while assisting Resident 2 to remain standing. RNA 1 was behind Resident 2 to adjust Merry Walker's seat. Resident 2 sat on the seat while RNA 1 reattached the Merry Walker's rear metal bar. RNA 2 wheeled Resident 2, who also used both feet to propel forward while seated in the Merry Walker, into the activity/dining room down the hallway. Resident 2's Merry [NAME] was observed with two front wheels and four rear wheels. RNA 2 stated Resident 2's Merry [NAME] had six brakes since each wheel had a separate brake. During an observation on 7/7/2026 at 10:07 a.m. in the resident's room, Resident 2 was seated in the Merry [NAME] and used small steps to propel forward. During an observation on 7/7/2026 at 10:09 a.m. in the resident's room, Resident 2 was seated in the Merry [NAME] when Licensed Vocation Nurse 5 (LVN 5) was observed locking two of the rear brakes. Resident 2 was observed with small, repetitive forward thrusts of the chest and body as if Resident 2 was attempting to move while seated in the Merry Walker. During an observation on 7/7/2026 at 12:35 p.m. in the activity/dining room, Resident 2 was seated in the Merry Walker. Resident 2 was encouraged but was unable to propel forward while seated in the Merry Walker. During an observation on 7/7/2026 at 2:21 p.m., Resident 2 was seated in the Merry [NAME] and observed with small, repetitive forward thrusts of the chest and body as if Resident 2 was attempting to move while seated in the Merry Walker. During a concurrent interview and record review on 7/8/2026 at 2:12 p.m. with Physical Therapist 1 (PT 1) and the Director of Rehabilitation (DOR), Resident 2's PT Evaluation, dated 5/6/2026, and PT Discharge summary, dated [DATE], were reviewed. PT 1 stated Resident 2 required CGA to walk which meant a person needed to be physically guiding Resident 2 for safety. PT 1 stated the PT Discharge Summary indicated Resident 2 walked with CGA for 60 feet without an assistive device. PT 1 stated PT 1 did not recommend Resident 2's Merry Walker. The DOR stated a physician (unknown) recommended Resident 2's Merry [NAME] during a QAPI meeting (unknown date) due to Resident 2's frequent falls. PT 1 described the Merry [NAME] as a walker with a chair that Resident 2 could not freely get out of to prevent Resident 2 from falling. The DOR stated PT 1 chose Resident 2's Merry [NAME] after the DOR and PT 1 searched online. During an interview on 7/9/2026 at 7:47 a.m. with RNA 1, RNA 1 stated Resident 2 used to walk without assistance about two months ago. During a telephone interview on 7/9/2026 at 8:21 a.m. with Resident 2's responsible party (RP 1), RP 1 stated Resident 2 used to walk and has gotten weaker in the past six months. RP 1 did not know if Resident 2's weakness was due to mental or physical decline. RP 1 stated the facility reported to RP 1 that Resident 2 needed the Merry [NAME] because Resident 2 could not sit upright, had difficulty standing and walking, and had multiple falls. During an interview on 7/9/2026 at 8:41 a.m. with the DOR, the DOR stated Resident 2's Merry [NAME] was ordered on a popular online shopping website. During a follow-up interview on 7/9/2026 at 8:50 a.m., the DOR stated the DOR had never heard of a Merry [NAME] prior to the (unknown) physician's recommendation during the QAPI meeting. The DOR stated PT 1 selected Resident 2's Merry Walker, and the DOR purchased it on a popular online shopping website instead of using a medical supply company because the facility needed it quickly. During an interview on 7/9/2026 at 10:30 a.m. with the Director of Nursing (DON), the DON stated Resident 2 used the Merry [NAME] after a QAPI discussion regarding Resident 2's frequent falls. The DON stated one (unknown) of the five physicians present during the QAPI meeting suggested the use of the Merry [NAME] since the facility was running out of ideas to prevent Resident 2's falls. During an observation on 7/9/2026 at 10:39 a.m. in Resident 2's room, RNA 2 assisted Resident 2 to stand while RNA 1 adjusted the seat behind Resident 2. RNA 1 and RNA 2 assisted Resident 2 to sit on the seat after securing its position in the Merry Walker. RNA 1 reattached the rear metal bar on the Merry [NAME] behind Resident 2. During an observation on 7/9/2026 at 11:14 a.m. in the activity/dining room, Resident 2 was observed sitting in the Merry [NAME] with the brakes activated. During a concurrent observation and interview on 7/9/2026 at 11:17 a.m. in the activity/dining room with the DON, Resident 2 was observed sitting in the Merry [NAME] with all six brakes activated on each wheel. Resident 2 was asked to unlock the brakes. The DON stated Resident 2 was unable to unlock the Merry Walker's brakes. The DON stated the staff needed to activate the Merry Walker's brakes while Resident 2 was seated to prevent Resident 2 from moving. During an interview on 7/9/2026 at 11:24 a.m. with the DON, the DON stated the Merry Walker's brakes could be released if a staff member was present while Resident 2 sat or walked in the Merry [NAME] to prevent Resident 2 from bumping into someone or tilting sideways while seated. During a concurrent interview and record review on 7/9/2026 at 12:44 p.m. with the DON, the DOR, and the Quality Assurance Registered Nurse (QA RN 1), Resident 2's physician orders, the QAPI meetings, and consents were reviewed in the medical record. The DON was unable to locate documentation from the QAPI meeting discussing the use and recommendation of Resident 2's Merry Walker. The DON stated Resident 2's medical record did not include a physician's order for the Merry [NAME] and should not have been used without a physician's order. The DON stated the Merry [NAME] was a physical restraint if the brakes prevented Resident 2 from moving. The DOR stated Resident 2 could not get out of the Merry [NAME] without assistance and did not know it was considered a physical restraint. QA RN 1 reviewed Resident 2's medical record and stated there was no assessment for the use of the Merry [NAME] as a physical restraint. The DOR and DON stated Resident 2 could potentially lose mobility without the ability to move and walk freely in the Merry Walker. During a follow-up interview and record review on 7/9/2026 at 3:59 p.m. with the QA RN 1, Resident 2's medical records and the facility's policy and procedure (P&P) titled, Use of Restraints, revised 1/2026, were reviewed. QA RN 1 stated Resident 2's Merry [NAME] matched the definition for a physical restraint. QA RN 1 stated the facility did not have the QAPI meeting notes discussing the physician's recommendations for Resident 2's Merry Walker. QA RN 1 stated the facility did not have a physician's order for the Merry Walker, an assessment of the Merry [NAME] as a physical restraint, and signed consent for the Merry Walker. QA RN 1 stated Resident 2's Merry [NAME] could cause psychosocial and mobility decline since it restricted Resident 2's ability to move. During a review of the facility's P&P titled, Use of Restraints, revised 1/2026, the P&P defined physical restraints as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restrict normal access to one's body. The P&P indicated there shall be a pre-restraining assessment and review to determine the need for restraints and to determine if there are less restrictive interventions. The P&P indicated Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative, and the physician's order should include the specific reason for the restraint, how it would benefit the resident's medical symptom, the type of restraint, and the period of time for the use of the restraint. Cross reference F641, F656, F688, F689

Based on interview and record review the facility failed to develop and implement (put into place) a comprehensive person-centered care plan (a personalized, written roadmap developed by the healthcare team that outlines health problems, goals, and the exact treatment steps) for two of 27 residents (Resident 2 and Resident 80) by failing to ensure to: 1.Develop a care plan for the use of Resident 2's Merry [NAME] (adaptive equipment that combines walker and chair to allow a person to walk independently and safely). 2.Develop a person-centered for Resident 80's low air loss mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries). These failures had the potential to affect Resident 2 and Resident 80's care and services and prevent the reassessment of the device's effectiveness. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 9/6/2023 and readmitted on [DATE] with diagnoses including encephalopathy (disease that affects the brain, causing changes in its function), schizophrenia (a mental illness that is characterized by hearing or seeing things that are not there), difficulty in walking, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and lack of coordination (functioning of muscle groups or body systems to perform smooth, efficient movements). During a review of Resident 2's History and Physical ([H&P] a record of a physician's comprehensive medical assessment and plan) dated 1/9/2026, the H&P indicated Resident 2 had fluctuating (unpredictable changes) capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 6/18/2026, the MDS indicated Resident 2 had clear speech, had difficulty communicating some words or finishing thoughts, understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 2 did not have any ROM limitations in both arms and legs and required partial/moderate assistance (helper does less than half the effort) for upper body dressing, rolling from lying on bed to either side in bed, transferring from lying to sitting on the side of the bed, sit-to-stand transfers, chair/bed-to-chair transfers, and walking 10 feet. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) for toileting and lower body dressing. During a review of Resident 2's Physical Therapy (PT- profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 2 required CGA for ambulating 60 feet without an assistive device. The PT Discharge recommendations indicated to transition Resident 2 to the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) for ambulation (the act of walking) with the Merry Walker. During a concurrent observation and interview on 7/6/2026 at 12:19 PM in the activity/dining room, Resident 2 was sitting on a seat in a wheeled device with multiple metal bars connected in a square shape around Resident 2. The metal bars extended above the height of Resident 2's head while seated. The device had blue padding attached to the metal bars. Restorative Nursing Aide 1 (RNA 1) initially stated Resident 2 was sitting in a wheelchair. RNA 1 then stated Resident 2 was seated in a Merry [NAME] after checking the physician's order for RNA. RNA 1 stated Resident 2 had a physician's order to place Resident 2 in the Merry [NAME] and had to check the resident's position every two hours. During a concurrent observation and interview on 7/7/2026 at 9:35 PM in Resident 2's room, Resident 2's transfer into the Merry [NAME] was observed. RNA 1 stated two people were required to transfer Resident 2 to the chair, referring to the Merry Walker. Restorative Nursing Aide 2 (RNA 2) removed the rear metal bar from the Merry Walker. Resident 2 required physical assistance to transfer from sit-to-stand. RNA 2 stood in front of the Merry [NAME] while assisting Resident 2 to remain standing. RNA 1 was behind Resident 2 to adjust Merry Walker's seat. Resident 2 sat on the seat while RNA 1 reattached the Merry Walker's rear metal bar. RNA 2 wheeled Resident 2, who also used both feet to propel forward while seated in the Merry Walker, into the activity/dining room down the hallway. Resident 2's Merry [NAME] was observed with two front wheels and four rear wheels. RNA 2 stated Resident 2's Merry [NAME] had six brakes since each wheel had a separate brake. During a concurrent interview and record review on 7/8/2026 at 2:12 PM with Physical Therapist 1 (PT 1) and the Director of Rehabilitation (DOR), Resident 2's PT Discharge summary, dated [DATE], were reviewed. PT 1 stated PT 1 did not recommend Resident 2's Merry Walker. The DOR stated a physician (unknown) recommended Resident 2's Merry [NAME] during a Quality Assurance Performance Improvement ([QAPI] a proactive, data-driven framework that combines quality checks with continuous process improvement to enhance patient outcomes, care quality, and overall quality of life) meeting (unknown date) due to Resident 2's frequent falls. PT 1 described the Merry [NAME] as a walker with a chair that Resident 2 could not freely get out of to prevent Resident 2 from falling. During a concurrent observation and interview on 7/9/2026 at 11:17 AM in the activity/dining room with the Director of Nursing (DON), Resident 2 was observed sitting in the Merry [NAME] with all six brakes activated on each wheel. Resident 2 was asked to unlock the brakes. The DON stated Resident 2 was unable to unlock the Merry Walker's brakes. The DON stated the staff (in general) needed to activate the Merry Walker's brakes while Resident 2 was seated to prevent Resident 2 from moving. During a concurrent interview and record review on 7/9/2026 at 11:58 AM with the DON and MDS Coordinator1 (MDS 1), the DON and MDS 1 stated the facility did not have a care plan indicating the use of Resident 2's Merry Walker. The DON stated Resident 2's Merry [NAME] would not be monitored for the effectiveness due to the absence of the care plan. During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 1/2026, the P&P indicated the care plan will include measurable objectives and describe the services furnished the to attain or maintain the resident's physical, mental, and psychosocial (thoughts, emotions, and mental) well-being. 2.During a review of Resident 80's admission Record, the admission record indicated the facility originally admitted Resident 80 on 8/5/2024 and readmitted Resident 80 on 6/19/2026 with diagnoses that included acute respiratory failure with hypoxia (your lungs suddenly stopped working well enough to move oxygen into your bloodstream, causing dangerously low oxygen levels in your body), dysphagia (difficulty swallowing), epilepsy (a brain condition that causes repeated, unprovoked seizures), homelessness, muscle weakness, lack of coordination, and unspecified psychosis (someone is experiencing a temporary, significant disconnect from reality, but their symptoms don't perfectly fit a specific mental health diagnosis). During a review of Resident 80's MDS dated [DATE], the MDS indicated Resident 80 sometimes could make herself (Resident 80) understood and sometimes had the ability to understand others. The MDS indicated Resident 80 needed substantial/maximal assistance (helper does more than half the effort) for eating, going from sitting to lying position, from lying to sitting position, and for rolling left and right while in bed. The MDS indicated Resident 80 was dependent for transferring from bed to chair, going on/off a toilet or commode (a portable, chair-like toilet with a bucket underneath), getting in/out of a tub/shower, toileting hygiene (cleaning self after going to the bathroom), showering, personal hygiene (comb hair, applying makeup, washing/drying hands/face) and upper/lower body dressing. During a review of Resident 80's Order Summary Report dated 7/10/2026, the Order Summary Report indicated Resident 80 had a physician order for a LALM. During a review of Resident 80's History and Physical (H&P - the most formal and complete assessment of the patient and the problem) dated 7/10/2026, the H&P indicated Resident 80 did not have the capacity (ability) to understand and make decisions. The H&P indicated Resident 80 had diagnoses that included dementia (a progressive state of decline in mental abilities), failure to thrive (a condition in older adults marked by physical and mental decline), and anorexia (a medical term for a loss of appetite). The H&P indicated Resident 80 was on hospice (special end-of-life care for people with terminal illnesses). During a concurrent interview and record review on 7/7/2026 at 1:20 PM with the DON, Registered Nurse 2 (RN 2), the Wound Care Nurse (WCN), and Licensed Vocational Nurse 3 (LVN 3), Resident 80's medical record was reviewed. The DON, RN 2, and WCN stated Resident 80 did not have a care plan for a LALM. The DON, RN 2, WCN, and LVN 3 stated the facility should have created a care plan for Resident 80's LALM. During a concurrent interview and policy review on 7/9/2026 at 3:53 PM with the DON, the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 1/2026 was reviewed. The P&P indicated a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's (in general) physical, psychosocial (the close connection between a person's thoughts, feelings, mental health and their social environment), and functional needs (the physical or mental help a patient requires to safely get through the day, such as bathing, getting dressed, and walking) is developed and implemented for reach resident. The P&P indicated the facility would develop and implement a comprehensive person-centered care plan for each resident (in general). The DON stated the facility should have put in a care plan for Resident 80's LALM. The DON stated the care plan for Resident 80 should have been in place to see if Resident 80's goals were being met. The DON stated the facility did not follow their P&P.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as high risk for falls and dependent in Activities of Daily Living (ADLs), did not experience multiple falls, one resulting in injury, by failing to: 1. Initiate an individualized plan of care upon admission on [DATE] when Resident 1 was identified as having a high fall risk. 2. Update the care plan and interventions when Resident 1 had an unwitnessed fall on 11/16/2025. 3. Ensure staff adhered to the facility's policy and procedure titled Falls - Clinical Protocol (revised 12/2024), which requires staff and physicians to identify and implement interventions to prevent falls and mitigate clinically significant consequences. 4. Evaluate and analyze hazards and risks following repeated unwitnessed falls. As a result of these failures, Resident 1 had multiple unwitnessed falls (11/16/2025, 11/23/2025) and on 12/1/2025 Resident 1 slid from the bed, landing face down on the floor, resulting in a three cm laceration to the left forehead. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 on 12/2/2025 for generalized pain following the fall, with diagnoses of thoracic spine strain (discomfort in the mid-back, between the shoulder blades and lower ribs, often caused by muscle strain, poor posture, overuse, or joint issues, though more serious causes like nerve compression or fractures exist) and left shoulder contusion (bruise from direct impact, causing pain, swelling, stiffness, and discoloration [black-and-blue] as blood vessels leak under the skin). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnosis that included acute respiratory failure with hypoxia (severe, sudden condition where the lungs can't get enough oxygen into the blood), other lack of coordination, and other abnormalities of gait (a manner of walking or moving the foot) and mobility (ability to move arounds freely and easily). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills were severely impaired. The MDS indicated Resident 1 was dependent on oral hygiene, toileting, bathing and dressing. The MDS indicated Resident 1 was also dependent with mobility, helper does all of the effort, with Resident 1 laying on back to roll left and right side, sit on side of bed to lying flat on the bed, lying on the back to sitting on the side of the bed and with no back support, come to a standing position from sitting and transfer to and from a bed to chair. The MDS also indicated Resident 1's ability to get on and off a toilet commode was not attempted due to medical conditions or safety concerns. During a record review of Resident 1's fall risk assessment dated [DATE], the fall risk assessment indicated score of 14. According to the falls assessment tool, if the total score is above 10, the resident should be considered high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. During a record review Resident 1's admission care plan, for the admission date 11/11/2025, unable to locate documentation of a high risk for fall care plan, no care plan initiated and no intervention in place. During a review of Resident 1's Situation, Background, Assessment, Request (SBAR-communication framework widely used in healthcare to ensure clear, concise, and organized information exchange among team members.) Communication Form, dated 11/16/2025 timed at 4:16 a.m., the SBAR indicated Resident 1 slid out of bed and found sitting on the floor at bedside with no visible injuries or bruises noted and Resident 1 denied any acute pain. During a record review of Resident 1's fall risk assessment dated [DATE], indicated score of 19.During a review of review of the care plan titled Resident 1 noted sliding out of bed, dated 11/16/2025, the care plan intervention indicated fall precautions implemented such as bed at lowest locked position and frequent visual checks done by staff to ensure safety and monitoring. During review of Resident 1's care plan titled, Risk for fall initiated 11/17/2025, the care plan indicated anticipate and meet Resident 1's needs, Resident 1 needs prompt response to all request for assistance and follow facility fall protocol. During review of Resident 1's Occupational Treatment (OT) Encounter Notes, dated 11/17/2025, the notes indicated Resident 1's functional status as total dependence with dressing, toileting and bathing and unable to sit or stand during ADL. The notes indicated Resident 1 required extra time to initiate and complete given task. The notes also indicated that Resident 1's cognitive status and nursing care required were complexities and barriers impacting OT therapy session. During a review of Resident 1's SBAR Communication Form, dated 11/23/2025 timed at 9:06 p.m., the SBAR indicated Resident 1 was found on the floor by his bedside. During a review of Resident 1's SBAR Communication Form, dated 12/1/2025 timed at 10:30 p.m., the SBAR indicated a loud sound came from Resident 1's room and Resident 1 was found lying on the floor on his left side faced down. The SBAR further indicated Resident 1 had been attempting to use urinal on the edge of his bed until he slipped off the bed. The SBAR also indicated Resident 1 sustained a laceration on his left forehead above the eyebrow and reported a pain level of 7/10 and when assessed using the two-finger test, stated he were seeing 4 fingers(double). During an interview on 12/16/2025 at 4:02 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 depends totally on assistance with ADL's including toileting. LVN 1 stated Resident 1 was incontinent and able to tell the staff when he is wet. LVN 1 stated Resident 1's uses the urinal only when his spouse is present. LVN 1 stated that after Resident 1 fell on [DATE], the care plan should be floor mat, frequent (every hour and a half) visual checks and addressing why Resident 1 fell. Since there is no care plan done none of this intervention was implemented. LVN 1 said when Resident 1 fell again, the nurse needed to determine why he fell, review his medications, and assess whether confusion, attempts to get up, or anxiety caused the fall. LVN 1 said finding the cause of the second fall is necessary to change the care plan and prevent more falls. LVN 1 said, If the care plan stays the same with no changes to interventions Resident 1 can get hurt and it means we are not doing our job properly. LVN 1 said the LVN assigned to the resident initiates care plan changes, and the RN completes the assessment, follows up with the physician, and revises the care plan further. LVN 1 said the goal is to prevent Resident 1 from falling again and getting injured. During an interview on 12/17/2025 at 11:06 a.m. with LVN 2, LVN 2 stated Resident 1 responds verbally with episodes of confusion, especially at night. LVN 2 stated Resident 1 tries to get out of bed by pulling his upper body using the side rails. LVN 2 stated while assisting CNA 1 with another resident room, LVN 2 and CNA 1 heard a loud bang sound that came from Resident's 1 room. When they went to Resident 1's room, they found Resident 1 on the floor with the urinal next to him and urine on the floor. LVN 2 stated that Resident 1 told him, on 12/1/2025 after Resident 1 fell, he was at the edge of the bed trying to use the urinal and slipped out of bed. LVN 2 said he cannot confirm if Resident 1 slipped as described because Resident 1's cognition is impaired. LVN 2 said he forgot to update the care plan after the fall on 12/1/2025 and learned about it from Medical Records staff the next day. LVN 2 said he completed the care plan on paper the day after the fall and gave it to Medical Records. LVN 2 said he did not verify whether Medical Records received the care plan he submitted. During a concurrent interview and record review on 12/17/2025 at 12:07 p.m., with RN 1, Resident 1's care plan dated 11/10/2025 and 11/17/2025 and fall risk assessment dated [DATE] and 11/16/2025 were reviewed. The fall risk assessment dated [DATE] showed a score of 14. The admission care plan dated 11/10/2025 indicated no documented safety concern and did not address the risk of falls. RN 1 stated Resident 1 was high risk for falls based on fall assessment on 11/10/2025 and staff should have initiated a care plan for risk for falls. The fall risk assessment dated [DATE] S/P fall showed a score of 19. RN 1 said staff did not initiate care plan for actual fall on 11/16/2025. RN 1 stated she was the RN on duty when Resident 1 had another fall on 12/1/2025. RN 1 stated care plan should have been revised with changes in the interventions based on findings why Resident 1 keeps falling. RN 1 stated there should be a care plan addressing Resident 1's behavior with interventions such as frequent safety reminders and hourly check on Resident 1. RN stated it is important to have an updated, current care plan to prevent falls from recurring of which could result in injury or possible death. During an interview on 12/17/2025 at 2:40 p.m., with Director of Nursing (DON), DON stated a care plan is done on admission and reviewed and revise it as needed. The DON stated staff should have revised Resident 1's care plan after the fall on 11/23/2025 and completed a fall risk assessment. The DON stated it is important to assess what was missing from the initial care plan and change or add interventions based on their effectiveness. The DON stated staff must determine why the fall occurred and identify factors that explain the resident's behavior that increases fall risk so they can address them. The DON stated after a fall, staff must review the care plan, identify needed changes, and determine additional interventions. The DON said the care plan guides the care provided to the residents, and if staff fail to update it, the facility is not taking steps to prevent another fall. The DON further stated the plan of care becomes ineffective when staff do not update the care plan. The DON said failing to include a known issue in the care plan can lead to more falls and potentially cause injuries. During review of the GACH 1 records titled Emergency Department Reports (EDR) dated 12/2/2025, the EDR indicated Resident 1's presented for the GACH Emergency Department with generalized body pain after a fall and laceration to the left eyebrow. The EDR indicated Resident 1's visit diagnosis as forehead laceration, closed injury, cause of injury - accidental fall, thoracic spine strain and left shoulder contusion. During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 2/2024, the P&P indicated, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the fall is unclear.or if the individual continuous to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. The P&P also indicated, Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls to address the risks of clinically significant consequences of falling.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. During a review of the facility's fall prevention potential intervention dated 12/2024 nursing measures indicated toileting schedule, proper positioning, and use of non-slip material to prevent sliding. During a review of facility's P&P titled, Care Plans - Baseline, dated 12/2024, the P&P indicated, to assure that a resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of admission. