Every finding on record at Laurel Creek Health Center

Based on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice and resident's needs for Resident 1 by failing to administer oxygen (a life sustaining gas that travels from lungs to the blood and helps convert food into energy), when Resident 1 was found with critically low oxygen levels in the blood (a dangerous, life-threatening condition when the oxygen not reaching body tissues often causing confusion, rapid breathing, and altered level of consciousness-a change in arousal and responsiveness that ranges from mild to severe e.g. lethargy to coma state). In addition, the facility did not initiate cardiopulmonary resuscitation (CPR -an emergency treatment performed in an effort to preserve the function of the brain and other vital organs when a person has no pulse (pulse can be checked from an artery located on wrist or neck) and is not breathing or not breathing adequately), when Resident 1 was found unresponsive, pulseless, and not breathing. These failures denied Resident 1 life-sustaining treatments and interventions during an emergency and resulted in Resident 1's death.A review of Resident 1's Face Sheet (a summary of patient's demographic, clinical information, physician name) indicated the facility admitted Resident 1 on 5/2/26. Resident 1's diagnoses included endometrial cancer (cancer of the inner lining of the womb), pulmonary embolism (a condition when a blood clot get stuck into the lungs obstructing blood flow), and depression.A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 5/8/26 indicated that the resident scored 14 out of 15 in a Brief Interview for Mental Status (BIMS, an assessment tool used to determine cognition status using total scores with a range of zero to 15, a score of 13-15 denotes intact cognition) indicating the resident was cognitively intact. The MDS assessment indicated Resident 1 used wheelchair for mobility and required maximum (staff does the majority of the lifting and maneuvering) assistance from staff to transfer to and from wheelchair.A review of Resident 1's Physician Orders for Life -Sustaining Treatment (POLST form - a document containing medical orders to be honored by health care staff during a medical emergency) signed by Resident 1 and the physician on 8/19/22 indicated Resident 1's choices were for full treatment/full code (perform resuscitation and all appropriate lifesaving measures, including oxygen, CPR, and other interventions used to help a person breathe when the airway is blocked) if found pulseless or not breathing.A review of nursing progress note (NPN) documented by licensed nurse (LN 1) on 6/23/26 at 12:12 p.m., indicated Resident 1 left the facility at 8:30 a.m., via wheelchair accompanied by her husband to have laboratory blood work done at the clinic and returned back to facility on 6/23/26 at 11:15 a.m.A further review of NPN indicated that upon returning resident to her room, Resident 1's husband requested LN 1 to call 911 due to the resident's decline in responsiveness. LN 1 documented that on 6/23/26 at 11:25 a.m., Resident 1 was found unresponsive, with heart rate elevated to 120 beats per minute (BPM- unit of measurement; normal range typically 60 to 80), with oxygen saturation (measurement of oxygen level in the blood, commonly known as oxygen saturation) initially reading at 45% (normal range is 98 to 100%), then down to 34% on room air (without supplemental oxygen). NPN indicated that LN 1 called 911 (emergency services) at 11:26 a.m., verified that Resident 1 was Attempt Resuscitation [full code, including CPR], and then prepared resident's documents, including face sheet, medication list, and other documents required for the transfer of resident to the Emergency Room. The NPN indicated that after LN 1 verified that Resident 1 was full code and printed POLST form from computer, LN 1 returned to resident and spouse in the room, rechecked Resident 1's blood pressure, heart rate, respiratory rate, and oxygen level. LN 1 documented Resident 1 did not have a pulse and was not breathing. The NPN indicated further, Charge nurse [LN 1] requested aid from station 2 charge nurse [LN 2] for help moving the resident onto her back from wheelchair for upcoming CPR, then pushed the crash cart [an emergency cart that contains life-saving equipment and medications during medical emergencies] located in the activities/dining room area towards the res' [resident's] room. NPN indicated that when LN 1 and LN 2 entered Resident 1's room the Fire Department (emergency team) was already there. NPN indicated that Resident 1 was pronounced (officially declared) dead on 6/23/26 at 11:43 a.m.During a joint interview on 7/8/26 at 11:55 a.m., with Administrator (ADM) and Director of Nursing (DON), the DON stated Resident 1 was stable when the resident left the facility earlier that morning on 6/23/26. The DON stated Resident 1 was found unresponsive, with elevated heart rate, and critically low oxygen level after returning from the clinic at 11:25 a.m. When the DON was asked what measures were initiated, the DON explained, Oxygen was not administered, LVNs can't administer oxygen per new regulations. The DON validated that CPR was not started, the resident was still sitting in wheelchair, and did not receive supplemental oxygen. The DON stated LN 1 called 911 and then called LN 2, who was a registered nurse (RN, a nurse with advanced training) for assistance, but when LN 1 and LN 2 came to resident's room, the emergency responders were already in the room. The DON stated that Resident 1 was pronounced dead shortly thereafter.During an interview on 7/8/26 at 1:48 p.m., Certified Nursing Assistant (CNA 1) stated she was assigned to Resident 1 on 6/23/26. CNA 1 described Resident 1 as alert and in stable condition when the resident left the facility in the morning. CNA 1 stated she was at lunch when Resident 1 came back and was shocked when she found out Resident 1 passed away, and then added, It was completely unexpected.During an interview with LN 3 on 7/8/26 at 2:10 p.m., LN 3 explained the steps to be taken during emergencies. LN 3 stated, If resident is full code and found hypoxic [low oxygen] and unresponsive - get resident down if not in bed and start resuscitation, CPR and rescue breathing [blow air into someone's mouth] immediately. Call for help. LN 3 explained that anyone should start CPR, but whoever staff found resident unresponsive should stay with the resident and start CPR. LN 3 added, From what I heard resident [Resident 1] passed [died] sitting in her wheelchair and the CPR was never initiated.During an interview with LN 4 on 7/8/26 at 2:25 p.m., LN 4 stated the nurses were provided with walkie-talkie to radio call for help when assistance was needed.During a telephone interview with LN 1 on 7/8/26 at 3:30 p.m., LN 1 stated she was employed by the staffing registry (a company that provides temporary healthcare workers) and had been working at the facility for 2 to 3 shifts every week. LN 1 explained that she was the assigned nurse for Resident 1 on 6/23/26. LN 1 stated Resident 1 looked normal.Did not complain of pain or shortness of breath, and.did not look like she was short of breath on 6/23/26 before leaving the facility. LN 1 stated she was at lunch when she was notified by CNA 2 that Resident 1 returned back to the facility on 6/23/26 around 10-11 a.m. LN 1 explained, The resident did not look good; she was unresponsive. her blood pressure was low, heart rate 120 [BPM], and her oxygenation level was critically low, and continued going down. LN 1 added. I did not administer oxygen because I am not allowed to. When LN 1 was asked if she initiated CPR at that time, LN 1 stated she did not. LN 1 continued, I left the room and called 911. I had to prepare transfer documents, some of them were in her paper chart but I could not find her POLST. I logged in [electronic records], verified that she [Resident 1] was full code, and printed her POLST. When LN 1 was asked if she called for assistance, she stated, I was unable to call for assistance because I left my walkie-talkie in a break room. LN 1 acknowledged that she could have directed someone else to call 911 and prepare transfer documents, and then added, There was nobody in resident's room with me and there was nobody around in the hallway. During a continued interview with LN 1 on 7/8/26 at 3:30 p.m., LN 1 stated that when she went back to check on Resident 1, the resident did not have a pulse and was not breathing. LN 1 explained that Resident 1 was sitting in wheelchair and the CPR was not started. LN 1 added, We would need at least two people to move her [Resident 1] to the floor to start CPR. LN 1 stated she left unresponsive and pulseless Resident 1 and went to Station 2 down the hall to get help. LN 1 stated by the time she and LN 2 grabbed a crash cart and returned to resident's room, the fire department was already there. LN 1 validated that no life-saving measures including CPR were initiated and the resident died while still sitting in her wheelchair.There was no documented evidence that LN 1 administered oxygen upon finding Resident 1 unresponsive, with elevated heart rate and critically low oxygen saturation level. Furthermore, LN 1 did not call for assistance and did not immediately initiate CPR after verifying that Resident 1 was full code status and after establishing Resident 1 had no pulse and was not breathing. Resident 1 resided in room [ROOM NUMBER] and rather than immediately initiating life-saving interventions, LN 1 left the resident's room to locate another nurse (LN 2), walking past eight (8) residents' rooms before getting staff assistance. LN 1 and LN 2 then walked around the corner passing four (4) residents' rooms to retrieve the crash cart and subsequently returning to Resident 1's room. LN 1 and LN 2 passed an additional 7 residents' rooms before arriving to Resident 1's bedside which created a delay in initiating life-saving measures during the emergency.During a telephone interview with CNA 2 on 7/8/26 at 3:50 p.m., CNA 2 explained, Resident's husband asked to send nurse out to check on resident because she did not look good. I went and I got [LN 1's name] from lunch. CNA 2 stated that after alerting LN 1 regarding Resident 1's husband request, she did not assist LN 1 with Resident 1's care.During a telephone interview with LN 2 on 7/9/26 at 3:20 p.m., LN 2 stated that on 6/23/26 she was approached by LN 1, who was the assigned nurse to Resident 1. LN 2 stated, She told me that she needed help to do CPR, we grabbed crash cart, and both walked to the resident's room. The ambulance was already there. LN 2 stated nurses had walkie-talkies with them to call for assistance, but she was not radioed (paged) for assistance with Resident 1's CPR prior to LN 1's approaching her.During a concurrent interview and record review with DON on 7/8/26, at 2:50 p.m., the DON acknowledged that Resident 1 was in critical condition on 6/23/26 when LN 1 evaluated her at 11:25 a.m. The DON acknowledged that another staff should have called 911 and prepared documents for the transfer to hospital while LN 1 stayed with Resident 1. The DON stated that all nurses and CNAs were certified to administer CPR. The DON stated, [LN 1's name] should have started CPR after verifying the code status.Nobody initiated the CPR. The DON validated that Resident 1 was not provided any life-saving measures, including CPR for 10 minutes when Resident 1 was found unresponsive at 11:25 a.m., until 11:35 a.m., when the resident died. The DON was asked where the other staff were, including LN 2 to assist LN 1 with the emergency situation. The DON replied, I don't see that RN [LN 2] was involved in all of this, I don't know what she did . according to the progress note she came when the emergency staff was there.During a concurrent interview and record review on 7/8/26 at 3:05 p.m., the NPN dated 6/23 26 was discussed with the facility's Administrator (ADM). The ADM stated LN 1 was not allowed to administer oxygen but could have started the CPR. The ADM was asked what life-saving measures were initiated during the 10 minutes when Resident 1 was found unresponsive with critically low oxygen saturation until the resident became pulseless and not breathing. The ADM stated, This resident was a large woman.and it would take 3-4 staff to get her to the floor and start CPR. The ADM stated the facility was well staffed, had an RN on duty on that day and the staff was [would have been] able to move Resident 1 to the floor and start CPR, but it was not done. The ADM validated that Resident stayed in her wheelchair where she died, and no life-saving measures were provided. The ADM added, From what is documented, I do not see that RN [LN 2] was involved to administer oxygen and any help with CPR. I don't see that RN was assisting LVN and CPR [was] not started.A review of the facility's P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation and Basic life Support [BLS], dated 2001, indicated that personnel must complete the training on the initiation of cardio pulmonary resuscitation (CPR) and basic life support (BLS) for victims of sudden cardiac arrest [means the heart suddenly stops beating and pumping blood effectively to the rest of the body]. The P&P indicated, Staff are trained to follow current American Heart Association (AHA) guidelines and recommendations for the sequence of resuscitation.If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a staff member who is trained in CPR/BLS shall initiate CPR.The facility select and identify.designate a team leader on each shift who is responsible for coordinating and directing other team members during rescue efforts.A review of the current American Heart Association (AHA) guidelines published 10/22/25, retrieved from cpr.heart.org on 7/8/26 indicated that resuscitation should be started immediately once cardiac arrest is recognized. The AHA indicated the following sequence for a healthcare provider: 1. Recognize cardiac arrest (the person is unresponsive), not breathing normally or is only gasping); check for a pulse for no more than 10 seconds and if no pulse begin CPR. 2. Activate the emergency response system; call for help, have someone bring the crash cart. 3. Begin high-quality CPR immediately, starting with chest compressions. The AHA emphasized that any delay in initiating resuscitation efforts should be minimized because every minute without CPR decreases the chance of person's survival.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 39 when the controlled drug (a medication that may be abused or cause addiction) record form was not filled out and signed accurately. This failure has the potential to result in diversion of the residents' unused controlled medications.Findings:During an inspection of the Controlled Medication Disposition Log located in a secure locked cabinet at Station 1 on 4/15/26 at 10:25 a.m., the April 2026 Log had a total of five medication entries which coincided with the controlled medication in the bin within the cabinet. The April 2026 Log was missing the transferring licensed nurse's signature as well as the date the medications were removed from the medication carts to be stored in the secured locked cabinet before destruction.During an interview on 4/15/26 at 10:30 a.m. with the Director of Nursing (DON), the DON confirmed the Controlled Medication Disposition Log for April 2026 was missing the signature of the transferring licensed nurse and well as the date the transfer occurred. The DON confirmed this was not the standard process for the facility or pharmacy services.During review of the facility log titled Controlled Medication Disposition Log, dated April 2026, the log input data included, Resident Name, Medication number and Pharmacy, Medication and Strength, Quantity of Medication, Transferred By, Received By, and Date.During review of the facility policy and procedure (P&P) titled, Discarding and Destroying Medications, dated 6/2025, the P&P indicated, Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with the federal and state and local regulations governing .controlled substances.the collector is responsible for managing .and training facility staff on the procedures associated with collection and storage of controlled substances awaiting disposal.The medication disposition records contains, as a minimum, the following information . i. Signature of witnesses.

Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 2 of 4 sampled residents (Resident 23 and 39) for a census of 39.1. For Resident 23, a licensed nurse administered the wrong strength of eye drops, a medication to treat and prevent dry eye, per Physician Orders.2. For Resident 39, a licensed nurse did not educate and instruct the resident per manufacturer guidelines when administering a Metered Dose Inhaler (MDI), (a handheld, pressurized device used to treat breathing issues by delivering a specific amount of medicine directly into the airways). These failures resulted in 2 errors identified out of 34 opportunities for error during the observation of medication administration; the facility medication error rate was 5.88%. Findings:1. During an observation of medication administration on 4/14/26 at 9:05 a.m., Licensed Nurse (LN) 2 was observed preparing and administering Sodium Chloride Hypertonicity Ophthalmic (saltwater solution for the eyes) Solution, Brand name Muro 128 (an eye drops for dry eyes) 5% (percentage, strength of medication), one drop in each eye for Resident 23.Reconciliation of the observation of medication administration with Resident 23' s current Physician Orders, dated 2/23/26, indicated, Muro 128 2% eye drops one drop in each eye daily for dry eyes.During an interview on 4/14/26 at 10:45 a.m. with LN 2, LN 2 opened the medication cart and confirmed that in the resident medication drawer Muro 128 5% eye drops had been administered. LN 2 reviewed Resident 23's current order and acknowledged physician order was for a 2% strength eye drop, not the 5% which was given. During an interview on 4/15/26 at 10:50 a.m. with the DON, the DON acknowledged the nurse should have followed the Physician Order and administered the right medication.During a review of the facility policy and procedures titled, Administering Medications, dated April 2019, the P&P indicated, 4. Medications are administered in accordance with prescriber orders.2. During an observation of medication administration on 4/14/26 at 8:40 a.m., LN 3 was observed preparing and administering Fluticasone-Salmeterol (a combination of two medications used to treat breathing issues) 250/50 mcg (microgram, unit of measure) During administration of MDI, LN 3 instructed Resident 39 to place their mouth around the device and breathe in and out while LN 3 held device and pressed a button administering the powder medication. Reconciliation of the medication administration per manufacturer's guideline on the packaging box Before you breathe in your dose, breathe out (exhale) as long as you can while you hold the device away from your mouth. Do not breathe into the mouthpiece. Put the mouthpiece to your lips. Breathe in quickly and deeply through the mouthpiece. Do not breathe in through your nose. Remove the device from your mouth and hold your breath for about 10 seconds, or for as long as is comfortable for you. Breathe out slowly for as long as you can.During an interview on 4/14/26 at 10:30 a.m. with LN 3, LN 3 stated, she did not instruct the Resident to take a breath out pre-administration and then take a deep breath in while she presses button to release medication. LN 3 was not aware of the manufacture's guidelines post administration to hold breath for 10 seconds to properly deliver the medication. LN 3 confirmed these steps were not part of her instructions for Resident 39.During an interview on 4/15/26 at 10:50 a.m. with the DON, the DON acknowledged the nurse should have followed the manufacturer's instructions to administer the medication.During a review of the facility policy and procedures titled, Administering Medications, dated April 2019, the P&P indicated, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication .and right method and route of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly labeled and stored in accordance with accepted standards of practice when:1. Multiple opened and undated multidose containers of glucose test strips (strips that can be used to measure blood sugar levels) were found in the medication carts, which had the potential to result in staff using expired, or ineffective glucose test strips to monitor residents blood glucose levels.2. Two over-the-counter eye drop bottles were found at Resident 55's bedside dresser.These failures may result in medications not being stored and maintained in a manner that will will ensure their safety, integrity and proper use placing the residents at risk for contamination, reduced effectiveness, and medication errors. Findings: 1. During an inspection of medication cart 2 located at nursing station 2 on [DATE] at 9:00 a.m. with Licensed Nurse (LN) 3, two open bottles of glucose test strips were found without an open date label. During an interview on [DATE] at 9:15 a.m. with LN 3, LN 3 was unable to find the open date and therefore was unable to provide the product's expiration date. LN 3 acknowledged that without the open date the product expiration date could not be calculated and both sets of test strips should have been removed and discarded from the active medication area. During an inspection of medication cart 1 located at nursing station 3 on [DATE] at 9:50 a.m. with LN 2, an open bottle of glucose test strips was found without an open date label. During an interview on [DATE] at 9:55 a.m. with LN 2, LN 2 was also unable to find the open date and therefore was unable to provide the product's expiration date. LN 2 confirmed the product expiration date could not be calculated and the test strips should have been removed and discarded from the active medication area. During an interview on [DATE] at 10:45 a.m. with the Director of Nursing (DON), the DON acknowledged that open dates were needed to be documented on the glucose test strip bottles to know the expiration date. During a review of the manufacturer's label printed on all three test strip bottles, the label indicated, Use within 90 days, (3) months after opening. During a review of the facility's Policy and Procedures (P&P) titled, Administering Medications, April dated 2019, the P&P indicated, When opening a multi-dose container, the date opened shall be recorded on the container. 2.During a review of Resident 55's Detailed Summary (DS) indicated, Resident 55 was admitted [DATE] with diagnoses including Wedge Compression Fracture Lumbar Vertebrae (the spine bones on the lower back has been crushed more in the front than the back.) During a review of Minimum Data Set (MDS- a federally mandated resident assessment tool) indicated, Resident 55 has moderate cognitive impairment. During an observation on [DATE], at 10 a.m. in Resident 55's room, two different bottles of eye drops were found on top Resident 55's bedside dresser. Resident 55 stated, she uses the two eye drops for her dry eyes. During a concurrent interview and record review on [DATE] at 11:28 a.m. with LN2, LN 2 was asked to locate a physician order and self-administration assessment for Resident 55. LN2 confirmed that no physician order and no self-administration assessment were found in Resident 55's electronic medical records. LN 2 stated, the expectation for medication storage, is that all medications need to be kept in the medication cart for safe storage. LN 2 further stated, keeping the over-the-counter medications in the medication cart will prevent misuse and will prevent contamination of the medication being used. During a review of the facility's policy and procedure titled, Medication Labeling and Storage. Dated, February 2023, indicated, .Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident medications are assigned to an individual cubicle, drawer.to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 39 out of 39 residents when:1. Several various metal sheet pans and lids in clean and ready-to-use storage areas a. Were stacked wet while stored away b. Were dusty and oily2. Three large food storage bins had plastic containers for scoops inside the three food storage bins3. Pantry had four open milk cartons without an opened and use by dates written.4. Breakfast meal cart was left wide open, and unattended. These failures had potential to cause food borne illnesses in a highly susceptible population who received food from the kitchen. Findings: 1.During a concurrent observation and interview with Certified Dietary Manager (CDM) on 4/14/26 at 8:20 a.m., at the kitchen's initial tour, several metal sheet pans stored at the clean and ready-to use storage areas were observed stacked wet and were dusty and oily. The metal pans included: 5 full sheet table pans (wet) 6 full sheet covers/lid (dusty and oily) 1 full sheet muffin tray (dusty and oily) The CDM confirmed that the metal sheet pans, and lids were wet, dusty and oily. CDM confirmed and stated that dishes must be fully dry before stacking, and the trays must be kept clean when stacked at the ready-to-use storage area to prevent food -borne- illnesses. During a telephone interview on 4/16/26 at 11:38 a.m. with Registered Dietician (RD) stated, dishes, trays, and tray covers must be fully air dried before stacking and storage. RD further stated, all metal trays and lids need to be properly cleaned before storage in the ready-to-use area. During a review of facility's Policy and Procedure (P&P) titled, Cleaning and Sanitizing Basics, dated 2023, P&P indicated, .All utensils and equipment should be allowed to air dry. Never towel dry. During a review of facility's P&P titled, Food Preparation and Service, dated, 2001, the P&P indicated, .Food and nutrition services prepare, distribute, and serve food in a manner that complies with safe food handling practices. 2. During a concurrent observation and interview with CDM on 4/14/26 at 9:06 a.m., at the kitchen's initial tour three large food storage bins were found to have plastic containers inside used as a scoop. CDM confirmed the observation and stated there should not be any containers inside the food bin. CDM further stated, it can cause contamination and cause food-borne-illnesses. During a telephone interview on 4/16/26 at 11:38 a.m. with RD, RD stated, there should not be any scoops or any plastic containers inside the food storage bins. RD further stated, the scoops should be left outside the food storage bins in a clean and dry location to prevent any contamination. During a review of the facility's P&P titled, Scoops, dated 2023, the P&P indicated, .To store all scoops outside of ice machine and food storage bins.4.all other scoops used for flour, sugar, oats and similar bulk items will be stored outside of the storage container.a.scoops will be washed and sanitized on a daily basis. 3. During an observation on 4/16/26 at 10:20 a.m. in the Nurses' Station and Dining Room Pantry, four cartons of open milk without an open and use by date. CDM confirmed the observation. CDM stated that the milk cartons must have an open and use by date to prevent any food-borne illnesses. During a telephone interview on 4/16/26 at 11:38 a.m. with RD, the RD stated, her expectation is that the staff must write the open and use by date when opening any milk carton that is being used in the pantry. RD further stated, this will protect the residents and prevent food-borne illnesses. During a review of the facility's P&P titled, Food Storage, dated 2023, the P&P indicated, .All open food items will have an open date and use-by-date per manufacturer's guidelines. 4. During a concurrent observation and interview on 4/15/26 at 8:35 a.m. in hallway 2 with Certified Nursing Assistant (CNA) 2, the breakfast food cart containing 10 trays was left open in the hallway without staff present. CNA 2 confirmed the cart was left open and unattended and stated that when a food cart is left open, it may be accessed by others, and the food could become cold and exposed to contamination, including potential foodborne pathogens. During a telephone interview on 4/16/26 at 11:38 a.m. with RD, RD stated food cart doors should be kept closed to maintain food temperature and reduce the risk of foodborne pathogen growth and contamination. The RD stated food carts should be monitored at all times and not left unattended, as food may be accessed by others, potentially leading to contamination. The RD also stated food could be taken by another resident, including those with dietary restrictions or modified diets, which could pose a safety risk such as chocking. During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, revised 11/2022, the P&P indicated, .food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.food distribution means the processes involved in getting food to the resident . this may include.delivering meals to residents' rooms or dining areas.when meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart.

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when:Resident 1's nasal cannula tubing was found on the floor,Resident 10 and Resident 56's oxygen tubing were on the floor, Resident 10's nebulizer mask was not stored in a bag, and Resident 56's nasal cannula was not stored in a bag,Resident 25's nebulizer mask was not stored in a bag,Resident 19's CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) mask was not stored in a bag, and;Resident 4's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was on the floor and his CPAP mask was not stored in a bag.These failures had the potential to compromise resident's health and safety and potentially lead to the spread of communicable illnesses. Findings: 1.Review of a Detailed Summary (DS), Indicated Resident 1 was admitted February of 2026 with several diagnoses including bacterial pneumonia, pleural effusion (collection of fluid in the lung), interstitial pulmonary disease (a condition that causes progressive inflammation and irreversible scarring of lung tissue), and pulmonary candidiasis (a rare, severe lung infection that causes shortness of breath). Review of Physician's orders for Resident 1, indicated an order dated 2/12/25 for Oxygen via Nasal Canula (a lightweight, flexible tube used to deliver supplemental oxygen to a person who has trouble breathing) titrate (adjust) up 5 liters per minute (LPM-amount of oxygen that comes out every minute) for shortness of breath, or O2 sat (measures the percentage of oxygen in a person's blood) for saturation less than 90%. During a concurrent observation and interview on 4/14/26 at 9:54 a.m. with Licensed Nurse (LN) 1, Resident 1's nasal cannula tubing was observed on the floor between Resident 1's nightstand and garbage can. LN 1 confirmed the above findings and stated nothing should be on the floor due to the risk of bacterial contamination. During an interview on 4/16/26 at 11:05 a.m. with the Infection Preventionist (IP), the IP stated that the nasal cannula tubing should be stored in a infection prevention pouch after it is cleaned and dried by the LN. If the nasal cannula tubing is on the floor, it can increase the chance of infection to the resident. 2.During a review of Resident 10's DS, DS indicated, Resident 10 was admitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a long-term lung condition that makes it hard to breathe) and Bacterial Pneumonia (a lung infection caused by bacteria). During a review of Resident 10's Physician Orders (PO), dated 4/2/26, the PO indicated, .Continuous oxygen (O2- gas in the air we breathe) inhalation at 4 liters per minute (LPM-amount of oxygen that comes out every minute)/ Nasal Cannula (NC-small tube that goes under the nose to give oxygen.) During a review of Resident 10's medication order, dated 4/8/26, indicated, Ipratropium 0.5mg-albuterol 3mg (milligram) (2.5 mg base)/3 ml(milliliter) nebulization (breathing in medication through a mist to help with breathing) 4x a day. During a review of Resident 56 DS indicated, Resident 56 was admitted [DATE] with diagnoses including malignant neoplasm (harmful abnormal growth of cells) of the tongue, and gastrostomy (a feeding tube made through the belly to give food, fluids and medicine.) During a review of Resident 56's PO, dated 4/15/26, indicated Oxygen 2 LPM via NC. During an observation on 4/14/26 at 10:40 a.m. in Resident 10's room, Resident 10's nebulizer mask was found on top of the bedside dresser without a storage bag, and her oxygen tubing was on the floor. During an observation on 4/14/26 at 11:10 a.m. in Resident 56's room, Resident 56 nasal cannula was on the top of her bedside dresser without a storage bag, and her oxygen tubing was on the floor. During an interview on 4/14/26 at 11:26 a.m. with LN 2, LN 2 confirmed the oxygen tubing for Resident 10 and Resident 56 were on the floor, and the Resident 10's nebulizer mask and Resident 56 nasal cannula were on top of their bedside dresser without a storage bag. LN 2 further stated, he does not store it in a bag. During an interview on 4/16/26 at 11:05 a.m. with the Infection Preventionist (IP), the IP stated that the nasal cannula tubing should be stored in an infection prevention pouch after it is cleaned and dried by the LN. If the nasal cannula tubing is on the floor, it can increase the chance of infection to the resident. IP further stated nebulizer tubing should be in an infection prevention pouch after it is cleaned and dried. The Licensed Nurse (LN) is responsible for making sure it gets in the bag. If on the floor it can cause an infection to the resident. 3. During a review of Resident 25's DS, the DS indicated Resident 25 was admitted on [DATE] with diagnoses that included sleep apnea (OSA-breathing repeatedly stops and starts during sleep) and bronchiectasis (lung airways are permanently widened, damaged and scarred). During a review of Resident 25's PO, the PO indicated, Resident 25 had an order for ipratropium 0.5 mg (milligram)-albuterol 3 mg (2.5mg base)/3 mL (milliliter) nebulization solution (inhalation solution use to treat and prevent wheezing and shortness of breath) .every 4 hours as needed for coughing and wheezing. During a concurrent observation and interview on 4/14/26 at 9:40 a.m. in Resident 25's room, Resident 25's nebulizer mask was stored in an upright position, hooked to the side of the nebulizer machine. Licensed Nurse (LN) 2 confirmed the nebulizer mask was not stored in a bag and stated it had not been stored in a bag. During an interview on 4/16/26 at 11:05 a.m. with IP, IP stated nebulizer equipment should be stored in an infection prevention pouch after cleaning and drying and that licensed nursing staff were responsible for ensuring proper storage. During a review of the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy)-Prevention of Infection, dated 11/2011, the P&P indicated, infection control considerations related to oxygen administration . keep the oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use .infection control considerations related to medication nebulizers.store the circuit in plastic bag, marked with date and resident's name, between uses. 4. During a review of Resident 19's DS, the DS indicated Resident 19 was admitted on [DATE] with diagnoses that included obstructive sleep apnea. During a review of Resident 19's PO, the PO indicated, Resident 19 had an order for CPAP-On @ HS (at bedtime)/ OFF @ AM (morning).for OSA. During a review of Resident 19's Care Plan (CP), the CP indicated, Resident 19 required CPAP during sleep and interventions included assisting with donning/doffing (putting on/removing) CPAP daily. During an observation on 4/14/26 at 9:45 a.m. in Resident 19's room, Resident 19's CPAP mask was hanging on an open shelf and was not stored in a bag. 5. During a review of Resident 4's DS, the DS indicated Resident 4 was admitted on [DATE] with diagnoses that included benign prostatic hyperplasia (enlargement of the prostate gland), retention of urine and OSA. During a review of Resident 4's PO, the PO indicated Resident 4 had on order for .CPAP OFF at AM; ON at HS.Foley Catheter for urinary retention. During a review of Resident 4's CP, the CP indicated Resident 4 had CAUTI (catheter-associated urinary tract infection) and intervention included foley catheter care. During an observation on 4/14/26 at 10:35 a.m. in Resident 4's room, Resident 4 was sitting in a recliner chair. Resident 4's catheter tubing was on the floor, and the CPAP mask was hanging on a wall hook and was not stored in a bag. During an interview on 4/16/26 at 11:08 a.m. with IP, IP stated that CPAP masks should also be stored in an infection prevention pouch and that failure to do so could increase the risk of infection. IP further stated catheter tubing should not be on the floor due to the risk of infection. During a review of the facility's P&P titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, dated 09/2017, the P&P indicated, .it is the responsibility of the interdisciplinary team to maintain vigilant practices to prevent CAUTIs.after aseptic insertion, maintain a sterile closed drainage system. P&P for CPAP mask storage was requested; however, facility did not provide the requested policy.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate meals/diets for 12 out of 39 sampled residents (Residents 3, 4, 16, 22, 23, 25, 26, 27, 28, 37, 39 and 43) when meal trays were being checked by unlicensed staff prior to delivery.This failure had the potential for residents on therapeutic diets to receive the wrong foods; residents with food sensitivities/allergies receiving inappropriate foods; and those on modified texture diets receiving inappropriate food items all of which could lead to complications and adverse reactions.Findings: During dining observation in the dining room on 4/16/26 at 11:55 a.m., observed Residents 3, 4, 16, 22, 23, 26, 27, 28, 37, 39 and 43 sitting at tables waiting for lunch to be served.During a concurrent observation and interview on 4/16/26 at 12:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 checked the meal trays prior to serving them to residents in the dining room. CNA 1 stated he was the only staff member that checked the meal trays and they were not checked before coming to the dining room.During an interview on 4/17/26 at 9:09 a.m. with the Director of Nursing (DON), the DON stated her expectation was that a Licensed Nurse (LN) should be checking the meal ticket and tray before the meal is served to the resident. The DON stated a potential negative outcome would be that the CNA may miss a change in the residents' diet.Review of the facility's policy titled, Menu Planning dated 2023, it indicated, NA(Nurse's AIDE)/CNAs deliver trays to the resident after licensed nursing has checked the trays according to Verification of Diets served by nursing policy.

Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. An ice machine was not clean; 2. Refrigerated food and a nutritional shake were not labeled with open, prepared, use by, or expiration dates; and, 3. The concentration of the sanitizer solution for a sanitation solution (red) bucket was less than 200 ppm. These failures had the potential to cause food-borne illness in a highly susceptible population of 31 of 31 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on [DATE] at 8:16 a.m. with Director of Dietary Services (DDS), during the initial kitchen tour, an ice machine was observed to have dark stains resembling rust in a compartment directly next to ice bin, white matter on the exterior of the ice machine, and white debris in the ice scoop container. The DDS stated that an outside vendor is responsible for maintenance of the ice machine and the ice machine was serviced last week. During an interview on [DATE] at 10:00 a.m. with the Dietary Manager (DM), DM confirmed rust inside inner compartments, white stains outside the ice machine, and debris inside ice scoop container. DM stated that an outside vendor was responsible for maintenance of the ice machine every 6 months. DM further stated facility staff were responsible for cleaning the ice machine weekly. DM acknowledged the expectation was for the ice machine to be clean including the ice scoop container. During a review of the facility's policy and procedure (P&P) titled, Cleaning procedure #24- Ice Machine, undated, the P&P indicated, .ICE SCOOP .Keep it protected from contamination . During a review of the ice machine's service manual, dated ,d+[DATE], the service manual indicated, .Clean and sanitize the ice machine every six months for efficient operation .if the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment . 2. During a concurrent observation and interview on [DATE] at 8:27 a.m. with Dietary Supervisor (DS) and DM, during the kitchen's initial tour, an open tray of pasteurized eggs was not labeled with a received, opened, or use by date. DS confirmed the tray of eggs was not labeled. During a concurrent observation and interview on [DATE] at 10:49 a.m. with Licensed Nurse 3 (LN 3), there were two plates of dessert from the kitchen, in the Station 2 refrigerator. The food was not labeled with a prepared or use by date. LN 3 stated the food should have been labeled with a name and date. LN 3 further stated food could be spoiled if there was no date or wrong resident could have the received food. During a concurrent observation and interview on [DATE] at 10:33 a.m. with LN 1, there was an open carton of nutritional shake in the Station 3 refrigerator. The opened nutritional shake was not labeled with a use by date. LN 1 confirmed the nutritional shake did not have a use by date. LN 1 further stated she was not sure how long the shake could be kept once it was opened. During an interview on [DATE] at 10 a.m. with DM, DM acknowledged that food that was not properly labeled can be a risk for expired food being served to residents. During a review of the facility's P&P titled, Food storage revised [DATE], the P&P indicated, .All open food items will have an open and use-by-date . During a review of the facility's P&P titled, Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods revised [DATE], the P&P indicated, .foods produced in the community should be dated with day one .and discarded on or before the 7th day . 3. During a concurrent observation and interview on [DATE] at 8:37 a.m. with DM, during the kitchen's initial tour, a red sanitation bucket did not have the appropriate sanitizer solution. DM tested the solution in the red sanitation bucket. The solution tested below 200 ppm (parts per million). Dietary Aide 1 (DA 1) stated she prepared the solution with a mixture of soapy water and Quaternary ammonia solution (disinfectant). DM stated the concentration range for red bucket sanitizer solution should be ,d+[DATE] ppm and should not be mixed with soapy water. During an interview on [DATE] at 10:29 a.m. with [NAME] 1 (CK 1), CK 1 confirmed that he used the red sanitation bucket that had the diluted Quaternary ammonia solution to clean food preparation area. During an interview on [DATE] at 10 a.m. with DM, DM acknowledged the facility used Quat ammonia solution and not maintaining solution at an effective level was a risk for food contamination. During a review of the facility's P&P titled, Sanitizer Bucket for Cleaning Cloths revised [DATE], the P&P indicated, .Sanitizer buckets are filled with .appropriate sanitizer at a high concentration .Quat ppm at 200 .

Based on observation, interview, and record review, the facility had a 10.34% error rate when three medication errors out of 29 opportunities were observed during a medication pass for two of eight residents (Residents 4 and Resident 34). This failure resulted in medications not being given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: 1a. During a review of Resident 4's physician order, dated 1/28/25, the order indicated, .[Metoclopramide HCl] [used to treat nausea and vomiting] - 5 mg (milligrams, a unit of measurement) *via G-tube [gastrostomy tube, a tube that provides access to the stomach]* 3 times a day for gastroparesis [a condition that affects the stomach muscles and prevent proper stomach emptying] . During a medication administration observation on 2/12/25 at 8:29 a.m., Licensed Nurse (LN) 1 administered five medications including Metoclopramide 5 mg by mouth. During a concurrent interview and record review on 2/12/25 at 11:19 a.m. with LN 1, LN 1 verified the order for Metoclopramide was to be given via G-tube and LN confirmed Resident 4 received the medication by mouth. LN 1 stated, [It is] important to make sure there are no interactions, for [Resident 4], the medications can work faster if taken on G-tube. 1b. During a review of Resident 34's physician order, dated 1/29/25, the order indicated, Acetaminophen [used to treat mild to moderate pain] 325 mg tablet .1 tab By Mouth Every 6 hours while awake For pain . During a medication administration observation on 2/12/25 at 11:28 a.m., LN 1 administered three medications including two tablets of Acetaminophen. During a concurrent interview and record review on 2/12/25 at 1:12 p.m. with LN 1, LN 1 verified Resident 34's order indicated to give one tablet of Acetaminophen 325 mg. LN 1 confirmed two tablets of Acetaminophen were given instead of one. 1c. During a review of Resident 34's physician order, dated 2/1/25, the order indicated, Insulin lispro .100 unit/mL [milligrams, a unit of measurement] subcutaneous [under the skin] solution - Inject up to 10 units per sliding scale subcutaneously with meals Subcutaneous 3 times a day . During a medication administration observation on 2/12/25 at 11:28 a.m. with LN 1, LN 1 was observed giving 3 units of Insulin Lispro on Resident 34's left abdomen. No food tray was observed at bedside. During a concurrent interview and record review on 2/12/25 at 1:12 p.m. with LN 1, LN 1 confirmed Resident 34's physician order indicated to give Insulin Lispro with meals. LN 1 confirmed Resident 34 did not have lunch yet and stated, They give snacks in between meals, his numbers are usually high . During an interview on 2/13/25 at 2:17 p.m. with the Director of Nursing (DON), the DON stated, If physician order is to give medication with meals, expectation is for it to be given with meals .if there are any concerns, clarify with the doctor .Medications are to be given as ordered and as scheduled, if to be given outside the schedule, clarify with the doctor. During an interview on 2/13/25 at 3:05 p.m. with the Pharmacy Consultant (PC), the PC stated, [The] expectation is to follow specifically what the order says, to maintain some consistency. During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame .

Based on observation, interview, and record review, the facility failed to ensure: 1. Expired and discontinued medications were not available for resident use; 2. Expired COVID-19 (a highly contagious respiratory disease caused by a virus) Test Kits were not available for resident use; 3. Opened single-use vial was discarded after use; 4. Medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and, 5. Medication refrigerator was maintained in proper working condition. These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage. Findings: 1. During a concurrent observation and interview on 2/11/25 at 10:49 a.m. with Licensed Nurse 3 (LN 3), an inspection of Station 2 Medication Storage Room identified the following expired and discontinued medications and medical supplies: - 28 Hydrogel absorbent sheet wound dressing (provide a moist environment for wounds to promote faster healing), expired 2/10/25; - Anasept gel antimicrobial skin and wound gel (used to cleanse and prevent infection of minor and serious wounds), 2 tubes expired on 11/1/24 and one tube expired on 10/19/24; and, - 5 Enteral (involves putting food substances or medicine into the digestive system) feeding bags with attached gravity set, expired on 9/8/2024. The LN 3 confirmed the items identified in Station 2 Medication Storage Room were expired and should have been removed from the facility's stock. During an observation on 2/11/25 at 11:37 a.m. in Nurse Station 3, two containers of bleach germicidal (used to kill or prevent the growth of germs) wipes were observed on top of the cart. The containers indicated the wipes were expired on 12/22/24. During a concurrent observation and interview on 2/11/25 at 11:40 a.m. with Nursing Supervisor 1 (NS 1), an inspection of Station 3 Medication Storage Room identified one container of expired bleach germicidal wipes with expiration of 2/8/25, and inside the food refrigerator were two yogurts expired 2/2/25 and one yogurt expired 1/1/25. The NS 1 confirmed the items identified in Station 2 Medication Storage Room were expired and should have been removed from the facility's stock. The NS 1 also confirmed the expired bleach wipes in Station 3 and stated, If they are expired, they don't work. During a concurrent observation and interview on 2/11/25 at 2:52 p.m. with LN 3, an inspection of Station 2 Medication Cart identified the following expired and discontinued medications and medical supplies: - 5 Bisacodyl suppository (used to treat constipation), expired 2/10/25; and, - 1 Debrox earwax removal aid (used to soften and loosen excess ear wax) - no open date, expired 11/1/24. The LN 3 confirmed the items identified in Station 2 Medication Cart were expired and should have been removed from the facility's stock. During a concurrent observation and interview on 2/12/25 at 11:37 a.m. with LN 1, an inspection of Station 3 Medication Cart identified the following expired and discontinued medications and medical supplies: - 1 Miralax (used to treat constipation) 26.9 oz bottle, expired on 1/2025; and, - 1 box containing 9 sachets arginaid arginine powder (supplement to support the nutritional needs of people with chronic wounds), expired on 12/4/24. The LN 1 confirmed the items identified in Station 3 Medication Cart were expired and should have been removed from the facility's stock. 2. During an observation on 2/11/25 at 11:32 a.m. in Nurse Station 2, a box of BinaxNOW COVID-19 test kits was observed on top of the cart. The lot number on the box was peeled off and an expiration date of 5/2025 was handwritten on the box. The box contained multiple BinaxNOW test kits and a box of Osang Healthcare (OHC) containing two self-test kits with expiration date of 12/9/23. During a concurrent interview and record review on 2/11/25 at 11:35 a.m. with the Infection Preventionist (IP), a list of COVID-19 test extension of expiration dates was provided by the IP. The list indicated the lot numbers for BinaxNOW with corresponding extended expiration dates. The list did not indicate any lot number with expiration date of 2025. The list further indicated the OHC test kits' lot number was extended until 12/9/24. The IP stated the list provided was the latest list and confirmed the test kits were expired. During an interview on 2/11/25 at 3 p.m. with the Administrator (ADM), the ADM stated the facility received the COVID-19 test kits from another facility during the pandemic. The ADM stated they should have pulled out the expired kits when they received the new stocks. During an interview on 2/13/25 at 11:50 a.m. with the IP, the IP stated, We should not keep expired [medications and supplies], risk of efficacy is affected, not effective anymore and the potential side effects are more increased if they are expired, and they are less effective. During an interview on 2/13/25 at 2:17 p.m. with the Director of Nursing (DON), the DON stated expired medications should be in the destruction area. The DON further stated, If it's expired it should not be given, and we don't want to take the risk for it to be given .Those should be tossed. When asked regarding the expired COVID-19 test kits, the DON stated, We already went through, and we discarded everything that we were not sure off .It can result in incorrect results. During a telephone interview on 2/13/25 at 3:05 p.m. with the Pharmacy Consultant (PC), the PC stated, .certain medication, we make sure they are labeled, not expired, we don't want to give resident expired medications. During a review of the facility's policy and procedure (P&P) titled 4.1: STORAGE OF MEDICATIONS, dated 6/2015, the P&P indicated, Procedures .H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal .Expiration Dating (Beyond-use dating) .G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner . 3. During a concurrent observation and interview on 2/11/25 at 11:40 a.m. with NS 1, an inspection of Station 2 Medication Storage Room identified an undated open single-dose sterile water vial inside the medication refrigerator. NS 1 confirmed the observation and stated the sterile water vial should be labeled with resident name and open date. During an interview on 2/13/25 at 2:17 p.m. with the DON, the DON stated opened vials are expected to be labeled with open date, and single-use vials should be discarded after use. During a review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated, 13. Vials labeled as single dose or single use are not used on multiple residents. Such vials are used only for one resident in a single procedure . 4. During a concurrent observation and interview on 2/11/25 at 10:49 a.m. with LN 3, an inspection of Station 2 Medication Storage Room identified one box of acetaminophen suppositories (administered rectally to treat mild to moderate pain) with peeled resident label. LN 3 confirmed the observation and verified unable to identify the resident on the label. During a concurrent observation and interview on 2/11/25 at 11:40 a.m. with NS 1, an inspection of Station 2 Medication Storage Room identified one box of acetaminophen suppositories with peeled resident label inside the medication refrigerator. NS 1 confirmed the observations and verified unable to identify the resident on the label on the box of acetaminophen. The NS 1 stated, We shouldn't rip the label, it should be destroyed, it might be used for residents. During a concurrent observation and interview on 2/12/25 at 11:37 a.m. with LN 1, an inspection of Station 3 Medication Cart identified one box of Culturelle probiotics (used to improve digestion and restore the natural balance of good bacteria in the digestive system) with peeled resident label. LN 1 confirmed the observation and stated, It needs to be thrown out because we don't know who it was for. During an interview on 2/13/25 at 2:17 p.m. with the DON, the DON stated, Once a medication is discontinued, they [staff] store them in the medication room for discarding . During a review of the facility's P&P titled Medication Labeling and Storage, revised 2/2023, the P&P indicated, Medication labeling .1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices .8. If medication containers have missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items . 5. During a concurrent observation and interview on 2/12/25 at 12:07 p.m. with LN 4, an inspection of Station 1 Medication Storage Room identified ice buildup on the medication refrigerator containing flu vaccines. LN 4 confirmed the observation. During a concurrent observation and interview on 2/13/25 at 9:03 a.m. with the DON in Station 1 Medication Storage Room, ice buildup was still observed on the medication refrigerator containing flu vaccines. The DON confirmed the observation. During an interview on 2/13/25 at 2:17 p.m. with the DON, the DON stated, Fridges are not supposed to have ice buildup, it could affect the temperature and cause temperature fluctuations. During a review of the facility's P&P titled Medication Labeling and Storage, revised 2/2023, the P&P indicated, The facility stores all medications, and biologicals in locked compartments under proper temperature, humidity and light controls .

Based on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) for lunch on 2/12/25 when four residents (Resident 4, 10, 16, 17) who were on Pureed (diet for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) received 1/4 cup serving of meat instead of 1/2 cup of meat as indicated on the menu. This failure had the potential to result in compromising the medical and nutrition status of the four residents. Findings: During an observation of lunch meal service on 2/12/25 beginning at 11:39 a.m., the following was observed: Residents 4, 10, 16, 17 who were on a pureed diet, received 1/4 cup of pureed chicken. A concurrent review of the facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, WEEK 2 EXTENDED MENUS, WEDNESDAY WEEK 2 indicated that residents on pureed diet should have received 1/2 cup of pureed chicken. During an interview on 2/12/25 at 11:42 a.m. with Dietary Manager (DM), DM confirmed the blue scoop used to serve pureed chicken during lunch that day was equivalent to 1/4 cup. During a follow up interview on 2/14/25 at 10:00 a.m. with DM, DM acknowledged that not following the menu can affect residents nutrition. During a review the facility's policy and procedure (P&P) titled, Food Preparation and Timing dated 1/1/18, indicated, .Food preparation begins with menu. It should be followed to ensure that adequate nutrients are being served .

