Every finding on record at Las Alturas Nursing & Transitional Care

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure Resident #1 had the appropriate isolation and precaution signage posted outside of his door or room due to having a suprapubic catheter (a device inserted into the bladder to drain urine if an individual could not urinate on their own) with an infection in his urine.The facility failed to ensure Resident #1's EBP orders were removed when the facility added Resident #1's Contact Isolation orders on 07/13/2026.The facility failed to ensure Resident #1's EBP care plan was removed when Resident #1 began Contact Isolation on 07/13/2026.These failures could place residents at risk for cross-contamination and infection due to inappropriate precautions being used.The findings included:Record review of Resident #1's face sheet, dated 07/16/2026, revealed a [AGE] year-old male with an original admission date of 06/19/2021, and a current admission date of 09/09/2024. Diagnoses included Obstructive and Reflux Uropathy (when urine cannot flow correctly through the urinary tract and caused reflux, or backward flow, into the kidneys).Record review of Resident #1's active physician order summary, reviewed 07/16/2026, revealed a current order, with a start date of 07/13/2026, for Contact Precautions due to ESBL (groups of bacteria which could be resistant to common antibiotics) in the urine. The physician order summary revealed an active physician order with a start date of 06/08/2026 for EBP: Practice EBP as indicated every shift for high contact activity. The orders indicated a start date of 07/14/2026, for Meropenem Intravenous (a broad-spectrum antibiotic used to treat infections) 1 GM every 12 hours for 14 days.Record review of Resident #1's Annual MDS assessment, dated 05/16/2026, revealed a BIMS score of 09, which revealed moderately impaired cognition. The Annual MDS assessment also revealed Resident #1 had an indwelling catheter. Resident #1's MDS revealed an active diagnosis of Neurogenic Bladder (a condition which affects bladder function due to the nervous system) and Obstructive Uropathy. Record review of Resident #1's lab results, dated 07/13/2026, revealed Resident #1 had ESBL in his urine, and contact precautions should be initiated.Record review of Resident #1's care plan initiated 06/18/2025 and revised 07/13/2026, revealed Resident #1 was at risk for infection or recurrent/chronic infection related to compromised medical conditions:. Urinary Catheter, ESBL in the urine. Interventions included: Contact Precautions x 14 days; Enhanced Barrier Precautions for high contact activity. Resident #1's Care Plan Report included a currently active care plan intervention initiated on 10/15/2025 for EBP when in contact with suprapubic catheter. An observation of Resident #1's room on 07/16/2026 at 3:41 PM revealed an EBP sign on the door. In an interview on 07/16/2026 at 2:13 PM, CNA-A stated she was not sure who placed the precaution signs on residents' doors, but she thought maybe it was the charge nurse. She also knew what PPE to wear when taking care of a resident by the sign on the door. She was unsure of other ways to tell if a resident was on isolation other than asking the charge nurse. In an interview on 07/16/2026 at 2:13 PM, the DON stated the ICP was supposed to put up the contact precautions sign and updated the infection control care plan after the order was obtained. She stated Resident #1 was supposed to be on contact precautions since 07/13/2026, and cross-contamination could happen if staff were not wearing the proper PPE to provide care for the resident. In an interview on 07/16/2026 at 5:14 PM, the ICP stated the floor nurses were usually the ones who obtained the orders for antibiotics after they reported the labs to the providers. The ICP stated one of the ways she was aware there was a new order for antibiotics was by checking the 24 hour report every day when she was working. She stated sometimes the floor nurses reported the information verbally to her, and once she was aware a resident had a new infection or antibiotic, she obtained the order for precautions or isolation, updated the care plan, and placed the appropriate signs and PPE on the resident's door. She stated the order and care plan were in there for contact isolation, but the orders and care plans for EBP were never removed, and she understood how it could confuse someone if they were not sure which precautions to use for the resident's current condition. She also stated the previous care plan for EBP was wrong as it only identified utilizing EBP when in contact with the catheter, and not for all high contact activities. She stated she was not sure why there was an EBP sign on Resident #1's door instead of a contact isolation sign. She thought she had previously put up the correct sign, but sometimes family members pull them down or remove them, and the incorrect sign got hung back up. Record review of the facility's Infection Prevention and Control Policy, revised April 2024, revealed 3. Surveillance: The charge nurse will notify the attending physician and the Infection Preventionist of suspected infections. 9. Prevention of Infection: (9) implementing appropriate isolation precautions when necessary and following established general and disease-specific guideline such as those of the Centers for Disease Control (CDC). 11. Categories: Types of Isolation Precautions: . Contact Precautions may be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. EBP may be indicated as a recommendation by the CDC (when Contact Precautions do not otherwise apply) . 12. Implementation of Isolation and /or Precautions: Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE.Record review of the CDC: Long-Term Care Facilities (LTCFs): Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: A. Wounds or indwelling medical devices, regardless of MDRO colonization status; B. Infection or colonization with an MDRO. Contact Precautions: Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room. Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices. Implementation: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk of needs and accommodation being unmet.Record review of a face sheet dated 3/1/2026 indicated Resident #1 was a [AGE] year-old who male, admitted [DATE], with diagnoses including Schizophrenia Disease (a chronic, severe mental disorder characterized by disruptions in thought, perception, emotions, and behavior), Hypertension (high blood pressure), Dementia (significant decline in mental ability-such as memory, thinking and reasoning-that is severe enough to interfere with a person's daily life and activities), and Cirrhosis of the liver (irreversible, late-stage scarring (fibrosis of the liver caused by chronic diseases like hepatitis, alcohol abuse, or fatty liver disease). Review of a quarterly MDS assessment, dated 1/15/2026, indicated Resident #1 had a BIMS score of 3 which indicated severe cognitive impairment. The MDS indicated Resident #1 was able to understand others and to make his needs known verbally. The MDS also indicated Resident #1 needed maximum assistance with toileting hygiene, showering, upper and lower body dressing and moderate assistance with personal hygiene. Record review of Resident #1's care plan, undated, revealed, Resident #1 had a focus goal of call light use and cognition and safety awareness with an intervention to keep resident's call light within reach of the resident and remind the resident of the call light location. During an observation and interview on 2/28/2026 at 2:40 p.m., Resident #1 was in his room, Resident #1 was in his bed with lots of movement, upon entering the room it was observed that Resident #1 did not have his call light as it was on the bedside table outside of the reach of Resident #1. Resident # 1 stated he wanted some cookies and juice. During an interview on 2/28/2026 at 2:45 pm, RN A stated she was unaware Resident #1 could not reach the call light, and the call light should have been left where Resident #1 could reach it. RN A stated the NA may have repositioned the resident and left the call light on the bedside table. RN A stated it was expected that Resident #1 should always have his call light in reach as it was the expectation that all residents have their call light in reach at all times. During an interview on 2/28/2026 at 3:03 pm, NA B stated she did care for Resident #1 today and did reposition Resident #1 in bed. NA B stated she thought she placed the call light within reach of Resident #1 before leaving the room to get supplies. CNA B stated it was expected for the call lights to always be within reach of all residents, including Resident #1. NA B stated since Resident #1 was without his call light he could have fallen or not have had his needs met. During an interview on 3/1/2026 at 12:30 p.m., the DON stated it was not acceptable for residents to not be able to reach the call light. The DON stated she provided re-education to staff about call lights being in reach of all residents to include Resident #1. The DON stated Resident #1's result of not having the call light within reach could mean his needs may not have been met. During an interview on 3/1/2026 at 1:20 p.m., the Administrator stated it was his expectation and the facility's policy for all residents to be within reach of the call light. The Administrator stated he was aware Resident #1 was repositioned by NA B on 2/28/2026 and Resident #1's call light was not within reach of Resident #1. The Administrator stated he was informed NA B went to gather supplies and was gone no more than 10 minutes; however, it was still against policy to leave any resident without the call light. Record review of facility policy titled, Routine Resident Care dated 3/14/2019 and revised 01/2024, reflected, Resident call lights should be answered timely and resident requests are addressed, if permitted. Call lights should be placed within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 5 residents (Resident #4) reviewed for pain management. The facility failed to identify and provide pain management for Resident #4 for at least 1 month throughout January and February of 2026.These failures could place residents at risk of increased pain and poor quality of life. The findings included:Record review of Resident #4's face sheet dated 02/11/2026 revealed Resident #4 was a [AGE] year-old female with an original admission date of 11/08/2022, and a current admission date of 12/21/2023. Pertinent diagnoses included: Cerebral Infarction (a type of stroke which occurs when a blood clot blocks a brain artery, leading to a loss of blood flow to a specific area of the brain), Dysphagia (difficulty in swallowing, which could occur at any stage of the swallowing process), and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning), Gout (a common and complex form of arthritis which could affect anyone), Osteoarthritis (the most common form of arthritis which occurs when the protective cartilage which cushions the ends of the bones wears down over time, leading to pain, stiffness, and reduced mobility), Pain to Right Knee, Pain to Ankle and Joint of Right Foot, Effusion of Right Knee (commonly known as water on the knee, occurs when excess fluid accumulates in or around the knee joint, and could be caused by various factors, including arthritis, ligament injuries, or other conditions)Record review of Resident #4's BIMS assessment, dated 02/10/2026, revealed a BIMS score of 15, which revealed intact cognition.Record review of Resident #4's Annual MDS dated [DATE] revealed a diagnosis of pain in the right knee. Record review of Resident #4's care plan dated 01/11/2024 revealed Resident #4 was at risk for experiencing pain related to gout and/or osteoarthritis. Interventions included administering pain medication as recommended and attempt non-pharmacological interventions to promote comfort and relaxation.Record review of Resident #4's physician orders, started 04/02/2024, and revised 02/10/2026, revealed an order for Tylenol 325 MG, give 2 tablets by mouth every 4 hours as needed for elevated temperature or pain. There was also a new order, started 02/10/2026, for Tramadol, give one tablet by mouth every 6 hours as needed for pain. In an observation on 02/10/2026 at 9:40 AM, Resident #4 was observed to be able to slowly answer every question the SW asked her, whether verbally, in writing, hand gestures, or shaking her head yes or no. She was able tell the SW she had pain in her low back for a month, and she had been trying to tell staff, but no one had given her pain medication.In an interview on 02/09/2026 at 1:15 PM Resident #4 was able to answer all basic questions and show surveyor where she was having pain. She nodded that she had pain in her low back (as she pointed to low back) but nodded and mouthed no that the nurses never gave her anything for the pain. In an interview on 02/10/2026 at 8:41 AM, LVN-J stated Resident #4 was able to use the call light and answer simple questions. LVN-J initially stated Resident #4 had pain at times, and she told the CNAs when she had pain, and then the CNAs would let LVN-J know, and she would give her pain medication for it. LVN-J then stated she had asked Resident #4 about pain, but she did not recall Resident #4 complaining of pain over the past 1.5 months, so she had not given her anything for pain. In an interview on 02/10/2026 at 10:30 AM, CNA-K stated she worked the hall which Resident #4 was on. She stated Resident #4 had difficulty with communication but could say some things, as well as text and write. She stated Resident #4 never told her she had pain, but CNA-K stated she also never asked Resident #4 if she had pain. She stated if she had known Resident #4 had pain, she would have reported it to the charge nurse. CNA-K stated she should have asked Resident #4 about pain because being in pain could affect how people feel and act. In an interview on 02/11/2026 at 8:26 AM, the DON stated pain was subjective, so if Resident #4 was stating she had pain, then she believed her. The DON stated if Resident #4 had been having pain over the past month, she felt like it would have been identified by either the charge nurse who assessed her each shift for pain, or when the managers did the Ambassador Rounds in the mornings. She stated she did not recall Resident #4 or anyone else reported the pain but also stated the managers did not specifically ask Resident #4 about pain when they rounded on her. The DON stated she did not want any of the residents to be left in pain, so she had addressed the pain issue with Resident #4, as well as started an in-service about pain and pain management with the staff. Record review of the facility's Pain Management policy, implemented 03/14/2019 and revised January 2025, revealed The goal of the community pain management program is that pain is identified and treated timely, effectively and consistently. The community recognized the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life.

Based on observation, interview, and record review the facility failed to ensure kitchen staff served food in a sanitary manner. The facility failed to ensure food was dated and sealed for 9 items in the refrigerator. These failures could place residents at risk of foodborne illnesses. Finding Included: In observation and initial tour of the facility kitchen on 02/08/26 at 10:45 AM the kitchen refrigerator revealed a package of yellow cheese was open and undated. A plastic bag of grey meat substance found undated and open in refrigerator. A clear plastic bag of cooked biscuits was found undated and unsealed in the refrigerator. A bag of salad was found unsealed and undated in the refrigerator. A container of green peppers was found uncovered unprotected from being exposed to air and prevent contamination. A bag of white cheese was found undated and unsealed exposed to air and becoming contaminated. A bag of yellow cheese was undated and unsealed exposed to air and becoming contaminated. A bag of Cilantro was found open and undated exposed to air and becoming contaminated. A package of luncheon meat was found undated in the kitchen refrigerator. In an interview on 02/08/26 at 11:01 AM with [NAME] O she stated all staff were responsible for making sure all items were dated, covered and closed. [NAME] O stated the residents could get sick if the food was contaminated. All spoiled food must be thrown away, and all staff responsible to make sure no spoiled food is in the refrigerator. [NAME] O stated she did not know who put the meat in the refrigerator to thaw out or how long it had been there. [NAME] O stated she will start to be more aware of what food is left in the refrigerator so she can throw away old food and keep it from being used. In an interview on 02/08/26 at 11:11 AM with DA N, she stated all items received must be dated when put in the pantry, refrigerator, and freezer. DA N stated she did not see or know who put the meat to thaw out in the refrigerator. DA N stated the DM usually handles the shipments of food they receive and sometimes gets a helper from the staff working to help her. DA N stated she knew it was important to date food items, so the residents didn't get served expired food. In an interview with DA P he stated he knew it was important to make sure all stored food must have a date so that expired food was not served. DA O stated he did not see the items that were open and not dated. DA P stated he did not know about the meat thawing in the refrigerator. DA P stated he would be more observant of the refrigerator items being left open and not dated. In an interview on 02/08/26 at 11:29 AM the DM stated all items stored in the panty, refrigerator, and freezer must be dated, sealed, or covered, so the food is not exposed to air and becomes contaminated. The DM stated the food items left undated open and unsealed were thrown away and replaced with new dated food items. The grey meat substance was ground beef left to be thawed out and must have been forgotten in the refrigerator, but this meat would never be cooked and served to residents, it must be thrown away. The DM stated the cheese, luncheon meat, salad, cilantro, and biscuits were thrown away. The DM stated the green peppers that were covered would be washed before use. The DM stated the items left open or uncovered by the staff must have been done because they were in a hurry and forgot to be reseal the food item. The DM stated she will reeducate the staff on the importance of dating any food items received and stored in the panty, refrigerator, and freezer. The DM stated she will make sure each staff member understands the importance of closing any food items after use so that the item is not exposed to air and become contaminated. The DM stated it was all staff's responsibility to ensure the safety of the food the kitchen serves. In a second observation and interview of the kitchen on 02/09/2026 at 11:32 AM DA M was seen cutting and plating cake with a bare hand. DA M stated the cake was to be served to the residents and forgot to glove her hands as she was in a hurry to finish. She stated she knew it was important to wear gloves after washing them but was in a hurry and forgot to put them on. DA M stated it was important to always wear gloves, so the food was not contaminated and possibly make the residents sick. DA M stated it was important to make sure all food was safe for the residents by storing and handling the food properly by dating and sealing it after use. In an interview on 02/09/26 at 4:01 PM with the Dietitian she stated it was the responsibility of the DM and cook to make sure the food is not expired. The Dietitian stated all staff were responsible for making sure food was covered and sealed after use. The Dietitian stated the cook and dietary aide are responsible for dating left over food. The Dietitian stated if the DM cannot date the food shipment, the dishwasher usually will help her if not another staff member. In a third observation and interview of the facility kitchen on 02-09-26 at 4:16 PM [NAME] P was seen plating food on trays without gloves. [NAME] P stated she was not aware that gloves must be worn when severing food with utensils as she was not touching the food with her bare hands. [NAME] P stated she was not aware of needing to wear gloves while serving. In a second interview on 02/09/26 at 4:30 PM with the DM, she stated she would educate all staff members on the proper serving procedures when handling and serving any food that is not served prepackaged. The DM stated all staff handling food to be prepared and served must put on gloves while handling ready to serve food and must never be touched food of any kind bare handed that is served to the residents. In record review of the policy and procedures for Food Storage dated 01/25/25 stated, To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. In record review of the policy and procedures for General Kitchen Sanitation dated 01/25/25 stated The facility recognizes that foodborne illnesses have the potential to harm elderly and frail residents. All Nutrition & Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. In record review of Food Preparation and Handling it stated, To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and HACCP guidelines. In record review of policy and procedure for Employee Sanitation dated 06/19/19 stated The Nutrition and Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illnesses.6. Glove use with direct food contact.