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/2024, the P&P indicated, The Care Planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. During a review of the facility's P&P titles, Care Planning - Interdisciplinary Team, dated 12/2024, the P&P indicated, our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, interview, and record review, the facility failed to manage pain on the hands, legs, and stomach for one of three sampled residents (Resident 436) by failing to: 1. Address the Resident 436's request for adequate pain management, 2. Evaluate the effectiveness of the resident's pain medication, 3. Notify the resident's physician that pain management intervention was unsuccessful and for consultation. This failure resulted in Resident 436's to continue experiencing severe, unrelieved and uncontrolled pain from 5/11/2024 to 5/22/2024. Resident was unable to walk due to leg pain, felt her pain was stressful, could not perform usual activities (decline in performing daily activities). Findings: During a concurrent observation and interview on 5/20/2024 at 10 AM, Resident 436 was lying in bed, with facial grimacing, and taking long and deep breaths. Resident 436 stated, I need pain medication, it takes hours to get my pain medications, my legs and arms hurt. The resident stated pain medication delays were reported to the head staff but was unable to recall any staff names. During an interview on 5/21/2024 at 11:29 AM with Resident 436, the resident stated feeling pain on both hands, legs, and abdomen. Resident 436 stated he was unable to walk as usual because of the leg pains and the pain was stressful. During an interview on 5/21/2024 at 11:35 AM with Licensed Vocational Nurse (LVN) 6, LVN 6 stated, Resident 436 had pain medication (oxycodone-acetaminophen, a controlled pain medication that treats moderate to severe pain) ordered every six hours, but resident asks for medication at least every two to three hours. LVN 6 stated, the resident's pain was not controlled but the resident's uncontrolled pain had not been reported to a physician nor had been discussed with interdisciplinary team (IDT, a team of professionals from different fields). During an interview on 5/21/2023 at 12:20 PM with Certified Nursing Assistant (CNA) 6, CNA 6 stated, staff assisted Resident 436 with activities of daily living. CNA 6 stated Resident 436 liked to get up, but the resident complains of pain and did not do much activity. During a concurrent observation and interview on 5/22/2024 at 9:57 AM, with Resident 436, Resident 436 was in bed, grimacing, asking for pain medication. The resident stated, I am in a lot of pain on my hands and legs, my legs are numbed, I cannot walk, my stomach hurts. I am just waiting for my pain medications. During an interview on 5/22/2024 at 10 AM with LVN 3, LVN 3 stated Resident 436 asked for more pain medication at least once or twice a day. LVN 3 stated the resident could decline psychosocially (mind and behavior) and decline from participating with activities if pain was not managed. During an interview on 5/22/2024 at 10:30 AM with LVN 3, LVN 3 stated Resident 436's physician was called and updated on the resident's pain status. During an interview on 5/23/2024 at 8:30 AM with Resident 436, the resident stated, I am still in pain on my legs, it is affecting my mobility, I like to walk with my walker but unable to do it more than a couple of steps because of the pain. During a concurrent interview and record review on 5/23/2024 at 8:35 AM with LVN 3 at Resident 436's room, Resident 436's Pain Assessment Flowsheet dated from 5/12/2024 to 5/20/20224 and Medication Administration Record (MAR) dated May 1 to May 31, 2024 were reviewed. The MAR indicated when oxycodone-acetaminophen 5-325 milligrams (mg, a unit of measure) one tablet by mouth was administered, the resident's pain was 8 out of 10 (a numeric pain scale with zero meaning no pain and 10 meaning the worst pain imaginable) from 5/11/2024 to 5/15/2024, on 5/17/2024, from 5/19 to 5/22/2024, and 7 out of 10 on 5/16/2024 and 5/18/2024. LVN 3 stated Resident 436 was given pain medication on an average of two or three times a day out of the four times maximum allowed for her pain medication order (oxycodone-acetaminophen). During a concurrent interview and record review on 5/23/2024 at 8:55 AM with LVN 7, Resident 436's Pain Assessment Flow Sheet for the month of May 2024 was reviewed. The record indicated the pre (prior) pain medication administration assessment was a pain rating of 8 out of 10 on the pain scale. LVN 7 stated, the resident was not getting adequate pain medication. LVN 7 stated there was no prior pain management reported to the resident's physician, and no pain consultation was initiated. LVN 7 stated the resident was likely to decline if the pain was not managed. During an interview on 5/23/2024 at 1:15 PM with the Director of Nursing (DON), the DON stated, the licensed staff was expected to notify residents' changes in condition to the charge nurses and physicians. The DON stated Resident 436 was likely to decline physically and psychosocially if pain was not controlled. During a telephone interview on 5/23/2024 at 3 PM with Resident 436's physician (MD, medical doctor)1, MD 1 stated, Resident is drug seeking, has neuropathic pain (a condition that affects the nerves in the body). MD 1 stated the facility staff did not notify him of the resident's pain status until the morning of 5/22/2024. MD 1 stated, the resident can benefit from better pain management. During a review of Resident 436's Admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to unspecified cirrhosis (a disease condition that scars and damages liver), anxiety disorder, and abnormalities of gait and mobility. During a review of Resident 436's physician's order dated 5/9/2024, indicated the following orders: 1. Oxycodone-acetaminophen oral tablet 5-325 mg give one tablet by mouth every six hours as needed for severe pain for 3 months using pain rating scale 7-10. 2. Acetaminophen oral tablet (a medication that treats minor pain and lowers fever), give 650 mg every four hours as needed for mild pain, using pain rating scale 1-3. During a review of Resident 436's Baseline Care Plans, dated 5/9/2024 indicated, the resident was alert and oriented. During a review of Resident 436's History and Physical (H&P) dated 5/10/2024 indicated the resident had the capacity to make and understand decisions. During a review of Resident 436's Care Plan, dated 5/22/2024 indicated the resident was at risk for acute (sudden) or chronic (persisting for a long time) pain related to disease process with interventions including to monitor, record, report to nurse resident's complaints of pain or requests for pain treatment; and notify the resident's physician if interventions were unsuccessful or if current complaint was a significant change from resident's experience of pain. During a review of the facility's policy and procedure titled Change in a Resident's Condition and Status dated September 2023, indicated, the nurse will notify the resident's attending physician or physician on call except in medical emergencies, notifications will be made within twenty-four (24) hours of change occurring in the resident's medical/mental condition or status. During a review of the facility's policy and procedure titled Pain-Clinical Protocol, dated September 2023, indicated, the staff will evaluate and report the resident/patient's use of standing and PRN (when necessary or as needed) analgesics (a medication to relieve pain) .If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the care and supervision to prevent falls as evidenced by: -Failing to correctly assess Resident 1 as indicated on the Fall Risk Assessment and identify Resident 1 was at high risk for falls. -Failing to care plan for Resident 1's non-compliance with the front wheel walker and the resident's refusal of staff assistance with ambulation. As a result, on 11/7/2023, Resident 1 fell and sustained a hematoma (an abnormal collection of blood outside of the blood vessel) to the head and a femoral neck fracture (broken upper thigh bone) and an impacted subcapital right femoral neck fracture (break in the upper thigh bone). Findings: A review of the Admission Record indicated the facility admitted Resident 1 on 6/22/2020 and readmitted the resident on 11/15/2023 with diagnoses including encephalopathy (brain dysfunction that can appear as confusion, memory loss, personality changes and/or coma in the most severe form), dementia (impaired ability to remember, think, or make decisions that interferes with doing every day activities), heart failure (when heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), rhabdomyolysis (a condition in which damaged muscle breaks down rapidly), adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), abnormalities of gait (a person's manner of walking) and mobility, and lack of coordination. A review of the History and Physical (H&P) dated 4/6/2023, indicated Resident 1 did not have the capacity to understand and make decisions due to the reason of Alzheimer's (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). The H&P further indicated Resident 1 had a history of Alzheimer's, gait disorder, and poor memory. A review of the Physician's Order dated 4/28/2023, indicated Resident 1 could ambulate (walk) using a front wheel walker (FWW) ad lib (as desired) around the facility as tolerated. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 10/27/2023, indicated Resident 1 had moderately impaired cognition (decisions poor; cues/supervision required), had impaired vision, and had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 1 had no impairment to the upper/lower extremities and utilized a walker and required partial/moderate assistance for showering/bathing, and required supervision or touching assistance for personal hygiene, putting on/taking off footwear, lower body dressing, and upper body dressing. The MDS indicated Resident 1 required set up or clean up assistance for toileting, oral hygiene, eating, rolling left and right, sitting to lying, lying to sitting on the side of the bed, toilet transfer, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. The MD further indicated Resident 1 was continent of bowel and bladder. According to a review the Interdisciplinary Plan of Care Review Form dated 7/27/2023, Resident 1 was provided safety education to continue use of the FWW when ambulating. The Interdisciplinary Plan of Care Review Form indicated Resident 1 was explained the risk of fall/injury if their gait had imbalance and of the non-compliance of using a FWW. The Plan of Care Review form indicated Resident 1 understood the risk and benefits of preventing falls. A review of the Care Plan initiated on 7/31/2023, indicated Resident 1 was at risk for falls related to the disease processes of lack of coordination, dementia, and abnormalities of gait and mobility. The care plan indicated the goals for Resident 1 to be free of falls, free of minor injury, and to not sustain serious injury through the review date. The care plan interventions indicated to anticipate and meet Resident 1's needs, to be sure the resident's call light was within reach, and to encourage the resident to use it for assistance as needed. The care plan interventions indicated Resident 1 needed prompt response to all requests for assistance, needed to be evaluated for and supplied appropriate adaptive equipment or devices as needed; to re-evaluate as needed for continued appropriateness; and to ensure least restrictive devices. The care plan interventions indicated Resident 1 needed a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, a front wheel walker, a wheelchair or side rails as ordered, had rails on walls, personal items within reach, and bilateral upper side rails. A review of the Fall Risk assessment dated [DATE], indicated Resident 1 had a fall risk score of 8 (a total score above 10 represents a high risk for falls). The Fall Risk Assessment indicated Resident 1 had intermittent confusion or poor safety awareness, no falls in the past three months, was ambulatory, had adequate vision (with or without glasses), had a balance problem while standing, had a balance problem while walking, required the use of an assistive device, no noted drop of systolic blood pressure (top number) between lying and standing, took 1-2 medications currently and/or within the last seven days, and had no predisposing disease present (from the list of hypotension, vertigo (dizziness), cerebral vascular accident [CVA], Parkinson's disease, loss of limb, seizure, arthritis, osteoporosis, or fractures). The Fall Risk Assessment did not indicate whether Resident 1 was low or moderate risk for falls. A review of the Interdisciplinary Plan of Care Review Form dated 10/23/2023, indicated Resident 1 was able to walk independently with the FWW ad lib. The Plan of Care Review Form indicated Resident 1 did not have a fall incident for three months and had no behavioral issues. The Plan of Care Review Form indicated Resident 1 had a FWW available at bedside, was stable to ambulate in and out of bed and the rest room, had socks and a FWW within reach, and the assistive device was working properly without issues in maintenance. A review of the Fall Risk assessment dated ,d+[DATE] (no documentation of year), indicated Resident 1 had a fall risk score of 6 (a total score above 10 represents high risk for fall). The Fall Risk Assessment indicated Resident 1 had intermittent confusion or poor safety awareness, no falls in the past three months, was ambulatory, had normal gait and balance, no noted drop of systolic blood pressure between lying and standing, takes 1-2 medications currently and/or within the last seven days, and had no predisposing disease present (from the list of hypotension, vertigo, CVA, Parkinson's disease, loss of limb, seizure, arthritis, osteoporosis, or fractures). The Fall Risk Assessment indicated the vision status portion of the assessment was not completed. The Fall Risk Assessment did not indicate whether Resident 1 was low or moderate risk for falls. According to a review of the Joint Mobility assessment dated [DATE], there were no problems noted in the summary for Resident 1 and Resident 1 was to continue ad lib ambulation. A review of the Physician's Order dated 11/7/2023, indicated to send Resident 1 to the General Acute Care Hospital (GACH)'s emergency room (ER) for evaluation of hematoma (an abnormal collection of blood outside of a blood vessel) on the right forehead. A review of the Progress Note dated 11/7/2023 at 1:31 PM, indicated at 1:20 PM the Certified Nursing Assistant (CNA) was passing by and noted that Resident 1 was sitting on the floor leaning towards the door with blood on the face and some drops on the floor. The Progress Note indicated the CNA alerted the Licensed Nurse (LN) immediately, an assessment was done and Resident 1 was able to verbalize what happened stating Resident 1 tried to pick up something on the floor. The Progress Note indicated the floor was free from scattered belongings and was dry. Resident 1's bilateral lower extremity and upper extremity range of motion was conducted and indicated there was no limitation, no pain, and no facial grimacing. The Progress Note indicated Resident 1 was assisted back to bed with a two-person assist, had no complaints of pain or discomfort during the transfer. A body re-assessment was done, and indicated Resident 1 had no pain and no swelling on both hips, knees, or part of the body. The Progress Note indicated Resident 1 was noted with a hematoma on the right side of the forehead, first aid was rendered and an ice pack was applied. Resident 1 was noted with a five-centimeter skin tear which was cleansed with normal saline, applied with steri-strips, and covered with a dry dressing. The Progress Note indicated Resident 1 had an elevated blood pressure of 195/110 (normal blood pressure between 90/60 millimeters of mercury (mmHg) and 120/80 mmHg), the paramedics and Resident 1's physician were notified. The Progress Note further indicated the paramedics arrived at 1:45 PM and transferred Resident 1 to the GACH. A review of the Situation Background Assessment and Recommendation (SBAR) Communication Form and Progress Note dated 11/7/2023 at 1:51 PM, indicated Resident 1 had an unwitnessed fall in the room and sustained a large hematoma to the right side of the forehead with bleeding. The SBAR note indicated Resident 1 remained awake and responsive during the transfer to the Emergency Department. The SBAR note indicated Resident 1's blood pressure was 195/110, pulse 88, respirations 22, temperature 97.2, and oxygen saturation 97%. A review of the Computed Tomography (CT, an imaging exam that takes pictures of the inside of the body) of the brain without contrast (refers to a substance taken by mouth or injected into a vein that causes the particular organ under study to be seen more clearly) result dated 11/7/2023 at 3:24 PM, indicated Resident 1 had a right frontal soft tissue hematoma. A review of the right hip x-ray (an imaging procedure that takes pictures of the inside of the body using radiation) results dated 11/7/2023 at 3:57 PM, indicated Resident 1 had a concern for a fracture of the femoral neck/head junction on the right side (break in the upper thigh bone). A review of the GACH History and Physical (H&P) dated 11/8/2023 at 10:42 AM, indicated Resident 1 was admitted to the GACH on 11/7/2023. The H&P indicated Resident 1 was brought to the GACH after having had a fall and per nursing home documentation Resident 1 missed the rail and fell with hematoma to the right upper forehead. The H&P indicated Resident 1 was seen and evaluated in the ER by the ER physician and neurosurgery (specializes in the diagnosis and surgical treatment of disorders of the central and peripheral nervous system). The H&P indicated a subsequent brain imaging was done which showed a small contusion (type of hematoma). The H&P indicated Resident 1 had a laceration (deep cute or tear in the skin) on the right upper forehead that was repaired using prolene sutures (sterile sutures). The H&P indicated a CT of the brain was obtained which showed Resident 1 had a 6 millimeter (mm, a measure of length) right temporal hemorrhage/cortical contusion (brain bruise). The H&P indicated a CT of the hip was also done which showed Resident 1 had an impacted subcapital right femoral neck fracture (break in the upper thigh bone). A review of the CT of the brain without contrast imaging result dated 11/8/2023 at 2:04 AM, indicated Resident 1 had the second CT due to head trauma with worsening mental status and concern for delayed hemorrhage. The CT indicated Resident 1 had interval development of 6 mm right temporal hemorrhagic cortical contusion. According to a review of the x-ray of the right femur dated 11/8/2023 at 2:38 AM, redemonstrated Resident 1 had an impacted subcapital femoral neck fracture. A review of the GACH Orthopedic Surgery (physicians who specialize in surgery of bones and joints) Note dated 11/14/2023 at 2:04 PM, indicated Resident 1 was to be on strict non-weight bearing to the right lower extremity. The note further indicated Resident 1 had non-operative fractures and was to receive Eliquis 2.5 mg by mouth twice daily due to the resident's high risk for deep vein thrombosis (DVT, blood clot formation in a deep vein). During an observation on 11/20/2023 at 10 AM, Resident 1 was observed with a bump to the right upper side of the forehead and a small laceration above their right eye. Resident 1 was observed with the bed in low position with floor mats to the left and right side of the bed. Resident 1's FWW was observed at bedside. During a concurrent interview, Resident 1 stated he got the bump on the forehead when he Turned the corner a little too fast, and hit his head on the corner. Resident 1 stated he did not remember the date or the time the fall happened. Resident 1 stated he did not call the nurses for help because he did not need help. Resident 1 stated, I don't need to call for help to the bathroom, if I need to go I will go by myself. On 11/20/2023 at 10:29 AM, during an interview, CNA 1 stated she was walking past Resident 1's room when she saw the resident sitting on the floor by the door with blood. CNA 1 stated there was blood on the floor and on Resident 1's head. CNA 1 stated Resident 1 was confused and was not able to say what happened. CNA 1 stated there was a lot of blood on the floor. CNA 1 stated she called the charge nurse to report what she saw. During an interview on 11/20/2023 at 10:37 AM, CNA 2 stated she was assigned to take care of Resident 1 the day the resident had the fall. CNA 2 stated she was with another resident when Resident 1 was found and indicated staff had called for her. CNA 2 stated when she went to Resident 1's room, the resident was already on the floor and the charge nurse was with them. CNA 2 stated prior to Resident 1 having the fall, the resident would get up and go to the bathroom by themselves. CNA 2 stated Resident 1 had moments of confusion. CNA 2 stated Resident 1 had a FWW next to him but never used it. CNA 2 stated sometimes Resident 1 would call out for help if he saw someone walking by, but stated the resident was reluctant to have assistance, stating that when staff would offer help the resident would refuse. CNA 2 stated prior to Resident 1 having the fall, the resident did not have a bed alarm or floor mats. During an interview on 11/20/2023 at 11:40 AM, Resident 2 stated Resident 1 was his roommate. Resident 2 stated prior to Resident 1 having the fall, Resident 1 would walk to the bathroom on his own. Resident 2 stated sometimes Resident 1 would not use the FWW. Resident 2 stated Resident 1 often refused staff help and stated staff would even tell the resident it might be better to use diapers. Resident 2 stated Resident 1 refused staff help a lot. During an interview on 11/20/2023 at 2:03 PM, Licensed Vocational Nurse (LVN) 1 stated she had been taking care of Resident 1 since the resident had been in the facility in 2022. LVN 1 stated the day Resident 1 fell she saw the resident on the floor with his back against the door. LVN 1 stated she saw a hematoma on the side of Resident 1's head that was slightly bigger than a tennis ball. LVN 1 stated Resident 1 had dementia, was confused, would recognize you but could not remember your name and would start talking about random things. LVN 1 stated Resident 1 would not come out of the room but would go back and forth to the bathroom. LVN 1 stated Resident 1 did not like to use the FWW and would forget he was a little unsteady. LVN 1 stated Resident 1 would refuse help. LVN 1 stated Resident 1 had a shuffle kind of step. LVN 1 stated Resident 1 had orders that he was free to walk around the facility with the walker. LVN 1 stated Resident 1 was required to use the FWW which he refused to use. LVN 1 stated Resident 1 did not have a bed alarm or floor mats prior to the resident having the fall. On 11/21/2023 at 9:48 PM, during an interview, the Director of Rehab (DOR) stated Resident 1 had a quarterly check-up for physical therapy (PT) and indicated the resident no longer needed assistance from the Restorative Nursing Assistant (RNA) and was able to walk ad-lib with a FWW. The DOR stated Resident 1 was stable on his feet, needed some close level assistance but after several months RNA was stable, stronger, and able to walk on his own. During an interview on 11/21/2023 at 10:04 AM, RNA 1 stated Resident 1 was discharged from RNA services before the resident had the fall. RNA 1 stated Resident 1 was walking by themselves with a FWW. RNA 1 stated prior to the fall, Resident 1 was walking to the bathroom from his bed with the FWW. RNA 1 stated Resident 1 could walk on his own but would tell the resident to always call for help before he got up. RNA 1 stated Resident 1 would always refuse and say, No I can do it. Don't bother me, so staff let him do it but would watch him to make sure the resident got back to bed ok. During a concurrent interview and record review, on 11/21/2023 at 11:40 AM, Resident 1's Fall Risk assessment dated ,d+[DATE] and MDS dated [DATE] was reviewed with Registered Nurse (RN) 1. RN 1 stated he was working as RN supervisor the day Resident 1 fell , and indicated he was called to come and see the resident after he fell . RN 1 stated he saw Resident 1 was bleeding profusely and needed to be sent out. RN 1 stated the fall risk assessment was done incorrectly. RN 1 stated Resident 1's fall risk assessment was not complete and indicated the score should be 13 not 8. RN 1 stated based on the MDS, Resident 1 had intermittent confusion or poor safety awareness, was ambulatory/continent, required the use of an assistive device, had a poor (with or without glasses-unable to read regular print) vision status, takes 1-2 medications and had three or more predisposing disease based on the active diagnoses in the MDS. RN 1 stated Resident 1 was supposed to be a high risk for falls, and would have required a bed alarm, low bed, a room closer to the station, and a more visual eye on the resident. RN 1 stated the day Resident 1 fell the resident did not have floor mats or a bed alarm, and indicated he did not see a FWW at bedside. During a concurrent interview and record review, on 11/21/2023 at 12 PM, Resident 1's Fall Risk assessment dated ,d+[DATE] and MDS dated [DATE] were reviewed with Minimum Data Set Assistant (MDSA). MDSA stated she usually did the fall risk assessments and indicated sometimes the licensed nurses help her to do them as well. MDSA stated the fall risk assessments were done quarterly. MDSA stated Resident 1's Fall Risk assessment dated ,d+[DATE] was conducted this year 2023. MDSA stated the Fall Risk Assessment was not done completely. The MDSA stated the vision status portion was not completed, the gait/balance portion was done incorrect and should have indicated Resident 1 required the use of an assistive device. The MDSA stated the predisposing disease response on the fall risk assessment was based on whether Resident 1 had hypotension, vertigo, CVA, Parkinson's Disease, Loss of Limb, seizure, arthritis, osteoporosis, fractures. The MDSA stated when looking at Resident 1's active diagnoses on the MDS, the resident had three or more predisposing diseases that would contribute to the resident's risk of falls. A review of Resident 1's Care Plan on 11/21/2023 at 12:15 PM, indicated there was no specific care plan for Resident 1's non-compliance of ambulating with a FWW or refusal of staff assistance with ambulation. During a concurrent interview and record review, on 11/21/2023 at 12:32 PM, Resident 1's Fall Risk assessment dated ,d+[DATE], MDS dated [DATE], and care plan were reviewed with LVN 1. LVN 1 stated the fall risk assessment was done incorrectly. LVN 1 stated Resident 1's fall risk assessment was not complete and indicated the score should be 13 not 8. LVN 1 stated based on the MDS, Resident 1 had intermittent confusion or poor safety awareness, was ambulatory/continent, required the use of an assistive device, had a poor (with or without glasses-unable to read regular print) vision status, takes 1-2 medications, and had three or more predisposing diseases based on the active diagnoses in the MDS. LVN 1 stated Resident 1 was a high risk for falls, and needed more interventions such as floor mats, bed alarm, and visual monitoring. LVN 1 stated Resident 1 did not have a specific care plan for the refusal of FWW or refusal of staff assistance to prevent falls. LVN 1 stated the fall risk assessment and care plans were important to prevent falls and to provide appropriate interventions. LVN 1 stated the day Resident 1 fell , the resident did not have floor mats or a bed alarm. During a concurrent interview and record review, on 11/21/2023 at 1:33 PM, Resident 1's Fall Risk assessment dated ,d+[DATE], MDS dated [DATE], and Care Plan were reviewed with the Director of Nursing (DON). The DON stated fall risk assessments were done on admission, quarterly, annually, and with change of condition. The DON stated the purpose of a fall risk assessment was to determine the interventions a resident may need to prevent falls. The DON stated the fall risk assessment dated ,d+[DATE] was done incorrectly. The DON stated the vision status portion was not completed, the gait/balance portion was done incorrect and should have indicated Resident 1 required the use of an assistive device. The DON stated the MDSA's predisposing disease response on the fall risk assessment was based on whether Resident 1 had hypotension, vertigo, CVA, Parkinson's Disease, loss of limb, seizure, arthritis, osteoporosis, or fractures. The DON stated when looking at Resident 1's active diagnoses on the MDS, the resident had three or more predisposing diseases that would contribute to the resident's risk of falls. The DON stated Resident 1 had cognitive impairment, heart failure, anemia, neurological disorders, and balance and gait disorders which according to facility policy were conditions that may contribute to the risk of falls. The DON stated there was no care plan that specifically addressed Resident 1's refusal for staff assistance to the bathroom or refusal of use of FWW to prevent falls. The DON stated the care plan should be specific to the resident and indicated Resident 1 had issues with non-compliance before. The DON stated Resident 1's refusal of staff assistance when ambulating to the bathroom and refusal of the FWW should have been care planned. The DON indicated there was no care planning for non-compliance for Resident 1's refusal of staff assistance with ambulation or the refusal to use the FWW with ambulation. The DON indicated identifying a resident was at high risk for falls and through care planning could have prevented falls. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, reviewed 1/2023, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological, and functional needs was developed and implemented for each resident. Assessments of residents were ongoing and care plans were revised as information about the resident and resident's conditions change. A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, reviewed 1/2023, indicated care plan goals and objectives were defined as the desired outcome for a specific resident problem. Care plan goals and objectives were derived from information contained in the resident's comprehensive assessment and were resident oriented, were behaviorally stated, were measurable, and contain timetables to meet the resident's needs in accordance with the comprehensive assessment. A review of the facility's policy and procedure titled, Fall Risk Assessment, reviewed 1/2023, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information. The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). The staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living capabilities, activity intolerance, continence and cognition. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that were not modifiable. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing reviewed 1/2023, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls include fever, infection, delirium and other cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypotension, functional impairments, visual deficits and incontinence. Medical factors that contribute to the risk of falls include arthritis, heart failure, anemia, neurological disorders and balance and gait disorders.