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 33 when: 1. Unlabeled and undated jug of distilled water used for CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) was observed on the floor at Resident 13's bedside; 2. Coffee mug was observed on a commode seat in Resident 31's bathroom; 3. Blood pressure (BP) cuff was not disinfected after use between residents (Resident 139, Resident 2, Resident 188, and Resident 4); 4. BP cuff and BP machine was not disinfected with appropriate disinfectant; 5. Dust particles were observed on the exhaust in the clean linen room in the laundry area; 6. Dirt and black stagnant water was observed on the drain at the back of washers in the laundry area; 7. Resident 4, who used a CPAP, had an opened and unlabeled bottle of distilled water on his nightstand; and 8. Resident 5, who had a chronic pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), was not on Enhanced Barrier Precautions (EBP- a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MRDOs]). These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), and potential exposure to these residents. Findings: 1. During a review of Resident 13's admission record, the record indicated Resident 13 was admitted in [DATE] with diagnoses that included sepsis (a life-threatening blood infection) and obstructive sleep apnea (intermittent airflow blockage during sleep. Resident 13's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 13 had moderate cognitive impairment. During a review of Resident 13's physician order, dated, [DATE], the order indicated, C-PAP machine - Apply at bedtime and OFF in AM [morning] For Sleep apnea . During a review of Resident 13's care plan, undated, the care plan indicated, [Resident 13] Utilizes Continuous Positive Airway Pressure (CPAP) for COPD [chronic obstructive pulmonary disease, a chronic lung disease causing difficulty in breathing] .Monitor proper functioning of the device and make sure its [sic] clean . During a concurrent observation and interview on [DATE] at 9:13 a.m. with Resident 13 in his room, an unlabeled and undated jug of open distilled water used for CPAP was observed on top of the nightstand. Resident 13 stated he does not use CPAP very often and cannot remember when the last use was. During an observation on [DATE] at 3:13 p.m. in Resident 13's room, a jug of unlabeled and undated open jug of distilled water was observed on the floor on the side of the nightstand. During an interview on [DATE] at 9:38 a.m. with Licensed Nurse (LN) 4, LN 4 stated CPAP machines are filled with distilled water. LN 4 stated jugs are labeled to know when it was opened and if it can still be used. LN 4 stated, .we don't know if it was two months already. During a concurrent observation and interview on [DATE] at 9:44 a.m. with LN 4 in Resident 13's room, an opened, unlabeled and undated jug of distilled water was observed on the floor on the side of the nightstand. LN 4 confirmed the observation and stated, [Staff] usually label it .It should not be on the floor. During an interview on [DATE] at 11:50 a.m. with the Infection Preventionist (IP), the IP stated distilled water should be labeled with the resident's name and anything for therapeutic purposes have an open date to know how long it has been used. The IP further stated jugs of distilled water are not placed on the floor for infection control. During an interview on [DATE] at 2:17 p.m. with the Director of Nursing (DON), the DON stated any fluids should be dated upon opening so staff will know when to discard them. During a review of the facility's policy and procedure (P&P) titled CPAP/BiPAP [Bilevel Positive Airway Pressure, a breathing support therapy to deliver oxygen under positive pressure] Support, revised ,d+[DATE], the P&P indicated, 5. Humidifier (if used): a. Use clean, distilled water only in the humidifier chamber . 2. During a review of Resident 31's admission record, the record indicated Resident 31 was admitted in [DATE] with diagnoses that included cerebral infarction (blood flow to the brain is interrupted, causing brain tissue to die), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and unsteadiness on feet. Resident 31's MDS indicated Resident 31 was cognitively intact. During an observation on [DATE] at 10:08 a.m. in Resident 31's bathroom, a mug with a small amount of coffee was observed on top of the commode seat. During a concurrent observation and interview on [DATE] at 10:10 a.m. with Certified Nursing Assistant (CNA) 3 in Resident 31's bathroom, CNA 3 confirmed the mug was on top of the commode seat and stated she put it there and forgot to take it. CNA 3 stated, It is important not to do that because of hygiene. During an interview on [DATE] at 11:50 a.m. with the IP, the IP stated coffee mugs are taken out to be washed once the resident was done with it. When a photo of the mug on the commode seat was shown, the IP stated, That's not supposed to be there .That is considered contaminated. The IP added that it was a hazard and an infection control issue and stated, It's definitely contaminated .that's not acceptable to me. During a review of the facility's P&P titled Infection Prevention and Control Program, revised ,d+[DATE], the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 3. During a medication administration observation on [DATE] at 7:34 a.m. with LN 1, LN 1 was observed checking Resident 139's blood pressure before giving medications. After obtaining the blood pressure, LN 1 removed the cuff from Resident 139's left upper arm and hanged it on the blood pressure machine stand without sanitizing or disinfecting it. During a medication administration observation on [DATE] at 7:49 a.m. with LN 1, LN 1 was observed checking Resident 2's blood pressure before giving medications using the same blood pressure cuff and machine used for Resident 139. After obtaining the blood pressure, LN 1 removed the cuff from Resident 2's left upper arm and hanged it on the blood pressure machine stand without sanitizing or disinfecting it. During a medication administration observation on [DATE] at 8:08 a.m. with LN 1, LN 1 was observed checking Resident 188's blood pressure before giving medications using the same blood pressure cuff and machine used for Resident 139 and Resident 2. After obtaining the blood pressure, LN 1 removed the cuff from Resident 188's left upper arm and hanged it on the blood pressure machine stand without sanitizing or disinfecting it. During a medication administration observation on [DATE] at 8:14 a.m. with LN 1, LN 1 was observed checking Resident 4's blood pressure before giving medications using the same blood pressure cuff and machine used for Resident 139, Resident 2, and Resident 188. After obtaining the blood pressure, LN 1 removed the cuff from Resident 4's left upper arm and hanged it on the blood pressure machine stand without sanitizing or disinfecting it. During an interview on [DATE] at 8:36 a.m. with LN 1, LN 1 stated bleach wipes are used to disinfect blood pressure cuffs in between residents. LN 1 confirmed the blood pressure cuff was not disinfected in between residents during the medication pass observation and stated, [It is] important to prevent cross contamination. During an interview on [DATE] at 11:50 a.m. with the IP, the IP stated, We disinfect equipment before and after use in between residents, we have sanitizing wipes on all stations . During an interview on [DATE] at 2:17 p.m. with the DON, the DON stated the expectation was to disinfect blood pressure cuffs between each resident to not spread potential infection. During a review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment, revised ,d+[DATE], the P&P indicated, 5. Reusable items are cleaned and disinfected or sterilized between residents . 4. During a medication administration observation on [DATE] at 9:17 a.m. with LN 2, LN 2 was observed disinfecting the blood pressure cuff and machine with hand sanitizer wipes before checking Resident 11's blood pressure after using it from another resident. During an interview on [DATE] at 12:18 a.m. with LN 2, LN 2 confirmed she used the hand sanitizer wipes and stated she should have used the manufacturer-approved disinfectant wipes. LN 2 further stated, [It is] important because that wipe [manufacturer-approved disinfectant wipe] is used to kill bacteria on equipment and the wipe that was used do not. During an interview on [DATE] at 11:50 a.m. with the IP, the IP stated hand sanitizer wipes are used for residents' hands before and after eating. The IP stated, If it's not according to manufacturer's directions, it should not be used. During an interview on [DATE] at 2:17 p.m. with the DON, the DON stated the expectation was to disinfect equipment using the manufacturer-approved wipes. During a review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment, revised ,d+[DATE], the P&P indicated, (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches .(3) Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA [Environment Protection Agency]-registered disinfectant labeled for use in healthcare settings . 5. During a concurrent observation and interview on [DATE] at 12:58 p.m. with the Lead Housekeeper (LHS) in the clean linen area of the laundry room, dust particles were observed on the exhaust and the LHS confirmed the observation. During a concurrent observation and interview on [DATE] at 9:31 a.m. with the Maintenance Coordinator (MC) in the clean linen area of the laundry room, dust particles were still observed on the exhaust. The MC confirmed the observation and stated that it should be clean. During an interview on [DATE] at 11:50 a.m. with the IP, when a photo of the exhaust was shown, the IP stated, .the likelihood [of the dust falling] was less likely but nevertheless, it should also be clean, the function is lesser if it's full of dust, and by gravity, it could fall. The IP further stated, .vents should be clean, not just for the linen but also for the people working there [laundry area]. During a review of the facility's P&P titled Departmental (Environmental Services) - Laundry and Linen, revised ,d+[DATE], the P&P indicated, 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination . 6. During a concurrent observation and interview on [DATE] at 12:58 p.m. with the LHS in the washer area of the laundry room, dirt and black stagnant water was observed on the drain at the back of the washers and the LHS confirmed the observation. During an interview on [DATE] at 9:31 a.m. with the MC, the MC stated he cleaned the drain yesterday [[DATE]] after being notified about it. The MC stated, .it probably not supposed to look like that. During an interview on [DATE] at 1:28 p.m. with the IP, the IP stated the drainage in the washer room was not included in the monitoring for Legionella (a bacteria commonly found in water) because there was no report or any problem. The IP stated, I did not see the drainage, I did not know any open drainage. The IP further stated, We need to update the water management areas .that's definitely a water management issue .We missed that one .we don't want any stagnant water. During a review of the facility's P&P titled Departmental (Environmental Services) - Laundry and Linen, revised ,d+[DATE], the P&P indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . 49950 7. During a review of Resident 4's face sheet (contains a summary of basic information about the resident), the face sheet indicated, Resident 4 was admitted to the facility [DATE] with multiple diagnoses which included pneumonia (an infection/inflammation in the lungs). During a review of Resident 4's Physician's Orders, the Physician's Orders indicated Resident 4 had a CPAP and needed assistance with CPAP. During a concurrent observation and interview on [DATE] at 10:03 a.m., an open bottle of distilled water was on Resident 4's nightstand next to the CPAP machine. The bottle was not dated with an open or use by date. Resident 4 stated that he used the CPAP at night and is not sure how long the open bottle of distilled water had been there. During an interview on [DATE] at 9:38 a.m. with Licensed Nurse (LN) 4, LN 4 stated CPAP machines are filled with distilled water. LN 4 stated jugs are labeled to know when it was opened and if it can still be used. During an interview on [DATE] at 9:35 a.m. with Director of Nursing (DON), DON stated the expectation is for open bottles of distilled water to be labeled with open and use by date. DON acknowledged risk for resident to use expired distilled water if open bottles are not labeled. During a review of the facility's policy and procedure (P&P) titled CPAP/BiPAP [Bilevel Positive Airway Pressure, a breathing support therapy to deliver oxygen under positive pressure] Support, revised ,d+[DATE], the P&P indicated, 5. Humidifier (if used): a. Use clean, distilled water only in the humidifier chamber . 8. During a review of Resident 5's face sheet, the face sheet indicated, Resident 5 was admitted to the facility February 2019 with multiple diagnoses including dementia (a progressive state of decline in mental abilities). During a review of Resident 5's skin evaluation form, dated [DATE], the skin evaluation form indicated Resident 5 had a pressure injury to her left buttock from [DATE] and needed treatment. During an observation on [DATE] at 3:35 p.m., enhanced barrier precautions (EBP, infection control measures) were not in place for Resident 5 including signs on the door or outside Resident 5's room and personal protective equipments (PPEs) were not readily available outside Resident 5's room. During an interview on [DATE] at 9:35 a.m. with DON, DON stated EBP should be observed for residents at high risk for infection including pressure ulcers. During a review of the facility's P&P, titled Enhanced Barrier Precautions, revised [DATE], the P&P indicated, .EBP's are indicated .for residents with wounds .wound generally include chronic wounds .i.e., pressure ulcers .signs are posted in the door or wall outside residents room indicating the type of precautions and PPE required .PPE is available outside of the residents rooms .

Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 16) received nectar thickened liquids as ordered by the physician, when Resident 16 was served thin liquids by Certified Nursing Assistant (CNA 2). This failure had the potential for Resident 16 to experience aspiration (accidental inhalation of food or fluids into the airways or lungs) and choking. Findings: During a review of Resident 16's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 16 was admitted to the facility May 2024 with multiple diagnoses which included pneumonia (an infection/inflammation in the lungs). During a review of Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/4/24, the MDS indicated Resident 16 had difficulty swallowing and required a mechanically altered diet (change in texture of food or liquids). During a review of Resident 16's physician's orders, dated 9/17/24, the physician's orders indicated, .DIET .Nectar Thick Liquids . During a review of Resident 16's care plan, undated, the care plan indicated, .Resident is at nutritional risk .approach .diet as ordered . During a concurrent observation, interview, and record review on 02/11/25 at 12:24 p.m., Resident 16 was having lunch in the main dining hall. Resident 16 was drinking a glass of regular water and coughing between sips. The tray ticket on Resident 16's tray indicated Resident 16 was on a pureed diet with nectar thickened liquids. Certified Nursing Assistant 2 (CNA 2) confirmed Resident 16 should not have been given regular water. CNA 2 stated, I am sorry. I placed the regular water at each station at the start of the meal and forgot to take hers (Resident 16) away. I did bring her nectar thickened apple juice, that she already drank, but I forgot to come back and take the water away. During an interview on 2/14/25 at 9:35 a.m. with the Director of Nursing (DON), the DON stated the expectation was for all diet orders to be followed (therapeutic and textured). The DON acknowledged there was a risk for aspiration if textured diet orders were not followed. During a review of the facility's policy and procedure ( P&P) titled, Therapeutic Diets, revised October 2017, the P&P indicated, .a 'therapeutic diet' is considered a diet ordered by a physician .as part of treatment for a disease or clinical condition .for example .altered consistency diet .

Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 35) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 35's routine dose of antidepressant was not discontinued after it was changed to PRN (as needed) and the PRN order did not have a specified end date. This failure had the potential to result in unnecessary medication for Resident 35, which had the potential for increased risk and exposure to side effects associated with psychotropic medications. Findings: During a review of Resident 35's admission record, the record indicated Resident 35 was admitted in January 2025 with diagnoses that included insomnia (trouble falling asleep or staying asleep) and depression (a condition characterized by persistent feelings of sadness, loss of interest, and low energy that interfere with daily life). Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 35 had intact cognition. During a review of Resident 35's physician order, dated 1/12/25, the order indicated, Trazodone [medication used to treat depression] 50 mg [milligrams, a unit of measurement] tablet .Give 0.5 tab via G-tube [gastrostomy tube, a tube that provides access to the stomach] At bedtime for Depression . During a review of Resident 35's physician order, dated 2/9/25, the order indicated, Trazodone 50 mg tablet .0.5 tab G-tube At bedtime as needed For depression . The order further indicated the stop date 00/00/00. During a review of Resident 35's Interdisciplinary Notes, dated 2/7/25, the notes indicated, [Resident 35] noted to have refused routine trazodone at bedtime 4x [four times] this week. [Resident 35] noted to be asking for trazodone later in NOC [night] shift 2x [two times] this week. Faxed MD [Medical Doctor] asking to change routine trazodone to PRN. Awaiting response . During a review of Resident 35's document FAX TO PHYSICIAN, dated 2/7/25, the document indicated, Resident has been refusing 0.5 tab (50mg) Trazodone at bedtime 4x this week. Resident has been asking for Trazodone later in NOC shift. Can we change routine order to PRN? .RESPONSE: OK. Verbal order received 2/9/25. During a review of Resident 35's Interdisciplinary Notes, dated 2/9/25, the notes indicated, .Gave okay to change Trazodone to PRN so [Resident 35] can get at night time when he chooses . During a concurrent interview and record review on 2/13/25 at 2:17 p.m. with the Director of Nursing (DON), the DON confirmed Resident 35 had an order for Trazodone PRN. The DON stated, [Resident 35] had a routine before but it was discontinued now [2/13/25], it was clarified with the doctor. The DON confirmed Resident 35's Trazodone PRN order started on 2/9/25 and verified that the order did not have a stop date. During a concurrent telephone interview and record review on 2/13/25 at 3:05 p.m. with the Pharmacy Consultant (PC), the PC confirmed Resident 35 had an order for Trazodone 0.5 tab PRN for depression started on 2/9/25 and verified the routine dose was cancelled on 2/13/25. The PC stated, It should have been discontinued when they changed it to PRN .so he doesn't get double the dose .I guess they didn't catch it right away . The PC further stated the PRN order was recently added and stated, .they would need a stop date . to make sure psychotropic use is being monitored. During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, revised 7/2022, the P&P indicated, 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: .b. Anti-depressants .3 .Psychotropic medication management includes: .b. dose (including duplicate therapy) .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record .a. PRN orders for psychotropic medications are limited to 14 days .(1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order .

Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for one of 14 sampled residents (Resident 34) when Resident 34's Insulin Lispro (a fast-acting type of insulin - a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was not administered with meals as ordered by the physician. This failure had the potential to result in the drop in Resident 34's blood sugar and the potential for Resident 34 to experience signs and symptoms of low blood sugar. Findings: During a review of Resident 34's admission records, the records indicated Resident 34 was admitted in January 2025 with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 34's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 34 had intact cognition. During a review of Resident 34's physician order, dated 2/1/25, the order indicated, Insulin lispro .100 unit/mL [milligrams, a unit of measurement] subcutaneous [under the skin] solution - Inject up to 10 units per sliding scale subcutaneously with meals Subcutaneous 3 times a day . During a review of Resident 34's care plan, undated, the care plan indicated, [Resident 34] is receiving insulin Lispro .for diabetes .Assess and monitor for s/s [signs and symptoms] of hypo/hyperglycemia [low/high blood sugar] . During a medication administration observation on 2/12/25 at 11:28 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed giving 3 units of Insulin Lispro on Resident 34's left abdomen. No food tray was observed at bedside. During a concurrent interview and record review on 2/12/25 at 1:12 p.m. with LN 1, LN 1 confirmed Resident 34's physician order indicated to give Insulin Lispro with meals. LN 1 confirmed Resident 34 did not have lunch yet and stated, They give snacks in between meals, his numbers are usually high . During an interview on 2/13/25 at 2:17 p.m. with the Director of Nursing (DON), the DON stated, If physician order is to give medication with meals, expectation is for it to be given with meals .if there are any concerns, clarify with the doctor .Medications are to be given as ordered and as scheduled, if to be given outside the schedule, clarify with the doctor. During an interview on 2/13/25 at 3:05 p.m. with the Pharmacy Consultant (PC), the PC stated, [The] expectation is to follow specifically what the order says, to maintain some consistency. During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . During a review of the facility's P&P titled Insulin Administration, revised 9/2014, the P&P indicated, Purpose .To provide guidelines for the safe administration of insulin to residents with diabetes .3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .Characteristics and Types of Insulin 1. The three key characteristics of insulin are: a. Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose .2. The four types of insulin and their characteristics are: .Type .Rapid-acting .Onset .10-15 minutes .

Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 8), received sufficient fluids to maintain adequate hydration per resident's care plan and per Registered Dietician's assessment. This failure increased Resident 8's risk for dehydration (not enough fluids in the body to carry out normal functions) that can result in complication of the resident's medical conditions. Findings: A review of the Resident 8's admission records indicated the facility admitted the resident in 2024 with multiple diagnoses which included Parkinson's disease with dyskinesia (a progressive disease of the nervous system marked by involuntary shaking, muscular rigidity, and slow, imprecise movement of face, arms and legs), dementia (a progressive state of decline in mental abilities), and constipation (a problem with passing stool, caused by lack of fluids, dietary fiber, and exercises). A review of physician order for Resident 8 dated 12/3/24 indicated, Intake & Output [I&O] Record [the process of measuring and recording how much fluid resident consumes and excretes] once daily. Calculate 24 hour total of I & O from all sources. A review of the Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 12/9/24 indicated Resident 8 scored 12 out of 15 on assessment of cognitive status, which indicated the resident had moderate cognitive impairment. A review of Resident 8's undated 'Alteration in ADLs (activities of daily living, routine tasks/activities such as eating, bathing, dressing and toileting a person performs daily to care for themselves)' care plan indicated the resident required one person and extensive assist for eating. A review of Resident 8's undated 'Hydration Maintenance' care plan indicated, the resident was at risk for dehydration related to constipation. The nursing interventions included,Offer fluids between meals. Keep fluids within resident reach. Encourage fluids during cares [sic] .Encourage resident to consume fluids provided with meals and with medications. A review of the nutrition assessment completed by Registered Dietitian (RD, a healthcare professional who is specialized in food and nutrition) dated 2/4/25 indicated that Resident 8's estimated fluid needs were 1300 milliliters (ml, a unit of measurement of amount) every day. The RD recommended to monitor Resident 8's weights, skin integrity, oral intake, and laboratory results. A review of Intake-Output (I&O) records for the month of January 2025 indicated the average daily intake of fluids was approximately 820 milliliters per day. This represented an average of 480 milliliters per day less than the RD's assessed fluids needs for Resident 8. A review of the I&O records from 2/1/25 through 2/12/25 indicated Resident 8 had an average of 900 milliliters of fluids each day, which was 400 milliliters less than the RD's assessed fluids needs per day. During a concurrent observation and interview on 2/11/25, at 10:48 a.m., with Resident 8 in her room, the resident sat in wheelchair next to her bed. Resident 8 had a soft voice and was able to carry out a minimal conversation. The resident's bedside table was placed in front of resident's wheelchair but there was no water pitcher on the table. A small plastic water cup with cover was observed on the table behind the resident's wheelchair and was not within resident's reach. Resident 8's right hand was visibly shaking when she attempted to grab the call light. Resident 8 stated she was not able to reach her cup with water and added, I shout for help when I'm thirsty and my mouth is dry. During a follow up observation on 2/11/25, at 1:25 p.m., the resident was lying in bed on the left side, propped with pillows. A small plastic cup with brown substance was observed on the small table behind the residents bed, approximately 2-3 feet away and there was no water pitcher observed in resident's room. The resident's bedside table was observed at the entrance to the resident's bathroom. Resident 8 stated she had no water available to drink. During an observation on 2/12/25, at 8:25 a.m., Resident 8 was sitting in wheelchair in her room with breakfast tray in front of her. A small amount of juice was noted in the plastic cup. There was no water pitcher observed on the resident's table or anywhere in the resident's room. Resident 8 stated she liked ice water but the staff did not offer it to her this morning. After a moment, Resident 8 was observed calling help, help and waved her hand when the resident observed a CNA walking in the hall. The CNA was overheard saying ok and continued walking in the hall. The CNA passed the resident's room, entered another resident's room, and closed the door. Resident 8 continued calling help, help in her soft voice. During an observation on 2/12/25, at 4:25 p.m., Resident 8 was lying in bed on her side facing left side of the bed propped by pillows. Bedside table was observed away from the resident on the opposite side of the room. A plastic jug with small amount of water was observed on the small table behind the resident's bed, not within reach. Resident's call light was observed wrapped around the right side rails, hanging toward the floor not within resident's reach. Resident 8 feebly stated, My mouth is so dry. Resident 8 whispered that staff did not offer her water and nodded her head when asked if she wanted to have some water. During an interview on 2/12/25, at 4:30 p.m., Certified Nursing Assistant (CNA 1) stated Resident 8 was confused most of the time, but was able to state her needs. CNA 1 stated Resident 8 liked to drink ice cold water and asked for it when she wanted a drink. CNA 1 stated that Resident 8 had really bad shaking in both of her hands, but the right hand was worse and required assistance with feeding. CNA 1 added that if Resident 8 was not assisted, the resident would spill food and drinks. CNA 1 entered Resident 8's room and acknowledged that the bedside table was away and the call light and water jug were not within resident's reach. CNA 1 stated, She [Resident 8] doesn't know how to use the call light anyway. She always shouts for help and if she needs water. CNA 1 stated the CNAs were supposed to offer water to Resident 8 in between meals. During an interview on 2/12/25, at 4:50 p.m., with Nursing Supervisor (NS) 2, the NS 2 stated the CNAs had to offer the residents water or other beverages throughout the day and in between meals and the nurses were giving water with medications. NS 2 explained that evening shift nursing supervisor totaled the resident's fluids intake for the day and documented in the clinical records. The NS 2 did not provide any answer when asked how the facility monitored Resident 8's fluid intake to identify if the resident was meeting her recommended fluid needs and getting enough hydration. During a telephone interview with RD on 2/12/25, at 2:12 p.m., the RD stated that residents were assessed for their nutrition and hydration needs about two weeks after their admission. The RD explained that to determine if the residents had met their required fluid needs, the residents were reassessed later and the new recommendations were added if needed. The RD stated she sent nutritional recommendations to the dietary manager (DM) who communicated the information to nursing staff. The RD stated she could not remember if she reassessed Resident 8's fluid intake or if she was notified that the resident was not meeting the estimated fluid needs. A review of the facility's policy titled, Hydration - Clinical Protocol, dated 2001, indicated, The physician and staff will help define the individual's current hydration status .The staff .will provide supportive measures such as supplemental fluids .The staff will monitor for the .development, progression .of fluid .imbalance in at-risk individuals. During an interview with Director of Nursing (DON) on 2/13/25, a 10:03 a.m., the DON was asked if the facility had a system in place to monitor residents' fluid intake to ensure their fluid needs were met. The DON explained that CNAs documented the fluid amount the resident consumed on paper logs and then documented electronically for each shift and the evening shift supervisors calculated and entered the total amount into resident's electronic chart. The DON added, RD keeps an eye on that, also nurses address [fluid intake] in their weekly summaries. The DON reviewed the RD's recommendations for Resident 8 to have 1300 milliliters of fluids each day. The DON reviewed nursing weekly summaries dated 2/6/25 and 2/13/25 and acknowledged that the nurses documented in their summaries the amount of the fluid the resident received and validated that the amount was below RD's recommendations. The DON reviewed 24 hour documentation of Resident 8's I&O and acknowledged that the resident have not met her recommended fluid needs per January and February. The DON stated Resident 8's fluid needs were not identified and were not addressed during interdisciplinary meetings. The DON validated that not having proper hydration placed Resident 8 at risk for dehydration and could lead to other health issues related to constipation. The DON added that water and/or other fluids should be always available at Resident 8's bedside to prevent dehydration. The DON stated she would expect nursing to follow the RD's recommendations for fluid needs, expect CNAs round on Resident 8 more frequently, offer, encourage water in between meals, and the nurses address Resident 8's fluid consumption in their weekly summaries or progress notes.

Based on interviews and record reviews, the facility failed to ensure one out of two sampled resident (Resident 1) did not develop a pressure ulcer when the facility did not follow their policy and procedure for prevention of pressure injuries such as inspecting the skin daily when performing or assisting with personal care or activities of daily living (ADL, tasks of everyday life), did not continually evaluate Resident 1 ' s potential for skin breakdown per physician ' s order and request a preventative treatment prescribed by the physician once Resident 1 became incontinent of both bladder (the ability to control on when to empty the urine)and bowel function (the ability to control when to have a bowel movement). These failures resulted to Resident 1 acquiring a stage 2 pressure ulcer (PU, a shallow open ulcer with a red or pink wound bed, caused when an area of skin is placed under pressure ). Findings: A review of Resident 1 face sheet (demographics) indicated he was admitted on [DATE] with a diagnoses of Essential Hypertension (HTN, high blood pressure), Hyperlipidemia (HLP, an elevated level of lipids like cholesterol and triglycerides in your blood) and Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high). His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 1/23/24 Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) condition of residents, indicated Resident 1 had a short term and long-term memory impairment. Resident 1 ' s MDS assessment also indicated he was always incontinent of both bladder and bowel. His MDS assessment also indicated Resident 1 had 1 unhealed pressure ulcer when he was discharged at the facility on 1/23/24. Resident 1 ' s admission note dated 1/2/24 22:34 indicated the admission skin assessment was done, and the coccyx (tailbone) and bony prominences (areas where bones are close to the surface and areas that are under the most pressure are at greatest risk for developing pressure sores) were intact. His skin Interdisciplinary Team (IDT, professional disciplines, as appropriate, will work together to provide the greatest benefit for the resident) note dated 1/22/24 13:58 indicated Resident 1 was noted with a Stage 2 PU on his left buttock. A review of Resident 1 ' s PO indicated there was no order for preventive treatment once Resident 1 became incontinent of bowel and bladder function. Further review of Resident 1 ' s Physician Order (PO, the instruction the physician had written for a resident ' s treatment) dated 1/2/24, indicated to complete the Braden Scale assessment (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ulcer) upon admission and then weekly for the next 4 weeks. There was only 1 Braden Scale Skin Assessment completed dated 1/3/24, the score was 17, indicating Resident 1 had a mild risk for developing pressure ulcer. As per Braden Scale Skin assessment dated [DATE], Resident 1 ' s skin was occasionally moist, walks occasionally during the day but for very short distance, had slight limited ability to change and control body position, had inadequate food intake, and issue with friction and shear during movement in bed or chair. There were no further Braden Scale Skin Assessment completed after 1/3/24. A review of Resident 1 ' s ADL charting did not indicate he was being offered toileting or incontinence care every 2 hours. There were no documentations provided to indicate Resident 1 was being turned and repositioned every 2 hours. During an interview on 2/20/24 at 10:12 a.m., Unlicensed Staff A stated it was the facility ' s policy to ensure residents were turned and repositioned every 2 hours to offload weight and to check and change incontinent residents every 2 hours or more often as needed. Unlicensed Staff A stated staff would also apply a barrier cream on residents who were incontinent. Unlicensed Staff A stated not doing these could result to development of pressure sores, open wounds, pain and infections. During an interview on 2/20/24 at 10:30 a.m., Licensed Staff B stated it was the facility ' s P&P with pressure sore prevention to turn and reposition residents every 2 hours as needed and as tolerated and to check and change incontinent residents every 2 hours or more often as needed. Licensed Staff B stated residents who were incontinent were more prone to develop pressure ulcer so it was important to initiate a preventive treatment per physician ' s order. Licensed Staff B stated if these were not done, residents could develop pressure ulcer. When asked how often a Braden Scale Skin Assessment should be completed, Licensed Staff B stated Braden Scale Skin Assessment must be completed upon admission then weekly. Licensed Staff B stated if not done weekly, staff could miss important changes in risk factors that could be addressed to decrease likelihood of a resident developing a pressure ulcer. During an interview on 2/20/24 at 11:12 a.m., Licensed Staff C stated it was the facility ' s P&P with pressure ulcer prevention to turn and reposition residents every 2 hours, to provide good perineal care and to check and change incontinent residents every 2 hours and as needed. Licensed Staff C stated if these were not done, it meant facility policy was not followed which could result to worsened pressure injury, infection and pain. Licensed Staff C stated quality of life decreases when a resident was in pain. Licensed Staff C stated once a resident was deemed incontinent, a preventative treatment should be requested to the physician. Licensed Staff C stated if these were not done, resident could develop pressure ulcer. When asked how often a Braden Scale Skin Assessment should be completed, Licensed Staff C stated it should be completed upon admission then weekly. Licensed Staff C stated if this was not done weekly, staff may not be able to address risk factor changes that could lessen the likelihood of resident developing a pressure ulcer. During an interview on 2/20/24 at 12:06 p.m., Unlicensed Staff D stated for pressure ulcer prevention, it was facility ' s policy to ensure residents were turned and repositioned every 2 hours and to provide incontinence care every 2 hours or more often as needed. Unlicensed Staff D stated if these were not done, it could lead to the development of new skin issues or worsening of pressure ulcer. Unlicensed Staff D stated staff also provide a preventative treatment to apply on resident who were incontinent to prevent them from developing pressure sore. During an interview on 2/20/24 at 12:20 p.m., the MDS coordinator stated it was the facility ' s policy to turn and reposition residents every 2 hours, to provide incontinent care every 2 hours or more often as needed and to use barrier cream for incontinent residents per physician ' s order to decrease the risk of residents acquiring a pressure ulcer. When asked if Resident 1 had an individualized turning and repositioning schedule based on his risk factors, the MDS coordinator stated Resident 1 did not have an individualized turning and repositioning schedule based on his risk factor. The MDS coordinator verified Resident 1 pressure ulcer was acquired while he was at the facility. When asked when does staff conduct skin assessments, the MDS coordinator stated the Braden Scale Skin assessment was done upon admission and weekly for the next 3 weeks post admission per facility policy. The MDS coordinator stated staff should follow this and if this was not done, then the facility was not following the skin policy. The MDS coordinator stated if the Braden Scale Skin assessment was not done, there could be risk for staff to miss skin and risk changes, that if known, staff could implement interventions to decrease the risk of resident developing a pressure ulcer. The MDS coordinator stated skin issues could develop and worsen if not being assessed regularly. During an interview on 2/20/24 at 12:40 p.m., the Director of Nursing (DON) stated it was the facility ' s policy to turn and reposition residents every 2 hours or more frequently as needed, to provide incontinent care to residents every 2 hours and more often as needed to decrease the risk of residents developing a pressure ulcer. The DON stated Resident 1 ' s skin was intact upon admission, however on 1/15/24, it was noted he developed a pressure ulcer on his left buttock up to his tail bone. Per the Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) skin review note dated 1/22/24, the Stage 2 PU on Resident 1 ' s left buttock size was 5.0 by 1.0 centimeter (cm, a unit of measure). DON stated Resident 1 ' s pressure sore developed in the facility. The DON was unable to determine if Resident 1 ' s pressures ulcer was avoidable or unavoidable. When asked when staff conducts skin assessments, the DON stated the Braden Scale Skin Assessments was done upon admission then weekly for the next 4 weeks per facility policy. The DON stated the Braden Scale Skin Assessment was important because it identifies a residents ' risk for developing pressure sore. The DON stated if the Braden Scale Skin Assessment was not done per facility policy, it could lead to missing other skin issues. The DON stated it could also lead to missed related risk factors that predispose residents to pressure sore development. During an interview on 2/23/24 at 10:01 a.m., a request was made to see Resident 1 ' s daily skin assessment. The DON was only able to provide 1 skin evaluation form dated 1/15/24 and 5 shower skin sheets dated 1/3/24, 1/6/24, 1/10/24, 1/17/24 and 1/20/24. The shower skin sheet on 1/17 and 1/20 did not indicate Resident 1 had a pressure ulcer on his left buttocks. A review of the facility ' s policy and procedure (P&P) titled Prevention of Pressure Injuries, revised 4/2020, the P&P indicated to assess the resident on admission for existing pressure injury risk factors and to repeat risk assessments weekly and upon any changes in condition .inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living .use a barrier product to protect skin from moisture .reposition all residents with or at risk of pressure injuries on an individualized schedule .frequency for repositioning based on residents risk factors and current clinical practice. Based on interviews and record reviews, the facility failed to ensure one out of two sampled resident (Resident 1) did not develop a pressure ulcer when the facility did not follow their policy and procedure for prevention of pressure injuries such as inspecting the skin daily when performing or assisting with personal care or activities of daily living (ADL, tasks of everyday life), did not continually evaluate Resident 1's potential for skin breakdown per physician's order and request a preventative treatment prescribed by the physician once Resident 1 became incontinent of both bladder (the ability to control on when to empty the urine)and bowel function (the ability to control when to have a bowel movement). These failures resulted to Resident 1 acquiring a stage 2 pressure ulcer (PU, a shallow open ulcer with a red or pink wound bed, caused when an area of skin is placed under pressure ). Findings: A review of Resident 1 face sheet (demographics) indicated he was admitted on [DATE] with a diagnoses of Essential Hypertension (HTN, high blood pressure), Hyperlipidemia (HLP, an elevated level of lipids like cholesterol and triglycerides in your blood) and Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high). His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 1/23/24 Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) condition of residents, indicated Resident 1 had a short term and long-term memory impairment. Resident 1's MDS assessment also indicated he was always incontinent of both bladder and bowel. His MDS assessment also indicated Resident 1 had 1 unhealed pressure ulcer when he was discharged at the facility on 1/23/24. Resident 1's admission note dated 1/2/24 22:34 indicated the admission skin assessment was done, and the coccyx (tailbone) and bony prominences (areas where bones are close to the surface and areas that are under the most pressure are at greatest risk for developing pressure sores) were intact. His skin Interdisciplinary Team (IDT, professional disciplines, as appropriate, will work together to provide the greatest benefit for the resident) note dated 1/22/24 13:58 indicated Resident 1 was noted with a Stage 2 PU on his left buttock. A review of Resident 1's PO indicated there was no order for preventive treatment once Resident 1 became incontinent of bowel and bladder function. Further review of Resident 1's Physician Order (PO, the instruction the physician had written for a resident's treatment) dated 1/2/24, indicated to complete the Braden Scale assessment (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ulcer) upon admission and then weekly for the next 4 weeks. There was only 1 Braden Scale Skin Assessment completed dated 1/3/24, the score was 17, indicating Resident 1 had a mild risk for developing pressure ulcer. As per Braden Scale Skin assessment dated [DATE], Resident 1's skin was occasionally moist, walks occasionally during the day but for very short distance, had slight limited ability to change and control body position, had inadequate food intake, and issue with friction and shear during movement in bed or chair. There were no further Braden Scale Skin Assessment completed after 1/3/24. A review of Resident 1's ADL charting did not indicate he was being offered toileting or incontinence care every 2 hours. There were no documentations provided to indicate Resident 1 was being turned and repositioned every 2 hours. During an interview on 2/20/24 at 10:12 a.m., Unlicensed Staff A stated it was the facility's policy to ensure residents were turned and repositioned every 2 hours to offload weight and to check and change incontinent residents every 2 hours or more often as needed. Unlicensed Staff A stated staff would also apply a barrier cream on residents who were incontinent. Unlicensed Staff A stated not doing these could result to development of pressure sores, open wounds, pain and infections. During an interview on 2/20/24 at 10:30 a.m., Licensed Staff B stated it was the facility's P&P with pressure sore prevention to turn and reposition residents every 2 hours as needed and as tolerated and to check and change incontinent residents every 2 hours or more often as needed. Licensed Staff B stated residents who were incontinent were more prone to develop pressure ulcer so it was important to initiate a preventive treatment per physician's order. Licensed Staff B stated if these were not done, residents could develop pressure ulcer. When asked how often a Braden Scale Skin Assessment should be completed, Licensed Staff B stated Braden Scale Skin Assessment must be completed upon admission then weekly. Licensed Staff B stated if not done weekly, staff could miss important changes in risk factors that could be addressed to decrease likelihood of a resident developing a pressure ulcer. During an interview on 2/20/24 at 11:12 a.m., Licensed Staff C stated it was the facility's P&P with pressure ulcer prevention to turn and reposition residents every 2 hours, to provide good perineal care and to check and change incontinent residents every 2 hours and as needed. Licensed Staff C stated if these were not done, it meant facility policy was not followed which could result to worsened pressure injury, infection and pain. Licensed Staff C stated quality of life decreases when a resident was in pain. Licensed Staff C stated once a resident was deemed incontinent, a preventative treatment should be requested to the physician. Licensed Staff C stated if these were not done, resident could develop pressure ulcer. When asked how often a Braden Scale Skin Assessment should be completed, Licensed Staff C stated it should be completed upon admission then weekly. Licensed Staff C stated if this was not done weekly, staff may not be able to address risk factor changes that could lessen the likelihood of resident developing a pressure ulcer. During an interview on 2/20/24 at 12:06 p.m., Unlicensed Staff D stated for pressure ulcer prevention, it was facility's policy to ensure residents were turned and repositioned every 2 hours and to provide incontinence care every 2 hours or more often as needed. Unlicensed Staff D stated if these were not done, it could lead to the development of new skin issues or worsening of pressure ulcer. Unlicensed Staff D stated staff also provide a preventative treatment to apply on resident who were incontinent to prevent them from developing pressure sore. During an interview on 2/20/24 at 12:20 p.m., the MDS coordinator stated it was the facility's policy to turn and reposition residents every 2 hours, to provide incontinent care every 2 hours or more often as needed and to use barrier cream for incontinent residents per physician's order to decrease the risk of residents acquiring a pressure ulcer. When asked if Resident 1 had an individualized turning and repositioning schedule based on his risk factors, the MDS coordinator stated Resident 1 did not have an individualized turning and repositioning schedule based on his risk factor. The MDS coordinator verified Resident 1 pressure ulcer was acquired while he was at the facility. When asked when does staff conduct skin assessments, the MDS coordinator stated the Braden Scale Skin assessment was done upon admission and weekly for the next 3 weeks post admission per facility policy. The MDS coordinator stated staff should follow this and if this was not done, then the facility was not following the skin policy. The MDS coordinator stated if the Braden Scale Skin assessment was not done, there could be risk for staff to miss skin and risk changes, that if known, staff could implement interventions to decrease the risk of resident developing a pressure ulcer. The MDS coordinator stated skin issues could develop and worsen if not being assessed regularly. During an interview on 2/20/24 at 12:40 p.m., the Director of Nursing (DON) stated it was the facility's policy to turn and reposition residents every 2 hours or more frequently as needed, to provide incontinent care to residents every 2 hours and more often as needed to decrease the risk of residents developing a pressure ulcer. The DON stated Resident 1's skin was intact upon admission, however on 1/15/24, it was noted he developed a pressure ulcer on his left buttock up to his tail bone. Per the Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) skin review note dated 1/22/24, the Stage 2 PU on Resident 1's left buttock size was 5.0 by 1.0 centimeter (cm, a unit of measure). DON stated Resident 1's pressure sore developed in the facility. The DON was unable to determine if Resident 1's pressures ulcer was avoidable or unavoidable. When asked when staff conducts skin assessments, the DON stated the Braden Scale Skin Assessments was done upon admission then weekly for the next 4 weeks per facility policy. The DON stated the Braden Scale Skin Assessment was important because it identifies a residents' risk for developing pressure sore. The DON stated if the Braden Scale Skin Assessment was not done per facility policy, it could lead to missing other skin issues. The DON stated it could also lead to missed related risk factors that predispose residents to pressure sore development. During an interview on 2/23/24 at 10:01 a.m., a request was made to see Resident 1's daily skin assessment. The DON was only able to provide 1 skin evaluation form dated 1/15/24 and 5 shower skin sheets dated 1/3/24, 1/6/24, 1/10/24, 1/17/24 and 1/20/24. The shower skin sheet on 1/17 and 1/20 did not indicate Resident 1 had a pressure ulcer on his left buttocks. A review of the facility's policy and procedure (P&P) titled Prevention of Pressure Injuries , revised 4/2020, the P&P indicated to assess the resident on admission for existing pressure injury risk factors and to repeat risk assessments weekly and upon any changes in condition .inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living .use a barrier product to protect skin from moisture .reposition all residents with or at risk of pressure injuries on an individualized schedule .frequency for repositioning based on residents risk factors and current clinical practice.