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 (Resident #139 and Resident #7) of 5 residents reviewed for infection control and transmission-based precautions, policies, and practices. The facility failed to ensure CNA A performed hand hygiene between glove changes after providing personal care to Resident #139. The facility failed to ensure CNA A performed hand hygiene for at least 20 seconds or greater after transferring Resident 139 from the bed to the shower chair. The facility failed to ensure Resident #7 was placed on the proper infection control precautions for the diagnosis of ESBL Resistant. These failures could place residents at risk of infection through cross contamination of pathogens and infectious diseases. The findings included: Resident #139:Record review of Resident #139's face sheet dated 02/11/26 reflected a [AGE] year-old-female with an original admission date of 03/11/22. Diagnoses include dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and type 2 diabetes (insufficient production of insulin in the body). During an observation on 02/10/26 at 4:08 PM, CNA A was observed removing her gloves after transferring Resident #139 from the bed to the shower chair, and putting on a new pair of gloves without performing hand hygiene. During an observation on 02/10/26 at 4:44 PM, CNA A was observed removing her gloves, washing her hands for approximately 6 seconds. In an interview on 02/10/26 at 4:54 PM, CNA A stated she was nervous and forgot to sanitize hands after removing her gloves. CNA A stated hands should be washed for approximately 30 seconds to remove germs and bacteria. CNA A stated proper hand hygiene prevented cross-contamination and disease. CNA A stated that if the resident was in contact with the germs, they could get sick. In an interview on 02/11/26 at 9:03 AM, the ICP stated staff were supposed to perform hand hygiene between all glove changes. The ICP stated hand hygiene should be done to prevent cross contamination and potentially exposing wounds or residents to bacteria. The ICP stated staff should be washing their hands for at least 20 seconds or more to remove as many microorganisms as possible. In an interview on 02/11/26 at 10:41 AM, the DON stated all staff should be washing hands or hand sanitizing between every glove change. The DON stated proper hand hygiene helps to prevent cross-contamination. The DON stated that stopping the spread of infection is part of infection prevention. The DON stated staff should be washing their hands for 60 seconds per facility protocol. Record review of the facility's Handwashing/Hand Hygiene policy dated January 2023 reflected: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for situations such as this (including but not limited to): Between gloves changes/After removing gloves 8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Record review of the WCN's Dressing Change/Wound Care skills check off dated 01/31/26 reflected: 9. Clean wound as indicated, may pat or blot surrounding skin with a clean sterile dry gauze to dry the area as needed.Resident #7's findings included:Record review of Resident #7's face sheet dated 02/11/2026 revealed Resident #7 was a [AGE] year-old male with an original admission date of 05/08/2025, and a current admission date of 12/04/2025. Pertinent diagnoses included: Necrotizing Fasciitis (also known as flesh-eating disease, a serious bacterial infection which affects the tissue under the skin), Extended Spectrum Beta Lactamase Resistance (ESBLs were enzymes [substances which regulate the rate at which chemical reactions proceed] produced by certain bacteria which were resistant to a wide range of antibiotics, which complicates treatment options for the infection), and Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #7's Quarterly MDS dated [DATE] revealed a BIMS score of 15, which revealed intact cognition. The MDS also revealed Resident #7 had an indwelling catheter, as well as an ostomy (a surgically created opening or stoma), and open lesions. The MDS revealed Resident #7 had IV access and was receiving IV antibiotics.Record review of Resident #7's care plan initiated 07/28/2025 and revised 01/16/2026 revealed Resident #7 was at risk for recurrent or chronic infection related to compromised medical condition (suprapubic urinary catheter and open wounds). Interventions included EBP when in contact with suprapubic urinary catheter.Record review of Resident #7's physician orders, started 12/07/2025 and revised 01/16/2026, revealed an order for EBP every shift when in contact with suprapubic urinary catheter and/or open wounds. Record review of Resident #7's Discharge Summary, Final Report, dated 11/23/2025, revealed Resident #7 was started on wound care, consulted by the infectious disease physician and the general surgeon. Wound cultures were obtained showing Klebsiella ESBL positive. In an observation on 02/08/2026 at 12:11 PM, Resident #7 was observed to have had an EBP sign posted on his door, with EBP PPE located outside of his room. In an interview on 02/11/2026 at 8:41 AM, the ICP stated Resident #7 had Necrotizing Fasciitis and ESBL. She stated he had sacral (lower area of spine near tailbone), bilateral (Pertaining to both sides) buttocks, and bilateral heel wounds, and the Necrotizing Fasciitis was in colostomy stoma (a surgically created opening in the abdominal wall that allows stool to exit the body into a pouch when the colon or rectum cannot function normally), but she was not sure where the ESBL was located. The ICP stated the ESBL diagnosis was added to Resident #7's list on 12/04/2025. She stated Resident #7 had completed his IV antibiotics, but he could still be colonized or a carrier of ESBL. The ICP stated no follow up labs were performed on Resident #7 when he came back from the hospital in December 2025, but follow-up labs should have been done to assess for ESBL status. She stated the facility placed him on EBP for the wounds, but he should have been placed on contact precautions for the ESBL. The ICP stated since Resident #7 was not placed on contact precautions this could have caused cross-contamination if the appropriate PPE was not being utilized by everyone who entered the room. She also stated there had not been any other concerns or evidence of any other residents in the facility having ESBL. The ICP stated she was the person who wrote the orders for the type of precautions needed, as well as placed the signs and PPE by the residents' room. She stated she thought she may have overlooked Resident #7's need for contact precautions since he had previously been on EBP. In an interview on 02/11/2026 at 10:25 AM, the DON stated Resident #7 was placed on EBP due to the Foley, colostomy, and the wounds. She stated since he was diagnosed with ESBL, he should have been placed on contact precautions to prevent spread of infection and cross contamination. The DON stated typically the ICP wrote the orders for precautions, but any nurse, including herself, should have caught this and clarified it. The DON stated no other residents have been affected by this incident she knew of.Record review of the facility's Infection Prevention and Control policy, dated 03/13/2019 and revised April 2024, revealed The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. 10. Isolation Precautions: implementation of and discontinuation of isolation precautions should be in collaboration with the licensed nurse, physician, nurse practitioner, medical director, and if indicated through collaboration with the state or local health department. In addition to Standard Precautions, Contact Precautions may be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment.Review of the CDC hand washing procedures on CDC.gov, it reflected:With soap and water:Wet your hands with warm water. Use liquid soap if possible. Apply a nickel- or quarter-sized amount of soap to your hands.Rub your hands together until the soap forms a lather and then rub all over the top of your hands, in between your fingers and the area around and under the fingernails.Continue rubbing your hands for at least 15 seconds. Need a timer? Imagine singing the Happy Birthday song twice.Rinse your hands well under running water.Dry your hands using a paper towel if possible. Then use your paper towel to turn off the faucet and to open the door if needed.

Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #139) of 3 residents reviewed for incontinent care and indwelling urinary catheters. The facility failed to ensure Resident #139's indwelling urinary catheter tubing was secured during personal care to prevent dislodgement and injury. This deficient practice has the potential to result in urinary tract infections and at risk of accidental pulling of the catheter tubing and/or injury. The findings included: Record review of Resident #139's face sheet dated 02/11/26 reflected a [AGE] year-old-female with an original admission date of 03/11/22. Diagnoses include dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and type 2 diabetes (insufficient production of insulin in the body). Record review of Resident #39's care plan initiated on 03/12/22 and revised on 05/30/24 reflected: Resident #139 required a catheter r/t neurogenic bladder (condition in which nerve damage or neurological disorders disrupt the normal communication between the brain, spinal cord, and bladder, leading to loss of bladder control). Interventions included: Catheter Care every shift and as indicated. Provide a catheter secure band/tape as indicated. Offer/provide a privacy bag or cover drainage bag as indicated.On 02/10/26 at 4:28 PM, CNA A and CNA B were both observed transferring Resident #139 from the bed to the shower chair. Both CNA A and CNA B did not have Resident #139's Foley catheter anchored during the time of the transfer from the bed to the shower chair, during the shower and during dressing the resident. In an interview on 02/10/26 at 5:31 PM, CNA A stated Resident #139 should not have been moved without the Foley tubing being secured. CNA A stated Resident #139 did not have a catheter strap on her, but the strap was used to prevent any yanking and pulling during care or transfers. CNA A stated Resident #139's Foley could have possibly come out causing pain and discomfort. In an interview on 02/10/26 at 5:38 PM, CNA B stated Resident #139's Foley tubing was not secured while care was being provided and should have to prevent possible injury or pain to the resident. In an interview on 02/11/26 at 9:09 AM, the ICP stated Resident #139's Foley should have been secured with a strap to prevent any tugging or dislodging of the Foley and possibly hurting the resident causing trauma. The ICP stated she was responsible for teaching and the CNA Program at the facility, and she taught both CNA A and CNA B. The ICP stated the CNA staff were taught proper Foley care and both CNA A and CNA B knew Resident #139's Foley tubing should have been secured to the resident prior to care. In an interview on 02/11/26 at 10:50 AM, the DON stated Resident #139's Foley tubing should have been secured to prevent dislodgment and could cause injury or trauma to the resident. Record review of the facility's Routine Resident Care policy dated January 2024 reflected: 8. Residents who utilize with/without tubing should have the device and/or tubing properly secured. Staff should ensure that the device/tubing is properly attached to the bed/chair/wheelchair/assistive device in order to prevent/minimize risk of injury. Staff should handle the device/tubing with caution, adhering to all safety measures during patient care encounters, when the resident is mobile such as when out of bed, ambulating or when utilizing an assistive device such as a wheelchair in order to prevent accidental tugging or dislodging.

Based on observation, interview, and record review, the facility failed to update the comprehensive care plan and provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 Residents (Resident #4) reviewed for care plans.The facility failed to update Resident #4's care plan when her BIMS score changed from 08 to a 03 on her annual MDS dated [DATE]. This failure could place residents at risk of not receiving adequate or required care.The findings included:Record review of Resident #4's face sheet dated 02/11/2026 revealed Resident #4 was a [AGE] year-old female with an original admission date of 11/08/2022, and a current admission date of 12/21/2023. Pertinent diagnoses included: Cerebral Infarction (a type of stroke which occurs when a blood clot blocks a brain artery, leading to a loss of blood flow to a specific area of the brain), Dysphagia (difficulty in swallowing, which could occur at any stage of the swallowing process), and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning).Record review of Resident #4's Annual MDS dated [DATE] revealed a BIMS score of 03, which indicated severely impaired cognition. The MDS also revealed no evidence of an acute change in mental status and no pain or hurting at any time in the last 5 days.Record review of Resident #4's care plan dated 01/11/2024 revealed Resident #4 had impaired cognitive function or thought processes as evidenced by a BIMS score of 08 (moderately impaired cognition). Interventions included: ask yes or no questions to determine needs, communicate regarding capabilities and needs, discuss concerns about confusion, disease process, and nursing home placement; notify doctor of any changes in cognitive function, specifically changes in decision-making ability, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Record review of Resident #4's BIMS assessment dated [DATE] revealed a BIMS score of 15, which revealed intact cognition. In an interview on 02/10/2026 at 9:10 AM, the SW stated he did the BIMS assessment portion on the MDS. The SW stated if the resident was non-verbal or mostly non-verbal, he would have them write down answers to the question if they were capable, as well as he gave them options to shake their heads yes or no to applicable questions. He stated Resident #4 had not wanted to talk or participate on the date he did her last BIMS assessment, and because she was non-verbal and had a cognitive communication deficit, she ended up scoring a BIMS of 03, which dropped her down from her previous BIMS of 08. The SW stated sometimes he went back and reassessed the resident if he did not feel like the score was appropriate, but he had not reassessed Resident #4, even though he did not feel like 03 was an accurate BIMS score for her. The SW stated Resident #4 was able to tell staff if she had pain, and sometimes she would have behaviors or outbursts when she had pain. The SW stated he went to the care plan meetings, but the MDS nurse filled out the majority of the care plans. In an interview on 02/10/2026 at 9:54 AM, the MDS nurse stated the SW did the BIMS assessment and then MDS updated the care plan. She stated she could see Resident #4's care plan for the BIMS score of 08 was completed in January of 2024 and revised with no changes in October of 2024. The MDS nurse stated Resident #4's care plan relating to her BIMS score should have been revised when her BIMS score changed. She stated she was not sure why it had not been revised, but she may have overlooked it. In an interview on 02/11/2026 at 10:25 AM, the DON stated the social worker did the BIMS assessments and updated the BIMS on the care plan. The DON stated since Resident #4 was rated at a lower BIMS score than what she actually was, this could have caused staff to avoid asking Resident #4 important questions regarding her care or pain. The DON also stated the MDS nurse should have checked to make sure the care plans were accurate and up to date. Record review of the facility's Care Plan policy, implemented February 2017 and revised January 2024, revealed The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan should be updated quarterly thereafter, then annually and with significant changes in conditions.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #139) reviewed for ADL care. The facility failed to ensure Resident #139's hand contractures were cleaned and maintained appropriately This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.The findings include: Record review of Resident #139's face sheet dated 02/10/26 revealed a [AGE] year-old female with an admission date of 03/11/22. Resident #139's pertinent diagnoses included unspecified dementia (symptoms of cognitive decline are present but not clearly linked to a specific cause) and stiffness of unspecified joint (a general restriction, tightness, or difficulty moving a joint that cannot be classified elsewhere). Record review of Resident #139's quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained because the resident was rarely or never understood. Record review of Resident #139's comprehensive care plan revealed the contractures in her hands were not addressed. During an observation of Resident #139 lying in bed in her room at 10:33 AM on 02/10/26, Resident #139's hands were severely contracted with Resident #139 unable to move them. No item was placed in Resident #139's hands. Upon opening Resident #139's hands briefly, a strong foul odor was detected coming from Resident #139's hands. CNA D and RN E were both individually brought into Resident #139's room and detected the odor as well coming from Resident #139's hands. In an interview with CNA D at 10:39 AM on 02/10/26, CNA D stated sometimes the CNAs did put a little cloth in Resident #139's hands. CNA D stated Resident #139 did not like to have her hands opened because it hurt her. CNA D stated she opened up Resident #139's hands yesterday, but it did not have an odor then. CNA D stated the CNAs who bathed her in the shower room were supposed to clean her hands. CNA D stated she had not cleaned Resident #139's hands. CNA D stated the odor coming from Resident #139's hands today was a foul odor. CNA D stated it was important to take care of Resident #139's hands so her condition did not deteriorate. In an interview with RN E at 11:04 AM on 02/10/26, RN E stated she had not seen Resident #139 with a hand roll. RN E stated she had not seen a physician's order to place a hand roll in Resident #139's hands. RN E stated she did smell a foul, pungent odor coming from Resident #139's hands this morning. RN E stated the foul odor indicated to her that Resident #139's hands were not being cleaned properly. RN E stated this morning was the first time she had smelled the odor coming from Resident #139's hands. RN E stated it was important to properly care for Resident #139's contractures so her condition did not deteriorate at all. In an interview with the DON at 10:50 AM on 02/11/26, the DON stated there should not be a strong, foul odor coming from Resident #139's hands. The DON stated the odor indicated to her that Resident #139's hands were not being cleaned properly. The DON stated the CNAs had a daily task to perform hygiene care on Resident #139. The DON stated not caring for Resident #139's contractures appropriately could lead to a worsening of her condition and possibly lead to an infection. Record review of the facility policy Statement of Resident Rights implemented on February 2017 and revised on January 2023 revealed the following: .Resident/Patient Rights include:1. To all care necessary for them to have the highest possible level of health;2. To safe, decent and clean conditions.