Based on interview and record review, the facility failed to permit one of two sampled (Resident 1) to remain in the facility and not transfer or discharge her unless the transfer / discharge was necessary and appropriate. The facility failed to: -Ensure the reason for discharging Resident 1 was because of one of the following: the resident's welfare and the resident's needs could not be met in the facility; her care needs could not be met at the facility, her health had improved and no longer needed the services provided by the facility, for the safety of individuals in the facility due to Resident 1's clinical or behavioral status, because of Resident 1's lack of payment, or because the facility ceased operation. -Provide and document sufficient preparation and orientation to Resident 1 or responsible party for a safe and orderly transfer or discharge from the facility. On 8/1/2023, the facility discharged Resident 1 to her home where her medical and nursing needs could not be met, as Resident 1 required extensive assistance with activities of daily living (ADLs, eating, toileting, bathing, walking). As a result, on 8/15/2023 (two weeks after leaving the facility), Resident 1 was found in her home, by emergency services, covered in feces, after having fallen and sustaining a fracture. Resident 1 required transfer to a general acute care hospital (GACH) where she was admitted the same day for failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function) and sternum (breastbone) fracture. Cross Reference: F623 and F624 Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident, on 5/9/2023 with diagnoses including dementia (loss of memory, thinking and reasoning), secondary bone cancer (cancer that started somewhere else in the body has spread to the bones), gait and mobility abnormalities and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as a Responsible Party and FM 1 as the Medical Power of Attorney (POA). A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 5/10/2023, indicated the resident felt unsteady when standing and walking, and was worried about falling. The PT Evaluation indicated Resident 1 had decreased coordination, decreased strength, decreased functional mobility, reduced ADL participation, and increased physical exertion during daily living task and an increased need for assistance from others. A review of Resident 1's Skilled Nursing Facility Follow-Up Visit, dated 5/11/2023 indicated the resident's anticipated discharge arrangement was either custodial care at the facility (non-medical care that assists one with activities of daily living [including walking, getting in and out of bed, bathing, dressing, eating, and using the toilet]), home with home health, or another long-term care facility. The Follow Up Visit form indicated Resident 1 had chronic pain and Stage IV breast cancer with extensive vertebral metastases status post-surgery and radiation. A review of Resident 1's Activities of Daily Living (ADLs) Care Plan, initiated 5/11/2023 indicated the resident had a self-care performance deficit related to her gait disorder, a history of falls, lack of coordination and gait abnormalities. The care plan interventions included to discuss with resident/family/POA any concerns related to the loss of independence or the decline in function, to encourage the resident to use the call bell for assistance and PT and Occupational Therapy (OT) evaluation and treatment per Physician's Order. According to a review of the Care Plan, initiated 5/11/2023, Resident 1 was at risk for a pathological bone fracture (break in a bone that is caused by an underlying disease) related to osteoporosis (a bone disease when bone mass / density decreases) and the resident had a previous pathological fracture. The care plan interventions included Physical Therapy/Occupational Therapy to evaluate and treat as indicated, handle gently when moving or positioning, maintain body alignment and to support injured area with pillows and immobilize part as appropriate. A review of Resident 1's Cognitive (thinking, reasoning, and memory) Function Care Plan, initiated 5/11/2023, indicated the resident had impaired cognitive function or impaired thought processes related to diagnosis of dementia. The interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs. The interventions also included to cue, reorient, and supervise as needed. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/16/2023, indicated the resident's cognition (able to understand and make decisions) was intact. This indicated a discrepancy from the Cognitive Function Care Plan. The MDS indicated Resident 1 had a planned discharge and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance with one-person physical assist with bed mobility, transfer, walking, dressing and toilet use. The MDS indicated Resident 1 required limited assistance with one-person physical assist for personal hygiene, was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, getting on or off the toilet and when transferring between bed and chair or wheelchair. A review of the Physician's Orders, dated 6/6/2023 indicated Resident 1 was to continue: -Skilled Physical Therapy (PT) services daily 5 times a week for four weeks for treatment diagnosis of gait abnormality with current plan of care. -Skilled Occupational Therapy (OT) services daily five times a week for four weeks with treatment diagnosis of lack of coordination. Treatment plan includes therapeutic exercises, therapeutic activities, self-care training and safety awareness training. A review of Resident 1's Detailed Explanation of Non-Coverage Letter from the GACH, dated 6/28/2023, indicated why the current Medicare coverage should end. The GACH letter indicated according to the medical doctor, nurse practitioner, case management assessment and facility team, the resident was medically stable for discharge to custodial care or home, with 24-hour caregiver support. The letter indicated Resident 1's therapist reported the resident had reached new levels in bed mobility with caregiver assistance and transfers with caregiver assistance. The letter indicated if Resident 1 was discharged home with a 24-hour caregiver, she would receive home health skilled nursing, Physical/Occupational Therapy services with close follow up from the primary care physician. The letter indicated continued recuperation from Resident 1's illness could be safely provided with custodial care or home health services, if discharge to home with caregiver. A review of Resident 1's PT Discharge Summary, dated 7/6/2023, indicated the resident previously was living home alone with a couple of steps to enter, was using a front wheel walker and wheelchair, and the discharge recommendation was to discharge home with home health services. According to a review of the History and Physical (H&P), dated 7/20/2023, Resident 1 had the capacity to understand and make some decisions but may not be able to participate in complex decision making (such as for discharge planning). A review of the Physician's Order, dated 7/27/2023, indicated Resident 1 was to discharge home today with home health nurse, physical therapy (PT) and occupational therapy (OT) for safety. A review of the Post Discharge Plan of Care, dated 8/1/2023, indicated Resident 1 was to receive home health service and there was a phone number for the home health agency. A review of the Discharge Summary/Comprehensive Assessment form dated 8/1/2023, indicated Resident 1 required assist with bathing, dressing, eating, personal hygiene, transfers, bed mobility, toilet use and ambulation. Further review indicated the white resident copy remained attached to the yellow chart copy and remained in Resident 1's physical chart. According to a review of Resident 1's Notice of Transfer / Discharge form, dated 8/1/2023, the resident was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice of Transfer was not signed by Resident 1 or the Medical POA and was not provided 30 days prior. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/1/2023, indicated the resident's cognition was intact., Resident 1's discharge was planned, and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, moving between locations, toileting, and personal hygiene. A review of Resident 1's GACH Emergency Department (ED) Provider Note, dated 8/15/2023, indicated Resident 1 was brought in by rescue services, unclothed and covered in excrement (waste matter discharged from the bowels). The ED Note indicated Resident 1's housing condition was deplorable, and she fell at home. The GACH ED Note indicated Resident 1's Blood Urea Nitrogen Level was elevated at 38.6 (normal is 9.8 - 20.1, an indication that either the resident's kidneys are not functioning well or dehydration [losing more fluids than you take in]) and Resident 1 sustained a sternum fracture (the breastbone, the long flat bone located in the central part of the chest, most commonly results from blunt, anterior chest-wall trauma,, patients typically experience a sudden onset of sharp and intense chest pain at the time of injury and may increase during deep breathing, coughing, laughing or sneezing, results in an increased risk in pulmonary injuries). The ED Note indicated Resident 1 was admitted to the GACH for failure to thrive and sternum fracture. During a phone interview on 8/17/2023 at 3:56 PM, GACH Social Worker 1 (SW 1) stated there were concerns from an outside health agency that Resident 1's discharge from the facility was unsafe due to the resident's home had a lot of safety concerns. SW 1 stated the resident was unable to transfer herself or care for herself and Resident 1 was found covered in her feces. SW 1 further stated Resident 1 had a fall at home and was now admitted to the GACH with a sternum fracture. During a phone interview on 8/17/2023 at 4:11 PM, Registered Nurse Case Manager (RNCM) stated Resident 1 lived alone, did not have the income to pay caregivers and Resident 1's Family Member 1 (FM 1) had her own medical problems. RNCM stated Resident 1 was unable to transfer herself and during her visit to the resident, she was bedbound. She further stated during her visit on 8/3/2023, Resident 1 had water at her bedside and had not had food for 24 hours. The RNCM also stated during each visit, Resident 1 was found each time in urine and feces. During an interview on 8/18/2023 at 10:40 AM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was incontinent and required someone to clean her lower body and to change her incontinence brief. CNA 1 stated Resident 1 required two people to transfer her to a wheelchair and if Resident 1 was to go home she would need a caregiver to cook, clean and perform personal care. During an interview on 8/18/2023 at 12:14 PM, Director of Rehabilitation (DOR) stated Resident 1 was living alone prior to her admission. Our assessment indicated Resident 1 would never reach full independence and it was imperative for Resident 1 to go home with a caregiver. A caregiver was needed. I mean she can't function. She would basically be homebound as she can't go up and down those three steps without assistance. On 8/18/2023 at 12:47 PM, during a phone interview, Resident 1 stated, If I could have stayed at the facility I would have wished to stay. Resident 1 also stated she did not receive any discharge instructions prior to being discharged and did not recall any conversations with facility staff asking her about home health or about having a caregiver upon discharge. Resident 1 further stated she fell at home and was now hospitalized with a broken chest. During an interview on 8/18/2023 at 3:30 PM, Resident 1's Family Member 1 (FM 1) stated when the resident was discharged from the facility the resident lived alone and was unable to walk up the stairs to her apartment. FM 1 stated no one at the facility spoke to her about Resident 1 needing a caregiver at home and They [the facility staff] didn't tell me anything about discharge, they only talked with me about the finances. FM 1 stated Resident 1 was feeling so weak she could not change her incontinence brief and she stood and slipped in her own urine and was now hospitalized . During an interview on 8/21/2023 at 8:32 AM, Case Manager (CM) 1 stated Resident 1 was cleared by the Rehabilitation Department to go home, but CM 1 failed to indicate 'with home health services.' CM 1 informed Nurse Practitioner (NP) 1 and NP 1 ordered the discharge of Resident 1. CM 1 further stated the rehabilitation department recommended Resident 1 to receive 6 to 8 hours of caregiving services from FM 1. CM 1 further stated she discussed the resident's caregiver needs with Resident 1 and FM 1 but she did not document it in the resident's medical chart. CM 1 also stated she did not clarify the type of caregiving services and the quantity of services to be provided with the resident or FM 1. During an interview on 8/21/2023 at 10:37 AM, Nurse Practitioner 1 (NP 1) stated the facility told her Resident 1 was safe to go home with whatever her home situation was and she ordered the resident to go home with home health. NP 1 stated, I gave them the home health agency and generally the social worker contacts the home health. I feel like they (the facility staff) didn't give me the full picture. I trusted them and I shouldn't have. During an interview on 8/21/2023 at 11:20 AM, Social Services Assistant (SSA) stated it was important to make sure Resident 1's discharge was safe prior to her discharge. The SSA stated she did not know if Resident 1's discharge was safe because I don't know what kind of help she was going to get at home. The SSA also stated she did not follow-up with Resident 1 post discharge and home health services were not arranged. On 8/22/2023 at 10:36 AM, during an interview, the Director of Nursing (DON) stated Resident 1 should have been discharged with a 24-hour care giver support, this should have been communicated to the resident and family and this communication should have been documented. The DON also stated if a resident needs in home support it should be arranged prior to discharge and a possible outcome of not having a caregiver was injury to the resident. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge. The policy indicated residents were permitted to stay in the facility and not be transferred or discharge unless the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. The policy indicated the notice is given as soon as it is practicable but before the transfer or discharge. A review of the facility's P&P titled, Discharge Summary and Plan, revised 12/2016, indicated when a resident's discharge was anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. Every resident would be evaluated for his discharge needs and will have an individualized post discharge plan. The discharge plan will include arrangements that have been made for follow-up care and services. It also indicated a member of the Interdisciplinary Team (IDT) will review the final post-discharge plan with the resident and family at least 24 hours before the discharge is to take place. A review of the facility's policy and procedure (P&P) titled, Transfer and Discharge Documentation revised 12/2016, indicated each resident would be permitted to remain in the facility and not be transferred or discharged unless - the transfer or discharge was necessary for the resident's welfare and the resident needs cannot be met in this facility. The policy indicated when a resident is transferred or discharged from the facility, the following information will be documented in the medical record: the specific resident needs that cannot be met, and that an appropriate notice was provided to the resident and / or legal representative.

Based on interview and record review, for one of two sampled residents (Resident 1) the facility failed to ensure: -Resident 1 or the responsible party was notified at least 30 days before the resident was transferred or discharged or as soon as practicable before the discharge and the reasons for the move in writing and in a manner the resident understands. A review of the Notice of Transfer / Discharge form dated 8/1/2023 indicated Resident 1 was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice of Transfer was not signed by Resident 1 or the Medical Power Of Attorney (POA) and was not provided 30 days prior. As a result, on 8/15/2023 (two weeks after leaving the facility), Resident 1 was found in her home, by emergency services, covered in feces, after having fallen and sustaining a fracture. Resident 1 required transfer to a general acute care hospital (GACH) where she was admitted the same day for failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function) and sternum (breastbone) fracture. Cross Reference: F622 and F624 Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident, on 5/9/2023 with diagnoses including dementia (loss of memory, thinking and reasoning), secondary bone cancer (cancer that started somewhere else in the body has spread to the bones), gait and mobility abnormalities and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as a Responsible Party and FM 1 as the Medical Power of Attorney (POA). A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 5/10/2023, indicated the resident felt unsteady when standing and walking, and was worried about falling. The PT Evaluation indicated Resident 1 had decreased coordination, decreased strength, decreased functional mobility, reduced ADL participation, and increased physical exertion during daily living task and an increased need for assistance from others. A review of Resident 1's Skilled Nursing Facility Follow-Up Visit, dated 5/11/2023 indicated the resident's anticipated discharge arrangement was either custodial care at the facility (non-medical care that assists one with activities of daily living [including walking, getting in and out of bed, bathing, dressing, eating, and using the toilet]), home with home health, or another long-term care facility. The Follow Up Visit form indicated Resident 1 had chronic pain and Stage IV breast cancer with extensive vertebral metastases status post-surgery and radiation. A review of Resident 1's Activities of Daily Living (ADLs) Care Plan, initiated 5/11/2023 indicated the resident had a self-care performance deficit related to her gait disorder, a history of falls, lack of coordination and gait abnormalities. The care plan interventions included to discuss with resident/family/POA any concerns related to the loss of independence or the decline in function, to encourage the resident to use the call bell for assistance and PT and Occupational Therapy (OT) evaluation and treatment per Physician's Order. According to a review of the Care Plan, initiated 5/11/2023, Resident 1 was at risk for a pathological bone fracture (break in a bone that is caused by an underlying disease) related to osteoporosis and the resident had a previous pathological fracture. The care plan interventions included Physical Therapy/Occupational Therapy to evaluate and treat as indicated, handle gently when moving or positioning, maintain body alignment and to support injured area with pillows and immobilize part as appropriate. A review of Resident 1's Cognitive (thinking, memory, concentrating) Function Care Plan, initiated 5/11/2023, indicated the resident had impaired cognitive function or impaired thought processes related to diagnosis of dementia. The interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs. The interventions also included to cue, reorient, and supervise as needed. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/16/2023, indicated the resident's cognition (able to understand and make decisions) was intact. This indicated a discrepancy from the Cognitive Function Care Plan. The MDS indicated Resident 1 had a planned discharge and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance with one-person physical assist with bed mobility, transfer, walking, dressing and toilet use. The MDS indicated Resident 1 required limited assistance with one-person physical assist for personal hygiene, was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, getting on or off the toilet and when transferring between bed and chair or wheelchair. A review of the Physician's Orders, dated 6/6/2023 indicated Resident 1 was to continue: -Skilled Physical Therapy (PT) services daily 5 times a week for four weeks for treatment diagnosis of gait abnormality with current plan of care. -Skilled Occupational Therapy (OT) services daily five times a week for four weeks with treatment diagnosis of lack of coordination. Treatment plan includes therapeutic exercises, therapeutic activities, self-care training and safety awareness training. A review of Resident 1's Detailed Explanation of Non-Coverage Letter from the GACH, dated 6/28/2023, indicated why the current Medicare coverage should end. The GACH letter indicated according to the medical doctor, nurse practitioner, case management assessment and facility team, the resident was medically stable for discharge to custodial care or home, with 24-hour caregiver support. The letter indicated Resident 1's therapist reported the resident had reached new levels in bed mobility with caregiver assistance and transfers with caregiver assistance. The letter indicated if Resident 1 was discharged home with a 24-hour caregiver, she would receive home health skilled nursing, Physical/Occupational Therapy services with close follow up from the primary care physician. The letter indicated continued recuperation from Resident 1's illness could be safely provided with custodial care or home health services, if discharge to home with caregiver. According to a review of Resident 1's PT Discharge Summary, dated 7/6/2023, the resident previously was living home alone with a couple of steps to enter, was using a front wheel walker and wheelchair, and the discharge recommendation was to discharge home with home health services. A review of the History and Physical (H&P), dated 7/20/2023, indicated Resident 1 had the capacity to understand and make some decisions but may not be able to participate in complex decision making (such as for discharge planning). A review of the Physician's Order, dated 7/27/2023, indicated Resident 1 was to discharge home today with home health nurse, physical therapy (PT) and occupational therapy (OT) for safety. A review of the Post Discharge Plan of Care, dated 8/1/2023, indicated Resident 1 was to receive home health service and there was a phone number for the home health agency. A review of the Discharge Summary/Comprehensive Assessment form dated 8/1/2023, indicated Resident 1 required assist with bathing, dressing, eating, personal hygiene, transfers, bed mobility, toilet use and ambulation. Further review indicated the white resident copy remained attached to the yellow chart copy and remained in Resident 1's physical chart. According to a review of the Resident 1's Notice of Transfer / Discharge form, dated 8/1/2023, the resident was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice of Transfer was not signed by Resident 1 or the Medical POA and was not provided 30 days prior. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/1/2023, indicated the resident's cognition was intact., Resident 1's discharge was planned and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, moving between locations, toileting and personal hygiene. A review of Resident 1's GACH Emergency Department (ED) Provider Note, dated 8/15/2023, indicated Resident 1 was brought in by rescue services, unclothed and covered in excrement (waste matter discharged from the bowels). The ED Note indicated Resident 1's housing condition was deplorable, and she fell at home. The GACH ED Note indicated Resident 1's Blood Urea Nitrogen Level was elevated at 38.6 (normal is 9.8 - 20.1, an indication that either the resident's kidneys are not functioning well or dehydration) and Resident 1 sustained a sternum fracture (the breastbone, the long flat bone located in the central part of the chest, most commonly results from blunt, anterior chest-wall trauma,, patients typically experience a sudden onset of sharp and intense chest pain at the time of injury and may increase during deep breathing, coughing, laughing or sneezing, results in an increased risk in pulmonary injuries). The ED Note indicated Resident 1 was admitted to the GACH for failure to thrive and sternum fracture. During a phone interview on 8/17/2023 at 3:56 PM, GACH Social Worker 1 (SW 1) stated there were concerns from an outside health agency that Resident 1's discharge from the facility was unsafe due to the resident's home had a lot of safety concerns. SW 1 stated the resident was unable to transfer herself or care for herself and Resident 1 was found covered in her feces. SW 1 further stated Resident 1 had a fall at home and was now admitted to the GACH with a sternum fracture. During a phone interview on 8/17/2023 at 4:11 PM, Registered Nurse Case Manager (RNCM) stated Resident 1 lived alone, did not have the income to pay caregivers and Resident 1's Family Member 1 (FM 1) had her own medical problems. RNCM stated Resident 1 was unable to transfer herself and during her visit to the resident, she was bedbound. She further stated during her visit on 8/3/2023, Resident 1 had water at her bedside and had not had food for 24 hours. The RNCM also stated during each visit, Resident 1 was found each time in urine and feces. During an interview on 8/18/2023 at 10:40 AM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was incontinent and required someone to clean her lower body and to change her incontinence brief. CNA 1 stated Resident 1 required two people to transfer her to a wheelchair and if Resident 1 was to go home she would need a caregiver to cook, clean and perform personal care. On 8/18/2023 at 12:14 PM, during an interview, the Director of Rehabilitation (DOR) stated Resident 1 was living alone prior to her admission. Our assessment indicated Resident 1 would never reach full independence and it was imperative for Resident 1 to go home with a caregiver. A caregiver was needed. I mean she can't function. She would basically be homebound as she can't go up and down those three steps without assistance. During a phone interview on 8/18/2023 at 12:47 PM, Resident 1 stated, If I could have stayed at the facility I would have wished to stay. Resident 1 also stated she did not receive any discharge instructions prior to being discharged and did not recall any conversations with facility staff asking her about home health or about having a caregiver upon discharge. Resident 1 further stated she fell at home and was now hospitalized with a broken chest. During an interview on 8/18/2023 at 3:30 PM, Resident 1's Family Member 1 (FM 1) stated when the resident was discharged from the facility the resident lived alone and was unable to walk up the stairs to her apartment. FM 1 stated no one at the facility spoke to her about Resident 1 needing a caregiver at home and They [the facility staff] didn't tell me anything about discharge, they only talked with me about the finances. FM 1 stated Resident 1 was feeling so weak she could not change her incontinence brief and she stood and slipped in her own urine and was now hospitalized . During an interview on 8/21/2023 at 8:32 AM, Case Manager (CM) 1 stated Resident 1 was cleared by the Rehabilitation Department to go home, but CM 1 failed to indicate 'with home health services.' CM 1 informed NP 1 and NP 1 ordered the discharge of Resident 1. CM 1 further stated the rehabilitation department recommended Resident 1 to receive 6 to 8 hours of caregiving services from FM 1. CM 1 further stated she discussed the resident's caregiver needs with Resident 1 and FM 1 but she did not document it in the resident's medical chart. CM 1 also stated she did not clarify the type of caregiving services and the quantity of services to be provided with the resident or FM 1. On 8/21/2023 at 10:37 AM, during an interview, Nurse Practitioner 1 (NP 1) stated the facility told her Resident 1 was safe to go home with whatever her home situation was and she ordered the resident to go home with home health. NP 1 stated, I gave them the home health agency and generally the social worker contacts the home health. I feel like they (the facility staff) didn't give me the full picture. I trusted them and I shouldn't have. During an interview on 8/21/2023 at 11:20 AM, Social Services Assistant (SSA) stated it was important to make sure Resident 1's discharge was safe prior to her discharge. The SSA stated she did not know if Resident 1's discharge was safe because I don't know what kind of help she was going to get at home. The SSA also stated she did not follow-up with Resident 1 post discharge and home health services were not arranged. During an interview on 8/22/2023 at 10:36 AM, Director of Nursing (DON) stated Resident 1 should have been discharged with a 24-hour care giver support, this should have been communicated to the resident and family and this communication should have been documented. The DON also stated if a resident needs in home support it should be arranged prior to discharge and a possible outcome of not having a caregiver was injury to the resident. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge. The policy indicated residents were permitted to stay in the facility and not be transferred or discharge unless the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. The policy indicated the notice is given as soon as it is practicable but before the transfer or discharge.