Based on interviews and record reviews, the facility failed to ensure nursing staff were competent and had skills to provide nursing and related services to assure resident safety when the nurses did not follow the facility ' s policy and procedure on narcotic (drug that causes stupor or insensibility) count reconciliation (physical inventory of all controlled substances), when nurses left the medicine cart (med cart) keys on top of the med cart unattended and the nurses did not know Baza Cream (an incontinent cream that contains zinc oxide, a medicated cream, ointment or paste that treats or prevents skin irritation) requires a Physician Order (PO, the instruction the physician had written for a patients ' treatment ) prior to applying it on a resident skin. These failures were a safety risk that resulted in missing /unaccounted 3 tablets of narcotics (a medication that dulls the senses and treat pain) for one out of two sampled residents (Resident 2). These failures could lead to unauthorized access to the med cart, medication error (med error) and residents not receiving the correct treatment medication to address a skin issue. Findings: A review of resident 2 ' s face sheet (demographics) indicated she was admitted to the facility on [DATE] with a diagnoses of Parkinson ' s Disease (PD, a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Dysphagia (difficulty swallowing) and Hyperlipidemia (HLP, an elevated level of lipids like cholesterol and triglycerides in your blood). Her Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/2/24 Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) condition of residents, indicated Resident 2 had a short term and long-term memory impairment. A review of Resident 2 ' s PO indicated she had an order for a Percocet (a narcotic) 5 milligram (mg, a unit of measure) - 325 mg 1 tablet by mouth every 8 hours for pain management. A review of the letter addressed to the Department, dated 1/31/24 , indicated there were unexplained 3 missing tablets of Percocet 5 mg- 325 mg. During an interview on 2/23/24 at 10:01 a.m., the Director of Nursing (DON) stated based on her investigation, nobody could tell her where the missing Percocet went and her investigation did not provide an answer as to what happened in this situation. During an interview on 2/20/24 at 10:30 a.m. Licensed Staff B stated it was the facility ' s policy for nurses to reconcile narcotic count before the start and end of their shift to ensure narcotics count were accurate and to ensure there were no missing narcotics. When asked why staff need to do narcotic count reconciliation, Licensed Staff B stated it was done to prevent missing narcotics and to account for all narcotics. When asked what the risk were if a narcotic reconciliation was not done, Licensed Staff B stated it could result to medication errors, drug diversion and residents not receiving their pain medication. When asked where staff kept the med cart keys, Licensed Staff B stated med cart keys should be with the nurse at all times. When asked if it was ever okay to leave the med cart key on top of the med cart, unattended, Licensed Staff B stated no. Licensed Staff B stated med cart keys should be with the nurses even if they were on a break. When asked what the risk were if the med cart keys were left on top of the med cart, Licensed Staff B stated anybody could take the key and open the med cart. Licensed Staff B stated residents could also get into the med cart, take meds that was not meant for them that could affect them negatively. During an interview on 2/20/24 at 11:32 a.m., Licensed Staff C stated when she came on her morning shift on 1/22/24 and 1/23/24 the outgoing nurse from night shift never came to give her report nor do a narcotic count reconciliation. Licensed Staff C stated that on both days, she also did not complete a narcotic count reconciliation with the incoming nurse at the end of her shift. She stated she counted the narcotics by herself. When asked if the facility policy was followed when the narcotic count reconciliation with the incoming and outgoing nurse were not completed, Licensed Staff C answered no. When asked what the risk were of not completing the narcotic count reconciliation with the incoming and outgoing nurse before the start and the end of shift, Licensed Staff C stated, for the residents, there could be a risk for drug diversion, pain medication may not be available and resident would continue to be in pain which affects quality of life. Licensed Staff C stated she found the med cart key on top of the med cart unattended. Licensed Staff C stated on 1/22/24 and 1/23/24 the med cart keys were sitting at the top of the med cart unattended which was a no-no. Licensed Staff C stated it was always just sitting there when I come in. When asked what the risk were if med cart keys were left unattended at the top of a med cart, Licensed Staff C stated it was a safety issue as unauthorized person or a resident may get ahold of the key, open the med cart and take meds not meant for them. Licensed Staff C stated residents might get a hold of medications or take medications that would make them sick, could cause allergy, even death. Licensed Staff C stated not completing a narcotic count reconciliation per facility policy and not holding on to the med cart keys was a big safety and liability issue. During an interview on 2/20/24 at 12:13 p.m., Unlicensed Staff D stated she had seen nurses leave the med cart keys on top of the med cart sometimes. During an interview on 2/20/24 at 12:20 p.m., the Minimum Data Set (MDS) Coordinator stated it was the facility ' s policy to ensure narcotic count reconciliation was completed by 2 nurses at the beginning and end of shift. The MDS Coordinator stated if this was not done, it meant the facility policy was not followed. The MDS Coordinator stated this was unacceptable. When asked what the risk were if a narcotic count reconciliation was not completed by 2 nurses at the beginning and end of shift, she stated it was a safety issue, there could be a risk for discrepancy in narcotic count, narcotic could be stolen by anyone. The MDS coordinator stated the med cart keys should always be with the nurse and it was not acceptable to leave the med cart keys unattended on top of a med cart. The MDS Coordinator stated this was a safety issue. When asked what the risks were if the med cart keys were left on top of the med cart unattended, the MDS Coordinator stated it was a safety issue, anyone could take the key and gain access to the med cart. The MDS Coordinator stated only nurses were allowed access to med cart. During an interview on 2/23/24 at 10:01 a.m., the Director of Nursing (DON) stated it was the facility ' s policy to complete a narcotic count reconciliation between the incoming and outgoing nurses to verify narcotic counts were accurate and to prevent missing narcotics. The DON stated the facility policy was not followed if the nurses were not doing that. The DON stated not completing a narcotic count reconciliation between the incoming and outgoing nurses could result to narcotics missing and if unaccounted for, narcotic may not be available. When asked what the risks were for resident if a narcotic goes missing, the DON stated if there were no available narcotics, resident would continue to be in pain. When asked where nurses should keep the med cart keys, the DON stated med cart keys should be with the nurse at all times, even during break times. The DON also stated it was not okay to leave the med cart key unattended on top of the med cart. Leaving the med cart key unattended on top of the med cart meant the facility policy was not followed and it could result to unauthorized staff or residents gaining access to the med cart. The DON stated this was a safety issue. The DON stated staff were putting Baza cream on residents buttocks with every incontinent episodes. The DON stated Baza cream did not need an order because it was a nursing intervention. During an interview on 2/23/24 at 10:38 a.m., Licensed Staff E stated she was not sure if Baza cream had to have an order prior to applying on a resident skin. Licensed Staff E stated the facility had used Baza cream without a physician ' s order. Licensed Staff E stated the facility had no authorization to apply Baza cream on a resident ' s body without an order. Licensed Staff E stated putting Baza cream without a physician order could result to allergies, skin issue worsening and development of skin rashes. During an interview on 2/23/24 at 10:40 a.m., Licensed Staff F verified Baza cream had zinc oxide. Licensed Staff F stated the facility used Baza Incontinence cream for incontinence episode. Licensed Staff F stated, typically nurses at the facility do not ask the physician for a Baza cream order. During an interview on 2/23/24 at 11:07 a.m., the MDS Coordinator stated Baza cream should be ordered by the physician prior to applying on a resident ' s skin. The MDS Coordinator stated applying Baza cream without a physician order was beyond our scope of practice. During a telephone interview on 2/26/24 at 10:45 a.m., Licensed Staff G stated the facility policy was not followed when she did not complete a narcotic count reconciliation with another nurse before the start and end of her shift. Licensed Staff G stated not completing a narcotic count reconciliation could result to missing narcotics. Licensed Staff G stated the facility policy was also not followed when she left the med cart key unattended on top of the medication cart. Licensed Staff G stated not keeping the med cart key with her at all times could lead to unauthorized personnel or residents gaining access to the med cart. Licensed Staff G stated it was a safety issue. During a telephone interview on 2/26/24 at 3:00 p.m., the Pharmacist stated nurses should be completing a narcotic count reconciliation at the beginning and end of their shift. The Pharmacist stated not doing so could lead to missing narcotics. The Pharmacist stated staff should also be keeping the med cart keys with them and not leave the med cart key unattended on top of the med cart for safety purposes and to ensure only the nurses have access to the med cart. The Pharmacist stated Baza Incontinence cream is a medication that needs a physician ' s order before applying to a resident skin. The Pharmacist stated it should not be used without a physician ' s order. A review of the facility ' s policy and procedure (P&P) titled Controlled Substance Storage, revised 8/2014, the P&P indicated medications included in the Drug Enforcement Administration (DEA, the agency responsible for enforcing the controlled substances laws and regulations of the United States) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility .if a key system is used, the medication nurse on duty maintains the possession of the key to the controlled substance storage areas .at each shift change, or when keys were transferred, a physical inventory of all controlled substances is conducted by 2 licensed nurses and is documented. A review og the facility ' s P&P titled Administering Medication revised 4/2019, the P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. The P&P for Baza Cream use was requested but not provided. The DON stated the facility did not have a policy specific to Baza Cream usage. Based on interviews and record reviews, the facility failed to ensure nursing staff were competent and had skills to provide nursing and related services to assure resident safety when the nurses did not follow the facility's policy and procedure on narcotic (drug that causes stupor or insensibility) count reconciliation (physical inventory of all controlled substances), when nurses left the medicine cart (med cart) keys on top of the med cart unattended and the nurses did not know Baza Cream (an incontinent cream that contains zinc oxide, a medicated cream, ointment or paste that treats or prevents skin irritation) requires a Physician Order (PO, the instruction the physician had written for a patients' treatment ) prior to applying it on a resident skin. These failures were a safety risk that resulted in missing /unaccounted 3 tablets of narcotics (a medication that dulls the senses and treat pain) for one out of two sampled residents (Resident 2). These failures could lead to unauthorized access to the med cart, medication error (med error) and residents not receiving the correct treatment medication to address a skin issue. Findings: A review of resident 2's face sheet (demographics) indicated she was admitted to the facility on [DATE] with a diagnoses of Parkinson's Disease (PD, a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Dysphagia (difficulty swallowing) and Hyperlipidemia (HLP, an elevated level of lipids like cholesterol and triglycerides in your blood). Her Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/2/24 Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) condition of residents, indicated Resident 2 had a short term and long-term memory impairment. A review of Resident 2's PO indicated she had an order for a Percocet (a narcotic) 5 milligram (mg, a unit of measure) - 325 mg 1 tablet by mouth every 8 hours for pain management. A review of the letter addressed to the Department, dated 1/31/24 , indicated there were unexplained 3 missing tablets of Percocet 5 mg- 325 mg. During an interview on 2/23/24 at 10:01 a.m., the Director of Nursing (DON) stated based on her investigation, nobody could tell her where the missing Percocet went and her investigation did not provide an answer as to what happened in this situation. During an interview on 2/20/24 at 10:30 a.m. Licensed Staff B stated it was the facility's policy for nurses to reconcile narcotic count before the start and end of their shift to ensure narcotics count were accurate and to ensure there were no missing narcotics. When asked why staff need to do narcotic count reconciliation, Licensed Staff B stated it was done to prevent missing narcotics and to account for all narcotics. When asked what the risk were if a narcotic reconciliation was not done, Licensed Staff B stated it could result to medication errors, drug diversion and residents not receiving their pain medication. When asked where staff kept the med cart keys, Licensed Staff B stated med cart keys should be with the nurse at all times. When asked if it was ever okay to leave the med cart key on top of the med cart, unattended, Licensed Staff B stated no. Licensed Staff B stated med cart keys should be with the nurses even if they were on a break. When asked what the risk were if the med cart keys were left on top of the med cart, Licensed Staff B stated anybody could take the key and open the med cart. Licensed Staff B stated residents could also get into the med cart, take meds that was not meant for them that could affect them negatively. During an interview on 2/20/24 at 11:32 a.m., Licensed Staff C stated when she came on her morning shift on 1/22/24 and 1/23/24 the outgoing nurse from night shift never came to give her report nor do a narcotic count reconciliation. Licensed Staff C stated that on both days, she also did not complete a narcotic count reconciliation with the incoming nurse at the end of her shift. She stated she counted the narcotics by herself. When asked if the facility policy was followed when the narcotic count reconciliation with the incoming and outgoing nurse were not completed, Licensed Staff C answered no. When asked what the risk were of not completing the narcotic count reconciliation with the incoming and outgoing nurse before the start and the end of shift, Licensed Staff C stated, for the residents, there could be a risk for drug diversion, pain medication may not be available and resident would continue to be in pain which affects quality of life. Licensed Staff C stated she found the med cart key on top of the med cart unattended. Licensed Staff C stated on 1/22/24 and 1/23/24 the med cart keys were sitting at the top of the med cart unattended which was a no-no . Licensed Staff C stated it was always just sitting there when I come in . When asked what the risk were if med cart keys were left unattended at the top of a med cart, Licensed Staff C stated it was a safety issue as unauthorized person or a resident may get ahold of the key, open the med cart and take meds not meant for them. Licensed Staff C stated residents might get a hold of medications or take medications that would make them sick, could cause allergy, even death. Licensed Staff C stated not completing a narcotic count reconciliation per facility policy and not holding on to the med cart keys was a big safety and liability issue. During an interview on 2/20/24 at 12:13 p.m., Unlicensed Staff D stated she had seen nurses leave the med cart keys on top of the med cart sometimes. During an interview on 2/20/24 at 12:20 p.m., the Minimum Data Set (MDS) Coordinator stated it was the facility's policy to ensure narcotic count reconciliation was completed by 2 nurses at the beginning and end of shift. The MDS Coordinator stated if this was not done, it meant the facility policy was not followed. The MDS Coordinator stated this was unacceptable. When asked what the risk were if a narcotic count reconciliation was not completed by 2 nurses at the beginning and end of shift, she stated it was a safety issue, there could be a risk for discrepancy in narcotic count, narcotic could be stolen by anyone. The MDS coordinator stated the med cart keys should always be with the nurse and it was not acceptable to leave the med cart keys unattended on top of a med cart. The MDS Coordinator stated this was a safety issue. When asked what the risks were if the med cart keys were left on top of the med cart unattended, the MDS Coordinator stated it was a safety issue, anyone could take the key and gain access to the med cart. The MDS Coordinator stated only nurses were allowed access to med cart. During an interview on 2/23/24 at 10:01 a.m., the Director of Nursing (DON) stated it was the facility's policy to complete a narcotic count reconciliation between the incoming and outgoing nurses to verify narcotic counts were accurate and to prevent missing narcotics. The DON stated the facility policy was not followed if the nurses were not doing that. The DON stated not completing a narcotic count reconciliation between the incoming and outgoing nurses could result to narcotics missing and if unaccounted for, narcotic may not be available. When asked what the risks were for resident if a narcotic goes missing, the DON stated if there were no available narcotics, resident would continue to be in pain. When asked where nurses should keep the med cart keys, the DON stated med cart keys should be with the nurse at all times, even during break times. The DON also stated it was not okay to leave the med cart key unattended on top of the med cart. Leaving the med cart key unattended on top of the med cart meant the facility policy was not followed and it could result to unauthorized staff or residents gaining access to the med cart. The DON stated this was a safety issue. The DON stated staff were putting Baza cream on residents buttocks with every incontinent episodes. The DON stated Baza cream did not need an order because it was a nursing intervention. During an interview on 2/23/24 at 10:38 a.m., Licensed Staff E stated she was not sure if Baza cream had to have an order prior to applying on a resident skin. Licensed Staff E stated the facility had used Baza cream without a physician's order. Licensed Staff E stated the facility had no authorization to apply Baza cream on a resident's body without an order. Licensed Staff E stated putting Baza cream without a physician order could result to allergies, skin issue worsening and development of skin rashes. During an interview on 2/23/24 at 10:40 a.m., Licensed Staff F verified Baza cream had zinc oxide. Licensed Staff F stated the facility used Baza Incontinence cream for incontinence episode. Licensed Staff F stated, typically nurses at the facility do not ask the physician for a Baza cream order. During an interview on 2/23/24 at 11:07 a.m., the MDS Coordinator stated Baza cream should be ordered by the physician prior to applying on a resident's skin. The MDS Coordinator stated applying Baza cream without a physician order was beyond our scope of practice . During a telephone interview on 2/26/24 at 10:45 a.m., Licensed Staff G stated the facility policy was not followed when she did not complete a narcotic count reconciliation with another nurse before the start and end of her shift. Licensed Staff G stated not completing a narcotic count reconciliation could result to missing narcotics. Licensed Staff G stated the facility policy was also not followed when she left the med cart key unattended on top of the medication cart. Licensed Staff G stated not keeping the med cart key with her at all times could lead to unauthorized personnel or residents gaining access to the med cart. Licensed Staff G stated it was a safety issue. During a telephone interview on 2/26/24 at 3:00 p.m., the Pharmacist stated nurses should be completing a narcotic count reconciliation at the beginning and end of their shift. The Pharmacist stated not doing so could lead to missing narcotics. The Pharmacist stated staff should also be keeping the med cart keys with them and not leave the med cart key unattended on top of the med cart for safety purposes and to ensure only the nurses have access to the med cart. The Pharmacist stated Baza Incontinence cream is a medication that needs a physician's order before applying to a resident skin. The Pharmacist stated it should not be used without a physician's order. A review of the facility's policy and procedure (P&P) titled Controlled Substance Storage, revised 8/2014, the P&P indicated medications included in the Drug Enforcement Administration (DEA, the agency responsible for enforcing the controlled substances laws and regulations of the United States) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility .if a key system is used, the medication nurse on duty maintains the possession of the key to the controlled substance storage areas .at each shift change, or when keys were transferred, a physical inventory of all controlled substances is conducted by 2 licensed nurses and is documented. A review og the facility's P&P titled Administering Medication revised 4/2019, the P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. The P&P for Baza Cream use was requested but not provided. The DON stated the facility did not have a policy specific to Baza Cream usage.