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #67) of four residents reviewed for quality of care. 1. The facility failed to ensure the WCN followed doctor's orders (pat dry wound) during wound care for Resident #67. This failure could place residents at risk for not receiving appropriate care and treatment. The findings included:1. Record review of Resident #67's face sheet dated 02/0/26 reflected a [AGE] year-old-female with an original admission date of 09/24/21. Diagnoses include acute (sudden) respiratory failure with hypoxia (low level of oxygen in your body tissues), heart failure, type two diabetes (insufficient insulin production in the body), and chronic (recurring frequently) kidney disease. Record review of Resident #67's physician orders dated 02/06/26 reflected:Cleanse sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis) with wound cleanser, pat dry, apply collagen sheet (promotes healing by stimulating new tissue growth), and secure with super absorbent dressing every day and every shift for wound healing for Stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) and as needed for wound healing. Record review of Resident #67's quarterly MDS dated [DATE] reflected a BIMS of 3 (severe cognitive impairment). Record review of Resident #67's care plan initiated on 02/03/26 reflected:Resident #67 had a Stage 3 Pressure Ulcer to the sacrum r/t immobility.Interventions included:Administer treatments as ordered and monitor for effectiveness.During an observation of Resident #67's wound care on 02/09/26 at 9:42 AM, the WCN cleansed Resident #67's wound with wound cleanser and did not pat dry the wound as per doctor's orders. In an interview on 02/09/26 at 10:02 AM, the WCN stated she was nervous and forgot to pat dry after cleaning Resident #67's wound with wound cleanser. The WCN stated Resident #67's wound should be completely dry to prevent the wound from getting macerated (softened or separated by soaking in a liquid) and to maintain skin integrity. The WCN stated it was important to follow doctor's orders because they were person centered and individualized.In an interview on 02/09/26 at 3:46 PM, the DON, stated the WCN should have pat dried Resident #67's wound as per doctor's orders. The DON stated it was important to follow the doctor's orders so the wound could heal. The DON stated Resident #67's wound could get macerated and could delay healing. The DON stated there was no policy on wound care, but she did provide a policy on Professional Standard of Care. In an interview on 02/10/26 at 2:25 PM, the ICP stated the wound should have been pat dried to get the moisture out, and if not, it could cause maceration or slow healing. The ICP stated she did a skills check off with the WCN last month with no concerns noted. The ICP stated that the WCN was probably just nervous.

Based on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 7 residents (Resident #6 and Resident #2) reviewed for pharmacy services in that: The facility failed to ensure Resident #6 was administered insulin before breakfast as ordered by the physician. The facility failed to ensure the nurse cart for 400-hall was free from expired insulin pens.The facility failed to ensure expired insulin was not administered to Resident #2 on [DATE]. These failures could place residents at risk for non-therapeutic responses to medications.Findings included:1. Record review of Resident #6's face sheet dated [DATE] revealed a [AGE] year-old male with an admission date of [DATE]. The pertinent diagnosis included Type 2 Diabetes Mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). Record review of Resident #6's MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe impairment. Record review of Resident #6's comprehensive care plan dated [DATE] revealed the focus I have chronic health conditions & co-morbid conditions that have affected my physical function and may further affect my quality of life.[Diabetes Mellitus]. initiated on [DATE]. An intervention listed for the focus included Administer my medications, treatments, respiratory treatments/therapy and/or devices as order by my doctor initiated on [DATE]. Record review of Resident #6's order summary revealed an active order for Insulin Lispro Injection Solution Inject 5 units subcutaneously (situated or applied under the skin) before meals for [Diabetes Mellitus] initiated on [DATE]. During an observation of medication administration at 9:40 AM on [DATE], RN E administered 5 units of insulin lispro subcutaneously to Resident #6. In an interview with RN E at 11:04 AM on [DATE], RN E stated she administered Resident #6's morning insulin after he had already eaten breakfast on [DATE]. RN E stated she fell behind earlier that morning because another resident required more care than usual. RN E stated Resident #6's insulin should have been administered before breakfast as ordered by the physician. RN E stated not following physician's orders when administering insulin to residents could lead to unexpected blood glucose levels. In an interview with the DON at 10:50 AM on [DATE], the DON stated insulin should be administered as ordered by the physician. The DON stated Resident #6's insulin should have been administered before breakfast on [DATE] as ordered. The DON stated administering insulin outside of a physician's order could lead to either high or low blood sugar depending on the circumstances of the incident. 2 and 3. Record review of Resident #2's face sheet dated [DATE] revealed a [AGE] year-old female with an original admission date of [DATE] and a current admission date of [DATE]. The pertinent diagnosis included Type 2 Diabetes Mellitus. Record review of Resident #2's MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe impairment. Record review of Resident #2's comprehensive care plan dated [DATE] revealed the focus I have diabetes and I am at risk for: Complications associated with diabetes: Frequent Infections, Diabetic wounds, Vision Impairment, Hyper/Hypo-Glycemia (high and low blood sugar), Renal (Kidney) Failure, Cognitive/Physical Impairment initiated on [DATE]. An intervention listed for the focus included Administer my medications as recommended by my doctor, monitor labs as indicated. initiated on [DATE]. Record review of Resident #2's order summary revealed an active order for Lantus insulin Inject 10 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS. initiated on [DATE].Record review of Resident #2's February 2026 medication administration record revealed LVN F administered 10 units of Lantus insulin at 7:00 AM on [DATE] to Resident #2. During an observation of the 400-hall nurse cart at 4:25 PM on [DATE], a Lantus insulin pen with an open date of [DATE] in the top drawer. The label on the pen revealed it was ordered for Resident #2. In an interview with LVN F at 3:52 PM on [DATE], LVN F stated she administered Resident #2's Lantus insulin pen in her cart to Resident #2 around 7:00 AM on [DATE]. LVN F stated based on the open date written on the pen, the pen would have expired on [DATE], 28 days after it was opened. LVN F stated she was supposed to check the expiration dates on medications before administering them. LVN F stated administering expired insulin to a resident could lead to elevated glucose and cause excessive thirst or frequent urination. In an interview with the DON at 10:50 AM on [DATE], the DON stated expired insulin should not be stored in the nurse's carts. The DON stated insulin expired 28 days after it was taken out of the refrigerator. The DON stated an insulin pen opened on [DATE] would have expired on [DATE]. The DON stated expired insulin should not be administered to a resident because it may affect glucose in unpredictable ways leading to higher or lower glucose levels than expected. Record review of the facility policy titled Medication Administration implemented in [DATE] stated the following: 2.a. The nurse/medication aide shall be responsible to read and follow precautionary instructions on prescription labels.6. Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community. Record review of the facility policy titled Diabetes Management implanted on [DATE] and revised on [DATE] stated the following: Routine Care:. Anti-diabetic agents (insulin or oral anti-diabetic agents) should be administered as per physician order.

Based on interviews and record review, the facility failed to maintain clinical records that were accurately documented for 1 (Resident #13) of 5 residents reviewed for medical records. 1. The facility failed to ensure Resident #13's blood pressure readings were accurately documented for the month of January 2026. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #13's face sheet dated 02/10/26 reflected a [AGE] year-old-female with an original admission date of 05/13/23. Diagnoses include hypertensive heart disease (damage to the heart caused by long-term high blood pressure) and chronic (long-term) kidney disease. Record review of Resident #13's care plan initiated on 10/11/24 reflected Resident #13 had heart disease. Interventions included: Administer medications as ordered by my physician. Monitor vital signs as indicated and report abnormal findings to MD as indicated. Record review of Resident #13's MD orders reflected: Vitals one time a day. Start date, 08/16/23. Give Amlodipine Besylate oral tablet 5 MG. 1 tablet by mouth one time a day for HTN (high blood pressure). Hold if systolic blood pressure (top number) is less than 100. Start date 08/16/23. Record review of Resident #13's January 2026 blood pressure log reflected: 01/12/26 07:55 126/77 mmHg 01/12/26 09:04 126/77 mmHg 01/16/26 07:23 115/61 mmHg 01/16/26 09:13 115/61 mmHg 01/19/26 08:29 126/65 mmHg 01/19/26 09:33 126/65 mmHg 01/26/26 09:49 110/76 mmHg 01/26/26 11:48 110/76 mmHg 01/27/26 08:35 114/60 mmHg 01/27/26 09:01 114/60 mmHg 01/28/26 08:01 119/64 mmHg 01/28/26 09:29 119/64 mmHg 01/29/26 08:24 119/65 mmHg 01/29/26 09:37 119/65 mmHg 01/30/26 09:25 112/70 mmHg 01/30/26 12:07 112/70 mmHg In an interview on 02/10/26 at 8:15 AM, MA C stated there was a recall button on the system used when documenting resident blood pressures, and she would use it sometimes. MA C stated sometimes when Resident #13 refused to let her take their blood pressure, MA C stated she would use the previous blood pressure reading that was taken. MA C stated she should be documenting that Resident #16 was refusing her blood pressure to be taken instead of using the previous blood pressure recorded. MA C stated if Resident #13's blood pressure was documented wrong, the resident's blood pressure could become low if medication was given when it was not supposed to. In an interview on 02/11/26 at 10:32 AM, the DON stated MA C should not have been using the previous blood pressure readings recorded. The DON stated that if a blood altering medication was given to Resident #13 when her blood pressure was not actually taken, it could cause the resident's blood pressure to drop, causing potential complications. The DON stated a resident's blood pressure could change drastically within an hour of the last reading. The DON stated there was no policy on documentation but did provide a Professional Standard of Care Policy. Record review of the facility's Professional Standard of Care policy dated Jan. 2024 reflected: Compliance Guidelines: The community provides services that meet professional standards of quality and are provided by appropriately qualified persons (e.g., licensed, certified).

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in comprehensive assessment for 1 (Resident #139) of 8 residents reviewed for care plans. The facility failed to ensure Resident #139's care plan was developed by not including any plan of care for her contractures (permanent, rigid tightening of muscles, tendons, skin, or tissues around a joint, restricting movement and causing deformity) in her hands. This failure could place residents at an increased risk of needs going unmet or harm. The findings included:Record review of Resident #139's face sheet dated 02/10/26 revealed a [AGE] year-old female with an admission date of 03/11/22. Resident #139's pertinent diagnoses included unspecified dementia (symptoms of cognitive decline are present but not clearly linked to a specific cause) and stiffness of unspecified joint (a general restriction, tightness, or difficulty moving a joint that cannot be classified elsewhere). Record review of Resident #139's quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained because the resident was rarely or never understood. Further review revealed Resident #139 was dependent on staff to perform all effort for all functional abilities. During an observation of Resident #139 lying in bed in her room at 4:30 PM on 02/08/26, Resident #139's hands were severely contracted with Resident #139 unable to move them. No item was placed in Resident #139's hands. Record review of Resident #139's comprehensive care plan dated 02/10/26 revealed the contractures in her hands were not addressed. In an interview with LVN I at 8:46 AM on 02/11/26, LVN I stated she was the MDS Coordinator at the facility. LVN I stated it was her responsibility to ensure nursing-related items were added to residents' care plans. LVN I stated Resident #139's care plan did not currently have any plan of care for her contractures, but it should have. LVN I stated if the contractures were left off the plan of care then the floor nursing staff may not know to look for the issue, or they may not properly care for it. LVN I stated she was going to address the plan of care immediately. In an interview with the DON at 10:50 AM on 02/11/26, the DON stated Resident #139's contractures should have been care planned. The DON stated the IDT discussed what belonged in the care plan and the MDS coordinator would put it in the care plan. The DON stated it was important to ensure the care plan was accurate, so nursing staff could implement the appropriate interventions. Record review of the facility policy Care Plans implemented February 2017 and revised January 2024 revealed the following: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Agency, in accordance with State Law through established procedures for 1 out of 5 residents (Resident #1) reviewed for reporting of abuse/neglect. The facility failed to report an allegation of abuse of Resident #1 within 2 hours that occurred on 11/14/25 at around 4:00 PM. This failure could place residents at risk for potential abuse. The findings included:Record Review of Resident #1's face sheet dated 12/29/25 revealed a [AGE] year-old female with an admission date of 11/08/22. Resident #1's pertinent diagnoses included cerebral infarction (blocked artery cuts off blood flow to part of the brain, causing brain cells to die from lack of oxygen and nutrients). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated her cognition was severely impaired. Further review of the MDS revealed Resident #1 had no physical behavioral symptoms such as hitting, kicking, or pushing in the week leading up to the assessment. Record review of Resident #1's comprehensive care plan dated 12/29/25 revealed the focus I have a tendency to have combative behaviors and I may become physically aggressive towards staff when care is provided, I hit and bite initiated on 12/26/23 and revised on 11/18/25. Record review of the provider investigation revealed the following summary: On November 17, 2025, at approximately 5:00 PM, [NAIT A] notified nurse in charge that on Friday, November 14, 2025 during his shift, he could not recall time, he observed [CNA B] hit [Resident #1] on the arm while they were providing care to her. In an interview with CNA B at 3:04 PM on 12/29/25, CNA B stated on November 14th, 2025, she asked CNA C for assistance in bathing Resident #1 sometime in the afternoon. CNA B stated Resident #1 required two CNAs to transfer her from her bed to the shower chair. CNA B stated Resident #1 had a history of being combative when trying to bathe her. CNA B stated while her and CNA C were transferring Resident #1 to the shower chair, Resident #1 hit CNA C on her arm. CNA B stated CNA C had raised her own arm to protect herself from Resident #1's strikes, but at no point throughout the transfer did CNA C hit Resident #1. In an interview with CNA C at 3:28 PM on 12/29/25, CNA C stated CNA B asked her for assistance in helping shower Resident #1. CNA C stated Resident #1 had a history of getting aggressive with staff when they tried to bathe her. CNA C stated she never hit Resident #1 during the transfer, but that Resident #1 did hit her on her arm. CNA C stated once they got Resident #1 into the shower chair they were able to bathe her without any further incident. In an interview with Resident #1 at 3:50 PM on 12/29/25, Resident #1 stated she had never been physically abused by a staff member. Resident #1 stated that she did get aggressive with staff members sometimes when they tried to bathe her because the water was cold sometimes. In an interview with NAIT A at 4:55 PM on 12/29/25, NAIT A stated he was training with CNA B and CNA C on 11/14/25, the day of the alleged abuse incident. NAIT A stated Resident #1 was visibly uncomfortable and crying during her transfer. NAIT A stated Resident #1 insulted CNA C calling her a daughter of a bitch mother. NAIT A stated Resident #1 hit CNA C on the arm, and then CNA C hit Resident #1 back on her left arm in retaliation. NAIT A stated he thought he witnessed physical and mental abuse. NAIT A stated he did not report it immediately because he froze in the moment and did not know what to do. NAIT A stated he did not tell anyone about the incident until 11/17/25, 3 days later when he told his charge nurse. NAIT A stated he had been trained in school to report abuse immediately to keep residents safe. In an interview with LVN D at 5:30 PM on 12/29/25, LVN D stated she was the charge nurse for Resident #1 on 11/17/25. LVN D stated she could not remember who said it, but someone from administration told her to perform a head-to-toe skin assessment on Resident #1 on 11/17/25. LVN D stated she performed the head-to-toe skin assessment and the findings showed no abnormalities. In an interview with the DON at 5:41 PM on 12/29/25, the DON stated anytime a staff member witnessed something they thought might be abuse that should remove the resident from the situation and inform the administrator immediately. The DON stated the facility had 2 hours to report any allegations of abuse to all appropriate parties. The DON stated it was important to report all allegations immediately to keep residents safe and initiate the investigation as soon as possible. The DON stated she did not know why NAIT A waited 3 days to report his allegation of abuse to the administration. The DON stated all NAIT's were trained at orientation to report any possible abuse immediately to the administrator. In an interview with the ADM at 8:38 AM on 12/30/25, the ADM stated NAIT A should have tried to stop any abuse he thought he witnessed at the time it happened and then immediately reported it to the ADM. The ADM stated he did not know why NAIT A did not report the alleged abuse to the administrative staff immediately. The ADM stated he did not learn about the alleged abuse until 11/17/25, 3 days after the incident occurred on 11/14/25. The ADM stated once he found out about the alleged abuse he reported it to all necessary parties within the two-hour time limit. The ADM stated he conducted his investigation and concluded there was not enough evidence to substantiate any abuse allegation. The ADM stated it was important to report abuse immediately to ensure residents were not being treated by individuals accused of abusing them. Record review of the facility policy Abuse Guidance: Preventing, Identifying and Reporting revealed the following policy: .Reporting/Response- all alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are [sic] individuals as may be required by law and per the current state/federal reporting requirements.Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC's PL 19-17 (Replaces PL 17-18).- Are reported immediately,- But not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.The team member is required to report any abuse or neglect should it occur.