Based on interview and record review, the facility failed to provide sufficient preparation to ensure a safe discharge for one of two sampled residents (Resident 1) who had dementia (loss of memory, thinking and reasoning), secondary bone cancer, gait and mobility abnormalities and muscle weakness. On 8/1/2023, the facility discharged Resident 1 to her home where her medical and nursing needs could not be met, as Resident 1 required extensive assistance with activities of daily living (ADLs - eating, toileting, bathing, and walking). As a result, on 8/15/2023 (two weeks after leaving the facility), Resident 1 was found in her home, by emergency services, covered in feces, after having fallen and sustaining a fracture. Resident 1 required transfer to a general acute care hospital (GACH) where she was admitted the same day for failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function) and sternum (breastbone) fracture. Cross Reference: F622 and F623 Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident, on 5/9/2023 with diagnoses including dementia (loss of memory, thinking and reasoning), secondary bone cancer (cancer that started somewhere else in the body has spread to the bones), gait and mobility abnormalities and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as a Responsible Party and FM 1 as the Medical Power of Attorney (POA). A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 5/10/2023, indicated the resident felt unsteady when standing and walking, and was worried about falling. The PT Evaluation indicated Resident 1 had decreased coordination, decreased strength, decreased functional mobility, reduced ADL participation, and increased physical exertion during daily living task and an increased need for assistance from others. A review of Resident 1's Skilled Nursing Facility Follow-Up Visit, dated 5/11/2023 indicated the resident's anticipated discharge arrangement was either custodial care at the facility (non-medical care that assists one with activities of daily living [including walking, getting in and out of bed, bathing, dressing, eating, and using the toilet]), home with home health, or another long-term care facility. The Follow Up Visit form indicated Resident 1 had chronic pain and Stage IV breast cancer with extensive vertebral metastases status post-surgery and radiation. A review of Resident 1's ADLs Care Plan, initiated 5/11/2023 indicated the resident had a self-care performance deficit related to her gait disorder, a history of falls, lack of coordination and gait abnormalities. The care plan interventions included to discuss with resident/family/POA any concerns related to the loss of independence or the decline in function, to encourage the resident to use the call bell for assistance and PT and Occupational Therapy (OT) evaluation and treatment per Physician's Order. According to a review of the Care Plan, initiated 5/11/2023, Resident 1 was at risk for a pathological bone fracture (break in a bone that is caused by an underlying disease) related to osteoporosis (a bone disease when bone mass / density decreases) and the resident had a previous pathological fracture. The care plan interventions included Physical Therapy / Occupational Therapy to evaluate and treat as indicated, handle gently when moving or positioning, maintain body alignment and to support injured area with pillows and immobilize part as appropriate. A review of Resident 1's Cognitive (thinking, reasoning, remembering) Function Care Plan, initiated 5/11/2023, indicated the resident had impaired cognitive function or impaired thought processes related to diagnosis of dementia. The interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs. The interventions also included to cue, reorient, and supervise as needed. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/16/2023 (five days after the Cognitive Function Care Plan), indicated the resident's cognition was intact (able to understand and make decisions). This indicated a discrepancy from the Cognitive Function Care Plan. The MDS indicated Resident 1 had a planned discharge and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance with one-person physical assist with bed mobility, transfer, walking, dressing and toilet use. The MDS indicated Resident 1 required limited assistance with one-person physical assist for personal hygiene, was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, getting on or off the toilet and when transferring between bed and chair or wheelchair. A review of the Physician's Orders, dated 6/6/2023 indicated Resident 1 was to continue: -Skilled Physical Therapy (PT) services daily 5 times a week for four weeks for treatment diagnosis of gait abnormality with current plan of care. -Skilled Occupational Therapy (OT) services daily five times a week for four weeks with treatment diagnosis of lack of coordination. Treatment plan includes therapeutic exercises, therapeutic activities, self-care training and safety awareness training. A review of Resident 1's Detailed Explanation of Non-Coverage Letter from the GACH, dated 6/28/2023, indicated why the current Medicare coverage should end. The GACH letter indicated according to the medical doctor, nurse practitioner, case management assessment and facility team, the resident was medically stable for discharge to custodial care or home, with 24-hour caregiver support. The letter indicated Resident 1's therapist reported the resident had reached new levels in bed mobility with caregiver assistance and transfers with caregiver assistance. The letter indicated if Resident 1 was discharged home with a 24-hour caregiver, she would receive home health skilled nursing, Physical/Occupational Therapy services with close follow up from the primary care physician. The letter indicated continued recuperation from Resident 1's illness could be safely provided with custodial care or home health services, if discharge to home with caregiver. According to a review of Resident 1's PT Discharge Summary, dated 7/6/2023, the resident previously was living home alone with a couple of steps to enter, was using a front wheel walker and wheelchair, and the discharge recommendation was to discharge home with home health services. A review of the History and Physical (H&P), dated 7/20/2023, indicated Resident 1 had the capacity to understand and make some decisions but may not be able to participate in complex decision making (such as for discharge planning). A review of the Physician's Order, dated 7/27/2023, indicated Resident 1 was to discharge home today with home health nurse, physical therapy (PT) and occupational therapy (OT) for safety. A review of the Post Discharge Plan of Care, dated 8/1/2023, indicated Resident 1 was to receive home health service and there was a phone number for the home health agency. A review of the Discharge Summary/Comprehensive Assessment form dated 8/1/2023, indicated Resident 1 required assist with bathing, dressing, eating, personal hygiene, transfers, bed mobility, toilet use and ambulation. Further review indicated the white resident copy remained attached to the yellow chart copy and remained in Resident 1's physical chart. According to a review of Resident 1's Notice of Transfer / Discharge form, dated 8/1/2023, the resident was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice of Transfer was not signed by Resident 1 or the Medical POA and was not provided 30 days prior. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/1/2023, indicated the resident's cognition was intact., Resident 1's discharge was planned and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, moving between locations, toileting and personal hygiene. A review of Resident 1's GACH Emergency Department (ED) Provider Note, dated 8/15/2023 (two weeks after leaving the facility), indicated Resident 1 was brought in by rescue services, unclothed and covered in excrement (waste matter discharged from the bowels). The ED Note indicated Resident 1's housing condition was deplorable (shockingly bad in quality) and she fell at home. The GACH ED Note indicated Resident 1's Blood Urea Nitrogen Level was elevated at 38.6 (normal is 9.8 - 20.1, an indication that either the resident's kidneys are not functioning well or dehydration [losing more fluids than you take in]) and Resident 1 sustained a sternum fracture (the breastbone, the long flat bone located in the central part of the chest, most commonly results from blunt, anterior chest-wall trauma,, patients typically experience a sudden onset of sharp and intense chest pain at the time of injury and may increase during deep breathing, coughing, laughing or sneezing, results in an increased risk in pulmonary injuries). The ED Note indicated Resident 1 was admitted to the GACH for failure to thrive and sternum fracture. During a phone interview on 8/17/2023 at 3:56 PM, GACH Social Worker 1 (SW 1) stated there were concerns from an outside health agency that Resident 1's discharge from the facility was unsafe due to the resident's home had a lot of safety concerns. SW 1 stated the resident was unable to transfer herself or care for herself and Resident 1 was found covered in her feces. SW 1 further stated Resident 1 had a fall at home and was now admitted to the GACH with a sternum fracture. During a phone interview on 8/17/2023 at 4:11 PM, Registered Nurse Case Manager (RNCM) stated Resident 1 lived alone, did not have the income to pay caregivers and Resident 1's Family Member 1 (FM 1) had her own medical problems. RNCM stated Resident 1 was unable to transfer herself and during her visit to the resident, she was bedbound. She further stated during her visit on 8/3/2023, Resident 1 had water at her bedside and had not had food for 24 hours. The RNCM also stated during each visit, Resident 1 was found each time in urine and feces. During an interview on 8/18/2023 at 10:40 AM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was incontinent and required someone to clean her lower body and to change her incontinence brief. CNA 1 stated Resident 1 required two people to transfer her to a wheelchair and if Resident 1 was to go home she would need a caregiver to cook, clean and perform personal care. On 8/18/2023 at 12:14 PM, during an interview, the Director of Rehabilitation (DOR) stated Resident 1 was living alone prior to her admission. Our assessment indicated Resident 1 would never reach full independence and it was imperative for Resident 1 to go home with a caregiver. A caregiver was needed. I mean she can't function. She would basically be homebound as she can't go up and down those three steps without assistance. During a phone interview on 8/18/2023 at 12:47 PM, Resident 1 stated, If I could have stayed at the facility I would have wished to stay. Resident 1 also stated she did not receive any discharge instructions prior to being discharged and did not recall any conversations with facility staff asking her about home health or about having a caregiver upon discharge. Resident 1 further stated she fell at home and was now hospitalized with a broken chest. During an interview on 8/18/2023 at 3:30 PM, Resident 1's Family Member 1 (FM 1) stated when the resident was discharged from the facility the resident lived alone and was unable to walk up the stairs to her apartment. FM 1 stated no one at the facility spoke to her about Resident 1 needing a caregiver at home and They [the facility staff] didn't tell me anything about discharge, they only talked with me about the finances. FM 1 stated Resident 1 was feeling so weak she could not change her incontinence brief and she stood and slipped in her own urine and was now hospitalized . During an interview on 8/21/2023 at 8:32 AM, Case Manager (CM) 1 stated Resident 1 was cleared by the Rehabilitation Department to go home, but CM 1 failed to indicate 'with home health services.' CM 1 informed Nurse Practitioner (NP) 1 and NP 1 ordered the discharge of Resident 1. CM 1 further stated the rehabilitation department recommended Resident 1 to receive 6 to 8 hours of caregiving services from FM 1. CM 1 further stated she discussed the resident's caregiver needs with Resident 1 and FM 1 but she did not document it in the resident's medical chart. CM 1 also stated she did not clarify the type of caregiving services and the quantity of services to be provided with the resident or FM 1. On 8/21/2023 at 10:37 AM, during an interview, Nurse Practitioner 1 (NP 1) stated the facility told her Resident 1 was safe to go home with whatever her home situation was and she ordered the resident to go home with home health. NP 1 stated, I gave them the home health agency and generally the social worker contacts the home health. I feel like they (the facility staff) didn't give me the full picture. I trusted them and I shouldn't have. During an interview on 8/21/2023 at 11:20 AM, Social Services Assistant (SSA) stated it was important to make sure Resident 1's discharge was safe prior to her discharge. The SSA stated she did not know if Resident 1's discharge was safe because I don't know what kind of help she was going to get at home. The SSA also stated she did not follow-up with Resident 1 post discharge and home health services were not arranged. During an interview on 8/22/2023 at 10:36 AM, Director of Nursing (DON) stated Resident 1 should have been discharged with a 24-hour care giver support, this should have been communicated to the resident and family and this communication should have been documented. The DON also stated if a resident needs in home support it should be arranged prior to discharge and a possible outcome of not having a caregiver was injury to the resident. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge. The policy indicated residents were permitted to stay in the facility and not be transferred or discharge unless the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. The policy indicated the notice is given as soon as it is practicable but before the transfer or discharge. A review of the facility's P&P titled, Discharge Summary and Plan, revised 12/2016, indicated when a resident's discharge was anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. Every resident would be evaluated for his discharge needs and will have an individualized post discharge plan. The discharge plan will include arrangements that have been made for follow-up care and services. It also indicated a member of the Interdisciplinary Team (IDT) will review the final post-discharge plan with the resident and family at least 24 hours before the discharge is to take place. A review of the facility's policy and procedure (P&P) titled, Transfer and Discharge Documentation revised 12/2016, indicated each resident would be permitted to remain in the facility and not be transferred or discharged unless - the transfer or discharge was necessary for the resident's welfare and the resident needs cannot be met in this facility. The policy indicated when a resident is transferred or discharged from the facility, the following information will be documented in the medical record: the specific resident needs that cannot be met, and that an appropriate notice was provided to the resident and / or legal representative.

Based on interview and record review, the facility failed to identify and ensure one of two sampled residents (Resident 1), who was diagnosed with cystostomy (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) and was a high risk for pressure injury (sore or injury to the skin and underlying tissue caused by prolonged pressure on the skin), received care, treatment, and services in accordance with the professional standards of practice and the facility's policy and procedures by failing to: -Implement the Physician's Order to monitor Resident 1's intake and output (the measurement of the fluids that enter the body [intake] and the fluids that leave the body [output]). -Develop Resident 1's comprehensive person-centered care plan with interventions to monitor for enterocolitis (inflammation of both the small intestine and the colon) due to clostridium difficile (C. diff, bacterium that causes an infection of the large intestine). -Develop and implement a comprehensive person-centered care plan for Resident 1's suprapubic catheter (type of catheter left in place, inserted through a hole in the stomach and then directly into the bladder). - Assess and monitor Resident 1 for Stage II pressure injury (skin breaks open, usually tender and painful, looks like an abrasion, blister or shallow crater) including documenting repositioning schedules (a guideline to turn the body / change position in order to keep blood flowing and prevent pressure injury). As a result, on [DATE] (three weeks after admission), Resident 1 had altered level of consciousness, weakness with an elevated respiratory rate of 30 (normal 12 - 16), low oxygen saturation (amount of oxygen in the blood) of 89% (normal 95 - 100), a low blood pressure of ,d+[DATE] (normal ,d+[DATE]), and the resident was transferred to a general acute care hospital (GACH) and died two days later on [DATE]. Findings: a.A review of the admission record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses including gastrostomy tube (g- tube, a tube inserted through the belly that brings nutrition directly to the stomach) enterocolitis due to C.diff (infection in the stomach, requiring contact isolation [precautions require medical staff and visitors to wear gowns and gloves when entering the patient's room to prevent spread of infection]) and dementia (loss of memory, thinking and reasoning). A review of the Physician's Order dated [DATE] indicated Resident 1 was to receive a change in the suprapubic catheter as needed for leaks, soilage and sediments and to monitor Resident 1's intake and output (I & O) for 14 days. A review of the care plan initiated [DATE] indicated Resident 1 was at risk for a urinary tract infection (UTI) due to having an indwelling catheter (suprapubic catheter). The goal was for there to be no signs or symptoms of a UTI and will not have any complications for 90 days. The care plan interventions included to monitor for signs and symptoms of UTI and report to the physician, monitor urine color/consistency every shift, check skin every shift and report any changes immediately to physician, treatment nurse. The care plan indicated to change catheter every month or as needed if plugged, pulled out or with sedimentation. The care plan did not include to change the catheter as needed for leaks, soilage, or to monitor the resident's intake and output, per the physician's order. A review of Resident 1's medical record indicated there was no care plan for the diagnosis of Enterocolitis with C. diff. upon admission. According to a review of the Physician's Order dated [DATE], Resident 1 was removed from C. diff contact isolation. A review of the Minimum Data Set (MDS - a comprehensive assessment and care planning tool), dated [DATE], indicated Resident 1's cognitive skills were severely impaired (unable to make decisions). The MDS indicated Resident 1 required total dependence with bed mobility, transfer, eating, toileting, and personal hygiene. The MDS also indicated Resident 1 had a gastrostomy tube and one or more unhealed pressure injuries. A review of the Activities of Daily Living (ADL) documentation dated [DATE] indicated Resident 1 had a low urine output of 80 mL during the evening shift (normal is 240 mL). On [DATE] Resident 1 had a output of 100 mL, and on [DATE] a output of 100 mL during the evening shift. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a technique that can be used to facilitate prompt and appropriate communication between the health providers) dated [DATE] indicated Resident 1 had three episodes of loose watery stool with foul odor and mucus, and that the resident had a history of clostridium difficile. A review of Resident 1's Physician's Order dated [DATE] timed at 11:48 AM indicated the resident had an order for a stool collection for c. diff. According to a review of the facility's Laboratory Report dated [DATE], Resident 1's stool culture was positive for C. diff (two weeks after being removed from contact isolation). During an interview with Registered Dietician (RD) on [DATE] at 12:54 PM, when asked did she consider Resident 1's loose watery stools / diarrhea when estimating his fluid needs, the RD stated, I don't see anything about diarrhea going on with him based on the notes that I have. The RD indicated she did not add any water for water loss / dehydration (a harmful reduction in the amount of water and other fluids the body needs to work normally) for Resident 1's multiple episodes of diarrhea on [DATE]. During an interview on [DATE] at 11:07 AM, the Director of Nursing (DON) stated there was no documentation to indicate Resident 1's intake and output was monitored, per the physician's order on [DATE]. The DON stated, The I and O sheet is a separate sheet of paper and if one was done it would be in the chart. The DON stated, I & Os are a primary tool that we can provide to the doctor and registered dietician to make sure that the resident is receiving adequate hydration and nutrition. During an interview on [DATE] at 10:55 AM, the Medical Records Assistant stated after reviewing Resident 1's medical chart, there was no care plan for enterocolitis and C. diff noted since the resident's admission to the facility. On [DATE] at 12:07 PM, during an interview and concurrent review of Resident 1's medical record, the MDS nurse stated Resident 1 did not have a care plan for Enterocolitis due to C. diff upon admission. During an interview on [DATE] at 12:07 PM, the DON stated that Resident 1's output of 80cc to 100 cc on ,d+[DATE] -[DATE] should have been assessed by a licensed nurse and the doctor should have been called but were not. The DON stated, We need to monitor each resident's hydration status that's why we monitor output. During an interview on [DATE] at 2:37 PM, RN supervisor (RN 1) stated CNAs tell the licensed nurse how much the resident's intake and how much output from the urinal and then it was documented in the Medication Administration Record (MAR). During an interview with the Licensed Vocational Nurse (LVN 3) on [DATE] at 2:45 PM, she stated the CNAs measure the resident's urine from the urinal, and for the g- tube the measurement is taken from the g-tube machine regarding the I & O. On [DATE] at 11:50 AM, during an interview, the DON stated Resident 1 had a suprapubic catheter, and had a g-tube, so it was important to make sure Resident 1 was adequately hydrated and nourished. The DON stated that he could not find a C. diff care plan for Resident 1 and there should have been a short-term care plan for the enterocolitis C. diff upon admission to ensure to evaluate that the interventions were effective and to monitor for complications. The DON stated that the care plan interventions would include isolation, proper hand washing, to monitor for loose stools and to inform the doctor if the issue was not resolving. During an interview on [DATE] at 11:50 AM, the DON stated the catheter care order for Resident 1 should have been catheter care every day and as needed because if the resident's catheter became soiled or if the resident had loose stool, the catheter would have to be cleaned as needed. A review of the facility's Intake and Output policy and procedure, undated, indicated residents with an indwelling catheter, receiving enteral nutritional therapy (a form of nutrition delivered into the digestive system as a liquid. Drinking nutrition beverages or formulas and tube feeding are forms of enteral nutrition) require monitoring of intake and output every eight hours including a 24-hour total, weekly and monthly evaluation. Licensed Nurses shall monitor, and document fluids (in cubic centimeters, ccs) consumed by resident while taking medications on I & O forms/sheets provided. Licensed Nurses shall also monitor residents on enteral pump feedings at a minimum of every eight hours to ensure safe and accurate intake is received. Amount of resident output every shift shall be recorded in the I & O forms/sheets provided. Resident care plans shall be updated as necessary by licensed nurses and/or Resident Assessment Coordinator. A review of the Indwelling Catheter Care policy and procedure, undated, indicated the facility would provide necessary services relating to the use of indwelling catheter to prevent the resident from developing a related infection. The Licensed Nurse shall monitor the resident's urine output for color, cloudiness, sediments, odor, etc. Based on resident's condition, the catheter may need to be changed more or less often than every 30 days. Findings should be promptly reported to the physician. A review of the facility's policy and procedure titled, Hydration, undated, indicated licensed nurses shall be responsible for monitoring intake and output. b. A review of Resident 1's Skin Assessment form dated [DATE] indicated Resident 1 had a Stage II pressure injury on his sacrum (a large, triangular bone at the bottom of the spine, between the hip bones) measuring 5 x 6.5 x 0.2 centimeters and a scrotal excoriation (abrasion). A review of Resident 1's Stage II pressure injury care plan initiated on [DATE] indicated the resident had a sacral pressure ulcer with interventions including to perform a complete skin assessment and record, perform a nutritional screening, adjust diet / supplements as indicated to reduce the risk of skin breakdown and to assess and record the size, amount and characteristics of exudates, and pain status. A review of the Body and Skin Shower check dated ,d+[DATE] and [DATE] signed off by a CNA and a licensed nurse, indicated Resident 1's skin was intact, and the resident received a shower. The body and skin shower check form dated [DATE] indicated Resident 1 had a skin problem and skin discoloration on the sacrum area. The [DATE] body and skin shower check form indicated Resident 1 did not have a skin problem and did not have any skin discoloration. A review of Resident 1's nutritional assessment dated [DATE] indicated Resident 1 had increased nutrient needs due to the Stage II pressure injury and Resident 1's estimated fluid intake need was 1 mL/kcal consumed. According to a review of the Stage II sacral pressure injury care plan dated [DATE], Resident 1's pressure injury was resolved. A review of the Braden Scale Assessment for predicting pressure injury risk form dated [DATE] indicated Resident 1 was often moist, had limited mobility, nutrition was probably inadequate, and the resident had a potential problem with friction and shear (mechanical forces contributing to pressure ulcer formation). The Braden Scale Assessment indicated Resident 1's total score was 11, which represented a high risk for pressure injury development. A review of the facility's policy and procedure titled, Pressure Ulcers, undated, indicated facility staff must conduct a daily body check on all residents, the results of the daily body check shall be documented and submitted to the charge nurse for review and the CNA will promptly report to his/her charge nurse any resident identified to have impaired skin integrity. Those with a moderate pressure ulcer skin risk scored ,d+[DATE] shall assess skin daily, protect skin from moisture and encourage proper dietary intake. document implementation of repositioning schedules in the resident's medical chart, e.g., licensed progress notes, ADL charting or medication administration record. A review Resident 1's progress note dated [DATE] at 11:12 AM indicated the resident was noted to have Moisture Associated Skin Damage (MASD) on his sacrum that extended to both of his buttocks and resident was having episodes of watery stool. There was no documentation to indicate the suprapubic catheter was changed or cleaned due to Resident 1's loose watery stools, as the Physician's Order dated [DATE] indicated Resident 1 was to receive a change in the suprapubic catheter as needed for leaks, soilage and sediments. A review of Resident 1's nursing progress note dated [DATE] timed at 9:45 AM indicated that Resident 1 desaturated (low blood oxygen) on room air with an oxygenation of 89% (normal 95 to 100), the resident had a low blood pressure of ,d+[DATE] (normal ,d+[DATE]), and Resident 1 had a fast respiratory rate at 30 breaths per minute (normal 16 - 20). The nursing progress note indicated the nurse practitioner ordered Resident 1 to be transferred to the GACH via 911 for further evaluation. According to a review of the GACH history and physical dated [DATE], Resident 1 was moaning in distress. While in the emergency room (ER) the resident had a fever up to 102 Fahrenheit (normal 98.6), had a heart rate of 120 beats per minute (bpm - normal range is 60 to 100), and the white blood cell count (wbc- indicator of infection) was elevated at 53. The GACH H&P indicated Resident 1's urinalysis (urine test) appeared infectious; the resident required oxygen supplementation with six liters per minute (lpm). A review of the GACH's Critical Care Unit (CCU) History and Physical dated [DATE] indicated Resident 1 was found to be in septic shock likely due to urosepsis or C. Diff. Resident 1 was admitted to the Intensive Care Unit (ICU) and around 7 PM a rapid response was called for the resident's systolic blood pressure (SBP, top number) dropping to the 60s with heart rate in the 130's and that the resident was moaning and nonverbal. The GACH CCU H&P indicated pus was seen draining from around the resident's suprapubic catheter site and from his urethra (the tube through which urine leaves the body). The resident had hypernatremia (high sodium level) which was concerning for a lack of adequate hydration being provided prior to his current admission. The GACH CCU H&P indicated that the pressure injury on the sacrum may be secondary to not being turned adequately to avoid development. A review of Resident 1's death certificate dated [DATE] indicated Resident 1's immediate cause of death was septic cardiogenic shock (a life-threatening condition involving severe localized or system-wide infection where the heart suddenly can't pump enough blood to meet the body's needs), clostridium difficile colitis, and urinary tract infection. During an interview on [DATE] at 12:52 PM, the facility Treatment Nurse stated Resident 1 was admitted with a Stage II pressure injury and it was resolved on [DATE]. The treatment nurse stated, From then we did skin maintenance, but he started having a lot of watery stools on [DATE] and developed MASD (moisture acquired skin damage). The bowel movements were everywhere. Then the excoriation (abrasion) started on his scrotum. During an interview on [DATE] at 12:37 PM, the DON stated there was no Treatment Administration Record (TAR) for the month of [DATE] because the wound was resolved in [DATE]. However, Resident 1 did develop a MASD on [DATE] and there was no TAR documented. During an interview on [DATE] at 11:13 AM, CNA 1 stated, We have not documented turning the resident for about a year. CNA 1 also stated, If a resident has a large sore, they place the turning schedule on the wall. During an interview on [DATE] at 11:35 AM, the Treatment Nurse stated the facility did not have any documentation regarding the turning schedule for Resident 1 for August or [DATE]. On [DATE] at 11:50 AM, during an interview, the DON stated Resident 1's pressure injury can contribute to his dehydration and malnourishment. During an interview on [DATE] at 11:09 AM, the DON stated Resident 1 was a high risk for pressure injuries. The DON was unaware of where the daily skin assessments were documented in the chart and was unable to provide documentation of a daily body check of Resident 1, per the facility's Pressure Sore Risk Assessment policy. The DON also stated that Resident 1 was a high risk for pressure injuries, and it was important for Resident 1's skin to be assessed daily to assess the effectiveness of interventions to prevent and treat his pressure injury. The DON further stated that Resident 1's condition warranted a physician visit in order evaluate the care the resident need from the start of his admission. A review of the facility's policy and procedure titled, Pressure Sore Risk Assessment, undated, indicated pressure ulcer prevention precautions with score of 8 - 12 shall include to assess skin daily, keep skin clean and dry, protect skin from moisture using under pads and briefs, use ointment barriers to protect skin exposed to urine, stool or wound damage, decrease friction and shear, encourage proper dietary intake, reposition every two hours, care plans shall be developed to address risk factors to development or further development of pressure ulcer. The same policy indicated the facility staff must conduct a Daily Body Check of all residents. Results of daily body check shall be documented using the prescribed form and submitted to the charge nurse for review and signature. The charge nurse shall conduct a basic assessment and data collection based on the presented Daily Body Check and shall promptly notify the resident's physician of the findings. The same policy indicated daily monitoring of pressure ulcers shall also be done by documenting in the treatment administration record monitoring for signs of complications (e.g., soft tissue infection, redness, swelling, increased drainage), monitoring of integrity or status of dressings every shift (e.g. Whether dressing is intact and whether drainage is present or is not leaking).