Based on observation, interview and record review, the facility failed to ensure a resident was free from falls/accidents when they allowed a resident's spouse to ambulate (walk) the resident by herself with no appropriate gait training (helping a patient re-learn to walk safely and efficiently) provided, no return demonstration by the spouse that she could ambulate the resident by herself safely and staff did not follow the fall intervention to ensure a resident's bed height was appropriate as stated in the fall care plan for one out of two sampled residents (Resident 6). These falls resulted in two fractures (a break in bone) such as left super pubic ramus (upper part of hip) and fifth metacarpal bone (fifth finger joint) following a fall on 8/12/22 and multiple fractures such as right clavicle (collar bone), right femur (thigh), and right inferior and superior pubic rami (hip fracture) following a fall on 11/29/22. Findings: A review of Resident 6's face sheet (a facility demographic) indicated Resident 6 was initially admitted to the facility on [DATE]. Resident 6's diagnoses included End Stage Renal (kidney) Disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly, or a kidney transplant- a medical procedure that transfers a healthy kidney from one person into the body of a person who has little or no kidney function), Diabetes Mellitus (DM, a chronic, metabolic disease characterized by elevated levels of blood glucose - or blood sugar, which leads, over time, to serious damage to the heart, blood vessels, eyes, kidneys and nerves), Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) and Peripheral Vascular Disease (PVD, the narrowing or blockage of the vessels that carry blood from the heart to the legs). Resident 6's Minimum Data Sheet assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 12/13/22, Brief Interview of Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) had a score of 11 which indicated moderately impaired cognition. His MDS assessment also indicated he needed an extensive assistance of one person when performing his Activities of Daily Living tasks (ADL's, activities related to personal care such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a concurrent observation and interview on 3/6/23 at 2:55 p.m., Resident 6 was awake in bed. His bed height position from the floor to the top of the mattress was elevated and his call light button (a device used by a patient to signal his or her need for assistance from staff) was not in reach. When asked about the details of his falls at the facility, Resident 6 stated he could not recall any details of his falls. Resident 6 stated It's funny because I knew I fell but I could not remember the details about my falls. I do remember having broken bones after I fell though. During an interview on 3/9/23 at 2:23 p.m., Licensed Staff A stated, the facility's Fall Policy included completing fall risk assessment upon admission. Licensed Staff A stated, Fall care plans needs to be developed for all residents within 24 hours upon admission and as soon as possible after a fall incident. Licensed Staff A stated, staff should ensure residents were oriented to their room, call light button was always within reach, room was free from clutter and frequent visual rounding (staff lay eyes on the resident) as often as every 15 minutes if a resident was a high fall risk. Licensed Staff A stated Resident 6 was a high fall risk, however he was not on was not on every 15 minutes visual checks. When asked why, Licensed Staff A was silent. During a concurrent observation and interview in Resident 6's room on 3/9/23 at 3:59 p.m., Unlicensed Staff B stated, to decrease the risk of falls, the facility policy was to ensure the call light button was always within reach, the bed was in low position, and residents who were a high risk for falls were visually checked every 15 minutes. Unlicensed Staff B verified Resident 6 was a high fall risk. Unlicensed Staff B verified Resident 6's bed was in a high position and Resident 6's call light was not within reach. Licensed Staff B stated Resident 6 fell frequently and his bed should be in a low position and the call light should always be within reach. Licensed Staff B stated this was important to ensure the likelihood for falls and major injury was decreased. Unlicensed Staff B stated, if a call light button was not within a resident's reach, the resident would not be able to call for assistance, and the resident could feel frustrated, or would attempt to do a task themselves and they could end up hurting themselves. Unlicensed Staff B stated, staff were really concerned that Resident 6 would die from his most recent fall. Unlicensed Staff B was unsure of the exact date of Resident 6's most recent fall. Unlicensed Staff B stated, Resident 6 most recent fall resulted to a hip and clavicle fracture. Unlicensed Staff B stated Resident 6 sustained the fractures because he fell from the bed which was in a high position at the time of his fall. During a concurrent observation and interview on 3/9/23 at 4:07 p.m., Licensed Staff A verified Resident 6's bed was currently in a high position. Licensed Staff A stated, Resident 6 was a high risk for falls and his bed should be in low position to ensure risk for a fall with injury was decreased. During a concurrent interview and care plan record review in the conference room on 3/9/23 at 4:10 p.m., the Director of Nursing (DON) verified Resident 6's fall care plan (a document that outlines your assessed health and social care needs and how you will be supported. It specifies who will provide your care, what type of care you need and how the support will be given. The care plan also serves as a record of care provided) interventions, dated 1/10/23, included every 15 minutes visual rounding and appropriate bed height. When asked what appropriate bed height was for resident 6, the DON hesitated but responded, I believe it is whenever a resident's feet were touching the ground. She stated, the Physical Therapist (PT) or the Director of Staff Development (DSD) might have given the staff an in-service on what was the appropriate bed height for Resident 6. During an interview on 3/9/23 at 4:16 p.m., the DSD was unable to provide an answer on what the appropriate bed height for Resident 6 was. The DSD stated, the therapist would have given an in-service to staff explaining what the appropriate bed height for Resident 6 was. During an interview on 3/10/23 at 9:40 a.m., Licensed Staff C stated she was not sure what the appropriate bed height was for Resident 6 was. Licensed Staff C stated the appropriate bed height intervention was too vague. Licensed Staff C stated, the therapist would give a training to staff with regards to what was the appropriate bed height for Resident 6. Licensed Staff C stated she was not sure if the therapist had given a staff in-service on the appropriate bed height for Resident 6. Licensed Staff C stated, care plans should be clear and specific, and staff should follow the care plan consistently. Licensed Staff C stated, if care plans were not clear and were not being followed by staff, residents would be at risk for receiving care that is not in alignment with their goals. Licensed Staff C stated this could be a safety risk for falls and accidents. During an interview on 3/10/23 at 9:43 a.m., Unlicensed Staff D was unable to explain what appropriate bed height meant. Unlicensed Staff D stated, the therapist would do a staff teaching with transfer. Unlicensed Staff D stated, she did not recall receiving an in-service from the therapist on what the appropriate bed height for Resident 6 was. During an interview on 3/10/23 at 10:38 a.m., the Director of Staff Development (DSD) verified she had not given an in-service to staff indicating the appropriate bed height for Resident 6. DSD stated, care plans were supposed to be clear and specific. The DSD stated an appropriate bed height intervention was vague and staff could have different perception of what an appropriate bed height was. The DSD stated this was an issue. During a concurrent interview, and review of 11/2020 electronic medication administration record (EMAR, a digital version of a standard paper MAR), Fall Risk assessment dated [DATE] and 11/29/22, IDT notes (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) dated 8/15/22 and 11/30 22, care plan dated 10/20/22 and 1/10/22, Discharge Notes from the hospital dated 8/13/22, History and Physical documents from the hospital dated 11/30/22 record review in the conference room on 3/10/23 at 11:27 a.m., the MDS coordinator verified Resident 6 fell on [DATE] resulting in a displaced fracture of the left hand, fifth finger joint. The MDS coordinator verified Resident 6's Fall risk score dated 8/12/23 was 16 which indicated a high risk for falls. The MDS coordinator verified Resident 6 fell on [DATE] at 10:40 a.m. while ambulating in the hallway with a walker while his spouse was following with a wheelchair behind him. The MDS coordinator stated, responsible party (RP, the person who is responsible for paying for resident's medical bill and or making medical decisions on their behalf) were allowed to perform ADL's for their loved ones while at the facility as long as it was safe. The MDS coordinator stated, safety could only be established if the RP was provided training and teaching prior to performing a specific task and the RP demonstrated they were able to perform a specific task safely. The MDS coordinator stated she thought there was a teaching provided by the rehabilitation staff to Resident 6 spouse prior to allowing her to walk with the resident unassisted by staff. The MDS coordinator stated, if Resident 6's spouse wished to perform a specific task for him, it would be care planned. The MDS coordinator stated it would also need a doctor's approval before implementing. The MDS coordinator verified there were no documentation that Resident 6 spouse demonstrated she was safe to ambulate the resident by herself without staff assistance. The MDS coordinator also verified there was no care plan and no physician's acknowledgement indicating Resident 6 spouse was allowed to ambulate Resident 6 by herself without staff assistance. The MDS coordinator stated Resident 6 ambulating with his spouse, without staff assistance, potentially caused Resident 6 to fall on 8/12/22. The MDS coordinator stated, the missing gait training to Resident 6's spouse, lack of Resident 6 spouse return demonstration- a test of proficiency completed by a layman (not a member of a given profession) to show proficiency in ambulating Resident 6 by herself safely, missing physician acknowledgement, and missing care plan to indicate Resident 6's spouse was safe to ambulate him by herself, was a contributing factor for this fall on 8/12/22. The MDS coordinator verified Resident 6 had a fall on 11/29/22 which resulted in a right clavicle fracture, right hip fracture and right femur fracture. The MDS coordinator verified these fractures were the direct result of the fall on 11/29/22. The MDS coordinator stated care plans were important because it directed care for the residents. The MDS coordinator stated care plans should be clear and understandable by staff. When asked what the appropriate bed height for resident was 6, the MDS coordinator stated it meant Resident 6 should be sitting on the bed at a 90 degrees angle, knees on 90 a degree angle and with both feet touching the ground. When asked if staff knew this was what an appropriate bed height meant, the MDS coordinator responded, staff should know, usually the therapist would provide an in-service on what was the appropriate bed height for a resident. The MDS coordinator verified Resident 6 was on Restorative Nursing Assistant program (RNA, a program that increase the patients' independence, promote safety, preserve function, increase self-esteem, promote improvement in function and minimize deterioration) for ambulation three times a week, with no specific days. The MDS coordinator stated, staff were aware of Resident 6's dialysis days and made sure the RNA sessions did not fall on those dialysis days. The MDS coordinator verified Resident 6 should have had 12 RNA treatment sessions for 11/2022. The eMAR for 11/2022 indicated Resident 6 only had five RNA treatment sessions dated 11/9/22, 11/11/22, 11/16/22, 11/24/22 and 11/25/22 with one documented refusal. The MDS coordinator verified the RNA log in the eMAR was missing information on why Resident 6 missed a total of six RNA sessions. The MDS coordinator stated the RNA program was important because it could help strengthen Resident 6 and could help Resident 6 with safe ambulation. The MDS coordinator stated, the IDT note dated 11/30/22 indicated Resident 6 probably attempted to transfer and ambulate with no assistance from the staff. When asked if Resident 6's bed was at an appropriate height when he fell , the MDS coordinator was silent. The MDS coordinator stated that a bed not at an appropriate height could contribute to falls and could put residents at risk for falls and injuries. During an interview in the DSD's office on 3/10/23 at 1:49 p.m., the DSD stated, if the spouse would like to ambulate Resident 6 by herself, then it should have been care planned because that was an information the staff needed to know for safety purposes. The DSD stated Resident 6's spouse, ambulating him by herself, would need a physician's order as well. The DSD stated, if there was no physician's order that indicated Resident 6 spouse was allowed to ambulate the resident, the spouse should not have been ambulating Resident 6. The DSD stated if the spouse was allowed to ambulate Resident 6 by herself with no staff assistance, there would be guidelines to be followed prior to ambulating Resident 6 by herself. The DSD stated prior to allowing Resident 6 spouse to ambulate him by herself with no staff assistance, a care giving teaching on how to ambulate Resident 6 by herself safely should be given to Resident 6 spouse first. The DSD stated there should have been a note indicating Resident 6's spouse understood the teaching and and a return demonstration which would show she was capable to ambulate Resident 6 safely by herself. The DSD stated there should have been documentation that Resident 6's RP understood and was also able to execute the ambulation task safely. The DSD stated, not having a documentation indicating Resident 6's spouse was able to ambulate Resident 6 by herself safely, a physician's order or care plan indicating Resident 6's spouse was safe to ambulate with the resident could have contributed to his fall. The DSD stated, if these components were present, Resident 6's fall could have been prevented. During a concurrent interview and review of Physical Therapy Assistant (PTA) note dated 8/2/22, Residents 6's Discharge note from the hospital dated 8/13/22, History and Physical note from the hospital dated 8/13/22, fall care plan for 10/20/22 and 1/10/23,in the conference room on 3/10/23 at 2:17 p.m., the DON verified Resident 6 sustained a left super pubic ramus (upper part of hip) and fifth metacarpal bone (fifth finger joint) following a fall on 8/12/22 and multiple fractures such as right clavicle (collar bone), right femur (thigh), and right inferior and superior pubic rami (hip fracture) following a fall on 11/29/22. The DON verified that although the PTA had indicated in her daily skilled notes dated 8/2/22 that a caregiver teaching was provided to Resident 6's spouse, it did not indicate Resident 6 spouse was instructed on how to perform safe ambulation with the resident. The DON verified the PTA notes also did not indicate whether Resident 6 spouse was able to demonstrate she could ambulate Resident 6 by herself safely. The DON verified there was no physician's acknowledgement or care plan to indicate Resident 6 spouse was allowed to ambulate Resident 6 safely by herself. The DON stated there were no indications the physician was notified on whether Resident 6 spouse was safe to ambulate Resident 6 by herself. The DON stated Resident 6's fall on 8/12/22 could have been prevented if there was a clear indication through caregiver training, return demonstration, PTA notes, physician notes and care plan that Resident 6 spouse was safe to ambulate with him by herself. A request for every 15 minutes visual rounding documentation per the fall care plan dated 1/10/23 and pharmacist medication regimen review specific for the falls on 8/12/22 and 11/29/22 was requested but not provided. During an interview in the rehabilitation room on 3/10/23 at 3:07 p.m., the Director of Rehab services (DOR) stated the appropriate bed height was based on resident safety, meaning, whenever a resident was safe to transfer in and out of bed. The DOR stated, therapists were hesitant to use the appropriate bed height fall intervention because it changed so often. The DOR stated, she would not know how nursing staff would interpret which bed height was appropriate for a resident. The DOR confirmed the rehab department did not conduct an in-service to the nursing staff to indicate which bed height was appropriate for Resident 6. During a review of facility's policy and procedure (P&P) titled Falls - Clinical Protocol, revised 3/2018, the P&P indicated the staff, and the physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling. During a review of facility's policy and procedure (P&P) titled Fall Risk Assessment, revised 3/2018, the P&P indicated the staff, the attending physician and the pharmacist will review for medications that could relate to falls or fall risk . During a review of facility's policy and procedure (P&P) titled Falls and Fall Risks, Managing, revised 3/2018, the P&P indicated the staff will identify interventions related to resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling .fall risk factors such as incorrect bed height .in conjunction with the pharmacist, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period .