Based on observation, interview, and record review the facility failed to ensure resident environments remained free of hazards for four (602, 608, 610, 616) of 10 resident rooms in the 600 hall reviewed for environmental hazards. The facility failed to keep spray bottles with a yellow cleaning solution locked while not in use. This deficient practice could place residents at risk of an unsafe environment. The findings included: Record review of Resident #92's face sheet dated 11/19/24 revealed she was a [AGE] year-old female admitted [DATE] with a diagnosis of Dementia. During an observation on 11/19/24 at 8:41 AM, revealed in room [ROOM NUMBER] in the 600 hall, there was a spray bottle with a yellow cleaning solution labeled Halt Disinfectant, Cleaner, Deodorizer with approximately 3/4 full, was found out in the open on the floor next to the toilet. On 11/19/24 at 8:42 AM, Resident #92 was attemped to be interviewed however, she was not interviewable. Record review of Resident #386's face sheet dated 11/19/24 revealed he was a [AGE] year-old admitted [DATE] with a diagnosis of Dementia. During an observation on 11/19/24 at 8:45 AM, revealed in room [ROOM NUMBER] in the 600 hall, there was a full spray bottle with a yellow cleaning solution labeled Halt Disinfectant, Cleaner, Deodorizer was found out in the open on the counter next to the bathroom sink. On 11/19/24 at 8:46 AM, Resident #386 was attemped to be interviewed however, he was not interviewable. Record review of Resident #388's face sheet dated 11/19/24 revealed she was a [AGE] year-old admitted [DATE] with a diagnosis of Dementia During an observation on 11/19/24 at 8:53 AM, revealed in room [ROOM NUMBER] in the 600 hall, a spray bottle with a yellow cleaning solution labeled Halt disinfectant, Cleaner, Deodorizer was found out in the open on the counter in front of Resident #388's bed. On 11/19/24 at 8:42 AM, Resident #388 was attemped to be interviewed however, she was not interviewable. Record review of Resident #391's face sheet dated 11/19/24 revealed she was a [AGE] year-old admiitted 11/06/24 with a diagnosis of Dementia During an observation on 11/19/24 at 8:53 AM, in room [ROOM NUMBER] in the 600 hall, there was a spray bottle, approximately 3/4's full, with a yellow solution labeled Super HDQ L10 Cleanser/Disinfectant/Detergent/Fundicide that was found out in the open on the counter in the bathroom. On 11/19/24 at 8:42 AM, Resident #391 was attempted to be interviewed however, she was not interviewable. In an interview with LVN F on 11/18/24 at 03:45 PM, he stated that the spray bottles were for disinfecting purposes used by the facility staff when needed. LVN F said there was a risk that a resident could get poisoned if drank, eye irritation or blindness if the chemical was swollowed or spilled. In an interview with the housekeeping supervisor, HSKS, on 11/19/24 at 4:14PM, she stated the contents inside the spray bottles were used for disinfecting. The HSKS stated if ingested it could be harmful. The HSKS then stated that the Administrator asked for the spray bottles were to be available to staff. All other chemicals used to clean are locked in the housekeeping carts. In an interview with the DON on 11/20/24 at 04:08 PM, he stated all 4 spray bottles filled with disinfectant were removed immediately from the resident bathrooms that contained them. The DON stated the liquid in the bottles was used mainly for disinfecting beds, not a general disinfectant for all items. The DON said the bottles were stored in the bathrooms for a couple of weeks. He stated the spray bottles were stored in the bathrooms only the in 600 hall which was used for new admissions. The DON stated it depended if the resident had risky behaviors and dementia, they would not leave anything close to the resident that would pose a risk to him or her. The DON stated The disinfectant could cause harm to the resident if it was ingested. I do not think there are any residents in the facility currently that would ingest or spray the disinfectant inappropriately. In an interview with Administrator on 11/20/24 at 04:30 PM he stated he was unaware there were spray bottles in the bathrooms. He stated that every single one was removed from bathrooms to his knowledge. He stated the spray bottles were normally stored in a storage closet in the housekeeping closet secured. The DON stated a person with a mental condition could get harmed if they got a hold of the spray bottle and potentially ingested it or came in contact with eyes or skin. Record review of the facility's Cleaning and Disinfection of Resident Care Items and Equipment Policy and Procedure revised January 2023 revealed the policy did not include a procedure to store disinfecting products.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure kitchen equipment was in good condition. The facility failed to ensure kitchen equipment was kept clean. The facility failed to ensure items in the refrigerator were labeled and dated. These failures could place residents at risk for complications from food contamination. Observation of the kitchen and initial tour on 11/19/24 at 8:35 AM revealed 2 non-stick pans on the clean rack that were eroded to the metal on the bottoms and sides. There was a metal spatula in use with sharp jagged edges and the handle was melted with deep crevasses that had brown and black substances in and around them. There was a plastic spatula in use that had jagged edges. There was a serving scoop that had a reddish substance on the inside in the clean drawer with other utensils. There were two glasses of milk in the refrigerator that were unlabeled and undated. In an interview with the RD on 11/19/24 at 8:40 AM, she said the eroded non-stick pans looked like they needed to be replaced because the coating should not be coming off. She said kitchen staff should not be using the eroded non-stick pans because bits of the coating could be coming off and getting into the resident s' food. She said if the resident ' s consumed the bits of non-stick coating, they could get sick. She said if the residents drank the milk that was unlabeled and undated, it could be potentially spoiled and make the residents sick. She said the spatulas looked dangerous because of the sharp edges on the metal one and the plastic one looked like bits of it could come off, get in the resident ' s food and make them ill. In an interview with the [NAME] on 11/19/24 at 8:45 AM, she said she was going to throw away the eroded non-stick pans but had not gotten to it. She said they used the eroded pans to make grilled cheese sandwiches. She said the coating on the eroded non-stick pans could get into the food and make residents sick or make the food taste differently. She said the metal spatula could cut someone with the jagged edges and she had not noticed it before. She said the melted plastic handle of the metal spatula had crud in the crevasses. She said touching the dirty handle of the metal spatula could cause cross contamination and make resident sick. She said she used the metal spatula and other metal utensils in the non-stick pans. She said she was unaware they were supposed to be using plastic or nylon utensils in the non-stick pans. She said the jagged edges on the plastic spatula could break off into the food and the residents could chew the bits of plastic and get them stuck in their teeth or hurt their gums. She said the dirty scoop in the clean drawer should not have been there because she did not know what the substance was that was in it. She said the scoop should have been removed and re-washed. She said she did not know how long the glasses of milk were in the refrigerator. In an interview with the FSS food service supervisor since 11/2007 on 11/19/24 at 8:45 AM, she said all kitchen staff were responsible for making sure broken utensils and pans were taken out of service and discarded. She said she had 2 new non-stick pans (they were on the stove). She said the cooks were supposed to be using plastic or nylon utensils in the non-stick pans to avoid the coating from flaking into the food. She said the non-stick coatings were toxic and could get into the food and make residents sick. She said the dirty scoop in the clean drawer should not have been there. She said she was ultimately responsible for making sure equipment used in the kitchen was clean and in good condition. She said kitchen staff should know when utensils and equipment should be replaced and remove them from service so she could order replacements. She said the scoop should have been removed and re-washed. She said the metal spatula was an injury hazard because the jagged edges on the sides of it were very sharp and looked like bits of the metal were missing. She said all items in the refrigerator, freezer, and dry storage should be labeled and dated always. She said none of her staff knew how long the glasses of milk had been in the refrigerator because they were not labeled and dated. She said if items were not labeled and dated, they would not know when the item should be discarded. She said if a resident was to consume anything that was outdated it could make them sick because that was why they had use-by dates. The kitchen equipment policy was requested but not provided. Record review of the undated facility policy titled, Food Preparation and Handling revealed under Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and guidelines. Record review of the undated facility policy titled, Food Storage revealed under Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and guidelines. Under Procedure: 2. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. References: FDA (Food and Drug Administration) Food Code Ch. 4-1-101.11 Characteristics. Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion- resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated ware washings; (D) finished to have a smooth, easily cleanable surface; and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Ch. 4-101.18 Nonstick Coatings, Use Limitation. Multiuse kitchenware such as frying pans, griddles, saucepans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with non-scoring or non-scratching utensils and cleaning pads.

Based on observation, interviews, and record reviews the facility failed to review the resident ' s total program of care, including medications and treatments, at each visit for 1 of 8 residents (Resident #50) reviewed for resident records. The facility failed to ensure the physician's order was accurate and appropriate for Resident #50's levothyroxine order. The levothyroxine was ordered for 1:00 PM, when professional standards and practices for that medication indicated it should be given early in the morning before breakfast. This failure could place residents at risk for incorrect treatment decisions, evaluation, and plans compromising patient safety due to ineffective levels of thyroid hormone. The findings included: Record review of Resident #50's face sheet dated 11/21/24 reflected an [AGE] year-old female with an admitted [DATE]. Pertinent diagnoses included Acute Kidney Failure and dysphagia (difficulty swallowing). Record review of Resident #50's Quarterly MDS assessment section C, cognitive patterns, dated 11/05/24 reflected a BIMS score of 15 (no cognitive impairment). Record review of Resident #50's care plan revealed the problem I have a feeding tube in place r/t dysphagia initiated on 02/11/24 and revised on 11/11/24. Interventions listed to treat the problem revealed the following: Enhanced barrier precautions when in contact with feeding tube initiated on 11/18/24. HOB should be elevated when in bed, avoid flat while providing water flushes initiated on 02/11/24 and revised on 11/11/24. Provide local care to G-Tube site as ordered and monitor for s/sx of infection initiated on 02/11/24. RD to evaluate as indicated initiated on 11/11/24. Report to MD all abnormal findings as indicated initiated on 11/11/24. Further record review of Resident #50's care plan revealed the problem I have chronic health conditions & co-morbid conditions that have affected my physical function and may further affect my quality of life. Heart Disease, Thyroid Disorder initiated on 02/11/24 and revised on 11/11/24. Interventions listed to treat the problem revealed the following: Refer to skilled therapy services for strengthening, mobility as well as oxygen conservation techniques as indicated initiated on 02/11/24. Administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician. Provide care as tolerated and needed initiated on 11/11/24. Labs as ordered & report abnormal findings to MD as indicated initiated on 11/11/24. Monitor my vital signs & weights as indicated initiated on 11/11/24. Report all changes in condition to doctor and resident representative as indicated initiated on 11/11/24. Notify MD PRN any s/sx of complications of extremities: coldness of extremity, pallor [pale appearance], rubor [redness of the skin], cyanosis [shortage of oxygen in the blood] and pain initiated on 11/11/24. Observe MD PRN and s/sx of hypotension: dizziness, fainting, syncope [fainting or passing out], blurred vision, lack of concentration, nausea, fatigue, cold clammy pale skin initiated on 11/11/24. Record review of Resident #50's order summary revealed an active order dated 02/29/24 for Levothyroxine Sodium Oral Tablet 50 MCG, Give 1 tablet by mouth one time a day for Hypothyroidism signed by MD on 03/01/24. Further review of Resident #50's order summary revealed an active order dated 05/09/24 for Regular diet, Regular Texture texture [sic], Thin/Regular consistency. Record review of progress notes for Resident #50 revealed a progress note dated 02/29/24 from Therapy that reflected ST note: Diet recommendation: puree/thin with *assisted dining* for all meals. Med pass: crushed medications PO. Further review of progress notes for Resident #50 revealed a progress note dated 02/29/24 from Nursing that reflected received recommendation from ST for pureed texture meals with thin liquids, meds crushed, MD notified, approved recommendation, orders carried through, RP, DON notified. Record review of Resident #50's MAR dated 11/21/24 revealed Levothyroxine Sodium Oral Tablet 50 MCG was administered to the resident every day in March 2024 at 1:00 PM. Record review of Resident #50's MAR dated 11/21/24 revealed Levothyroxine Sodium Oral Tablet 50 MCG was administered to the resident every day in November 2024 up to 11/20/24 at 1:00 PM. Record review of Resident #50's laboratory results dated [DATE] revealed a TSH of 74.50 mIU/mL (TSH is thyroid stimulating hormone produced in the pituitary gland. TSH signals to the thyroid to produce more T3, or thyroxine, and T4, triiodothyronine. An elevated TSH indicates hypothyroidism, or and underactive thyroid). Review of the ranges listed on the laboratory results for TSH revealed the normal range to be 0.47 - 4.68 mIU/mL. During an observation of Resident #50 on 11/21/24 at 1:49 PM revealed the resident was administered Levothyroxine Sodium Oral Tablet 50 MCG by MA B. During an interview with MA B on 11/21/24 at 1:55 PM, MA B stated Resident #50 had received levothyroxine after lunch for as long as she could remember. MA B stated it was unusual, since every other resident that received levothyroxine always received it in the morning before breakfast. During an interview with the DON on 11/21/24 at 2:44 PM, the DON stated he had already spoken to the MD about the levothyroxine administered after lunch, and the MD had approved a new order to move it to be given at sunrise starting 11/22/24. The DON stated Resident #50 had not shown any symptoms of hypothyroidism since her admission at the facility. The DON stated Resident #50 received her medications via G-tube when she first arrived at the facility. The DON stated she received levothyroxine at 1:00 PM when she first arrived because that was her fasting time between receiving her feeding formula. The DON stated once she was able to eat a little, the levothyroxine was switched to be taken by mouth. The DON stated the timing of the levothyroxine order did not change. The DON stated levothyroxine was typically given in the morning before breakfast to best help with its absorption into the body. The DON stated that it was best practice to receive levothyroxine in the morning, but that given Resident #50's clinical picture, he could not say if the timing of the medication resulted in Resident #50's elevated TSH. During an interview with the MD on 11/21/24 at 3:19 PM, the MD stated the best time to take levothyroxine was 30 to 45 minutes before the first meal of the day. The MD stated the reason the medication should be taken at that time was because that was the best time for the medication to be absorbed into the body. The MD stated if there was a resident that was switching from taking meds and eating via G-tube to by mouth, he would move the levothyroxine timing to 30-45 minutes before the first meal of the day. The MD stated a lack of good absorption of levothyroxine into the body could result in weight gain and slowed movements. The MD stated he had not noticed any clinical sign or changes in Resident #50 demonstrating hypothyroidism. Record review of the facility policy titled Physician Services: Medical Director implemented on 02/17 and revised on 01/23 revealed the following: The medical director's responsibilities include but are not limited to: Directing and coordinating medical care in the organization; Participating in establishing policies, procedures, and guidelines designed to ensure the provision of adequate, comprehensive services; The medical director has administrative authority, responsibility, and accountability for the functions and activities of the medical staff at the community.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident # 88) of 6 residents reviewed for pharmacy services. 1. The facility failed to ensure that MA A accurately documented Resident #88's blood pressure when administering or holding Resident #88's blood pressure increasing medication. 2. The facility failed to ensure that MA A did not administer Resident #88's blood pressure increasing medication when Resident #88's blood pressure was outside of administration parameters or when MA A did not document a blood pressure on 12 opportunities. 3. The facility failed to ensure that MA B accurately documented Resident #88's blood pressure when administering Resident #88's blood pressure increasing medication. 4. The facility failed to ensure that MA B did not administer Resident #88's blood pressure medication when Resident #88's blood pressure was outside of administration parameters or when MA B did not document a blood pressure on 10 opportunities. 5. The facility failed to ensure that MA C did not administer Resident #88's blood pressure increasing medication when Resident #88's blood pressure was outside of administration parameters on 5 opportunities. 