Based on interview and record review, the facility failed to identify accident risks and hazards, and did not implement the care plan interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who required extensive assistance with locomotion off unit, the facility failed to provide the resident frequent reminders regarding safety, per the care plan and failed to provide an Interdisciplinary Team Meeting to identify any specific accident hazards or risks for Resident 1, per the facility policy. These deficient practices resulted in Resident 1 going out on pass, being hit in the street by a semi - truck, and found prone (lying flat on stomach) in center of street intersection. Resident 1 suffered a 6 inch avulsion (injury where the body structure is torn off by trauma) to center buttocks with fat exposed, scalp hematoma (bruising) to back of head, required multiple operations on his perineal area, and had a [DEVICE] (type of therapy used to heal wounds) in place while hospitalized . Findings: A review of the clinical record indicated Resident 1 was admitted to the facility, on 8/14/19, with [DIAGNOSES REDACTED]. A review of the Fall Risk Assessment record, dated 8/14/19, indicated Resident 1 was not considered a fall risk, with a score of 8. A total score above 10 represented a high risk for falls. The fall risk assessment indicated Resident 1 was not scored for gait and balance, muscular coordination or unstable when making turns, which indicated an incomplete assessment. A review of Resident 1's care plan, initiated 8/14/19, for High Risk for Fall and Injury related to unsteady gait, and weakness, indicated facility staff would minimize risk for falls and injury in the next three months. The care plan interventions indicated to implement fall precautions, provide a safe environment, provide adequate assistance during transfers, and provide frequent reminders regarding safety. According to a review of the History and Physical record, dated 8/15/19, Resident 1 had the capacity to understand and make decisions. A review of the Minimum Data Set (an a ssessment and care planning tool), dated 8/21/19, indicated Resident 1 required extensive assistance with locomotion off unit, which required staff providing weight-bearing support. The MDS indicated Resident 1's mental status was intact. A review of Resident 1's physician's orders [REDACTED]. A review of the care plan titled, (MONTH) go out on pass, dated 8/27/19, indicated the interventions were to explain the risks and benefits when signing out on pass, to notify the medical doctor if resident was non compliant with facility protocol, and for the resident to sign out in the book with destination and timeframe. According to a review of the clinical record there was no documented evidence of interdisciplinary team meetings (prompt communication between healthcare team) regarding the safety of out on pass order with Resident 1. A review of the Nurses Notes, dated 9/3/19, at 7:30 a.m., indicated Resident 1 was awake and able to make needs known. No complaints of any pain or distress. Vital signs stable. A review of the Release of Responsibility for Leave of Absence form, dated 9/3/19, indicated Resident 1 went out on pass at 1:30 p.m., with his signature on the form. The leave of absence form did not indicate the location, per the care plan, as the space for destination was blank. A review of the Prehospital Care Report Summary (ambulance report), dated 9/3/19, at 2:26 p.m.,(one hour after Resident 1 signed out) indicated [AGE] year old male found prone (lying flat on stomach) in center of street intersection, 6 inch avulsion (injury in which a body structure is torn off by trauma) to resident center buttocks with fat exposed, abrasion across both lower abdominal quadrants, and hematoma (bruising) to back of head secondary to auto versus pedestrian. The ambulance report indicated the witness stated patient was walking through cross walk and a semi-truck struck the resident causing him to get thrown approximately 10 feet. Resident 1 was placed in c-collar (neck collar to stabilize neck) as he would not tolerate being on his back. Further review of the Prehospital Care Report, dated 9/3/19, at 2:46 p.m., indicated Resident 1's blood pressure was 130/102 (normal range less than 120/60) with pulse 102 (normal less than 80). A review of Resident 1's general acute care hospital (GACH) emergency room (ER) record, dated 9/3/19, at 4:49 p.m., indicated a male was brought in by EMS (emergency medical service) as a trauma patient after he was reportedly a pedestrian struck by a truck. Resident 1 arrived prone as he reportedly was not able to tolerate being supine per EMS. A review of Resident 1's GACH Psychiatry Consult note, dated 9/5/19, at 10 a.m., indicated Resident 1 was status [REDACTED]. Resident 1 had an abrasion across lower abdomen from hip to hip, large sacral/gluteal abrasion and laceration that extended to the posterior anal into the mid sacral areas. Resident 1 stated that he was alone at the intersection and was the only one waiting to cross the street. A review of the GACH record dated, on 9/3/19, Resident 1 had rigid sigmoidoscopy (surgical procedure of examining of large intestine), wound irrigation (liquid solution poured over a wound to visualize an area), and debridement (removal of infected or diseased tissue). The resident had his external sphincter (layer of muscle encircling outside wall of anal opening) re-approximated with sutures due to the extensive laceration and a posterior sphincteroplasy (surgical reconstruction of sphincter muscle) and mucosal repair (wound repair). On 9/4/19, Resident 1 had irrigation and debridement of posterior wound with complex closure (layered and deeper repair of wounds) and penrose placement (surgical drain used to prevent build up of fluid in surgical site). On 9/8, the resident had exploration (to look into the organs and structures inside body) and debridement of wound. During an interview, on 9/24/19, at 2:20 p.m., the Director of Nursing (DON) stated that Resident 1 did not have an IDT meeting pertaining to the out on pass order. On 9/24/19, at 2:29, the Administrator was interviewed and stated he did not report this incident to the Department. On 11/4/19, at 2:32 p.m., Certified Nurse Assistant 1 (CNA 1) was interviewed over the telephone. CNA 1 stated that Resident 1 used his wheelchair the majority of the time at the facility and was not steady on his feet. During an interview, on 11/4/19, at 2:44 p.m., Licensed Vocational Nurse 2 (LVN) 2 stated he was Resident 1's nurse on the day of the accident. LVN 2 stated that he remembered Resident 1 signing himself out at the sign out book at the nurses station. When LVN 2 was asked if he provided Resident 1 frequent reminders regarding safety, per the care plan, LVN 2 did not respond. When LVN 2 was asked if it was safe for Resident 1 to go out on pass with the walker, LVN 2 did not respond. When LVN 2 was asked if he explained the risks and benefits to Resident 1 when he signed out on pass, LVN 2 did not respond. A review of the facility's policy titled, Safety and Supervision of Residents, revised 7/2017, indicated the facility strived to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Individualized, Resident-Centered Approach to Safety addresses safety and accident hazards for individual residents. The policy indicated the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: Communicating specific interventions to all relevant staff.

Based on interview and record review the facility failed to ensure each resident received treatment and care based on the comprehensive person centered care plan in accordance with professional standards of practice for one of three sampled residents (Resident 1). Resident 1, who had 4+ [MEDICAL CONDITION] (accumulation of fluid, when pressed pit is very deep, lasts as long as ,[DATE] minutes, dependent extremity is grossly distorted ,[DATE] mm), of the right and left foot, was not assessed and monitored for symptoms of [MEDICAL CONDITION] and facility staff did not elevate the resident's legs while sitting, per the care plan. This deficient practice resulted in Resident 1 being transferred to the General Acute Care Hospital (GACH), less than two weeks after admission, with complaints of shortness of breath (SOB), worsening of leg swelling / [MEDICAL CONDITION], occlusive thrombus (a stop or blood clot, blocking blood flow), and full [MEDICAL CONDITION]. Resident 1 expired on [DATE], at 11:08 p.m. Findings: On [DATE], an unannounced visit was made to the facility regarding a complaint regarding abuse and neglect. A review of the Admission Record indicated Resident 1 was admitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the Nursing Initial Assessment, dated [DATE], indicated Resident 1 was alert and oriented to person, place and time, experienced no pain, and did not receive pain medication regimen. The Nursing Assessment indicated Resident 1 had weakness of the left and right leg, with 4+ [MEDICAL CONDITION] on the right and left foot. A review of the Order Summary Report indicated an order dated [DATE], to measure and monitor the for adverse changes and extent of the [MEDICAL CONDITION] of the left and right foot. The order summary report indicated to notify the physician and monitor for signs and symptoms of skin breakdown and pain. A review of Resident 1's care plan for exhibiting or at risk for fluid volume excess, as evidenced by 4+ [MEDICAL CONDITION] on right and left foot, dated [DATE], indicated the goal was for Resident 1 not to experience any signs or symptoms of fluid overload, as evidenced by the absence of [MEDICAL CONDITION] and dyspnea (shortness of breath). The care plan interventions included the following: - Apply and remove compression stockings as ordered (specialized hosiery designed to help prevent the occurrence of, and guard against further progression of, venous disorders such as [MEDICAL CONDITION], and [MEDICAL CONDITION], elastic garments worn around the leg, compressing the limb). - Assess and monitor for symptoms of [MEDICAL CONDITION], shortness of breath (SOB) and weight gain - Notify physician if [MEDICAL CONDITION] continues or increase - Elevate legs as tolerated when sitting - Monitor intake and output as indicated - Monitor oxygen (O2) saturation as ordered and report abnormalities to physician - Monitor vital signs per order and report abnormalities to physician During an interview with the Director of Nursing (DON), on [DATE], at 12:35 p.m., a request was made to review the physician's order for Resident 1 and she stated she did not have the record. The DON called the medical records staff, who stated they did not have the record. A review of the Progress Notes indicated from [DATE], at 8:43 a.m., through [DATE], at 4 p.m., Resident 1 was alert and oriented making her needs known, denying pain. A review of the Progress Note, dated, [DATE], at 2:47 p.m., indicated the resident had been up in the wheel chair all shift. The Progress Note did not indicate Resident 1's legs were elevated, per the care plan interventions. A review of the Progress Note dated, [DATE], at 2:24 p.m., indicated Resident 1 remained alert and oriented, spending much time in her wheel chair. The progress note did not indicate Resident 1's legs were elevated. On [DATE], at 10:05 a.m., Resident 1 was up in the wheelchair at the nurses station. The progress note did not indicate Resident 1's legs were elevated, per the care plan. On [DATE], at 1:44 p.m., the progress note indicated Resident 1 was up in wheel chair at the nurses station. The progress noted did not indicate Resident 1's legs were elevated. On [DATE], at 2 a.m., the progress note indicated Resident 1 was in her wheel chair at the nurses station, yelling to go to the acute hospital, saying she did not like her bed and her room. The progress note indicated Resident 1 went to sleep in the wheel chair, and there was documentation regarding elevating Resident 1's legs. During an interview, on [DATE], at 2:15 p.m., when asked if there was any additional documentation regarding the assessment and monitoring of Resident 1's right and left foot [MEDICAL CONDITION] from [DATE] - [DATE], the DON stated the facility did not have it. A review of the Progress Note for care plan meeting, dated [DATE], at 2:41 p.m., during the care plan meeting with the MDS nurse, social services, and Resident 1's family via telephone, there was discussion of the medications, but no documentation regarding the 4+ [MEDICAL CONDITION] in Resident 1's right and left foot. A review of the Progress Notes, dated [DATE], at 3:30 p.m., indicated Resident 1 was received in the bed and was noted with increased [MEDICAL CONDITION] on both lower extremities. There was no documentation regarding elevating the resident's legs. The progress note indicated Resident 1's blood pressure was ,[DATE], the resident was placed on oxygen at two liters, via nasal cannula, and the resident remained alert and verbally responsive. The resident's family member requested to transfer the resident to the acute hospital. The progress note indicated an order to transfer the resident to the acute hospital was given per physician. At 5:22 p.m., the transfer was canceled and the physician ordered [MEDICATION NAME] to start that night, with chest X-ray in the morning. The progress note did not include the indication for the [MEDICATION NAME] or the chest X-ray. During an interview, on [DATE], at 2:20 p.m., a request was made to review the physician's order for Resident 1 and the DON stated the facility did not have it. A review of the Treatment Administration Record, for ,[DATE] - [DATE], indicated there was no change in measurement or monitoring for [MEDICAL CONDITION] in Resident 1's lower extremities. A review of the Minimum Data Set (a care planning and resident assessment tool), dated [DATE], indicated Resident 1 had modified independence in cognitive skills for daily decision making, required extensive assistance for activities of daily living, including bed mobility, and transfer from bed to chair. During an interview and record review with Licensed Vocational Nurse 1 (LVN 1), on [DATE], at 3:25 p.m., she stated the facility did not have any documentation to indicate Resident 1's legs were elevated. A review of the Progress Notes indicated on [DATE], at 1:40 p.m., Resident 1's blood pressure was low at ,[DATE] (normal 120 / 80), pulse rate was 116 (normal range 60 - 100), and the resident was placed in trendelenburg position (foot of bed elevated). The progress note indicated Resident 1 was placed on oxygen at two liters via nasal cannula, the physician was notified, and Resident 1 would be transferred to the GACH. The progress note indicated at 2:10 p.m., Resident 1 and the paramedics left the facility for further evaluation. A review of the GACH's Emergency Department Provider Notes indicated on [DATE], at 2:41 p.m., Resident 1 arrived with complaints of shortness of breath (SOB) and lower extremity [MEDICAL CONDITION]. The resident complained of recent worsening of leg swelling. At 6:24 p.m., an ultrasound of the legs was conducted. During the left Doppler (a noninvasive test that can be used to estimate the blood flow through your blood vessels), the Doppler could not be obtained from the femoral vein at mid thigh due to occlusive thrombus (blood clot). The GACH's ED Provider Notes indicated at 9:34 p.m., Resident 1 was in full [MEDICAL CONDITION], advanced cardiac life support was initiated, time of death was pronounced at 11:08 p.m. A review of the Certificate of Death indicated Resident 1's immediate cause of death was acute [MEDICAL CONDITIONS] (a blockage of an artery in the lungs by a substance that had moved from elsewhere in the body through the bloodstream). The Certificate of Death indicated conditions leading to cause of death included deep vein [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. On [DATE], at 2:25 p.m., during an interview, the DON stated she was unable to provide any information regarding the residents care occurring in (YEAR), as she was newly hired and there were limited medical records available to review. During an interview, on [DATE], at 3:10 p.m., Family Member 1 stated Resident 1 was uncomfortable in bed with lots of swelling in her legs. Family Member 1 stated she repeatedly asked the nurses to place compression stockings on the resident and to elevate her legs for the swelling. During interview, [DATE], at 1:20 p.m., Family Member 1 stated she saw Resident 1's legs dangling several times while in the wheel chair. Family Member 1 stated she brought some compression stocking to the facility and requested the staff place them on the resident and also insisted several times that the physician was called. A review of the facility policy titled, [MEDICAL CONDITION], Evaluation Guideline, indicated to evaluate residents who have [MEDICAL CONDITION] in order to investigate the cause and to assist with the development of the plan. Evaluation of [MEDICAL CONDITION] would be conducted and would be described in the medical record. A determination would be made if [MEDICAL CONDITION] was pitting or dependent [MEDICAL CONDITION]. The policy indicated 4+ [MEDICAL CONDITION] was a deeper pit after pressing approximately 8 mm. Indentation remains for a prolonged time after pressing, approximation in minutes. The policy indicated to notify the physician if this was a new condition or there was a change in the level of the [MEDICAL CONDITION], document and carry out any new orders. Identify possible causes of [MEDICAL CONDITION] and care plan as needed. Notify the resident and / or family of the changes in condition or treatment.