6. The facility failed to ensure that LVN D did not administer Resident #88's blood pressure increasing medication when Resident #88's blood pressure was outside of administration parameters on 6 opportunities. These deficient practices could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #88's admission record reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #88's diagnoses included incomplete quadriplegia c5-c7 (weakness or paralysis of all four limbs due to a cervical spinal cord injury), cervical region spinal stenosis (the space inside the bones of the neck becomes too narrow and press on the spinal cord and nerves), bed confinement status, hyperlipidemia (high cholesterol), and essential hypertension (high blood pressure). Record review of Resident #88's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12 which indicated that Resident #88 was cognitively intact. Record review of Resident #88's care plan on 11/19/24 reflected the following problems: 1. I have hypertension r/t CAD (narrowing of the arteries in the heart) and hyperlipidemia initiated on 7/30/21 and revised on 11/6/24. Interventions included the following: Obtain blood pressure readings QD (every day). Take blood pressure readings under the same conditions each time. For example, when I am sitting, use right arm initiated on 7/30/21. 2. I have chronic health conditions and comorbid conditions that have affected my physical function and may further affect my quality of life. Heart disease, neuropathic pain associated with other disease/ condition initiated on 10/9/24. Interventions included the following: Administer my medications, treatments, and diet as recommended by physician initiated on 10/9/24. Monitor my vital signs and weights as indicated initiated on 10/9/24. Notify MD PRN of any s/sx of hypotension: dizziness, fainting, blurred vision, lack of concentration, nausea, fatigue, and/or cold clammy pale skin initiated on 10/9/24. Record review of Resident #88's Order Summary Report on 11/19/24 reflected an active order dated 9/9/24 for Midodrine HCl Tablet 10mg, give 1 tablet my mouth three times a day for hypotension (low blood pressure). Do not give if systolic BP (the top number in a blood pressure) is 120mmHg or higher. Record review of Resident #88's BPS (Blood Pressure Summary) and MAR (Medication Administration Record) in PCC (the facility's electronic health record) dated 11/1/24 through 11/20/24 reflected the following: On 11/1/24 at 8:53pm BP was documented on the BPS as 156/89 by MA C. On 11/1/24 MA C documented on the MAR that the 7:00pm BP was 156/89 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/2/24 at 6:45pm BP was documented on the BPS as 148/70 by MA C. On 11/2/24 MA C documented on the MAR that the 7:00pm BP was 148/70 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/3/24 at 8:59am BP was documented on the BPS as 134/86 by MA A. On 11/3/24 MA A documented on the MAR that the 7:00am BP was 134/86 and the Midodrine was not administered due to BP being outside of parameters for administration. On 11/3/24 there was no documentation of the BP on the BPS between 8:59am and 7:33pm. On 11/3/24 MA A documented on the MAR that the BP at 1:00pm was 134/86 and the 1:00pm dose of Midodrine was administered (even though the BP documented was the same as the 8:59am BP on the BPS and the 7:00am BP on the MAR, and it was outside of parameters for administration). On 11/3/24 at 7:33pm BP was documented on the BPS as 146/83 by MA C. On 11/3/24 MA C documented on the MAR that the 7:00pm BP was 146/83 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/4/24 at 8:13am BP was documented on the BPS as 138/86 by MA A. On 11/4/24 MA A documented on the MAR that the 7:00am BP was 138/86 and the Midodrine was not administered due to BP being outside of parameters for administration. On 11/4/24 there was no documentation of BP on the BPS between 8:13am and 6:31pm. On 11/4/24 MA A documented on the MAR that the 1:00pm BP was 138/86 and the Midodrine was administered (even though the BP documented was the same as the 8:13am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/4/24 at 6:31pm BP was documented on the BPS as 134/80 by LVN D. On 11/4/24 LVN D documented on the MAR that the 7:00pm BP was 134/80 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/5/24 there was no BP documented on the BPS prior to 11:18am. On 11/5/24 MA A documented on the MAR that the 7:00am BP was 132/71 and the Midodrine was not administered due to BP being outside of parameters for administration (even though the BP documented was the same as the 11:18am BP on the BPS and the 1:00pm MAR) On 11/5/24 at 11:18am BP was documented on the BPS as 132/71 by MA A. On 11/5/24 MA A documented on the MAR that the 1:00pm BP was 132/71 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/5/24 at 6:40pm BP was documented on the BPS as 122/70 by LVN D. On 11/5/24 LVN D documented on the MAR that the 7:00pm BP was 122/70 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/6/24 there was no BP documented on the BPS prior to 5:17pm. On 11/6/24 MA A documented on the MAR that the 7:00am and 1:00pm BP was 122/70 and the Midodrine was administered (even though the BP documented for both 7:00am and 1:00pm were the same as the BP documented on 11/5/24 on the BPS at 6:40pm and on the MAR at 7:00pm, and it was outside of parameters for administration). On 11/6/24 at 5:14pm BP was documented on the BPS as 149/80 by MA C. On 11/6/24 MA C documented on the MAR that the 7:00pm BP was 149/80 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/7/24 at 7:14am BP was documented on the BPS as 133/74 by MA B. On 11/7/24 MA B documented on the MAR that the 7:00am BP was 133/74 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/7/24 there was no BP documented on the BPS between 7:14am and 7:12pm. On 11/7/24 MA B documented on the MAR that the 1:00pm BP was 133/74 and the Midodrine was administered (even though the BP documented was the same as the 7:14am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/8/24 there was no BP documented on the BPS prior to 12:17pm. On 11/8/24 at 12:17pm BP was documented on the BPS as 140/86 by MA A. On 11/8/24 MA A documented on the MAR that the 7:00am BP was 140/86 and the Midodrine was not administered because it was outside of parameters for administration (even though there was no BP documented on the BPS prior to 12:17pm and the BP documented on the MAR was the same as the 12:17pm BP on the BPS). On 11/8/24 at 8:51pm BP was documented on the BPS as 132/70 by MA C. On 11/8/24 MA C documented on the MAR that the 7:00pm BP was 132/70 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/9/24 at 8:41am BP was documented on the BPS as 137/86 by MA A. On 11/9/24 MA A documented on the MAR that the 7:00am BP was 137/86 and the Midodrine was not administered due to BP being outside of parameters for administration. On 11/9/24 there was no BP documented on the BPS between 8:41am and 8:52pm. On 11/9/24 MA A documented on the MAR that the 1:00pm BP was 137/86 and the Midodrine was administered (even though the BP documented was the same as the 8:41am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/10/24 there was no BP documented on the BPS prior to 1:42pm. On 11/10/24 MA A documented on the MAR that the 7:00am BP was 132/79 and the Midodrine was not administered due to BP being outside of parameters for administration (even though the BP documented was the same as the 1:42pm BP on the BPS and the 1:00pm MAR). On 11/10/24 at 1:42pm BP on the BPS was documented as 132/79 by MA A. On 11/10/24 MA A documented on the MAR that the 1:00pm BP was 132/79 and the Midodrine was administered (even though the BP documented was the same as the BP on the 7:00am MAR, and it was outside of parameters for administration). On 11/10/24 at 6:15pm the BP was documented on the BPS as 130/76 by LVN D. On 11/10/24 LVN D documented on the MAR that the 7:00pm BP was 130/76 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/11/24 at 6:49am BP was documented on the BPS as 142/87 by MA A. On 11/11/24 MA A documented on the MAR that the 7:00am BP was 142/87 and the Midodrine was not administered due to BP being outside of parameters for administration. On 11/11/24 there was no documentation of BP on the BPS between 6:49am and 6:41pm. On 11/11/24 MA A documented on the MAR that the 1:00pm BP was 142/87 and the Midodrine was administered (even though the BP documented was the same as the 6:49am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/11/24 at 6:41pm BP was documented on the BPS as 140/78 by LVN D. On 11/11/24 LVN D documented on the MAR that the 7:00pm BP was 140/78 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/12/24 at 6:59am BP was documented on the BPS as 122/84 by MA B. On 11/12/24 MA B documented on the MAR that the 7:00am BP was 122/84 and the Midodrine was administered (even though the BP was outside of parameters for administration). On 11/12/24 there was no documentation of BP on the BPS between 6:59am and 6:26pm. On 11/12/24 MA B documented on the MAR that the 1:00pm BP was 122/84 and the Midodrine was administered (even though the BP documented was the same as the 6:59am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/12/24 at 6:26pm BP was documented on the BPS as 120/69 by MA B. On 11/12/24 MA B documented on the MAR that the 7:00pm BP was 120/69 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/13/24 at 7:33am BP was documented on the BPS as 114/72 by MA B. On 11/13/24 there was no documentation of BP on the BPS between 7:33am and 7:00pm. On 11/13/24 MA B documented on the MAR that the 1:00pm BP was 114/72 and the Midodrine was administered (even though the BP documented was the same as the 7:33am BP on the BPS and the 7:00am MAR). On 11/14/24 at 7:52am BP was documented on the BPS as 117/62 by MA B. On 11/14/24 there was no documentation of BP on the BPS between 7:52am and 6:53pm. On 11/14/24 MA B documented on the MAR that the 1:00pm BP was 117/62 and the Midodrine was administered (even though the BP documented was the same as the 7:52am BP on the BPS and the 7:00am MAR). On 11/15/24 there was no documentation of BP on the BPS prior to 12:03pm. On 11/15/24 MA A documented on the MAR that the 7:00am BP was 140/82 and the Midodrine was not administered due to BP being outside of parameters for administration (even though the BP documented was the same as the 12:03pm BP on the BPS and the 1:00pm MAR). On 11/15/24 at 12:03pm BP on the BPS was documented as 140/82 by MA A. On 11/15/24 MA A documented on the MAR that the 1:00pm BP was 140/82 and the Midodrine was administered (even though the BP documented was the same as the BP on the 7:00am MAR, and it was outside of parameters for administration). On 11/15/24 at 5:01pm the BP was documented on the BPS as 189/97 by MA C. On 11/16/24 there was no BP documented on the BPS prior to 7:00pm. On 11/6/24 MA A documented on the MAR that the 7:00am and 1:00pm BP was 189/97 and the Midodrine was administered (even though the BP documented for both 7:00am and 1:00pm were the same as the BP documented 11/15/24 on the BPS at 5:01pm and on the MAR at 7:00pm, and it was outside of parameters for administration). On 11/16/24 at 7:00pm BP was documented on the BPS as 120/79 by LVN D. On 11/16/24 LVN D documented on the MAR that the 7:00pm BP was 120/79 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/17/24 there was no BP documented on the BPS between 9:39am and 8:00pm. On 11/17/24 there was no documentation on the MAR at 1:00pm of a BP or administration or non-administration of Midodrine. (Both the BP and the administration boxes were blank.) On 11/17/24 at 8:00pm BP was documented on the BPS as 137/79 by LVN D. On 11/17/24 LVN D documented on the MAR that the 7:00pm BP was 137/79 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/18/24 at 7:53am BP was documented on the BPS as 119/66 by MA B. On 11/18/24 there was no BP documented on the BPS between 7:53am and 7:09pm. On 11/18/24 MA B documented on the MAR that the 1:00pm BP was 119/66 and the Midodrine was administered (even though the BP documented was the same as the 7:53am BP on the BPS and the 7:00am MAR). On 11/19/24 at 7:41am BP was documented on the BPS as 122/66 by MA B. On 11/19/24 MA B documented on the MAR that the 7:00am BP was 122/66 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/19/24 at 1:58pm BP was documented on the BPS as 120/70 by MA B. On 11/19/24 MA B documented on the [NAME] that the 1:00pm BP was 120/70 and the Midodrine was administered (even though it was outside of parameters for administration). In an interview on 11/21/24 at 10:30am, MA A stated she had been an MA since 2012. MA A stated for the majority of the patients that had parameters, the parameters were in the system. MA A stated if the resident's BP was not within the parameters, she would let the nurse know, the nurse would tell her to hold the medication, and then she would document it on the MAR as held. MA A stated she checked the blood pressure before giving the medication and the BP got documented in the MAR and they were documented manually. MA A stated there was a box at the top of the page that had the last set of v/s, but they did not auto populate into the MAR. MA A stated she had never not checked the BP before giving a medication. In reference to Resident #88, MA A stated his BP was usually high in the morning then dropped lower in the afternoon. MA A stated on 11/16/24, she apparently failed to document the correct blood pressure when she administered the medication for the 7:00am and 1:00pm doses. MA A further stated on the days that it (the MAR) showed the same blood pressures for the 7:00am and 1:00pm doses that were the same as the night before (7:00pm dose), she just failed to document the correct BPs. MA A stated, I do always check the BP before I give or hold the medication and the BPs are documented as soon as I do them. MA A stated it was important to always check v/s because if someone was given a medication to raise their blood pressure and the blood pressure was already high, it could cause the resident to have a stroke, be hospitalized , or even pass away. MA A stated it was important to document correctly so that everyone knew what was going on with the resident, how he or she was doing and if the doctor was needing to make medication changes, they needed accurate documentation of vitals to be able to manage care appropriately. MA A stated the last in service on med admin was last month. In an interview on 11/21/24 at 10:55am, MA B stated if a resident was on medication that had vital sign parameters, she would check the v/s before she gave the medication, document it after she gave the medication, and if not within parameters, she would tell the nurse so she could hold the medication. MA B stated, I always check the v/s before I give the medication. I would not give the medication without checking the v/s to make sure it was within parameters, if there were any. In reference to Resident #88's Midodrine and the days that the same BPs were documented on the MAR at 7:00am and 1:00pm, MA B stated that she did check the BP on those days, but she guessed she did not document the BP, she just used the same ones as the morning check. MA B stated it was important to always document the BP because if there was a problem with it going up and down the doctor could change the medication if necessary. MA B stated it was important to always check it (the BP) first to make sure it was within the parameters to give. MA B stated if a BP was high, but it was not checked, and the resident was given this medication (Midodrine), it could cause them to have a heart attack or stroke, go the hospital, and possibly die. MA B stated the last in service on medication administration was sometime this year. In an interview on 11/21/24 at 11:54am the ADON stated that v/s were supposed to be checked right before a medication was given that had parameters for v/s. The ADON stated the v/s and the administration or hold of the medication was supposed to be documented right away. The ADON stated it was not appropriate to use v/s that were done with previous administrations or holds. The ADON stated it was important to check the v/s before administration because you had to know if the resident needed the medication or not and if a medication was given that was outside of parameters, it could cause the resident to have an adverse reaction, be hospitalized , or if the blood pressure went too high it could cause a hypertensive crisis, stroke, or death. The ADON further stated it was important to document v/s accurately and timely so the provider could make adjustments if needed, based on the correct information. The ADON stated, My expectation is for everyone to assess their residents and check their v/s as ordered by the provider and on the MAR. The ADON stated the last in-service on medication administration was within the last 3 days and that she would be doing another in-service with each medication aide and nurse to address these specific issues. The ADON stated usually when the BP was documented on the MAR, it would transfer to the v/s (BP) section of PCC (Point Click Care, the facility's electronic health record) and she was not sure why it did not transfer. In an interview on 11/21/24 at 12:15pm, the DON stated he talked to corporate about the v/s documentation on the MAR on 11/20/24 to see if there was a way to get the system to send an alert if any of the vital signs were outside of parameters. The DON stated, My expectation is for the MAs or the nurses to check the BP before giving the medication and to document immediately the v/s and whether it was administered or held. The DON further stated if the blood pressure was high and the Midodrine was given it could cause the resident's blood pressure to be higher which could lead to harm. The DON stated the last in-service on medication administration was 11/20/24 and that they would be doing another one today (11/21/24). The DON stated, In terms of oversite, we will be looking at which residents are getting meds that have parameters and reviewing their MARs to ensure that the medications and v/s are being done and charted appropriately. Record review of the facility's Medication Administration policy implemented March 2019 and revised January 2023 reflected in part: Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner. Responsible Disciplines: Licensed Nurses, CMAs 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. a. The nurse/ medication aide shall be responsible to read and follow precautionary or instructions on prescription labels. 5. If applicable and/ or prescribed, take vital signs or tests prior to administration of the dose. 6. Administer medications as ordered by the physician. Documentation: Initial the electronic administration record after the medication is administered to the resident.

Based on observation, interviews, and record reviews the facility failed to ensure drugs and biologicals were stored securely for 1 (Resident #34) of 5 residents reviewed for storage of medications. The facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards. As a result, this failure placed residents at risk of not getting ordered medications, and/or medications could have been diverted or ingested by another resident. Findings Included: Record review of Resident #34's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with an original admitted [DATE]. Diagnoses included Unspecified Dementia, Type 2 Diabetes, Primary Osteoarthritis, Osteoporosis, Stiffness of Joint, and Pain in Right Shoulder. Record review of Resident #34's MDS dated [DATE] revealed a BIMS score of 11. BIMS score 13-15 suggests resident's cognition is intact. Resident #34's care plan does not indicate that resident is allowed to administer own medications. Record review of care plan initiated 6/26/24 revealed Resident #34 had impaired cognitive function or impaired thought process related to dementia. Record review on 11/20/24 of physician's orders revealed no order for a pain cream for Resident #34's pain. The physician's orders also revealed there were multiple medications that the two tablets could have been, such as Metformin, Tylenol, Multivitamin, Potassium and Gabapentin. Observation 11/19/24 09:00 AM revealed Resident #34 was in bed rubbing her arm and shoulder. Bedside table was noted to have 2 large, white, oblong pills sitting on a napkin next to a souffle cup that had a thick, white paste in it. Interview on 11/19/24 at 09:15 AM with Resident #34, she stated she did not know what the pills were or where they came from. She stated the nurse probably left them there for her to take, but she did not like to take pills because they make her sick to her stomach. Resident #34 was also complaining of pain to her right arm and right shoulder. She stated the nurse was supposed to bring her a cream to put on it, but never brought it. Resident #34 stated she asks for the cream all the time, but they never bring her anything. She stated sometimes she can take Tylenol for the pain, but other times it upsets her stomach. Interview with LVN - E on 11/19/24 at 09:30 AM, she stated she had not passed any medication to Resident #34, and she wasn't sure if they were Resident 34's medication as they look like many other medications, so she would not have left the medications at the bedside. If the patient had refused them, she would have discarded them in her trash on her cart. She also stated Resident #34 does not have an order for a cream for pain, but that she would reach out to the provider to get an order. Interview with MA - J on 11/19/24 at 09:45 AM, she stated she never noticed the two white tablets or a cream sitting at the resident's bedside table, but stated they did not come from her because she actually watched the resident swallow her morning pills. If the resident had refused, she would have disposed of the medication appropriately in the trash or sharps container. Interview with LVN - I on 11/19/24 at 10:30 AM, she stated she doesn't remember seeing the pills or the cream at the bed side, but she didn't place them there because the resident took all the medication that she administered to her. She stated that if the resident had refused the medication, she would dispose of it properly. Interview with the Administrator on 11/20/24 at 04:45 PM, he stated that nurses are not supposed to leave medications at bedside. If medications are refused by resident, they should be disposed of properly. If medications are left at bedside a lot of things could happen like another resident could take them. Interview with the DON on 11/21/24 at 09:58 AM, he stated medications should never be left at bedside, and if a resident refused medication the nurse should dispose of meds appropriately in the sharps or use the chemical that is designated to dispose the medication in. If medications are left at bedside another resident could end up swallowing them. Record review of Medication Administration Policy revealed never administer medications from an unmarked container, never administer medications supplied for one resident to another resident, administer medications as ordered and according to the established medication administration schedule, avoid leaving medications with the resident to self-administer, and follow the medication/pharmacy guidelines for storage.

Based on record reviews and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (Resident #2 and Resident #3) of 12 residents reviewed for quality of care. 1a. The facility failed to ensure that Resident #2's Admission Assessment was accurately and timely documented in PCC on 9/16/23 when she returned to the facility from the hospital after having surgery. 1b. The facility failed to ensure that an incident in which Resident #2 cut her surgical incision drain tubing on 9/16/23 was timely documented. 2a. The facility failed to ensure that Resident #3's Post Fall Review was documented accurately and timely in PCC after she fell on [DATE]. 2b. The facility failed to ensure that Resident #3's Neuro Checks were accurately and timely documented in PCC after she fell on [DATE]. 2c. The facility failed to ensure that Resident #3's progress notes were timely documented in PCC on 6/15/24 and 6/16/24. 2d. The facility failed to ensure that Resident #3's Change in Condition Evaluation was documented accurately and timely in PCC when she began to experience pain on her right leg on 6/16/24. 2e. The facility failed to ensure that Resident #3's Change in Condition Evaluation was documented accurately and timely in PCC when she had bleeding from her surgical site incision on her right leg on 6/21/24. These failures could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Record review of Resident #2's admission record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included Alzheimer's disease, unspecified dementia, anxiety disorder, depressive episodes, hypertension (high blood pressure), hypertensive chronic kidney disease (kidney disease due to kidney damage done by high blood pressure), malignant neoplasm of left female breast (breast cancer), acquired absence of left breast and nipple (surgical removal of the breast), and cognitive communication deficit (difficulty with communication). Record review of Resident #2's quarterly MDS dated [DATE] reflected that Resident #2 had a BIMS score of 3 out of 15 which indicated that she had severe cognitive impairment. Resident #2 required total assistance with bathing/ showering. Resident #2 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/ taking off shoes, personal hygiene, rolling left and right in bed, sitting to lying flat on the bed, lying on the bed to sitting on the edge of the bed (without back support), transferring from bed to chair or chair to bed, getting on or off a toilet, getting into or out of a tub or shower, walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet. Record review of Resident #2's care plan reflected that Resident #2 had focuses of: A. Impaired cognitive function or though processes r/t Alzheimer's and dementia with interventions that included cue, reorient, and supervise as needed which was initiated and created on 5/10/21, B. ADL self-care performance deficit r/t Alzheimer's with interventions that included Resident #2 requiring set up assistance for toileting, transfers, repositioning in bed, dressing and eating which was initiated and created on 5/10/21, C. Bladder incontinence r/t Alzheimer's and dementia with interventions that included check me as needed and as required for incontinence which was initiated and created on 5/10/21, and D. Requirement of anti-depressant medication r/t anxiety which was created and initiated on 4/3/21. E. Risk for falls r/t wandering which was created and initiated on 4/3/21. Record review of Resident #2's Provider Order Summary Report reflected that Resident #2 had the following side effect monitoring and medication orders: a. Side effects- anti-convulsant order date 4/2/21. b. Side effects- anti-depressant order date 4/2/21. c. Side effects- sedative/ hypnotic order date 6/27/22. d. Depakote Delayed Release 125mg. Give 1 tablet PO BID for agitation. e. Lamotrigine 25mg. Give 2 tablets PO every morning and at bedtime for convulsions. f. Losartan Potassium 50mg. Give 1 tablet PO one time a day for HTN. g. Trazadone HCl 50mg. Give 1 tablet PO BID for anxiety and agitation. Record review of Resident #2's Admission assessment dated [DATE] at 4:41pm and signed by RN B on 9/21/23 reflected the following: a. The resident required catheter care/ catheter change. b. No EBP (enhanced barrier precautions) were clinically indicated. (Resident #2 had a surgical incision and a surgical drain from a left breast mastectomy that was done on 9/15/23) c. Actual or risk for infection- Focus: at risk for infection or recurrent/ chronic infection r/t compromised medical condition with interventions of report changes in condition to provider as clinically indicated and enhanced barrier precautions practices as clinically indicated. d. A catheter was required post-surgery J [NAME] (a surgical suction drain that gently draws fluid from a surgical site) with intervention of monitor for s/s (signs or symptoms) of infection. e. Vitals, Height, Weight: 1. Most recent weight: 167.5 pounds dated 9/1/23 at 3:58pm 2. Most recent height: 56 inches dated 4/5/21 at 8:24am 3. Most recent blood pressure: 109/83 dated 9/17/23 at 8:01am (1 day AFTER the effective date of this assessment which was 9/16/23 at 4:41pm) 4. Most recent temperature: 97.0 F dated 7/31/23 at 11:35pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 5. Most recent pulse: 72 dated 9/4/23 at 9:37am (12 days PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 6. Most recent respiration: 18 dated 7/31/23 at 11:24pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 7. Most recent O2 sats (oxygen saturation): 98% dated 7/31/23 at 11:25pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 8. Most recent pain level: 0 dated 9/16/23 at 7:15pm (2 hours AFTER the effective date/time of this assessment which was 9/16/23 at 4:41pm) f. Resident's communication is impaired related to: Not Applicable. (Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment) g. Head to toe skin assessment: 1. General skin condition: normal (Resident #2 had a left breast mastectomy on 9/15/23) 2. Skin condition: skin is intact, no identified skin issues (Resident #2 had a left breast mastectomy on 9/15/23) 2e. Skin concern/ risk plan of care: Focus: actual or at risk for skin impairment Interventions: apply treatment as ordered, keep clean and dry and apply skin barrier cream as indicated, pressure relieving cushion device in wheelchair as indicated, therapeutic pressure reducing mattress. (Did not address the surgical incision from Resident #2's left breast mastectomy on 9/15/23) h. Degree of physical activity- Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. (Resident #2 was ambulatory with a walker and required only supervision or touch assistance with walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet which was reflected in her MDS.) i. Mobility- Ability to change and control body position: No limitations: makes major and frequent changes in position. (Contradictory to the above assessment answer that Resident #2's ability to walk was severely limited or non-existent). j. Friction and shear- No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. (Contradictory to assessment answer (h) that Resident #2's ability to walk was severely limited or non-existent). k. Incontinence- Resident is incontinent to: Neither. (Contradictory to Resident #2's care plan which reflected bladder incontinence r/t Alzheimer's and dementia with interventions that included check me as needed and as required for incontinence which was initiated and created on 5/10/21). l. Fall risk assessment: 1. Recent falls: none in the last 12 months. (Resident #2 had an actual fall dated 9/20/22) 2. Medications (hypnotics, sedatives, anxiolytics, anti-depressants, anti-Parkinson's, diuretics, anti-hypertensives): Not taking any of these medications. (Contradictory to Resident #2's order summary report which reflected she was taking an anxiolytic, anti-depressant, and an anti-hypertensive). 3. Psychological (anxiety, depression, decline in cooperativeness, decline in insight/judgement): Does not appear to have any of these. 4. Cognitive status: Intact. (Contradictory to Resident #2's BIMS score of 3 which indicated severe cognitive impairment). 5. Automatic high risk status: Recent change in functional status and/or medications with the potential to affect safe mobility. (This answer contradicted the answer to (2) above which stated Resident #2 was not on medications with the potential to affect safe mobility). m. Exit seeking Tool: Is the resident physically able to leave the building on their own? no n. Hot liquid evaluation: None of the boxes are checked. o. If any boxes are checked yes, indicate which interim measures were put into place to enhance safety while therapy screen is pending: Focus- Resident has the potential for skin impairment/ burn r/t hot liquid encounters; needs disposable plastic lid on coffee cup for safety. (None of the boxes were checked for hot liquid evaluation). p. 48 hour care planning: 1. Care plan for self-care deficit- Focus: I have a self-care deficit. Intervention: Mobility- I use a wheelchair. (Resident #2 was ambulatory with a walker and required only supervision or touch assistance with walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet which was reflected in her MDS.) 2. Care Plan- Cognitive function/ dementia or impaired thought Process is not included. 3. Fall risk plan of care- Focus: at risk for falls r/t wandering. Actual fall 9/20/22. Record review of Resident #2's progress notes in PCC reflected an entry as follows: Late Entry Effective date: 9/16/23 at 12:47pm Created by: DON Created date: 10/9/23 at 12:52pm Note text: During rounds, was advised by SN (skilled nurse) and supervisor noted Jackson Pratt to have an incision made by the resident on the Jackson Pratt's tubing. This information was communicated to the PA (physician's assistant) and orders were given to seal the drainage tube and follow up with the surgeon. Nursing was able to seal the Jackson Pratt tube and drainage was noted at the end of the shift. No s/s of infection were noted in the area or to the resident's mastectomy area. 2. Record review of Resident #3's admission record reflected an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Alzheimer's disease, dementia, fall from bed (1/18/24), displaced intertrochanteric fracture of right femur (non-aligned fracture of the right thigh bone at the hip) (1/18/24), age-related osteoporosis (bone disease that causes bones to become weak and more likely to break) without current pathological fracture (broken bone not caused by force or impact) (1/16/24), polyosteoarthritis (pain in five or more joints at the same time), and generalized muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] reflected that Resident #3 had a BIMS score of 0 of 15 and a cognitive skills for daily decision making score of 3 which indicated severe impairment- resident never/rarely made decisions. Resident #3 required substantial/ maximal assistance for toileting hygiene, shower/ bathing self, lower body dressing, and putting on/ taking off footwear, rolling left and right in bed, sit on side of bed to lying flat on the bed, and transferring to and from a bed to chair (or wheelchair). Resident #3 required partial/ moderate assistance for upper body dressing, standing from a sitting position, and walking 10 feet. Resident #3 required supervision or touch assistance for personal hygiene. Resident #3 required set up or clean up assistance for eating and oral hygiene. Resident #3 did not attempt to walk 50 feet with two turns or to walk 150 feet due to medical condition or safety concerns nor did Resident #3 attempt to get on or off a toilet or get into or out of a tub/shower as she did not perform these activities in the past. Record review of Resident #3's care plan reflected Resident #3 had focuses of: A. Risk for falls r/t impaired cognition/mobility, poor safety awareness with goals of 1-3 fewer falls through next review date, not experiencing any significant injuries associated with a fall through next review date, and safety r/t falls will be managed with interventions for orthostatic hypotension (a condition where blood pressure drops when changing positions from saying to sitting and sitting to standing) through review date. Interventions included anticipate and meet needs, call bell within reach, bed at appropriate height when unattended, room rearrange Resident #7's bed closer to hers, routine rounds to help with safety checks by all team members, and call light sign B. Requirement of psychotropic medications and at potential risk for side effects with an intervention of educate care givers that sometimes a behavior outburst can indicate pain, hunger, thirst, or need of toileting, rest, activity, or comforting. C. Risk for experiencing discomfort or pain r/t history of right hip fractur and left distal femur fracture with interventions including Resident #3 being able to participate in pain assessment using the numerical pain scale. Record review of Resident #3's provider order summary report as of 6/15/24 reflected that Resident #3 had the following side effect monitoring and medication orders: a. Anti-depressant side effect monitoring. b. Anti-anxiety side effect monitoring. c. Hydroxyzine HCl. Give 12.5 mg by mouth every 8 hours as needed for anxiety. Ordered on 6/11/24) d. Amlodipine Besylate 10mg. Give 1 tablet PO once a day for HTN. Record review of Resident #3's Post Fall Review in PCC dated 6/15/24 at 7:08pm and signed by the DON on 6/19/24 reflected the following: 1. Date and time of fall: 6/15/24 at 7:00pm 2. Was the fall observed: No. 3. Most recent blood pressure: 152/74 on 6/19/24 at 7:41am (4 days AFTER the Post Fall Review effective date of 6/15/24). 4. Most recent pulse: 71 on 6/19/24 at 7:41am (4 days AFTER the Post Fall Review effective date of 6/15/24). 5. Most recent O2 sats: 97% on 6/18/24 at 11:20am (3 days AFTER the Post Fall Review effective date of 6/15/24). 6. Has patient received 1 or more of the following in the past 24 hours (antianxiety, anticoagulant, antipsychotic, cardiovascular, diuretic, hypnotic, or pain medication)? None of the boxes were checked. (Contradictory to Resident #3's order summary report which reflected that she was taking an anti-anxiety and an anti-hypertensive medication). Record review of Resident #3's Neuro Checks in PCC dated 6/15/24 at 7:00pm and signed by the DON on 6/19/24 reflected the following: The neuro checks were to be done every 15 minutes- 4 times (6/15/24 at 7:15pm, 7:30pm, 7:45pm, and 8:00pm), every 30 minutes- 4 times (6/15/24 at 8:30pm, 9:00pm, 9:30pm, and 10:00pm), every 1 hour- 4 times (6/15/24 at 11:00pm, 6/16/24 at 12:00am, 1:00am, and 2:00am), every 2 hours- 4 times (6/16/24 at 4:00am, 6:00am, 8:00am, and 10:00am), every 4 hours- 2 times (6/16/24 at 2:00pm and 6:00pm) and every 8 hours- 6 times (6/17/24 at 2:00am, 10:00am, 6:00pm, 6/18/24 at 2:00am, 10:00am, and 6:00pm). 1. 15 minute check-1st: A. Date/time: 6/15/24 at 7:15pm B.1. Level of consciousness: Alert C.1. Pupil response: Pupils equal and reactive to light: yes 2. Right pupil: Brisk 3. Left pupil: Brisk D.1.Motor functions: Hand grasps: Hand grasps are equal. 2. Moves all extremities: Yes 3. Moves right arm: Yes 4. Moves left arm: Yes 5. Moves right leg: Yes 6. Moves left leg: Yes 7. Unable to follow commands: No 8. Absent: No E.1. Resident response to pain: Appropriate pain response 2. Most recent pain level: 0 on 6/17/24 at 6:53am. (2 days AFTER the Neuro checks effective date of 6/15/24) F.1. Vitals: Most recent blood pressure: 128/79 on 6/17/24 at 7:48am (2 days AFTER the Neuro checks effective date of 6/15/24). 2. Most recent temperature: 98.0 on 4/18/24 at 4:11am (2 months BEFORE the Neuro checks effective date of 6/15/24). 