Based on observation, interview, and record review, the facility failed to ensure four of 24 sampled residents (Residents 1, 5, 15 and 18) and two randomly selected (RSRs 18 and 25) received the necessary care and services and followed the physician's orders. Resident 5, who had been receiving wound care for months, was not adequately assessed for pain and provided with pain medication prior to wound care as stipulated in Resident 5's plan of care (POC). Resident 5, who had a large right black gangrenous (necrosis or death of soft tissue due to obstructed circulation) foot measuring 18 centimeter (cm) x 11 cm. and depth UTD (unable to determine) and a right shin (the front of the leg below the knee) wound measuring 8 cm. x 2 cm. in depth, was not administered pain medication prior to wound care and was observed yelling, grimacing in pain, and thrashing around in bed. This deficient practice resulted in Resident 5 not being adequately assessed and experiencing avoidable pain during extensive wound care treatment. Resident 1, who had a cervical spine (neck) fracture, had a physician's order for a neck/chest/back brace to be in place at all times, except during hygiene care, the brace had been broken for two months and the facility failed to replace it. This failure resulted in Resident 1 being without a neck/chest/back brace for two months while complaining of dizziness, increased pain requiring large amounts of pain medications, and difficulty to perform ADLs, which resulted in Resident 1 staying in the bed. Residents 1, 15, and 25's physician's orders were not being followed. Resident 18, who received [MEDICAL TREATMENT] treatment three times a week, had a catheter (not a A/V shunt) the nurses were documenting bruit and thrills were being assessed (only for A/V shunts) and the licensed nurses did not know what to do if the catheter site bled. This deficient practice resulted in the licensed nurses not having a knowledge base to provide care for a [MEDICAL TREATMENT] resident, with potential to have an adverse effect. Findings: a. A review of Resident 5's Admission Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 5's [DIAGNOSES REDACTED]. occupational functioning). A review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/25/16, indicated Resident 5's memory was impaired as evident by a brief interview of mental status (BIMS) score of 3 (score of 8-15 means inter-viewable). According to the MDS, Resident 5 did not have recall and was non-English speaking and spoke Russian. Resident 5 was non-ambulatory (unable to walk) and required an extensive one-person assistance with activities of daily living (ADLs), such as dressing, eating, toilet use, and personal hygiene (shaving, brushing teeth, and combing hair). A review of Resident 5's care plan, initiated on 7/5/16, and titled, Potential for alteration in comfort/pain related to multiple gangrene; [MEDICAL CONDITION], indicated the staff's intervention included to provide pain medication to Resident 5 prior to planned activities, e.g. PT (physical therapy), OT (occupational therapy), and wound care. A review of Resident 5's physician's order for wound care, dated 8/5/16, and timed at 6:35 p.m., indicated to cleanse the right distal leg arterial wound with normal saline (NS), pat dry, paint with [MEDICATION NAME] (an antiseptic), cover with a dry dressing (DD) every day shift for 14 days. Another physician's order, dated 8/7/16, and timed at 2:04 p.m., indicated to cleanse right distal leg arterial wound right foot gangrene with Dakin's, 0.25% solution (a dilute solution containing sodium hypochlorite and boric acid, used as an antiseptic in the treatment of [REDACTED]. On 8/8/16 at 2:20 p.m., during Resident 5's wound care observation, the assistant director of nursing ((ADON) a licensed vocational nurse) was observed removing the dressing gauze saturated with dry yellowish-red stains from Resident 5's right foot with a foul smell permeating the room. Resident 5 was observed with facial grimaces when the dressing was being removed from the right leg. Resident 5 was repetitively saying in Russian, Dai Pokoi (leave me alone), Dai Pokoi (leave me alone), while kicking his feet and thrashing in the bed. Resident 5's right shin wound dressing was observed stuck in the pinkish in color wound bed that had yellowish slough (dead tissue in, or cast out from, living tissue) and was difficult to remove. The ADON pulled the dried dressing out of the wound bed and Resident 5 yelled out. The ADON, who was English speaking, was unable to communicate with Resident 5 to evaluate Resident 5's pain level. At 2:36 p.m., on 8/8/16, LVN 6, the medication nurse for Resident 5, stated she did not administer any pain medication to Resident 5 before the wound care treatment on 8/8/16 or any day prior to wound care. At 2:38 p.m., on 8/8/16, LVN 8, who speaks both English and Russian was called to Resident 5's room The ADON did not ask LVN 8 to translate to assess Resident 5's pain level. During the wound care, there was a multilingual pain scale posted on Resident 5's room wall with facial grimace with translations in English, Spanish, Tagalog, Chinese, Korean, Persian (Farsi), Vietnamese, and Japanese, with the exclusion of Resident 5's Russian language. On 8/9/16 at 7:40 a.m., LVN 8 was asked did she ask Resident 5 in Russian if he was in pain during the wound care treatment the day before (8/8/16). LVN 8 stated Resident 5 had dementia and was confused and did not respond directly to the question if he was in pain, but kept saying to get out and leave him alone. On 8/9/16 at 8:22 a.m., during an interview, a registered nurse (RN 4) stated Resident 5's right leg and foot wounds were being treated by the wound care physician. RN 4 stated the resident's family were aware the gangrenous foot and did not want Resident 5 to have it amputated. RN 4 stated the facility ' s plan was to stabilize the gangrenous foot. On 8/9/16 at 1:40 p.m., during a second wound care observation, RN 4 was observed preparing supplies for Resident 5's wound care. RN 4 who was English speaking proceeded with Resident 5's wound care at approximately 2 p.m. without assessing or evaluating Resident 5's pain. During the removal of Resident 5's wound's dressings, Resident 5 was observed grimacing and kicking his feet and thrashing in bed during the wound care. LVN 2, who was also at the bedside, stated Resident 5 was given two tablets of 325 milligram (mg) of Tylenol before lunch for Resident 5's newly forehead scratch pain approximately two hours before the right leg wound care. A review of Resident 5's Medication Administration Record (MAR) for the month of August 2016, indicated there was no pain medication ordered for Resident 5 for wound care as was indicated in Resident 5's plan of care, not even the Tylenol LVN 2 indicated he had given to Resident 5 before lunch. An hour later, on 8/9/16, at approximately 3 p.m., Resident 5's MAR indicated Tylenol tablet 325 mg, two tablets by mouth for pain was given that day at 12 p.m. On 8/9/16, at 2:46 p.m., the director of nurses (DON) stated, We do not pre-medicate our residents for wound care. The DON stated the nurses should assess the resident's pain and medicate as required before starting wound care treatment. The DON was informed about ADON not assessing Resident 5's pain and not providing medication for the resident's pain. The DON stated the ADON was new and her first day was on 8/8/16 (the day before). On 8/15/16, at 3:15 p.m., during an interview, the DON stated, while reviewing Resident 5's record, Resident 5 should have had a wet-to-dry dressing to the right shin wound because the wound dressing will stick to the wound, since it was deep, and once removed it would cause pain. A review of the facility's undated policy titled, Policy and Procedure on Pain Monitoring During Care and Treatment, indicated residents shall be monitored for any manifestation of pain such as: facial grimaces, crying, tearfulness, moaning, screaming or yelling, withdrawal from touch, and that pain and/or manifestation of pain associated with the following activities should be monitored: wound/pressure ulcer treatment, if a resident is manifesting pain during performance of ADL, ask the charge nurse to assess the resident. The charge nurse should review the physician's order for any order of pain medication and call the physician if there was no order for pain medication. b. During the facility's initial tour on 8/8/16 at 8:10 a.m., accompanied by a licensed vocational nurse (LVN 7), LVN 7 stated Resident 1 mostly stayed in bed, because his neck brace had been broken for over a month. While at Resident 1's bedside, Resident 1 stated the neck brace had been broken for two months. Resident 1 stated he had notified the social worker and there had not been a replacement of the brace as of yet. Resident 1 stated he becomes dizzy upon getting up out of bed and had difficulty in transferring from the bed to the chair and performing ADLs (activities of daily living) without the neck brace. While still at Resident 1's bedside, LVN 7 pointed to Resident 1's broken neck brace on the floor. The full neck and back brace was observed broken in multiple places with the areas taped in an attempted to secure the areas. At 10:50 a.m., on 8/8/16, during a subsequent interview, Resident 1 stated the brace had been broken for a while and that he cannot get up without the brace. Resident 1 stated he had notified the social worker, the nursing staff, the rehab staff and the physician. Resident 1 stated his physician told him he would get another brace, but the rehab staff told him his insurance would not pay for it. On 8/8/16 at 2:15 p.m., LVN 7 stated she had notified the director of nursing (DON) regarding Resident 1's broken brace. LVN 7 stated the DON had referred it to the rehabilitation (rehab) department. LVN 7 further stated Resident 1 cannot maintain his posture without the brace, so she took the brace to the rehab department and they said they cannot repair it. LVN 7 stated Resident 1's pain had increased since the brace had been broken. On 8/10/16 at 8:40 a.m., during an interview, the two social service designees (SSD 1 and 2) stated that they had recently heard about Resident 1's broken brace. They both stated they were informed about Resident 1's broken neck brace on 8/8/16. SSDs 1 and 2 stated Resident 1 had an appointment to be seen by the neuro surgeon (medical professional who specializes in surgery on the brain and peripheral nervous system), but they were unable to locate the note in the Resident 1's record. The SSDs stated Resident 1 also had an orthotic (a specialty concerned with the design, manufacture and application of orthoses (an externally applied device used to modify a body part)) appointment two weeks ago, but they were unable to locate that documentation in the resident's record. Both SSD 1 and 2 acknowledged that it was the rehab's responsibility to replace Resident 1's broken neck brace timely. At 9:10 a.m., on 8/10/16, during an interview, the facility's director of rehab services (DOR) stated on 7/14/16, the DON asked her to look at Resident 1's neck brace. She stated she did an evaluation on 7/15/16 and identified the need for a further referral. The DOR stated the orthotic person came to the facility on [DATE], and provided paperwork to be signed by Resident 1's physician. The DOR stated she had not seen the paper work and stated she did not follow-up on the issue and should had. The DOR acknowledged that she was aware of Resident 1's complaints of pain and immobility to function well without the use of the neck brace and stated it was the facility's responsibility to replace Resident 1's broken neck brace. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 6/30/16, indicated Resident 1 was alert and oriented with a BIMS score of 15 (8-15 means inter-viewable). According to the MDS, Resident 1 required a one-person physical assist in all ADLs (activities of daily living) except, eating and personal hygiene. The MDS, under Section JO400: Pain Frequency indicated Resident 1 had frequent pain that required pain medication. A review of a Nurse's Weekly Summary, dated 8/6/16, indicated Resident 1 required assistance with transferring, ambulation, bathing, and dressing. The summary indicated Resident 1 had complaints of pain and dizziness. A Review of Resident 1's physician orders, dated 5/14/16, indicated Resident 1 had an order for [REDACTED]. 1. [MEDICATION NAME] (a potent controlled narcotic) 4 mg one tab every four hours as needed for severe pain. 2. [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] drug (NSAID) works by reducing hormones that cause inflammation and pain in the body) 800 mg one tab every 12 hourly as needed for moderate pain. A review of Resident 1's Medication Administration Records (MARs) and Pain Assessment Medication Sheet for the months of 6/2016, 7/2016, and 8/2016, indicated Resident 1 received [MEDICATION NAME] 4 mg 42 times in 6/2016, 57 times in 7/2016, and 34 times for 8/2016 (from 8/1-8/15/16). A review of a physician's order, dated 7/1/16, indicated Resident 1 to have brace (neck extended to chest and back area) applied every day at all times and to remove only to do hygiene. A review of Resident 1's care plans indicated there was no plan of care for Resident 1's use of the neck brace or any assistive devices. There were also no Interdisciplinary Team Meeting (IDT) notes documented regarding Resident 1's broken neck brace with plans for replacement. A review of an online article by Medscape Reference, dated 1/25/16, titled General Principles of Fracture Care Treatment & Management, indicated the initial management of fractures consist of realignment of the broken bone and immobilizing it in a splint. The article stipulated splinting was critical in providing symptomatic relief for the patient, as well as in preventing potential neurologic and vascular injury. The ultimate goal of the fracture management was to ensure that once the fracture healed, it would return to its maximal possible function (http://emedicine.medscape.com/article/ 17-treatment). c. On 8/8/16 at 12:40 p.m., during an interview, Resident 15 stated she had problems with constipation and had to ask for a stool softener. A review of Resident 15's Physician's orders, dated 8/5/16, indicated to give Senna (a laxative is used treat constipation) tablet 8.6 milligrams (mg) give one tablet by mouth at bedtime for stool softener and hold for loose bowel movement (LBM). A review of Resident 15's Medication Administration Record (MAR), dated from 8/1/16 - 8/31/16, indicated Resident 15 was to received Senna at bedtime (9 p.m.) every night. However, on 8/7/16 and 8/8/16, Resident 15 received Senna at 6 p.m., instead of the prescribed time of 9 p.m. A review of Resident 15's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 15's [DIAGNOSES REDACTED].), displaced bicondylar fracture of left tibia (a bone break occurring in the shinbone affecting the knee joint, stability and motion), difficulty walking, muscle weakness, and status [REDACTED]. A review of Resident 15's admission assessment, dated 8/4/16, indicated Resident 15 was alert , oriented, cooperative, able to clearly communicate and required a one-person physical assist with transfers. The admission assessment also indicated Resident 15 was independent with eating, but required assistance with personal care and hygiene and wore a left lower extremity immobilizer (used to hold a joint or bone in place with a splint, cast, or brace). A review of a care plan titled, Constipation, dated 8/2016, indicated >Risk of constipation related to: impaired mobility; ADL functions; and use of pain medications. On 8/9/16 at 7:30 a.m., during an interview, a registered nurse (RN 2), stated she gave the Senna at 6 p.m. instead of 9 p.m., because Resident 15 was asking for a laxative so she gave it at 6 p.m. both days. RN 2 stated if was a laxative she did not have to wait until the prescribed time to give it. A licensed vocational nurse ( LVN 2) looked at Resident 15's MAR and stated the Senna was supposed to be given at 9 p.m. and there is only an hour grace before and after it could be given. d. On 8/10/16 at 8:58 a.m., during a medication pass observation, LVN 1 instilled three drops of [MEDICATION NAME] solution (([MEDICATION NAME] Peroxide) a form of peroxide to soften and remove earwax). Resident 1 asked where was his ear flush and she stated she would have to check the physician's order. According to Resident 1, the nurses have been flushing his ear all the time. A review of Resident 1's MAR for the month of 8/2016, indicated to administer [MEDICATION NAME] Solution 6.5 % instill three drops in left ear three times a day and hold for 3-5 minutes for four weeks. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 6/30/16, indicated Resident 1 was alert and oriented with a BIMS score of 15 (8-15 means inter-viewable). According to the MDS, Resident 1 required a one-person physical assist in all ADLs (activities of daily living) except, eating and personal hygiene. On 8/10/16 at 8:10 a.m., RN 5 stated, after reviewing Resident 1's clinical record, there was no physician's order to flush Resident 1's ear as stipulated on the ear solution container. RN 1 stated there should have been an order before the nurses were flushing Resident 1's ear. RN 1 stated she will call the physician to get an order to flush Resident 1's left ear. At 7:42 a.m., on 8 /15/16, LVN 7, who was Resident 1's medication nurse, stated she had been flushing Resident 1's ear with warm water since the ear drops were ordered. LVN 7 stated she followed the ear solution container and not the MAR. e. On 8/9/16 at 10:13 a.m., during a medication pass observation, Resident 25 was receiving oxygen 2 liter per nasal cannula ((N/C) a small tube to infuse oxygen). A review of Resident 25's Admission Face Sheet indicated Resident 25 was admitted to the facility on [DATE]. Resident 25's [DIAGNOSES REDACTED]. A review of Resident 25's Minimum Data Set (MDS), dated ,[DATE], indicated Resident 25 was non-English speaking (Korean) was unable to understand and be understood with memory problems. According to the MDS, Resident 25 was non-ambulatory and totally dependent upon staff for all care. On 8/10/16 at 9:15 a.m., during another medication pass observation, Resident 25 continued to receive oxygen therapy at one liter per N/C. A review of Resident 25's physician orders indicated there was no physician order for [REDACTED]. At 9:32 a.m., on 8/10/16, RN 5 reviewed Resident 25's physician orders and stated there was not an order for [REDACTED]. RN 5 stated she will call the physician and get an order for [REDACTED]. At 12:05 p.m., on 8/10/16, RN 5 stated the physician only ordered Resident 25 to have oxygen PRN (as needed) and she stated had since create a care plan and provided an inservice for oxygen use. A review of Resident 25's MAR indicated Resident 25's oxygen saturation level after receiving no oxygen had been normal on room air ranging from 94-97 percent ( %). A review of the facility's undated policy titled, Policy and Procedure on Oxygen Therapy, indicated administration of oxygen therapy shall be with physician's orders, except under emergency situations. f. A review of Resident 18's Admission Record indicated Resident 18 was admitted to the facility on [DATE], and recently readmitted on [DATE]. Resident 18's [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), an assessment an care screening tool, dated 7/2016, indicated Resident 18 was alert with good recall and memory (brief interview for mental status (BIMS) score of 14). According to the MDS, Resident 18 required assistance with a one-person physical assist with most activity of daily living. During an interview on 8/10/16 at 7:35 a.m., with Resident 18, stated that staff were not checking his [MEDICAL TREATMENT] access. During a concurrent interview with a licensed vocational nurse (LVN 8) stated she checks Resident 18's A-V fistula every four hours ((sic) Resident 18 had a [MEDICAL TREATMENT] catheter, not an AV fistula (a direct connection of an artery to a vein for a [MEDICAL TREATMENT] access)). LVN 8 stated she checked Resident 18's [MEDICAL TREATMENT] site by eyesight only. LVN 8 was questioned about what would she do in an emergency situation regarding the catheter site bleeding or catheter tip breaking off. LVN 8 stated she would apply pressure and call the physician. However, a record review of Resident 18's nurses notes indicated multiple documentation that Resident 18's catheter of assessment of bruit/thrill. However, Resident 18 did not have an AV fistula, but a catheter (bruit and thrills are only checked for AV shunts). There was also no documented plan for Resident 18 in case of an emergency management, such as bleeding. On 8/9/16 at 3:20 p.m., during an interview, LVN 9 was questioned about Resident 18's [MEDICAL TREATMENT] assessment and stated, If I am not mistaken both are same right (referring to the A/V fistula and catheter).? According to an online article by Davita [MEDICAL TREATMENT] Center, regarding AV shunts, indicated the vibration of blood going through an arm is called the thrill, and it should be checked several times a day, because if the thrill changes or stops it could be indicative of a blood clot formation and the physician should be immediately contacted. The bruit is assessed by using a stethoscope (an acoustic medical device for auscultation, or listening to the internal sounds), or even putting your ear to the access, you can hear the sound of blood flowing through the access site. If the sound increases in pitch or like a [MEDICATION NAME], the blood vessels could be tightening (called stenosis) and if severe, blood flow could be cut cut off completely. https://www.davita.com/kidney-disease/[MEDICAL TREATMENT]/treatment/arteriovenous-av-fistula-%2597-the-gold-standard-[MEDICAL TREATMENT]-access/e/1301

Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Residents 5 and 6) received the necessary care and services to prevent urinary tract infections ([MEDICAL CONDITION] a disease caused by microorganisms that invade the tissue of the kidneys, bladder, or urethra (tube leads to the bladder)), urethra trauma and had a medical justification for the continued use of an indwelling urinary catheter (tube inserted into the bladder via the urethra to drain urine). Resident 5, who had a urinary catheter placed per the family's request, had history of repeated urinary tract infections and pulling the urinary catheter out and sustaining penile ulcers (a sore on the skin or a mucous membrane of the penis). This deficient practice resulted in Resident 5 pulling the indwelling urinary catheter out several times causing trauma to the urethra (transports urine from the bladder to the outside of the body) by repeatedly pulling the catheter out, and having multiple UTIs, which put Resident 5 at risk for urosepsis (Sepsis is a life-threatening bacterial infection of the blood; urosepsis [MEDICAL CONDITION] that complicates a urinary tract infection), which could lead to death. Resident 6, who had an indwelling urinary catheter for wound care management (Stage IV pressure ulcers (deep sores caused by extended pressure)), had a history of [REDACTED]. This deficient practice resulted in Resident 6 having a UTI, trauma to the urethra (fibromuscular tube in that body that drains urine from the bladder), and hematuria (blood in the urine), which had the potential to result in a serious infection that can lead to death. Findings: a.On 8/8/16 at 8:10 a.m., during the facility's tour, accompanied by a registered nurse (RN 8), Resident 5 was observed lying in bed with an indwelling catheter draining blood-tinged urine with sediment ( presence of cells, casts, bacteria, crystals, etc.) in the tubing. RN 8 stated a urinalysis (a test performed on urine to assess for bacteria etc.) and C/S ((culture & sensitivity) performed to determine the presence of pathogenic bacteria for suspected urinary tract infection) were obtained on 8/7/16, to rule out a urinary tract infection. A review of Resident 5's Admission Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/25/16, indicated Resident 5's memory was impaired as evident by a brief interview of mental status (BIMS) score of 3 (score of 8-15 means inter-viewable). According to the MDS, Resident 5 did not have recall and was non-English speaking and spoke Russian. Resident 5 was non-ambulatory (unable to walk) and required an extensive one-person assist with activities of daily living (ADLs), such as dressing, eating, toilet use, and personal hygiene (shaving, brushing teeth, and combing hair) and total assistance with bathing. Several MDS, dated [DATE] (admission MDS), 7/12/16, and 7/19/16, under Section H0300 (urinary continence) indicated Resident 5's indwelling catheter had been in place since January 2016, without a medical justification. A review of an electronic nurses' note, dated 2/14/16 on the 7-3 p.m. shift, Resident 5 pulled out the indwelling catheter. The noted indicated Resident 5's family member visited and insisted the catheter be re-inserted. Urinary catheter was re-inserted. A review of an electronic nurses' note, dated 2/29/16, not timed, indicated Resident 5 was positive for VRE ([MEDICATION NAME]-resistant [MEDICATION NAME] are bacterial [MEDICATION NAME] that are resistant to the antibiotic [MEDICATION NAME]) in the urine and was started on Linezoid (an antibiotic used for the treatment of [REDACTED]. A review of an electronic nurses 'note, dated 3/11/16, and timed at 5 p.m., indicated Resident 5 had a positive UA of > 100, 00 colonies of Escherichia coli. Resident 5 was started [MEDICATION NAME](([MEDICATION NAME]) an antibiotic) 500 mg twice a day for 7 days for the UTI. A review of an electronic nurses' note, dated 4/19/16, and timed at 4:33 p.m., indicated Resident 5 was observed pulling on the urinary catheter. Another electronic note, the same day timed at 10:57 a.m., indicated there was an ulceration (a sore on the skin or a mucous membrane) on the tip of Resident 5's penis due to the Foley catheter. The note indicated the family was at the bedside and was informed that resident 5 did not have an indication for the use of an indwelling urinary catheter. A review of an electronic nurses' note, dated 4/20/16 (late entry), with a time of 10:36 a.m., indicated Resident 5's physician was called for permission to remove the indwelling urinary catheter due to Resident 5's constant pulling on it resulting in a penile ulceration. The note indicated physician stated, To call the resident's (Resident 5) family member and asked them. A review of a Licensed Nurses Weekly Summary, dated 6/27/16, indicated Resident 5 continued to have an indwelling urinary catheter and was currently being treated with antibiotics for a UTI. A review of a care plan, dated 7/6/16, and revised on 8/5/16 titled Resident has a Foley Catheter per Family's Request, indicated the resident would be free catheter-related trauma and UTIs. The staff ' s approaches included monitoring, record, and report signs of UTI, which included pain, burning, blood-tinged urine, cloudiness, elevated temperature, change in behavior and eating habits. A review of Resident 5's nurse's note, dated 8/7/16, and timed at 7-3 p.m. shift, indicated hematuria (blood in urine) was noted in Resident 5's indwelling urinary catheter. A review of a SBAR (situation, background, assessment and recommendation), dated 8/7/16, and timed at 12 p.m., indicated Resident 5 had hematuria (the presence of red blood cells (erythrocytes) in the urine) in the indwelling urinary catheter. The physician was notified with orders for Resident 5 to have a U/A and C/S. On 8/10/16 at 2 p.m., during a telephone interview, Resident 5's family member stated, We want him (Resident 5) to have a Foley catheter because the staff would let him stay wet, which would cause problems for his skin. Resident 5's family member stated the facility ' s nurses were not knowledgeable or well-trained. He stated one time they came to visit Resident 5 and he was found with blood everywhere after Resident 5 had pulled the indwelling catheter out and there was not a nurse in site. Resident 5's family member stated last week they had to tell the facility's staff about the blood in his (Resident 5) catheter and they asked for a UA and C/S to be performed. A review of Resident 5's UA laboratory results, collected on 8/7/16 and completed on 8/8/16, indicated the urine was straw-amber in color and cloudy many bacteria, > (greater than) 30 red blood cells (normal reference range (NRR) is 0-2) and >50 while blood cells (NRR is 0-5). The C/S, completed on 8/10/16, indicated there was >100,000 colonies of Proteus mirabilis. According to an online article, dated June 2012, titled Proteus mirabilis urinary tract infection and bacteremia, indicated Proteus mirabilis (a species of anaerobic, motile, rod-shaped bacteria found in putrid meat, abscesses, and fecal material and a common disease causing microorganism responsible for complicated UTIs that sometimes causes bacteremia (bacteria in the blood). <http://www.ncbi.nlm.nih.gov/pubmed/ 004> A review of Resident 5's physician's order, dated 8/11/16, and timed at 8:39 a.m., indicated to start Resident 5 on [MEDICATION NAME] (an antibiotic, used for treatment of [REDACTED]. The physician discontinued Bactrim DS that Resident 5 was receiving started on 8/7/16 for the right foot wound. A review of Resident 5's care plan, dated 8/11/16, and titled, Alteration in health Maintenance - Requires antibiotic for the treatment of [REDACTED]. On 8/15/16 at 3:26 p.m., during an interview, the director of nursing (DON) stated if a resident's family member request for a resident to have an indwelling urinary catheter and the physician approves the family's request, then we would honor it. The DON stated Resident 5's family was close to Resident 5's physician. The DON stated she does not like for residents to have urinary catheter, unless it was necessary, because it results in UTIs and sometimes urosepsis (a life-threatening bacterial infection of the blood; urosepsis [MEDICAL CONDITION] that complicates a urinary tract infection). According to an online article, dated 8/18/15, titled Catheter-Related Urinary Tract Infection, by Medscape Reference, indicated catheter-related urinary tract infection [MEDICAL CONDITION] occurs because urethral catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and causing mucosal irritation. The article