3. Most recent pulse: 66 on 6/17/24 at 7:48am (2 days AFTER the Neuro checks effective date of 6/15/24). 4. Most recent respiration: 18 on 4/18/24 at 4:11am (2 months BEFORE the Neuro checks effective date of 6/15/24). G. Observations: no neuro deficits The next 11 of the Neuro Checks were dated and timed correctly for when Resident #3 was supposed to be neurologically assed, however ALL of the vital signs (Sections E2 and F1-4) were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 2 days AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) these neurological assessments were documented as being completed. The 1st 2 hour check was incorrectly timed for 3:00am on 6/16/24. The correct date/time was 6/16/24 at 4:00am. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) this neurological assessment was documented as being completed. The 2nd 2 hour check was incorrectly timed for 5:00am on 6/16/24. The correct date/time was 6/16/24 at 6:00am. The only documentation done was: B.1. Level of consciousness: Alert C.1. Pupil response: Pupils are equal and reactive to light: Yes 2. Right pupil: Brisk 3. Left pupil: Brisk Sections D.1-8 (motor function) and E.1 (Resident response to pain) were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) this neurological assessment was documented as being completed. The 3rd and 4th 2 hour check were dated correctly but timed incorrectly. All the questions in sections A through E.1 were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) the neurological assessments were documented as being completed. The 1st and 2nd 4 hour checks, and all 6 of the 8 hour checks were blank where the assessment date and time were to be documented. All the questions in sections A through E.1 were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 6/17/24 (pain level, blood pressure, and pulse) or 4/18/24 (temperature and respirations). Record review of Resident #3's progress notes dated 6/11/24 to 6/28/24 in PCC reflected that Hydroxyzine (an anti-anxiety medication) was ordered on 6/11/24. Resident #3 received Hydroxyzine on 6/14/24 at 12:23pm. The following progress notes were late entries: 1. Type: Nursing progress note Effective: 6/15/24 at 9:28am Created: 6/18/24 at 10:30am Created by: DON Note: Resident performing restorative therapy with Restorative aide at this time, patient tolerated well restorative therapy. RP was notified. 2. Type: Nursing progress note Effective: 6/15/24 at 3:30pm Created: 6/18/24 at 10:31am Created by: DON Note: Family member was present at this time with resident. RP was helping resident to ambulate around the facility, resident was ambulating with the help of a walker. No pain noted at this time. 3. Type: Nursing progress note Effective: 6/15/24 at 7:00pm Created: 6/18/24 at 10:38am Created by: DON Notes: Informed by medication aide that resident was found on her knees next to her family member's bed. Upon entering the room, nurse noted resident was on her knees beside the bed. Resident stated she was trying to go and check on her family member, who is her roommate. With the assistance of CNA, SN carefully transferred the resident back to her own bed. A thorough head-to-toe assessment was conducted immediately, and no skin injuries, edema, or bruising were noted. ROM as previously noted with no s/s of pain to all four extremities. Notified MD and RP of incident. 4. Type: Nursing progress note Effective: 6/15/24 at 9:00pm Created: 6/18/24 at 10:40am Created by: DON Note: Resident was rounded at this time, no c/o pain or discomfort noted, and no s/s of distress. RP was notified. 5. Type: Nursing progress note Effective: 6/15/24 at 11:15pm Created: 6/18/24 at 10:46am Created by: DON Note: Resident was rounded at this time, no c/o pain or discomfort noted, and no s/s of distress. 6. Type: Nursing progress note Effective: 6/16/24 at 12:30am Created: 6/18/24 at 10:49am Created by: DON Note: CNA provided incontinent care at this time; no signs and symptoms of pain were noted, and the resident continued to sleep in bed comfortably. 7. Type: Nursing progress note Effective: 6/16/24 at 4:00am Created: 6/18/24 at 10:50am Created by: DON Note: CNA provided incontinent care at this time; no signs and symptoms of pain were noted, and the resident continued to sleep in bed comfortably. 8. Type: eINTERACT SBAR Summary for Providers Effective 6/18/24 at 7:00am Created: 6/18/24 at 11:01am Created by: RN B Situation: Pain to right leg with movement This started on: 6/16/24 (no time or time of day documented) Summarize your observations, evaluation, and recommendations: This morning, nurse was informed by the CNA that while changing resident and preparing for breakfast, noticed swelling above her right knee. Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg. Describe functional status changes: (Choices were needs more assistance with ADLs, general weakness, decreased mobility, fall, swallowing difficulty, no changes observed, and other). No changes were observed was checked. (Contradictory to the summarized statement that Resident #3 experienced pain when moving her leg. Vital signs evaluation: Are these the most recent vital signs taken after the change in condition occurred: Yes Most recent blood pressure: 128/79 dated 6/17/24 at 7:48am (1 day AFTER the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent pulse: 66 dated 6/17/24 at 7:48am (1 day AFTER the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent respiration: 18 dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent temperature: 98.0 dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent O2 sats: 98% dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Provider notification and feedback: Date and time of clinician notification: 6/16/24 at 12:00am (7 hours BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Recommendations of primary clinician: No bruising or signs of trauma noted at this time. Nurse immediately administered pain medication, advised CNA to leave the resident in bed, and notified the doctor of the situation. New orders were received for an x-ray of the right hip and knee. Pain status evaluation: Is a pain assessment relevant to the change in condition being reported? Answer: Not clinically applicable to the change in condition being reported. (Contradictory to the summarized statement of, Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg.) Does the resident have pain: Not answered. (Contradictory to the summarized statement of, Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg.) Pain location: Not answered. (See above) General background information: Primary diagnosis: not answered. List any medication changes made in the past week: Not answered. (Contradictory to the Order Summary Report as of 6/15/24 which reflected Resident #3 had an order for Hydroxyzine HCl. Give 12.5 mg by mouth every 8 hours as needed for anxiety that was ordered on 6/11/24) Resident representative notification: Date and time of family/ RP notification: 6/16/24 at 12:00am (7 hours before the effective date/time of 6/16/24 at 7:00am) 9. Type: Nursing progress note Effective: 6/16/24 at 3:00pm Created: 6/18/24 at 10:57am Note: The resident applied a right knee orthopedic brace. At this time, resident was noted trying to get out of bed. SN was at bedside. CNA stayed at the bedside to provide immediate supervision to prevent further injury. The resident was reoriented to time and place and rested comfortably in bed. RP was notified of nursing intervention at this time. 10. Type: eINTERACT SBAR Summary for Providers Effective: 6/21/24 at 9:15am Created: 6/23/24 at 11:17pm Created by: RN B Vital signs evaluation: Are these the most recent vital signs taken after the change in condition occurred: Yes Most recent blood pressure: 133/70 dated 6/23/24 at 7:21pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent pulse: 74 dated 6/23/24 at 7:21pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent respiration: 18 dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent temperature: 97.8 dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent weight: 127.0 dated 6/1/24 at 7:29pm. Most recent O2 sats: 97% dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Provider notification and feedback: Were the change in condition and notifications reported to primary care clinician: Yes Date and time of clinician notification: 6/21/24 at 12:00am (9 hours BEFORE the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). In an interview on 10/30/24 at 1:57pm RN C stated she had been working at the facility for 5 years. When asked about the readmission process, RN C stated when a resident was admitted after a hospital stay as a readmission, a progress note was put in the computer, and admission assessment was done, the primary provider would be notified, and any new orders would be entered. RN C stated the readmission assessment was done immediately upon the resident's arrival in the facility. RN C stated in reference to the resident's most recent vital signs, that they were on the top of the page in PCC. RN C stated there was a button to click that had recent vital signs that showed the previous vital signs, but you had to click on each one individually. In reference to what would be documented in the progress notes, RN C stated that any orders that were given, any risk management documentation, appointments, and any information that would need to be passed on to the next shift should be documented in the progress notes. RN C stated the SBAR was its own assessment but showed up in progress notes. RN C stated an SBAR and change in condition would be done for fever, abnormal vital signs, lethargy, and anything that has to do with a change in the resident's condition. RN C stated that progress notes were to be documented immediately. RN C stated notifications to the RP, provider, and ADON/ DON were done and documented immediately in PCC in the change in condition documentation. RN C stated she was familiar with Resident #2 and had her as a patient after her mastectomy. RN C stated she was not working the day of the incident with Resident #2's JP drain, but she was told that Resident #2 pulled out her JP drain. RN C stated Resident #2 had dementia, forgot things right away, and had to be redirected frequently. RN C stated the nurse who was in charge when the JP drain incident happened fixed the drain and it was still draining. LVN C stated if something like that happened on her shift, she would notify the surgeon, the RP and the DON immediately to see what the plan of action was. RN C stated the documentation would include the change in condition form or a risk management form in PCC and a progress note would be written, also in PCC. RN C stated the progress note would have a summary of what happened, who was contacted, and what the plan of care was. RN C stated the risk management documentation would have more detailed information and it would automatically generate the date, time, and resident information at the top of the form. In an interview on 10/30/24 at 2:37pm, the ADON stated she had been working at the facility as a floor nurse for 2 years, became the DCE (Director of Clinical Education) for 2 1/2 years and then became the ADON. The ADON stated when a resident was gone for a little while (to the hospital) a readmission assessment, medication reconciliation, and the whole screening and care planning were done again when the resident returned. The ADON stated anything that was new or changed was revised in orders and/ or care plans. The ADON stated when someone returned to the facility, the head to toe assessment and vital signs were done as soon as they got to the facility. The ADON stated the vital signs were pulled automatically to the admission form and the nurse had to change them to the correct vital signs. The ADON stated progress notes were used for documenting any changes, new orders, appointments, and anything related to the resident's clinical status. The ADON stated that change in condition documentation was used for any changes, critical laboratory result and any change in a resident's condition. The ADON stated it was done at the time of the change in condition. The ADON stated the provider, RP and DON were notified for any change in condition immediately. The ADON stated th [TRUNCATED]

Based on record reviews and interviews, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that were accurately documented for 2 (Resident #2 and Resident #3) of 12 residents reviewed for clinical records. 1a. The facility failed to ensure that Resident #2's Admission Assessment was accurately and timely documented in PCC on 9/16/23 when she returned to the facility from the hospital after having surgery. 1b. The facility failed to ensure that an incident in which Resident #2 cut her surgical incision drain tubing on 9/16/23 was timely documented. 2a. The facility failed to ensure that Resident #3's Post Fall Review was documented accurately and timely in PCC after she fell on [DATE]. 2b. The facility failed to ensure that Resident #3's Neuro Checks were accurately and timely documented in PCC after she fell on [DATE]. 2c. The facility failed to ensure that Resident #3's progress notes were timely documented in PCC on 6/15/24 and 6/16/24. 2d. The facility failed to ensure that Resident #3's Change in Condition Evaluation was documented accurately and timely in PCC when she began to experience pain on her right leg on 6/16/24. 2e. The facility failed to ensure that Resident #3's Change in Condition Evaluation was documented accurately and timely in PCC when she had bleeding from her surgical site incision on her right leg on 6/21/24. These failures could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Record review of Resident #2's admission record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included Alzheimer's disease, unspecified dementia, anxiety disorder, depressive episodes, hypertension (high blood pressure), hypertensive chronic kidney disease (kidney disease due to kidney damage done by high blood pressure), malignant neoplasm of left female breast (breast cancer), acquired absence of left breast and nipple (surgical removal of the breast), and cognitive communication deficit (difficulty with communication). Record review of Resident #2's quarterly MDS dated [DATE] reflected that Resident #2 had a BIMS score of 3 out of 15 which indicated that she had severe cognitive impairment. Resident #2 required total assistance with bathing/ showering. Resident #2 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/ taking off shoes, personal hygiene, rolling left and right in bed, sitting to lying flat on the bed, lying on the bed to sitting on the edge of the bed (without back support), transferring from bed to chair or chair to bed, getting on or off a toilet, getting into or out of a tub or shower, walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet. Record review of Resident #2's care plan reflected that Resident #2 had focuses of: A. Impaired cognitive function or though processes r/t Alzheimer's and dementia with interventions that included cue, reorient, and supervise as needed which was initiated and created on 5/10/21, B. ADL self-care performance deficit r/t Alzheimer's with interventions that included Resident #2 requiring set up assistance for toileting, transfers, repositioning in bed, dressing and eating which was initiated and created on 5/10/21, C. Bladder incontinence r/t Alzheimer's and dementia with interventions that included check me as needed and as required for incontinence which was initiated and created on 5/10/21, and D. Requirement of anti-depressant medication r/t anxiety which was created and initiated on 4/3/21. E. Risk for falls r/t wandering which was created and initiated on 4/3/21. Record review of Resident #2's Provider Order Summary Report reflected that Resident #2 had the following side effect monitoring and medication orders: a. Side effects- anti-convulsant order date 4/2/21. b. Side effects- anti-depressant order date 4/2/21. c. Side effects- sedative/ hypnotic order date 6/27/22. d. Depakote Delayed Release 125mg. Give 1 tablet PO BID for agitation. e. Lamotrigine 25mg. Give 2 tablets PO every morning and at bedtime for convulsions. f. Losartan Potassium 50mg. Give 1 tablet PO one time a day for HTN. g. Trazadone HCl 50mg. Give 1 tablet PO BID for anxiety and agitation. Record review of Resident #2's Admission assessment dated [DATE] at 4:41pm and signed by RN B on 9/21/23 reflected the following: a. The resident required catheter care/ catheter change. b. No EBP (enhanced barrier precautions) were clinically indicated. (Resident #2 had a surgical incision and a surgical drain from a left breast mastectomy that was done on 9/15/23) c. Actual or risk for infection- Focus: at risk for infection or recurrent/ chronic infection r/t compromised medical condition with interventions of report changes in condition to provider as clinically indicated and enhanced barrier precautions practices as clinically indicated. d. A catheter was required post-surgery J [NAME] (a surgical suction drain that gently draws fluid from a surgical site) with intervention of monitor for s/s (signs or symptoms) of infection. e. Vitals, Height, Weight: 1. Most recent weight: 167.5 pounds dated 9/1/23 at 3:58pm 2. Most recent height: 56 inches dated 4/5/21 at 8:24am 3. Most recent blood pressure: 109/83 dated 9/17/23 at 8:01am (1 day AFTER the effective date of this assessment which was 9/16/23 at 4:41pm) 4. Most recent temperature: 97.0 F dated 7/31/23 at 11:35pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 5. Most recent pulse: 72 dated 9/4/23 at 9:37am (12 days PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 6. Most recent respiration: 18 dated 7/31/23 at 11:24pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 7. Most recent O2 sats (oxygen saturation): 98% dated 7/31/23 at 11:25pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 8. Most recent pain level: 0 dated 9/16/23 at 7:15pm (2 hours AFTER the effective date/time of this assessment which was 9/16/23 at 4:41pm) f. Resident's communication is impaired related to: Not Applicable. (Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment) g. Head to toe skin assessment: 1. General skin condition: normal (Resident #2 had a left breast mastectomy on 9/15/23) 2. Skin condition: skin is intact, no identified skin issues (Resident #2 had a left breast mastectomy on 9/15/23) 2e. Skin concern/ risk plan of care: Focus: actual or at risk for skin impairment Interventions: apply treatment as ordered, keep clean and dry and apply skin barrier cream as indicated, pressure relieving cushion device in wheelchair as indicated, therapeutic pressure reducing mattress. (Did not address the surgical incision from Resident #2's left breast mastectomy on 9/15/23) h. Degree of physical activity- Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. (Resident #2 was ambulatory with a walker and required only supervision or touch assistance with walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet which was reflected in her MDS.) i. Mobility- Ability to change and control body position: No limitations: makes major and frequent changes in position. (Contradictory to the above assessment answer that Resident #2's ability to walk was severely limited or non-existent). j. Friction and shear- No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. (Contradictory to assessment answer (h) that Resident #2's ability to walk was severely limited or non-existent). k. Incontinence- Resident is incontinent to: Neither. (Contradictory to Resident #2's care plan which reflected bladder incontinence r/t Alzheimer's and dementia with interventions that included check me as needed and as required for incontinence which was initiated and created on 5/10/21). l. Fall risk assessment: 1. Recent falls: none in the last 12 months. (Resident #2 had an actual fall dated 9/20/22) 2. Medications (hypnotics, sedatives, anxiolytics, anti-depressants, anti-Parkinson's, diuretics, anti-hypertensives): Not taking any of these medications. (Contradictory to Resident #2's order summary report which reflected she was taking an anxiolytic, anti-depressant, and an anti-hypertensive). 3. Psychological (anxiety, depression, decline in cooperativeness, decline in insight/judgement): Does not appear to have any of these. 4. Cognitive status: Intact. (Contradictory to Resident #2's BIMS score of 3 which indicated severe cognitive impairment). 5. Automatic high risk status: Recent change in functional status and/or medications with the potential to affect safe mobility. (This answer contradicted the answer to (2) above which stated Resident #2 was not on medications with the potential to affect safe mobility). m. Exit seeking Tool: Is the resident physically able to leave the building on their own? no n. Hot liquid evaluation: None of the boxes are checked. o. If any boxes are checked yes, indicate which interim measures were put into place to enhance safety while therapy screen is pending: Focus- Resident has the potential for skin impairment/ burn r/t hot liquid encounters; needs disposable plastic lid on coffee cup for safety. (None of the boxes were checked for hot liquid evaluation). p. 48 hour care planning: 1. Care plan for self-care deficit- Focus: I have a self-care deficit. Intervention: Mobility- I use a wheelchair. (Resident #2 was ambulatory with a walker and required only supervision or touch assistance with walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet which was reflected in her MDS.) 2. Care Plan- Cognitive function/ dementia or impaired thought Process is not included. 3. Fall risk plan of care- Focus: at risk for falls r/t wandering. Actual fall 9/20/22. Record review of Resident #2's progress notes in PCC reflected an entry as follows: Late Entry Effective date: 9/16/23 at 12:47pm Created by: DON Created date: 10/9/23 at 12:52pm Note text: During rounds, was advised by SN (skilled nurse) and supervisor noted Jackson Pratt to have an incision made by the resident on the Jackson Pratt's tubing. This information was communicated to the PA (physician's assistant) and orders were given to seal the drainage tube and follow up with the surgeon. Nursing was able to seal the Jackson Pratt tube and drainage was noted at the end of the shift. No s/s of infection were noted in the area or to the resident's mastectomy area. 2. Record review of Resident #3's admission record reflected an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Alzheimer's disease, dementia, fall from bed (1/18/24), displaced intertrochanteric fracture of right femur (non-aligned fracture of the right thigh bone at the hip) (1/18/24), age-related osteoporosis (bone disease that causes bones to become weak and more likely to break) without current pathological fracture (broken bone not caused by force or impact) (1/16/24), polyosteoarthritis (pain in five or more joints at the same time), and generalized muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] reflected that Resident #3 had a BIMS score of 0 of 15 and a cognitive skills for daily decision making score of 3 which indicated severe impairment- resident never/rarely made decisions. Resident #3 required substantial/ maximal assistance for toileting hygiene, shower/ bathing self, lower body dressing, and putting on/ taking off footwear, rolling left and right in bed, sit on side of bed to lying flat on the bed, and transferring to and from a bed to chair (or wheelchair). Resident #3 required partial/ moderate assistance for upper body dressing, standing from a sitting position, and walking 10 feet. Resident #3 required supervision or touch assistance for personal hygiene. Resident #3 required set up or clean up assistance for eating and oral hygiene. Resident #3 did not attempt to walk 50 feet with two turns or to walk 150 feet due to medical condition or safety concerns nor did Resident #3 attempt to get on or off a toilet or get into or out of a tub/shower as she did not perform these activities in the past. Record review of Resident #3's care plan reflected Resident #3 had focuses of: A. Risk for falls r/t impaired cognition/mobility, poor safety awareness with goals of 1-3 fewer falls through next review date, not experiencing any significant injuries associated with a fall through next review date, and safety r/t falls will be managed with interventions for orthostatic hypotension (a condition where blood pressure drops when changing positions from saying to sitting and sitting to standing) through review date. Interventions included anticipate and meet needs, call bell within reach, bed at appropriate height when unattended, room rearrange Resident #7's bed closer to hers, routine rounds to help with safety checks by all team members, and call light sign B. Requirement of psychotropic medications and at potential risk for side effects with an intervention of educate care givers that sometimes a behavior outburst can indicate pain, hunger, thirst, or need of toileting, rest, activity, or comforting. C. Risk for experiencing discomfort or pain r/t history of right hip fractur and left distal femur fracture with interventions including Resident #3 being able to participate in pain assessment using the numerical pain scale. Record review of Resident #3's provider order summary report as of 6/15/24 reflected that Resident #3 had the following side effect monitoring and medication orders: a. Anti-depressant side effect monitoring. b. Anti-anxiety side effect monitoring. c. Hydroxyzine HCl. Give 12.5 mg by mouth every 8 hours as needed for anxiety. Ordered on 6/11/24) d. Amlodipine Besylate 10mg. Give 1 tablet PO once a day for HTN. Record review of Resident #3's Post Fall Review in PCC dated 6/15/24 at 7:08pm and signed by the DON on 6/19/24 reflected the following: 1. Date and time of fall: 6/15/24 at 7:00pm 2. Was the fall observed: No. 3. Most recent blood pressure: 152/74 on 6/19/24 at 7:41am (4 days AFTER the Post Fall Review effective date of 6/15/24). 4. Most recent pulse: 71 on 6/19/24 at 7:41am (4 days AFTER the Post Fall Review effective date of 6/15/24). 5. Most recent O2 sats: 97% on 6/18/24 at 11:20am (3 days AFTER the Post Fall Review effective date of 6/15/24). 6. Has patient received 1 or more of the following in the past 24 hours (antianxiety, anticoagulant, antipsychotic, cardiovascular, diuretic, hypnotic, or pain medication)? None of the boxes were checked. (Contradictory to Resident #3's order summary report which reflected that she was taking an anti-anxiety and an anti-hypertensive medication). Record review of Resident #3's Neuro Checks in PCC dated 6/15/24 at 7:00pm and signed by the DON on 6/19/24 reflected the following: The neuro checks were to be done every 15 minutes- 4 times (6/15/24 at 7:15pm, 7:30pm, 7:45pm, and 8:00pm), every 30 minutes- 4 times (6/15/24 at 8:30pm, 9:00pm, 9:30pm, and 10:00pm), every 1 hour- 4 times (6/15/24 at 11:00pm, 6/16/24 at 12:00am, 1:00am, and 2:00am), every 2 hours- 4 times (6/16/24 at 4:00am, 6:00am, 8:00am, and 10:00am), every 4 hours- 2 times (6/16/24 at 2:00pm and 6:00pm) and every 8 hours- 6 times (6/17/24 at 2:00am, 10:00am, 6:00pm, 6/18/24 at 2:00am, 10:00am, and 6:00pm). 1. 15 minute check-1st: A. Date/time: 6/15/24 at 7:15pm B.1. Level of consciousness: Alert C.1. Pupil response: Pupils equal and reactive to light: yes 2. Right pupil: Brisk 3. Left pupil: Brisk D.1.Motor functions: Hand grasps: Hand grasps are equal. 2. Moves all extremities: Yes 3. Moves right arm: Yes 4. Moves left arm: Yes 5. Moves right leg: Yes 6. Moves left leg: Yes 7. Unable to follow commands: No 8. Absent: No E.1. Resident response to pain: Appropriate pain response 2. Most recent pain level: 0 on 6/17/24 at 6:53am. (2 days AFTER the Neuro checks effective date of 6/15/24) F.1. Vitals: Most recent blood pressure: 128/79 on 6/17/24 at 7:48am (2 days AFTER the Neuro checks effective date of 6/15/24). 2. Most recent temperature: 98.0 on 4/18/24 at 4:11am (2 months BEFORE the Neuro checks effective date of 6/15/24). 3. Most recent pulse: 66 on 6/17/24 at 7:48am (2 days AFTER the Neuro checks effective date of 6/15/24). 4. Most recent respiration: 18 on 4/18/24 at 4:11am (2 months BEFORE the Neuro checks effective date of 6/15/24). G. Observations: no neuro deficits The next 11 of the Neuro Checks were dated and timed correctly for when Resident #3 was supposed to be neurologically assed, however ALL of the vital signs (Sections E2 and F1-4) were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 2 days AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) these neurological assessments were documented as being completed. The 1st 2 hour check was incorrectly timed for 3:00am on 6/16/24. The correct date/time was 6/16/24 at 4:00am. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) this neurological assessment was documented as being completed. The 2nd 2 hour check was incorrectly timed for 5:00am on 6/16/24. The correct date/time was 6/16/24 at 6:00am. The only documentation done was: B.1. Level of consciousness: Alert C.1. Pupil response: Pupils are equal and reactive to light: Yes 2. Right pupil: Brisk 3. Left pupil: Brisk Sections D.1-8 (motor function) and E.1 (Resident response to pain) were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) this neurological assessment was documented as being completed. The 3rd and 4th 2 hour check were dated correctly but timed incorrectly. All the questions in sections A through E.1 were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) the neurological assessments were documented as being completed. The 1st and 2nd 4 hour checks, and all 6 of the 8 hour checks were blank where the assessment date and time were to be documented. All the questions in sections A through E.1 were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 6/17/24 (pain level, blood pressure, and pulse) or 4/18/24 (temperature and respirations). Record review of Resident #3's progress notes dated 6/11/24 to 6/28/24 in PCC reflected that Hydroxyzine (an anti-anxiety medication) was ordered on 6/11/24. Resident #3 received Hydroxyzine on 6/14/24 at 12:23pm. The following progress notes were late entries: 1. Type: Nursing progress note Effective: 6/15/24 at 9:28am Created: 6/18/24 at 10:30am Created by: DON Note: Resident performing restorative therapy with Restorative aide at this time, patient tolerated well restorative therapy. RP was notified. 2. Type: Nursing progress note Effective: 6/15/24 at 3:30pm Created: 6/18/24 at 10:31am Created by: DON Note: Family member was present at this time with resident. RP was helping resident to ambulate around the facility, resident was ambulating with the help of a walker. No pain noted at this time. 3. Type: Nursing progress note Effective: 6/15/24 at 7:00pm Created: 6/18/24 at 10:38am Created by: DON Notes: Informed by medication aide that resident was found on her knees next to her family member's bed. Upon entering the room, nurse noted resident was on her knees beside the bed. Resident stated she was trying to go and check on her family member, who is her roommate. With the assistance of CNA, SN carefully transferred the resident back to her own bed. A thorough head-to-toe assessment was conducted immediately, and no skin injuries, edema, or bruising were noted. ROM as previously noted with no s/s of pain to all four extremities. Notified MD and RP of incident. 4. Type: Nursing progress note Effective: 6/15/24 at 9:00pm Created: 6/18/24 at 10:40am Created by: DON Note: Resident was rounded at this time, no c/o pain or discomfort noted, and no s/s of distress. RP was notified. 5. Type: Nursing progress note Effective: 6/15/24 at 11:15pm Created: 6/18/24 at 10:46am Created by: DON Note: Resident was rounded at this time, no c/o pain or discomfort noted, and no s/s of distress. 6. Type: Nursing progress note Effective: 6/16/24 at 12:30am Created: 6/18/24 at 10:49am Created by: DON Note: CNA provided incontinent care at this time; no signs and symptoms of pain were noted, and the resident continued to sleep in bed comfortably. 7. Type: Nursing progress note Effective: 6/16/24 at 4:00am Created: 6/18/24 at 10:50am Created by: DON Note: CNA provided incontinent care at this time; no signs and symptoms of pain were noted, and the resident continued to sleep in bed comfortably. 8. Type: eINTERACT SBAR Summary for Providers Effective 6/18/24 at 7:00am Created: 6/18/24 at 11:01am Created by: RN B Situation: Pain to right leg with movement This started on: 6/16/24 (no time or time of day documented) Summarize your observations, evaluation, and recommendations: This morning, nurse was informed by the CNA that while changing resident and preparing for breakfast, noticed swelling above her right knee. Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg. Describe functional status changes: (Choices were needs more assistance with ADLs, general weakness, decreased mobility, fall, swallowing difficulty, no changes observed, and other). No changes were observed was checked. (Contradictory to the summarized statement that Resident #3 experienced pain when moving her leg. Vital signs evaluation: Are these the most recent vital signs taken after the change in condition occurred: Yes Most recent blood pressure: 128/79 dated 6/17/24 at 7:48am (1 day AFTER the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent pulse: 66 dated 6/17/24 at 7:48am (1 day AFTER the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent respiration: 18 dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent temperature: 98.0 dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent O2 sats: 98% dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Provider notification and feedback: Date and time of clinician notification: 6/16/24 at 12:00am (7 hours BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Recommendations of primary clinician: No bruising or signs of trauma noted at this time. Nurse immediately administered pain medication, advised CNA to leave the resident in bed, and notified the doctor of the situation. New orders were received for an x-ray of the right hip and knee. Pain status evaluation: Is a pain assessment relevant to the change in condition being reported? Answer: Not clinically applicable to the change in condition being reported. (Contradictory to the summarized statement of, Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg.) Does the resident have pain: Not answered. (Contradictory to the summarized statement of, Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg.) Pain location: Not answered. (See above) General background information: Primary diagnosis: not answered. List any medication changes made in the past week: Not answered. (Contradictory to the Order Summary Report as of 6/15/24 which reflected Resident #3 had an order for Hydroxyzine HCl. Give 12.5 mg by mouth every 8 hours as needed for anxiety that was ordered on 6/11/24) Resident representative notification: Date and time of family/ RP notification: 6/16/24 at 12:00am (7 hours before the effective date/time of 6/16/24 at 7:00am) 9. Type: Nursing progress note Effective: 6/16/24 at 3:00pm Created: 6/18/24 at 10:57am Note: The resident applied a right knee orthopedic brace. At this time, resident was noted trying to get out of bed. SN was at bedside. CNA stayed at the bedside to provide immediate supervision to prevent further injury. The resident was reoriented to time and place and rested comfortably in bed. RP was notified of nursing intervention at this time. 10. Type: eINTERACT SBAR Summary for Providers Effective: 6/21/24 at 9:15am Created: 6/23/24 at 11:17pm Created by: RN B Vital signs evaluation: Are these the most recent vital signs taken after the change in condition occurred: Yes Most recent blood pressure: 133/70 dated 6/23/24 at 7:21pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent pulse: 74 dated 6/23/24 at 7:21pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent respiration: 18 dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent temperature: 97.8 dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent weight: 127.0 dated 6/1/24 at 7:29pm. Most recent O2 sats: 97% dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Provider notification and feedback: Were the change in condition and notifications reported to primary care clinician: Yes Date and time of clinician notification: 6/21/24 at 12:00am (9 hours BEFORE the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). In an interview on 10/30/24 at 1:57pm RN C stated she had been working at the facility for 5 years. When asked about the readmission process, RN C stated when a resident was admitted after a hospital stay as a readmission, a progress note was put in the computer, and admission assessment was done, the primary provider would be notified, and any new orders would be entered. RN C stated the readmission assessment was done immediately upon the resident's arrival in the facility. RN C stated in reference to the resident's most recent vital signs, that they were on the top of the page in PCC. RN C stated there was a button to click that had recent vital signs that showed the previous vital signs, but you had to click on each one individually. In reference to what would be documented in the progress notes, RN C stated that any orders that were given, any risk management documentation, appointments, and any information that would need to be passed on to the next shift should be documented in the progress notes. RN C stated the SBAR was its own assessment but showed up in progress notes. RN C stated an SBAR and change in condition would be done for fever, abnormal vital signs, lethargy, and anything that has to do with a change in the resident's condition. RN C stated that progress notes were to be documented immediately. RN C stated notifications to the RP, provider, and ADON/ DON were done and documented immediately in PCC in the change in condition documentation. RN C stated she was familiar with Resident #2 and had her as a patient after her mastectomy. RN C stated she was not working the day of the incident with Resident #2's JP drain, but she was told that Resident #2 pulled out her JP drain. RN C stated Resident #2 had dementia, forgot things right away, and had to be redirected frequently. RN C stated the nurse who was in charge when the JP drain incident happened fixed the drain and it was still draining. LVN C stated if something like that happened on her shift, she would notify the surgeon, the RP and the DON immediately to see what the plan of action was. RN C stated the documentation would include the change in condition form or a risk management form in PCC and a progress note would be written, also in PCC. RN C stated the progress note would have a summary of what happened, who was contacted, and what the plan of care was. RN C stated the risk management documentation would have more detailed information and it would automatically generate the date, time, and resident information at the top of the form. In an interview on 10/30/24 at 2:37pm, the ADON stated she had been working at the facility as a floor nurse for 2 years, became the DCE (Director of Clinical Education) for 2 1/2 years and then became the ADON. The ADON stated when a resident was gone for a little while (to the hospital) a readmission assessment, medication reconciliation, and the whole screening and care planning were done again when the resident returned. The ADON stated anything that was new or changed was revised in orders and/ or care plans. The ADON stated when someone returned to the facility, the head to toe assessment and vital signs were done as soon as they got to the facility. The ADON stated the vital signs were pulled automatically to the admission form and the nurse had to change them to the correct vital signs. The ADON stated progress notes were used for documenting any changes, new orders, appointments, and anything related to the resident's clinical status. The ADON stated that change in condition documentation was used for any changes, critical laboratory result and any change in a resident's condition. The ADON stated it was done at the time of the change in condition. The ADON stated the provider, RP and DON were notified for any change in condition immediately. The ADON stated that