stipulated the presence of a urinary catheter is the most important risk factor for bacteriuria (the presence of bacteria in the urine). Other bacteriuria factors included residents catheterized for longer duration, diarrhea, [MEDICAL CONDITION], and errors in catheter care (http://emedicine.medscape.com/article/ 35-overview). b. On 8/8/16 at 7:40 a.m., during the facility's initial tour, accompanied by a licensed vocational nurse (LVN 9), Resident 6 was observed in bed with eyes closed, lying in a supine position (back) with bilateral hand mittens. LVN 9 stated Resident 6 had bilateral hand mittens Resident 6 pulled out the indwelling urinary catheter (tube inserted into the bladder via the urethra to drain urine) the night before and had a history of [REDACTED]. A review of Resident 6's Admission Face Sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's [DIAGNOSES REDACTED]. and social symptoms that interfere with daily function), and an enlarged prostate (age associated prostate gland enlargement that can cause urination difficulty). A review of Resident 6's admission Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/1/16, indicated Resident 6's cognitive skills for daily decision-making were moderately impaired. Resident 6 was totally dependent on staff with transferring and required extensive assistance with personal hygiene. According to the MDS, Resident 6 had an indwelling urinary catheter (tube inserted into the bladder via the urethra) for urine to drain freely, and was always incontinent (involuntary control) of bowel movements. The MDS indicated Resident 6 had three Stage IV pressure ulcers and two unstageable pressure ulcers (full thickness skin and tissue loss) that were present upon admission. A review of Resident 6's physician telephone order, dated 6/25/16, and timed at 2:30 p.m., indicated to insert an indwelling urinary catheter for wound management and to notify the physician when the catheter was occluded (blocked) or leaking every day. A review of Resident 6's undated of Urinary Incontinence Assessment indicated Resident 6 had a history of [REDACTED]. A review of Resident 6's Medication Administration Record [REDACTED]. A review of a Licensed Personnel Progress Note, dated 7/28/16, and timed at 8:30 a.m., indicated a licensed vocational nurse (LVN 9) documented a late entry on 7/27/16, timed at 10 a.m., indicating Resident 6 had a behavior of pulling out the urinary catheter and had blood tinged urine. On 8/9/16 at 4 p.m., during a family interview, Resident 6's family member (FM 2) stated a few weeks prior, she found Resident 6 in the bed bleeding from his penis. FM 2 stated Resident 6 had pulled the indwelling urinary catheter out and the tubing was coiled around Resident 6's leg. FM 2 stated due to Resident 6's confusion he had the tendency to touch his penis, but did not have the capability to coil the indwelling urinary catheter around his leg. A review of an SBAR ((situation, background, assessment, and recommendations) communication tool indicating a resident's change of condition), dated 7/27/16, and timed at 9:30 p.m., indicated Resident 6 had hematuria (blood in the urine) with a low grade temperature. The SBAR indicated Resident 6 was noted sweating, warm to touch, had 100 milliliters (ml) of hematuria, an oral temperature of 99.5 degrees Fahrenheit (F) (normal reference range (NRR) is 98.6 F to 100.4 degrees F), and had a pulse of 116 beats per minute (NRR is 60 to 100 beats per minute). The SBAR indicated laboratory tests were completed. A review of Residents 6's physician's telephone order, dated 7/27/16, and timed at 9:48 p.m., indicated orders for complete blood count laboratory test, urinalysis (evaluates a sample of the urine), and urine culture sensitivity (a test that identifies the bacteria causing the infection in the urine). A review of Residents 6's physician telephone order, dated 7/27/16 and timed at 6:22 a.m., indicated orders for Resident 6 to receive [MEDICATION NAME] (an antibiotic medication to treat bacterial infections) tablet 500 mg orally, twice a day for UTI and hematuria for seven days, until 8/3/16. A review of a Licensed Personnel Progress Notes, dated 7/28/16 timed at 9 a.m. indicated Resident 6's penis was bleeding due to indwelling urinary catheter trauma. According to the registered nurse's (RN 6) documentation in the Resident 6's progress note, Resident 6 had a history of [REDACTED]. A review of a Diagnostic Laboratories and Radiology report, dated 7/28/16, indicated Resident 6's white blood cell count ((WBC) important part of the immune system to help fight infections by attacking bacteria) was elevated with abnormal levels of 15.66 (NRR is 4.00 to 10.00). The report indicated Resident 6's urine had a red colored turbid (cloudy) appearance, blood in the urine, and both red and white blood cells were present in the Resident 6 's urine. A review of the Diagnostic Laboratories and Radiology report, dated 7/30/16, indicated Resident 6's urinalysis and urine culture sensitivity result was positive for Escherichia Coli (E. Coli), a gram negative bacteria found in the environment, foods, and intestines of people and animals and [MEDICATION NAME] Spp organism (gram positive bacteria commonly found in urinary tract infections). A review of Resident 6's physician telephone order, dated 7/28/16 and timed at 9:22 a.m., indicated to reinsert the indwelling urinary catheter on 7/29/16, one time only for three days. A review of a physician's telephone order, dated 7/29/16, and timed at 9 a.m., indicated to discontinue Resident 6's indwelling urinary catheter, and to use a condom catheter (an external catheter made up of a rubber sheath, fit over the penis and connected to a tube attached to a drainage bag for urine to collect) for wound management. A review of Resident 6's physician telephone order, dated 8/1/16 and timed at 10 a.m., indicated to reinsert the indwelling urinary catheter and provide indwelling urinary catheter care. A review of the SBAR, dated 8/7/16 and timed at 10:30 p.m., indicated Resident 6 pulled out the urinary catheter and had minimal bleeding. The SBAR indicated a certified nursing assistant (CNA) was changing Resident 6 and the resident spontaneously pulled out the indwelling urinary catheter with the balloon (part of the catheter tube inflated to hold the catheter in place) still inflated. On 8/8/16 at 1:05 p.m., during an interview, CNA 6 stated Resident 6 had a condom catheter because Resident 6 pulled out the indwelling urinary catheter the night before. CNA 6 stated the resident pulled out the indwelling urinary catheter more than once in the past. A review of a Licensed Personnel Progress Note, dated 8/8/16, and timed at 2 p.m., indicated Resident 6 had a condom catheter. A review of a Licensed Personnel Progress Note, dated 8/9/16 and timed at 12 p.m., indicated a late entry documented for 8/8/16, on the 11 to 7 a.m. shift, that Resident 6 had slight bleeding noted in the urinary bag. On 8/9/16 at 10:07 a.m., during Resident 6's wound care treatment observation, the condom catheter was detached from Resident 6 and the resident was soiled with urine when CNA 4 lifted the Resident 6's bed sheet. The condom catheter's tubing was not anchored to the Resident 6's leg and did not have a device to hold it in place. A review of a Licensed Personnel Progress Note, dated 8/9/16, and timed at 11 p.m., indicated Resident 6 had a condom catheter intact with no bleeding noted. A review of Resident 6's physician orders did not indicate an order until 8/11/16, to apply a condom catheter, after the physician had ordered to reinsert Resident 6's indwelling urinary catheter on 8/1/16. A review of the facility's undated policy and procedure titled, External (Condom) Catheter, indicated it is the facility's policy to apply external catheters only with a physician's order. A review of Resident 6's physician and telephone orders, dated 8/11/16, and timed at 5 p.m., indicated to discontinue Resident 6's urinary catheter and apply the condom catheter for skin and wound management. The physician's order to apply a condom catheter on Resident 6 was ordered three days after Resident 6 was observed with a condom catheter. On 8/9/16 at 2 p.m., during an interview and a concurrent record review of Resident 6's medical record, the director of nurses (DON) stated there was only one entry documented by a licensed nurse indicating Resident 6's behavioral tendency of pulling out the urinary catheter. The entry was documented on 7/28/16, as a late entry, after Resident 6 pulled out the urinary catheter for the first time. No other documentation prior to Resident 6 pulling out the indwelling urinary catheter was found in the medical record to indicate Resident 6's behavior, and to prevent recurrence of accidental catheter dislodgement. On 8/10/16 at 9:40 a.m., during a wound treatment observation, Resident 6's condom catheter was intact; however, the condom catheter's tubing was not anchored to Resident 6's leg. There was no device to hold the tubing in place. On 8/10/16 at 9:42 a.m., during an interview, LVN 11 stated the condom catheter's tubing should be secured to the resident's leg but the tubing sometimes does not fit into the Stat Lock (brand name for a stabilization device to hold the urinary catheters in place). LVN 11 stated she will find something to secure the tubing. According to the American Journal of Nursing, dated December 2008, indication for securing or anchoring indwelling urinary catheter tubing included inadvertent catheter dislodgement, prevention if urethral trauma or erosion (gradual breaking down: the gradual destruction or reduction and weakening of something), irritation, discomfort and pain with catheter movement, and reduction of the risk of infection from repeated reinsertion of the indwelling urinary catheter. <http://journals.lww.com/ajnonline/Abstract/2008/ /Securing_the_Indwelling_Catheter.25.aspx> A review of Resident 6's care plan, titled, The Resident has Urinary Catheter for Wound Management and Incontinent for Bowel Function, dated 7/4/16, indicated the goal for Resident 6 to remain free from catheter-related trauma daily. According to the care plan, the staff's intervention was to check catheter tubing for kinks (twist or curve something that is otherwise straight), and indicate the number of times kinks noted each shift. However, the care plan was not revised after the staff observed Resident 6 pull out the urinary catheter on two separate occasions. A review of the facility's undated policy and procedure titled, Foley/Indwelling catheter, indicated the staff's care approaches should reflect steps to secure or anchor catheter to facilitate flow of urine and prevent excessive tension on the catheter. The policy indicated plan of care to monitor for complications resulting from use of a urinary catheter. Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Residents 5 and 6) received the necessary care and services to prevent urinary tract infections ([MEDICAL CONDITION] a disease caused by microorganisms that invade the tissue of the kidneys, bladder, or urethra (tube leads to the bladder)), urethra trauma and had a medical justification for the continued use of an indwelling urinary catheter (tube inserted into the bladder via the urethra to drain urine). Resident 5, who had a urinary catheter placed per the family ' s request, had history of repeated urinary tract infections and pulling the urinary catheter out and sustaining penile ulcers (a sore on the skin or a mucous membrane of the penis). This deficient practice resulted in Resident 5 pulling the indwelling urinary catheter out several times causing trauma to the urethra (transports urine from the bladder to the outside of the body) by repeatedly pulling the catheter out, and having multiple UTIs, which put Resident 5 at risk for urosepsis (Sepsis is a life-threatening bacterial infection of the blood; urosepsis [MEDICAL CONDITION] that complicates a urinary tract infection), which could lead to death. Resident 6, who had an indwelling urinary catheter for wound care management (Stage IV pressure ulcers (deep sores caused by extended pressure)), had a history of [REDACTED]. This deficient practice resulted in Resident 6 having a UTI, trauma to the urethra (fibromuscular tube in that body that drains urine from the bladder), and hematuria (blood in the urine), which had the potential to result in a serious infection that can lead to death. Findings: a.On 8/8/16 at 8:10 a.m., during the facility's tour, accompanied by a registered nurse (RN 8), Resident 5 was observed lying in bed with an indwelling catheter draining blood-tinged urine with sediment ( presence of cells, casts, bacteria, crystals, etc.) in the tubing. RN 8 stated a urinalysis (a test performed on urine to assess for bacteria etc.) and C/S ((culture & sensitivity) performed to determine the presence of pathogenic bacteria for suspected urinary tract infection) were obtained on 8/7/16, to rule out a urinary tract infection. A review of Resident 5's Admission Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/25/16, indicated Resident 5's memory was impaired as evident by a brief interview of mental status (BIMS) score of 3 (score of 8-15 means inter-viewable). According to the MDS, Resident 5 did not have recall and was non-English speaking and spoke Russian. Resident 5 was non-ambulatory (unable to walk) and required an extensive one-person assist with activities of daily living (ADLs), such as dressing, eating, toilet use, and personal hygiene (shaving, brushing teeth, and combing hair) and total assistance with bathing. Several MDS, dated [DATE] (admission MDS), 7/12/16, and 7/19/16, under Section H0300 (urinary continence) indicated Resident 5's indwelling catheter had been in place since January 2016, without a medical justification. A review of an electronic nurses' note, dated 2/14/16 on the 7-3 p.m. shift, Resident 5 pulled out the indwelling catheter. The noted indicated Resident 5's family member visited and insisted the catheter be re-inserted. Urinary catheter was re-inserted. A review of an electronic nurses' note, dated 2/29/16, not timed, indicated Resident 5 was positive for VRE ([MEDICATION NAME]-resistant [MEDICATION NAME] are bacterial [MEDICATION NAME] that are resistant to the antibiotic [MEDICATION NAME]) in the urine and was started on Linezoid (an antibiotic used for the treatment of [REDACTED]. A review of an electronic nurses 'note, dated 3/11/16, and timed at 5 p.m., indicated Resident 5 had a positive UA of > 100, 00 colonies of Escherichia coli. Resident 5 was started [MEDICATION NAME](([MEDICATION NAME]) an antibiotic) 500 mg twice a day for 7 days for the UTI. A review of an electronic nurses' note, dated 4/19/16, and timed at 4:33 p.m., indicated Resident 5 was observed pulling on the urinary catheter. Another electronic note, the same day timed at 10:57 a.m., indicated there was an ulceration (a sore on the skin or a mucous membrane) on the tip of Resident 5's penis due to the Foley catheter. The note indicated the family was at the bedside and was informed that resident 5 did not have an indication for the use of an indwelling urinary catheter. A review of an electronic nurses' note, dated 4/20/16 (late entry), with a time of 10:36 a.m., indicated Resident 5's physician was called for permission to remove the indwelling urinary catheter due to Resident 5's constant pulling on it resulting in a penile ulceration. The note indicated physician stated, To call the resident's (Resident 5) family member and asked them. A review of a Licensed Nurses Weekly Summary, dated 6/27/16, indicated Resident 5 continued to have an indwelling urinary catheter and was currently being treated with antibiotics for a UTI. A review of a care plan, dated 7/6/16, and revised on 8/5/16 titled Resident has a Foley Catheter per Family's Request, indicated the resident would be free catheter-related trauma and UTIs. The staff ' s approaches included monitoring, record, and report signs of UTI, which included pain, burning, blood-tinged urine, cloudiness, elevated temperature, change in behavior and eating habits. A review of Resident 5's nurse's note, dated 8/7/16, and timed at 7-3 p.m. shift, indicated hematuria (blood in urine) was noted in Resident 5's indwelling urinary catheter. A review of a SBAR (situation, background, assessment and recommendation), dated 8/7/16, and timed at 12 p.m., indicated Resident 5 had hematuria (the presence of red blood cells (erythrocytes) in the urine) in the indwelling urinary catheter. The physician was notified with orders for Resident 5 to have a U/A and C/S. On 8/10/16 at 2 p.m., during a telephone interview, Resident 5's family member stated, We want him (Resident 5) to have a Foley catheter because the staff would let him stay wet, which would cause problems for his skin. Resident 5's family member stated the facility ' s nurses were not knowledgeable or well-trained. He stated one time they came to visit Resident 5 and he was found with blood everywhere after Resident 5 had pulled the indwelling catheter out and there was not a nurse in site. Resident 5's family member stated last week they had to tell the facility's staff about the blood in his (Resident 5) catheter and they asked for a UA and C/S to be performed. A review of Resident 5's UA laboratory results, collected on 8/7/16 and completed on 8/8/16, indicated the urine was straw-amber in color and cloudy many bacteria, > (greater than) 30 red blood cells (normal reference range (NRR) is 0-2) and >50 while blood cells (NRR is 0-5). The C/S, completed on 8/10/16, indicated there was >100,000 colonies of Proteus mirabilis. According to an online article, dated June 2012, titled Proteus mirabilis urinary tract infection and bacteremia, indicated Proteus mirabilis (a species of anaerobic, motile, rod-shaped bacteria found in putrid meat, abscesses, and fecal material and a common disease causing microorganism responsible for complicated UTIs that sometimes causes bacteremia (bacteria in the blood). <http://www.ncbi.nlm.nih.gov/pubmed/ 004> A review of Resident 5's physician's order, dated 8/11/16, and timed at 8:39 a.m., indicated to start Resident 5 on [MEDICATION NAME] (an antibiotic, used for treatment of [REDACTED]. The physician discontinued Bactrim DS that Resident 5 was receiving started on 8/7/16 for the right foot wound. A review of Resident 5's care plan, dated 8/11/16, and titled, Alteration in health Maintenance - Requires antibiotic for the treatment of [REDACTED]. On 8/15/16 at 3:26 p.m., during an interview, the director of nursing (DON) stated if a resident's family member request for a resident to have an indwelling urinary catheter and the physician approves the family's request, then we would honor it. The DON stated Resident 5's family was close to Resident 5's physician. The DON stated she does not like for residents to have urinary catheter, unless it was necessary, because it results in UTIs and sometimes urosepsis (a life-threatening bacterial infection of the blood; urosepsis [MEDICAL CONDITION] that complicates a urinary tract infection). According to an online article, dated 8/18/15, titled Catheter-Related Urinary Tract Infection, by Medscape Reference, indicated catheter-related urinary tract infection [MEDICAL CONDITION] occurs because urethral catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and causing mucosal irritation. The article stipulated the presence of a urinary catheter is the most important risk factor for bacteriuria (the presence of bacteria in the urine). Other bacteriuria factors included residents catheterized for longer duration, diarrhea, [MEDICAL CONDITION], and errors in catheter care (http://emedicine.medscape.com/article/ 35-overview).

Based on interview and record review, the facility failed to ensure one of three sampled residents, Resident 1, who had a hard cast to the left lower extremity from the thigh to the beginning of the toes: 1. The licensed nurses monitored the exposed toes of the left foot for signs and symptoms of infection (such as odor, presence of fluid or drainage and increased temperature of the area), for circulation on the toes, changes in size, color, and presence of pain on the left foot. 2. The physician's orders [REDACTED]. 3. A care plan was developed for the care and use of a hard cast. 4. A policy and procedure was in place regarding cast care. As a result Resident 1 developed gangrene (dead tissue caused by an infection or lack of blood flow) of the left toes and a pressure sore Stage IV (deep ulcer with damage to the muscle and bone caused by pressure) to the dorsum (the upper surface) of the left foot. Findings: On August 10, 2015, at 10 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Quality of Care. A review of the clinical record indicated Resident 1 was initially admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized assessment care and screening tool), dated June 4, 2015, indicated Resident 1 was severely impaired in cognitive skills for daily decision-making and required total assistance from staff for activities with daily living. A review of Resident 1's history and physical examination [REDACTED]. A splint is a strip of rigid material used for supporting and immobilizing a broken bone of a limb that can easily be removed, while a cast is a shell made from plaster encasing a limb to stabilize and hold broken bones in place until healing. A cast removal requires special equipment. A review of the physician's orders [REDACTED]. According to the recapitulated physician's orders [REDACTED]. A review of the clinical record indicated there was no plan of care developed or updated regarding cast care (no longer a splint) to be provided to Resident 1. A review of Resident 1's physician's progress notes, dated June 22 and 29, 2015, documented by the nurse practitioner, indicated the resident had a cast, but there was no documentation of an assessment regarding the skin condition of the left toes. On June 29, 2015, the nurse practitioner documentation did not indicate the presence of any adverse changes to the left foot. The nursing notes, dated from May 29, 2015 through June 29, 2015, had no documented evidence the licensed nurse assessed the skin condition of Resident 1's left toes or the presence of a cast or a splint. A review of the Treatment Administration Record (TAR), dated from May 29 to June 29, 2015, indicated the licensed nurses monitored daily Resident 1's left lower extremity splint; however, there was no documentation the nurses monitored the blood circulation, by doing a capillary refill test (time taken for color to return to the area where pressure was applied to cause blanching), and there was no documentation of an assessment of the toes being warm / cool to touch, the presence/absence of pain on the toes, changes in size, presence or absence of swelling, or any other abnormality. There was no documentation regarding cast care provided to Resident 1. On June 29, 2015, at 4:15 p.m., the clinical record indicated Resident 1 went to a physician's appointment (Physician 3, primary care physician) and was found to have a dry gangrene on the left toes. The resident was transferred from the physician's office to a general acute care hospital (GACH). According to the GACH emergency room Physician's Progress Note, dated June 29, 2015, Resident 1 was found with Stage III/IV pressure sore (full thickness skin loss) to the left dorsum of foot, the left second toe was found with a Stage III pressure sore, and dry gangrene of all the toes of the left foot. The GACH treatment orders indicated a [DEVICE] (promotes healing through negative pressure wound therapy) or skin graft for the left dorsum Stage III/IV pressure sore and a recommendation of amputation of left toes gangrene. During an interview with the Director of Nursing (DON), on August 10, 2015, at 10 a.m., he stated Resident 1 was admitted to the facility with a splint and a cast extending from the left thigh to the foot, exposing the resident's toes. The DON, after reviewing the clinical record, stated there was no care plan developed for Resident 1's cast care and the facility had no policy and procedure addressing cast care. The DON stated Resident 1's nurse practitioner visited the resident frequently and on the nurse practitioner's last note, dated June 29, 2015, did not indicate Resident 1 had gangrene on the left toes. When asked if the treatment nurse had any documentation regarding Resident 1, the DON stated the treatment nurse would only document abnormal skin conditions if they were present. On September 1, 2015, at 2:30 p.m., during a telephone interview, Resident 1's nurse practitioner stated Resident 1 had a splint upon admission to the facility and was placed on a hard cast during the orthopedist visit (on June 3, 2015). During an interview with Licensed Vocational Nurse 1 (LVN 1), the treatment nurse, on August 10, 2015, at 11 a.m., he stated Resident 1's left leg was covered with a hard cast, and there was also a splint placed on top of the cast, while the resident's toes were exposed. When LVN 1 was asked how he monitored the resident's leg on a cast, he stated he checked the cast by placing his finger inside the cast, to check if there was a clearance of one inch from skin to cast. LVN 1 stated he elevated Resident 1's left leg, placed it on a pillow, and the resident's left toes had no discoloration and had no foul smelling odor. LVN 1 stated Resident 1's left toes were normal looking when he left the faciity on [DATE]. LVN 1 did not indicate if blood circulation and skin temperature of the left toes were monitored. According to mayoclinic.org, April 2015, for cast care contact the physician if : · Any increasing pain and tightness in the injured limb · Any numbness or tingling in the injured hand or foot · Any burning or stinging under the cast · Develops excessive swelling below the cast · Unable to move the toes or fingers of the injured limb or they become blue or cold · Develops a crack, soft spots or a foul odor in cast or gets the cast soaking wet and does not dry it properly · Patient says the cast feels too tight or too loose · Develops red or raw skin around the cast · Develops a fever of 101 F (38.3 C) or higher

Based on observation, interview, and record review, the facility failed to ensure timely blood sugar monitoring and administration of insulin per sliding scale (a set of instructions for administering dosages based on specific blood sugar readings) before meals, and administration of medications as ordered by the physician, and as stated in the plan of care and the facility's policy and procedure for 12 of 24 sample residents (3, 4, 6, 8, 9, 12, 15, 16, 17, 18, 19, and 20), and 11 randomly selected residents (25, 26, 27, 28, 29, 30, 31, 32, 33, 35, and 36) for a total of 23 out of 35 residents under the care of LVN 1 who was in charge of Medication Cart #2 in Nursing Station B. For 14 of 16 diabetic residents (Residents 3, 4, 8, 12, 17, 19, 20, 27, 28, 29, 30, 31, 32, and 33) out of 35 residents under the care of LVN 1, their blood sugar monitoring, which was ordered to be taken before lunch at 11:30 a.m. or 12 noon, were performed after lunch starting at 1:25 p.m. The one and a half up to two hours delay in monitoring and the lack of knowledge exhibited by LVN 1 regarding different types of insulin in relation to mealtime could have resulted in serious hypoglycemic (low blood sugar level) or hyperglycemic (high blood sugar level) reaction. For three of the 14 residents with delayed blood sugar monitoring (Resident 8, 17, and 19), insulin per sliding scale was administered for high blood sugar level. However, the elevated results were inaccurate because their levels were taken after they had eaten lunch. For 11 residents, Residents 6, 8, 9, 15, 16, 18, 20, 25, 26, 35, and 36, their morning prescribed medications were administered late which placed the residents at risk for complications and ineffective drug therapy. For Resident 8, an order to notify the physician if the blood sugar was over 400 milligrams per deciliters (mg/dL) was not implemented and the order to remove the [MEDICAL TREATMENT] shunt (access site) dressing four hours following the completion of [MEDICAL TREATMENT] was not followed which had the potential for delayed intervention and complications. Nursing Station B had a total census of 62 residents and two licensed nurses to pass medications during the 7 a.m. to 3 p.m. (day) shift. However, Nursing Station B had only one licensed nurse to pass medications during the 3 p.m. to 11 p.m. (evening) shift and the 11 p.m. to 7 a.m. (night) shift. LVN 1 was in charge of administering prescribed medications to 35 residents. 16 of 35 residents were diabetics and required blood sugar monitoring and insulin administration per sliding scale before meals, and 10 residents required administration of medications and nutrition via GT. Six of the 16 diabetic residents had GT. Compared to other licensed nurses during the day shift, LVN 1 was in charge of the most number of residents, most diabetic residents requiring blood sugar monitoring and insulin administration per sliding scale before meals, and more residents with GT. A week prior to the survey, LVN 1 informed the DON about her heavy assignment. On 10/8/12, three days prior to the survey, LVN 1 was followed by a nurse consultant during medication pass. According to LVN 1, the nurse consultant identified concerns about her workload and stated would recommend to reduce the workload burden. The DON acknowledged he was aware of the concerns brought up by LVN 1 and the nurse consultant. The facility had a system failure by not implementing corrective actions after identifying LVN 1's workload was heavy which resulted in delayed blood sugar monitoring and delayed administration of medications. On 10/11/12, at 3:50 p.m., the survey team declared an Immediate Jeopardy (IJ) and the facility's administrator, assistant administrator, and director of nursing were immediately notified of the serious findings. The facility developed an action plan in response to the IJ. The facility's action plan included the following: 1. Adding a third licensed nurse on Nursing Stations B to pass medications during the 7-3 shift, 2. Adding a second licensed nurse to pass medications during the 3-11 shift; 3. Removal of LVN 1 from administering medications; 4. Providing in-services to licensed nurses on timely medication administration, different actions of insulin, and on the importance of timely blood sugar monitoring; and 5. Scheduling a QA&A (Quality Assessment and Assurance) with the facility's team and the Medical Director the next day, 10/12/12. After verifying that the action plan was implemented, the survey team abated the IJ on the same day, 10/11/12, at 6:40 p.m. and the scope and severity for F-309 was reduced to E. Findings: 1. On 10/11/12, at 12:05 p.m., Resident 6 called the Evaluator into his room and complained he was very upset because it was already noon and he had not yet received his morning medications. At 12:30 p.m., during an interview, LVN 1 stated she was getting ready to finish the morning medication pass. When asked why the medication pass was not completed, LVN 1 explained she had not started the medication pass that morning until after 9 a.m. LVN 1 further stated she never finishes the medication pass on time because her workload was heavy. At 1:20 p.m., during an interview, LVN 1 stated the blood sugar checks ordered before meals at 11:30 a.m. had not been done yet. At 2:45 p.m., during an interview, LVN 1 stated 15 residents had an order for [REDACTED]. During the course of the interview, the MAR binder was reviewed with LVN 1. According to LVN 1, the residents with their corresponding blood sugar results taken starting at 1:25 p.m. were as follows: Resident 3's blood sugar (BS) was 120 mg/dL and no insulin coverage was given, Resident 4's BS was 126 mg/dL and no insulin coverage was given, Resident 8's BS was 400 mg/dL and 10 units of Insulin [MEDICATION NAME] was given. LVN 1 stated she checked the blood sugar level and administered the insulin at 12:30 p.m. with the lunch meal, Resident 12's BS was 95 mg/dL and no insulin coverage was given, Resident 17's BS was 215 mg/dL and three units of [MEDICATION NAME] Insulin was given, Resident 19's BS was 290 mg/dL and six units of Insulin [MEDICATION NAME] was given, Resident 20's BS was 125 mg/dL and no insulin coverage was given, Resident 27's BS was 125 mg/dL and no insulin coverage was given, Resident 28's BS was 93 mg/dL and no insulin coverage was given, Resident 29's BS was 98 mg/dL and no insulin coverage was given, Resident 30's BS was 135 mg/dL and no insulin coverage was given, Resident 31's BS was 116 mg/dL and no insulin coverage was given, Resident 32's BS was 134 mg/dL and no insulin coverage was given; however, this contradicted the MAR indicated [REDACTED] Resident 33's BS was 112 mg/dL and no insulin coverage was given. At 3 p.m. during an interview, LVN 1 stated her regular assignment was to pass medications for residents assigned to Medication Cart 2. LVN 1 stated she spoke to the DON the week prior about her workload. LVN 1 also stated the nurse consultant observed her during a medication pass three days prior on 10/8/12. LVN 1 stated the nurse consultant informed her that she would talk to the DON to divide the number of residents in Nursing Station B more evenly between the station's two medications carts to reduce her workload. As the interview with LVN 1 continued, she was asked if she knew the different types of insulin, such as short-acting and long-acting, in relation to mealtime. LVN 1 was unable to answer and stated regular insulin (a short-acting insulin) was a long acting insulin. When asked what type of insulin is given with food, she did not know. When asked what were the risks of checking blood sugar levels after the prescribed time and the risk of administering the insulin after the residents had already eaten, she did not answer. At 4 p.m., during an interview, the DON acknowledged LVN 1 informed him last week that her workload was heavy and the nurse consultant made a verbal recommendation to divide the residents more evenly between the two medication carts. At 5:30 p.m., LVN 5, who worked the 3-11 shift, stated he was responsible for both medication carts during his shift, a total current census of 62 residents. LVN 5 further indicated he had six residents with orders for FSBS at 4:30 p.m., and 10 residents to be done at 9 p.m. There were also 10 residents with GT who had medications due at 5 p.m., and at 9 p.m. Medication Nurse 3 then stated, "It's hard, but I have to do it." According to the facility's record, Nursing Station B had two medication carts for 62 residents during the 7 a.m. to 3 p.m. shift. 25 of the 62 residents required blood sugar checks by finger stick and 16 residents had GT for medication administration and nutrition. A review of LVN 1's assignment indicated she had 35 of 62 residents under her care. 16 of the 35 residents were diabetics and required blood sugar checks by finger stick and insulin administration per sliding scale before meals, and 10 residents had GT. Six of the 16 diabetic residents had GT. In comparison, Nursing Station A had 60 residents, with 18 residents requiring blood sugar checks by finger stick and six had GT. Therefore, LVN 1 was in charge of the most number of residents, diabetic residents requiring blood sugar checks with insulin administration per sliding scale before meals, and residents with GT. A review of the facility's record also indicated the meals time for Nursing Station A and B were as follows: Breakfast: 7:15 a.m. Lunch: 12:15 p.m. Dinner: 5:15 p.m. A review of Resident 3's clinical record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision-making, did not walk, received nutrition via GT, and needed extensive assistance in the rest of the ADLs. A physician's orders [REDACTED]. 71-130 mg/dL = no insulin coverage 131-150 mg/dL = one unit of insulin 151-200 mg/dL = two units of insulin 201-250 mg/dL = four units of insulin 251-300 mg/dL = six units of insulin 301-350 mg/dL = eight units of insulin 351-400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. According to the care plan, dated 5/27/12, the resident was at risk for hypo/[MEDICAL CONDITION] episodes related to diabetes mellitus and the goal was to minimize further episodes of hypo/[MEDICAL CONDITION] daily for 90 days. One of the approaches indicated to administer Humalog Insulin [MEDICATION NAME] with accucheck (blood sugar check) AC meals (before meals) and QHS (at bedtime). A review of Resident 4's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the resident was able to make his needs known and understand others, and required extensive assistance in ADLs. A physician's orders [REDACTED]. 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. According to the care plan, dated 10/3/12, the resident was at risk for hypo/[MEDICAL CONDITION] related to diabetes and one of the goals was to have no signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered, and administer Regular Insulin per sliding scale before meals and at bedtime. A review of Resident 6's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly assessment MDS, dated [DATE], indicated the resident was alert and able to make his needs known, and required extensive to total assistance from staff for ADLs. A review of Resident 8's clinical record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the resident was alert and able to make his needs known, did not walk, needed supervision when eating and required extensive assistance in the rest of the ADLs. A physician's orders [REDACTED]. 0 -140 mg/dL= no insulin coverage 150 -199 mg/dL = two units of insulin 200 -249 mg/dL = four units of insulin 250 -299 mg/dL = six units of insulin 300 -349 mg/dL = eight units of insulin 350 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. A care plan dated 3/13/12, indicated the resident has labile blood sugars related to diabetes mellitus. The approaches included to obtain the resident's finger stick blood sugars as ordered and FSBS TID (three times a day) before meals with Insulin [MEDICATION NAME] per sliding scale. In addition by 1:20 p.m., the resident had not yet received [MEDICATION NAME] 20 grams (for ammonia level maintenance) orally four times a day, scheduled at 9 a.m., 1 p.m., 5 p.m., and 9 p.m., [MEDICATION NAME] 3200 mg (to reduce blood levels of phosphorus in people with [MEDICAL CONDITION] who are on [MEDICAL TREATMENT]) orally three times daily with meals scheduled at 7:15 a.m., 12:15 p.m., and 5:15 p.m. and [MEDICATION NAME] 20 mg orally daily for pain management scheduled at 9 a.m. A delay in administration of [MEDICATION NAME] and [MEDICATION NAME] had the potential to result in receiving the same medication too close to the next scheduled dose which could lead to uneven blood levels. A delay in administration of [MEDICATION NAME] could result in ineffective pain management. A review of Resident 12's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the significant change in status MDS assessment dated [DATE], the resident was able to make her needs known and able to understand others usually, and required extensive to total assistance in ADLs. A physician's orders [REDACTED]. BS less than 110 mg/dL = no coverage 111-126 mg/dL = two units of insulin 127-150 mg/dL = three units of insulin 151-200 mg/dL = four units of insulin 201-250 mg/dL = six units of insulin 251-300 mg/dL = eight units of insulin 301-350 mg/dL = 10 units of insulin 351-400 mg/dL = 12 units of insulin BS over 400 mg/dL = 14 units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 8 p.m. A care plan dated 4/27/12, developed for hypo/[MEDICAL CONDITION] related to diabetes mellitus, the approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered. A review of Resident 17's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. 111-150 mg/dL = one unit of insulin 151-200 mg/dL = two units of insulin 201-249 mg/dL = three units of insulin 250-299 mg/dL = four units of insulin 300-349 mg/dL = five units of insulin 350-399 mg/dL = six units of insulin BS over 400 mg/dL = seven units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 12 a.m., 6 a.m., 12 noon, and 6 p.m. The care plan dated 9/14/12, developed for the resident's risk for hypo/[MEDICAL CONDITION] related to diabetes mellitus, had a goal for the resident not to have signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered before meals and every bedtime with [MEDICATION NAME] R Insulin SQ injection per sliding scale. A review of Resident 19's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. A care plan dated 3/1/12, developed for the resident's risk of hypo/[MEDICAL CONDITION] related to diabetes and one of the goals was to have no signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to obtain resident ' s finger stick blood sugars as ordered and accucheck before meals and at bedtime with sliding scale. A review of Resident 20's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the resident usually was able to make her needs known and understand others, and required limited to extensive assistance in ADLs. A physician's orders [REDACTED]. 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin and call the physician If BS below 60 = give orange juice and call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., and 4:30 p.m. A care plan dated 5/22/12, developed for the resident's risk of hypo/[MEDICAL CONDITION] related to diabetes and the goal was to have no signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to obtain labs as ordered with abnormal results reported promptly to the physician. A review of Resident 27's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the resident was able to make his needs known, was able to understand others, and required extensive assistance in ADLs. A physician's orders [REDACTED]. BS below 150 mg/dL = no coverage 150 -199 mg/dL = one unit of insulin 200 -249 mg/dL = two units of insulin 250 -299 mg/dL = three units of insulin 300 -349 mg/dL = four units of insulin 350 -400 mg/dL = five units of insulin BS over 400 mg/dL = call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. A care plan dated 9/28/12, developed for the resident's risk for hypo/[MEDICAL CONDITION] related to diabetes had a goal for the resident not to have signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered before meals and at bedtime with [MEDICATION NAME] Insulin SQ injection per sliding scale. A review of Resident 28's clinical record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the resident was able to make his needs known, was able to understand others, did not walk, and required extensive assistance in ADLs. A physician's orders [REDACTED]. BS below 150 mg/dL = no coverage 150 -199 mg/dL = one unit of insulin 200 -249 mg/dL = three units of insulin 250 -299 mg/dL = five units of insulin 300 -349 mg/dL = seven units of insulin 350 -400 mg/dL = nine units of insulin BS over 400 mg/dL or below 45 mg/dL = call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. According to the care plan dated 6/11/12, the resident was at risk for hypo/[MEDICAL CONDITION] related to diabetes and one of the goals was to have no signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered. A review of Resident 29's clinical record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. According to the significant change in status MDS assessment dated [DATE], the resident sometimes was able to make his needs known and understand others, did not walk, and required extensive to total assistance in ADLs. A physician's orders [REDACTED]. BS below 70 mg/dL = give orange juice per GT 150 -199 mg/dL = two units of insulin 200 -249 mg/dL = four units of insulin 250 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL and below 70 mg/dL = call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 12 a.m., 6 a.m., 12 noon, and 6 p.m. According to the care plan, dated 5/7/12, the resident was at risk for hypo/[MEDICAL CONDITION] related to diabetes and one of the goals was to have no signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered. A review of Resident 30's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the resident usually was able to make her needs known and understand others, had modified independence for cognitive skills for daily decision making, did not walk, and was totally dependent on staff in ADLs. A physician's orders [REDACTED]. BS below 70 mg/dL = give orange juice per GT and call the physician 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 12 a.m., 6 a.m., 12 noon, and 6 p.m. A care plan dated 3/5/12, developed for the resident's risk of hypo/[MEDICAL CONDITION] related to diabetes had a goal for the resident to have blood sugar level below 120 mg/dL and not to require additional insulin for 90 days. The approaches included to obtain resident's finger stick blood sugars as ordered. A review of Resident 31's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to quarterly MDS assessment dated [DATE], the resident sometimes was able to make his needs known and understand others, did not walk, and required extensive to total assistance in ADLs. A physician's orders [REDACTED]. BS below 70 mg/dL = give orange juice per GT and call the physician 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 12 a.m., 6 a.m., 12 noon, and 6 p.m. According to the care plan dated 3/7/12, the resident was at risk for hypo/[MEDICAL CONDITION] related to diabetes and one of the goals was to have no signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered. A review of Resident 32's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the resident was able to make his needs known and understand others, did not walk, and required extensive assistance in ADLs. A physician's orders [REDACTED]. Another order indicated to administer three units of [MEDICATION NAME] Insulin SQ injection TID before meals and hold for BS over 150 mg/dL, and [MEDICATION NAME] 10 units SQ daily at bedtime. However, a review of the MAR indicated [REDACTED]. The blood sugar monitoring and the insulin injection was ordered for 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. According to the care plan dated 10/8/12, the resident was at risk for hypo/[MEDICAL CONDITION] related to diabetes and one of the goals was to have no signs and symptoms of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, blood sugar check before meals and at bedtime, call the physician for BS below 70 and over 300, and administer [MEDICATION NAME] Insulin three units SQ injection TID before meals but hold for BS below 150 mg/dL. A review of Resident 33's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the resident was able to make his needs known and understand others, did not walk, needed supervision when eating, and required extensive to total assistance in ADLs. A physician's orders [REDACTED]. BS below 70 = give orange juice and call the physician 0 -149 mg/dL = no coverage 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. A review of the summary of the facility's job description for the Licensed Vocational Nurse indicated duties and responsibilities which included rendering professional nursing care to residents, performing nursing techniques for the comfort and well-being of the resident, maintaining resident's medical records on nursing observations, assisting physician during treatment and examination of the resident, and administering prescribed medications. According to the facility's undated policy and procedure titled "Guidelines for Medication Administration," routinely ordered medications will be administered at the times specified in the Standard Times for Medication Doses described in Appendix M. Appendix M specified the time for AC (before meals) as 6:30 a.m., 11:30 a.m., and 4:30 p.m. A review of the Consultant Pharmacist's Recommendation to the Inter-Disciplinary Team (IDT), dated 10/15/12, indicated a recommendation to either discontinue if feasible the vitamins and supplements for 24 residents in Nursing Station B or if not feasible, to consider changing the administration times to reduce the AM (morning) medication pass pill burden. On 10/15/12, at 10:30 a.m., during an interview with the facility's Pharmacy Consultant, he said he was not aware of licensed staff's delaying medication administrations, not being well versed in different types of insulin and their protocols, and inaccurate administering medications. On 10/18/12, at 4 p.m. during an interview with RN Supervisor 1, she stated she was unaware of the morning medication pass not being completed in a timely manner. The RN supervisor then indicated she had not observed LVN 1 taking the whole shift to pass medications, nor could she recall any of the residents complaining that their medications were late. She also stated she did not recall a conversation with LVN 1 regarding her workload. 2. On 10/11/12 at 12:30 p.m., a review of the MAR book with LVN 1, disclosed the morning medication administration for Residents 6, 8, 9, 15, 16, 18, 20, 25, 26, 35, and 36 was not documented. LVN 1 stated she had not yet given their medications and explained she usually began the medication pass with the residents who received medications via GT, residents who were requesting pain medications, then she would administer medications for the other residents afterwards, as they "Did not require a lot of attention". A review of Resident 15's clinical record disclosed an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. The M

Based on observation, interview and record review, the facility failed to ensure timely blood sugar monitoring (checking the amount of sugar in blood) and administration of insulin per sliding scale (a set of instructions for administering dosages based on specific blood sugar readings) before meals as ordered by the physician, as stated in the plan of care and as per facility's policy and procedure for three of 14 sample residents (18, 38, and 44) and three randomly selected residents (45, 46, and 49). For Residents 18, 38, 44, 45, 46, and 49, who had diabetes mellitus (high levels of sugar in blood), the blood sugar accucheck (also known as fingerstick (puncturing/pricking the finger tip to obtain a small amount of blood) blood sugar check) ordered for 4:30 p.m. (prior to the evening meal), were not obtained until 6:30 p.m., two hours after the scheduled time and after the residents had eaten dinner. This deficient practice resulted in the licensed nursed ineffectively managing the residents' diabetes. Checking blood sugar levels after meals provided inaccurate readings for insulin administration since the blood sugar level is affected by the consumption of food. Delayed accuchecks resulted in delayed insulin administration which could result in diabetic complications due to [DIAGNOSES REDACTED] (low blood sugar which can lead to [MEDICAL CONDITIONS] or coma) or [MEDICAL CONDITION] (high blood sugar which can lead to damage to nerves, blood vessels, and other body organs can occur). Findings: On 12/20/12 at 6:30 p.m., a review of Resident 18's MAR indicated [REDACTED]. When LVN 8, the 3 p.m. to 11 p.m. shift medication nurse, was asked if there were other residents who were scheduled for 4:30 p.m. accucheck, he indicated there were four other residents (Residents 44, 45, 46 and 49). A subsequent review of the MAR binder disclosed Residents 38, 44, 45, 46 and 49, had no documented blood sugar results. When LVN 8 was queried as to why there was no documentation of the 4:30 p.m. accucheck results for the residents, he stated he had asked for assistance from another nurse (RN 4) to do the accucheck and give the needed insulin to the residents since he was running late with the afternoon medication pass. LVN 8 further explained there were a total of three medication carts and three MAR binders for Nursing Station B, and three medication nurses during the 7 a.m. to 3 p.m. shift, but there were only two medication nurses during the 3 p.m. to 11 p.m. shift so the third MAR binder was shared by the two medication nurses. According to the facility's meal schedule, the dinner meal was scheduled at 5:15 p.m. On 12/21/12 at 2:45 p.m., during an interview, the DON acknowledged on 12/2012, the blood sugar levels of Resident 18, 44, 45, 46, and 49 were not checked before dinner as ordered. The DON explained LVN 8 was running behind with the afternoon medication pass and asked RN 4 to help him check the blood sugar levels of the residents. However, RN 4 did not check the levels because the MAR binder was in the medication cart used by LVN 8 and LVN 8 was being followed by an Evaluator for medication pass. According to the facility's undated policy and procedure titled "Guidelines for Medication Administration," routinely ordered medications will be administered at the times specified in the Standard Times for Medication Doses described in Appendix M. Appendix M specified the time for AC (before meals) as 6:30 a.m., 11:30 a.m., and 4:30 p.m. 1. A review of Resident 18's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision-making, required a wheelchair for mobility and extensive assistance with ADLs. A physician's orders [REDACTED]. Blood sugar (BS) less than 150 = no insulin coverage 150 - 199 milligrams per deciliter (mg/dL) = one unit of insulin 200 - 249 mg/dL= two units of insulin 250 - 299 mg/dL= three units of insulin 300 - 349 mg/dL= four units of insulin BS less than 70 mg/dl = give orange juice and call MD BS greater than 400= call the physician There was no documented plan of care developed for the resident's risk of complications related to diabetes. According to the MAR, the blood sugar monitoring with insulin coverage per sliding scale was scheduled at 6:30 a.m. and 4:30 p.m. According to the Situation- Background-Assessment-Recommendation (SBAR) form dated 12/20/12, the resident had a late accucheck but had no significant changes in condition. The BS was taken at 6:30 p.m. with a result of 88 mg/dl and no insulin coverage was required. During the Recertification survey completed on 10/22/12, Resident 18 was found to be affected by delayed diabetic medication administration. According to the facility's plan of correction with a completion date of 11/12/12, on the Statement of Deficiencies and Plan of Correction CMS-2567 form issued to the facility on [DATE], the resident was re-evaluated. The DON and the Pharmacy Nurse consultant and the Quality Assurance nurse gave inservice to licensed nurses (including LVN 8) and on timely medication administration. 2. A review of Resident 44's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE], indicated the resident was alert and oriented, and required extensive assistance with most ADLs. A physician's orders [REDACTED]. BS less than 150= no insulin 150-199 mg/dL = one unit 200-249 mg/dL = 3 units 250-299 mg/dL = five units 300-349 mg/dL = seven units 350-400 mg/dL = nine units Greater than 400 mg/dL = call the physician There was no documented plan of care developed for the resident's risk of complications related to diabetes. According to the MAR, the blood sugar monitoring with insulin coverage per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. A review of the SBAR form dated 12/20/12, the resident had a late accucheck, had no significant changes in condition, the BS was taken at 6:30 p.m. with a result of 125 mg/dl. No insulin coverage was needed. 3. A review of Resident 45's clinical record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE], indicated the resident was moderately cognitively impaired, and required extensive to total assistance with her ADLs. A physician's orders [REDACTED]. BS less than 150 mg/dL = no insulin 150-199 mg/dL = one unit 200-249 mg/dL = 3 units 250-299 mg/dL = five units 300-349 mg/dL = seven units 350-400 mg/dL = nine units Greater than 400 mg/dL = call the physician A care plan dated 8/20/12, developed for the resident's risk for hypo/[MEDICAL CONDITION] episodes related to diabetes mellitus, had a goal to minimize further episodes of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to obtain blood sugar checks as ordered and to administer medication as ordered. According to the MAR, the blood sugar monitoring with insulin coverage per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. A review of the SBAR form and the MAR indicated [REDACTED]. The BS was taken at 6 p.m., the result was 256 mg/dl, the physician was notified and no insulin was given. 4. A review of Resident 46's clinical record disclosed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE], indicated the resident was alert and oriented, and required extensive to total assistance with ADLs. A physician's orders [REDACTED]. 100-150 mg/dL = no insulin 151-200 mg/dL = two units 201-250 mg/dL = four units 251-300 mg/dL = six units 301-350 mg/dL = eight units 351-400 mg/dL = 10 units BS greater than 400= 12 units and call the physician A plan of care dated 11/9/12, developed for the resident's risk for hypo/[MEDICAL CONDITION] episodes related to diabetes mellitus, had a goal to minimize further episodes of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to obtain the resident's FSBS as ordered and to administer medications as ordered. According to the MAR, the blood sugar monitoring with insulin coverage per sliding scale was scheduled at 6:30 a.m. and 4:30 p.m. A review of the SBAR form dated 12/20/12, indicated a late accucheck with no significant changes in condition. The BS was taken at 6:30 p.m. with a result of 130 mg/dl. No insulin coverage was needed. 5. A review of Resident 49's record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Assessment, dated 12/19/12, indicated the resident was alert, able to make his needs known, and required extensive assistance with ADLs. A physician's orders [REDACTED]. 71-130 mg/dL= no insulin 131-150 mg/dL= one unit 151-200 mg/dL= two units 201-250 mg/dL= four units 251-300 mg/dL= six units 301-350 mg/dL= eight units 351-400 mg/dL= 10 units Greater than 400= 12 units and call the physician According to the MAR, the blood sugar monitoring with insulin coverage per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. A review of the SBAR and the MAR indicated [REDACTED]. The BS was taken at 6:30 p.m. and the result was 170 mg/dl. The physician was notified and no insulin was given. 6. A review of Resident 38's clinical record disclosed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE], indicated the resident was alert and oriented, was unable to walk, and required extensive staff assistance with most ADLs. A care plan dated 2/22/12, developed for the resident's risk for hypo/[MEDICAL CONDITION] episodes related to diabetes mellitus, had a goal to minimize further episodes of hypo/[MEDICAL CONDITION] daily for 90 days. The approaches included to obtain FSBS as ordered and to administer insulin three times daily before meals per sliding scale. A physician's orders [REDACTED]. 0-150 mg/dL= no coverage 151-200 mg/dL= one unit 201-250 mg/dL= three units 251-300 mg/dL= five units 301-350 mg/dL= nine units 351-400 mg/dL= 10 units BS greater than 400= 12 units and call the physician According to the MAR, the blood sugar monitoring with insulin coverage per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. On 12/21/12 at 3:50 p.m., during an interview, RN 3 stated RN 4 obtained the resident's blood sugar level the previous day at 4:30 p.m. but did not document it and did not give insulin to the resident. RN 3 stated RN 4 gave her the BS result written on an alcohol pad wrapper. The result was 206 mg/dL and the resident did not get the three units of insulin ordered at 4:30 p.m. According to the American Diabetes Association (www.diabetes.org/), blood sugar monitoring is the main tool to check diabetes control. The target blood glucose range in plasma (liquid component of the blood) before meals is from 70 to 130 milligrams per deciliters (mg/dl) and the target range after meals is less that 180 mg/dl. Untreated, high blood glucose causes problems such as nerve damage, kidney or eye problems, [MEDICAL CONDITION], and stroke. According to the book Fourth Edition Pathophysiology (2010), page 959, intensive insulin schedules are an attempt to mimic normal insulin secretion closely and are considered important for optimal control. This deficient practice is a repeated finding from the Recertification survey completed on 10/22/12. The facility's plan of correction with a completion date of 11/12/12, on the Statement of Deficiencies and Plan of Correction CMS-2567 form issued to the facility on [DATE], indicated the DON, the Pharmacy Nurse consultant and the Quality Assurance nurse gave inservices to licensed nurses (including LVN 8 and RNs 1, 3 and 4) pertaining to timeliness of medication administration, timely monitoring of diabetic residents's blood sugar level, insulin administration. The licensed nurses were evaluated for skills, competency and compliance with policies and procedures.