Based on observation, interview and record review, the facility failed to ensure that three of 12 sampled residents (Residents 23, 25, 141) had interdisciplinary (interventions from all departments) and comprehensive person-centered care plans that addressed their preferences (choices), goals (measurable expected outcomes) and interventions (care and services necessary to achieve those goals) when: 1) Resident 23 was on a Regular diet (one that does not include any dietary restrictions). A care plan for food preferences of broth, cheese & crackers, and pineapple to treat weight loss recommended by Registered Dietician (RD) was not developed, implemented and no interventions. 2) Resident 23 was taking Remeron (antidepressant) for depression (A mental health disorder characterized by persistently low mood or loss of interest in activities). A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using each medication, potential unwanted adverse side effects or specific target interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological (non-medication) interventions for Resident 23 to achieve her goals. 3) Resident 25 was taking Trazadone (antidepressant) for depression. A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using each medication, potential unwanted adverse side effects or specific target interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological (non-medication) intervention for Resident 25 to achieve her goals. 4) Resident 141 had a doctor's order for continuous oxygen. A care plan for Oxygen administration was not developed and no specific goals and amount of oxygen to deliver (how much oxygen to give) to achieve and nursing and other IDT intervention for respiratory care. These failures had the potential to result in worsening symptoms for these residents to have not receive the care they needed to treat their medical and mental conditions. Findings: (1) Resident 23 Regular Diet A record review titled Detailed Summary dated 11/14/22 for Resident 23, revealed she was admitted on [DATE] with diagnosis of Sepsis (Severe Infection) due to bacterial infection and on Palliative (specialized medical care for people living with a serious illness) Care. A Depression illness was not listed as her diagnosis. A record review titled Physician's Orders dated 11/14/22, the Primary Medical Doctor (PMD) ordered Regular diet for Resident 23. During a concurrent observation and record review on 3/6/23 at 12:15 p.m., in the Resident 23's room, Unlicensed Staff T brought in Resident 23's lunch tray and placed it on top of a bedside table. Resident 23 was laying in her bed, and responded to questions with the sound of a moan, then closed her eyes. This Surveyor checked the contents of the lunch tray and compared with the corresponding meal ticket. Resident 23 had a regular diet with turkey loaf on the lunch tray. The meal ticket revealed no food preference of broth, cheese & crackers and pineapple listed. Unlicensed Staff T assisted Resident 23 with her meal but Resident 23 did not eat. Unlicensed Staff T did not offer an alternate meal or the recommended food preferences. A review of record titled IDT (Interdisciplinary Team) Notes, under RD (Registered Dietitian), dated 2/23/23, revealed Regular diet, prefers broth, cheese and crackers, pineapple, dislikes Ensure/health shakes. A review of Resident 23's Care Plan dated 1/13/23 revealed, under Nutrition, [Resident 23] has a potential risk for altered nutritional status and/or weight loss. Under Approach Offer house supplement per recommendation. The care plan did not reflect, under approach or interventions, the preferences recommended by the RD. (2) Resident 23 Remeron A Review of Physician's Orders for Resident 23 dated 11/18/22 revealed start date 11/20/22, to give Remeron 7.5 mg (milligrams) tablet once daily at nighttime for depression. A Review of Resident 23's Medication Administration Record (MAR) dated 1/23, 2/23, 3/23, revealed under Behavior Monitoring, Monitor for statements of 'I would better off dead.' All shifts for 1/23, 2/23, 3/23 documented 0, which indicated zero episodes of statements, I would be better off dead. During an interview on 03/10/23 at 2:38 p.m., Licensed Staff U stated nurses usually write observed behaviors in the Behavior Monitoring portion of the electronic chart in the MAR. A review of Resident 23's Care Plan revealed, no Depression diagnosis. Under Problems, there was no behavioral monitoring pertaining to depression noted, no medication Remeron was noted or monitoring for any side effect from taking Remeron. (3) Resident 25 Trazadone A record review titled Detailed Summary dated 1/14/23 for Resident 25, revealed she was admitted on [DATE] with diagnosis of Diabetes (increase sugar in the blood) with kidney disease, a heart condition which required a pacemaker (a small device that's placed implanted in the chest to help control the heartbeat), and hemiplegia (one sided weakness of the body). Depression was not listed as her diagnosis. A record review titled Physician's Orders dated 1/20/23 revealed, give Trazadone 50 mg tablet by mouth at bedtime for depression. A record review titled Care Plan for Resident 25 revealed, under Problems, Depression diagnosis was not noted. The intention for the use of Trazadone medication was not noted nor the monitoring of Resident 25's behavior, side effects of Trazadone or goals for treatment. (4) Resident 141 Oxygen A record review titled Detailed Summary for Resident 141 revealed she was admitted on [DATE] with diagnosis of heart disease with heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), pleural effusion (A buildup of fluid between the tissues that line the lungs and the chest), chronic respiratory failure, with hypoxia (oxygen deficiency) and hypercapnia (abnormally elevated carbon dioxide (CO2) levels in the blood.) Respiratory failure results from acute (severe or intense degree) or chronic (long term) impairment of gas (air) exchange between the lungs and the blood causing hypoxia, low oxygen in the blood with or without hypercapnia - the failure of the lung to properly remove carbon dioxide (CO2). During an observation on 03/07/23 at 10:13 a.m., Resident 141 received oxygen via nasal cannula (nc - a plastic tube attached to nose) which delivered 3 Liters of oxygen (amount of oxygen). A record review titled Physician's Orders dated 2/22/23 revealed, Oxygen via Nasal Cannula Continuous for Pleural Effusions. A record review titled Care Plan start date 2/22/2023 revealed, [Resident 141] at risk or falls related to Pleural effusion, Hypertensive Heart Disease with Heart Failure Goal: Minimize risk or falls and injuries. Under Approach: there was no oxygen amount (liters) of oxygen to deliver in the Care Plan, Goals for Oxygen therapy, or any Monitoring for adverse reactions. A record review titled Care Plan start date 3/9/2023, revealed [Resident 141] requires continuous oxygen related to pleural effusions, Goal date 6/7/23 [Resident 141] will be able to taper off supplemental oxygen need through next review. Under Approach: Administer oxygen as ordered start date 3/9/23. This care plan did not discuss the amount of oxygen to deliver. During an interview on 3/9/23 at 2:59 p.m. DON stated Resident 141's [lung] Problem must be in the Care Plan. DON stated oxygen administration must be in Care Plan such as the amount of oxygen to deliver to a resident. DON stated, if there was no indication of the amount of oxygen to deliver, a resident may suffer from severe respiratory distress if there was too much or too little oxygen administered. A review of Facility's Policy & Procedure titled Care plans, Comprehensive Person-Centered revised on 3/2022 revealed, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under interpretation and implementation, #2, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status) and no more than 21 days after admissions. #4 (f, g) Participate in determining the type, amount, frequency, and duration of care. Receive the services and/or items included in the plan of care.

Based on interview and record review, the facility failed to mitigate the risk of accidents for one (Resident 1) of the three sampled residents, when Resident 1 fell and facility staff did not document completing an assessment of Resident 1 or determine if new interventions to minimize Resident 1's risk of falling and injury were warranted. This failure did not minimize the fall or injury risks to Resident 1, who suffered a second fall within hours and required transfer to a higher level of care for management of pain and fractures of the left sixth, seventh, eight, ninth and tenth ribs. Findings: A review of Resident 1's Face Sheet (e.g., a document indicating resident demographics and diagnoses) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, [CONDITION(S)], and a history of falling. A review of Resident 1's fall risk assessment from admission indicated Resident 1 scored at-risk for falling, due to her history of falls, age, medications, greater need for assistance with mobility and balance, and cognitive deficits. During an interview on 11/22/21, at 12:04 p.m., Certified Nurse Assistant (CNA) B stated Resident 1 fell twice on 11/6/21. CNA B stated the first fall occurred between 4:30 p.m. and 5:00 p.m., before dinner time, and the second fall occurred after Resident 1 had eaten dinner. Regarding the first fall, CNA B stated she found Resident 1 sitting on the floor facing her bed. CNA B stated she recalled the bedside table was pushed a little bit away from the side of the bed. CNA B stated that Resident 1 verbalized she had tried to remove her pants just prior to falling. CNA B stated she called the licensed nurse assigned to the resident, and together they assisted Resident 1 back to bed. During an interview on 11/22/21, at 12:31 p.m., Director of Nursing (DON) A stated she was aware Resident 1 suffered a fall on 11/6/21 at or around 8:00 p.m.; however, DON A stated she was not aware Resident 1 had fallen between 4:30 p.m. and 5:00 p.m., before dinner. DON A stated after a resident's fall, licensed nursing staff should assess the resident, document the incident and the assessment, notify the attending physician and responsible party, initiate or revise the resident's care plan, complete an incident report, and initiate neuro-checks (e.g., assessments of the patient's nervous system). During an interview on 11/22/21, at 12:49 p.m., DON A stated two falls in close proximity of time should be treated as a new fall every time, and each documented. During an interview on 11/22/21, at 12:38 p.m., Licensed Nurse D stated she was a charge nurse for the night shift for the night of 11/6/21, into the morning of 11/7/21. Licensed Nurse D stated she recalled CNA E had notified her Resident 1 had fallen twice during the prior shift. During an interview on 2/4/22, at 12:47 p.m., Licensed Nurse C stated Resident 1 fell twice on 11/6/21. Licensed Nurse C stated Resident 1's first fall occurred around 5:00 p.m. Licensed Nurse C stated she did not document the first fall because she was very busy and documenting two falls was unnecessary. Licensed Nurse C stated nursing staff initiated new interventions after the first fall, such as placing a floor mat next to the bed and lowering the bed to its lowest position; however, Licensed Nurse C stated she did not document any of the interventions in the medical record, and stated her failure to document was a mistake. During an interview on 5/20/22, at 8:50 a.m., CNA B stated she recalled first fall on 11/6/21. CNA B stated Resident 1's bed was at a regular height, or the height of CNA B's waist level, and no floor mat was placed. Similarly, CNA B stated Resident 1's bed was at regular height during the second fall. CNA B stated she knew Resident 1's bed was not lowered to its lowest position after Resident 1's first fall because Resident 1 commenced reading after the first fall. CNA B stated Resident 1 used the bedside table to read, and the bedside table could not be pushed in front of the resident if the bed was in its lowest position. CNA B stated that Resident 1 preferred the door of her room closed and staff kept it closed after the first fall. CNA B stated facility staff did not place a landing pad (e.g., floor mat) next to Resident 1's bed until after the resident's second fall. During a concurrent interview and record review on 7/15/22, at 9:12 a.m., DON A stated two falls were not documented in Resident 1's medical record. DON A stated if the other fall had been documented, Resident 1's medical record would reflect: Language indicating the location of the fall, time and position of the resident when found, whether the fall was witnessed, what led to the fall, the findings of a post-fall assessment including the neurocheck, whether the fall resulted in injury, and a note indicating the attending physician and responsible party were notified as well as any changes made to the resident's care plan. During a review of Resident 1's medical record, the Interdisciplinary Notes, dated 11/6/21, indicated no entry that Resident 1 suffered a fall around 4:30 p.m. or 5:00 p.m. on 11/6/21. During a review of Resident 1's medical record, the Interdisciplinary Notes dated 11/6/21, at 9:07 p.m., indicated Licensed Nurse C documented Resident 1 suffered an unwitnessed Fall, at 8:00 p.m. The note indicated staff were checking-on the resident every 15 minutes before this fall and had seen the resident as close as 5 minutes before the fall. The note indicated a CNA observed the resident reading books just prior to the fall, and at 8:00 p.m. staff observed Resident 1 on the floor in a sitting position next to her bed. The note indicated Resident 1's post-fall assessment and neurological checks were within normal limits, and the resident exhibited no apparent injury. During a review of Resident 1's medical record, the Interdisciplinary Notes, dated 11/7/21, at 4:13 a.m., indicated that at 3:20 a.m. Resident 1, informed [the] nurse that she thinks she is having a [CONDITION(S)]. When asked where the pain is, she pointed to her lower ribcage . said it just hurts! And it hurts to breathe! The record also indicated that at 3:40 a.m. the Fire department arrived, then followed by the EMT [(Emergency Medical Technician)], and that at 3:47 a.m. Resident [1] left the building. During a review of Resident 1's hospital medical record, the Final Report of a [Computed Tomography Scan], dated 11/7/21, at 7:15 a.m., indicated Resident 1 had suffered Acute, displaced fractures of the left sixth, seventh, eight, ninth, and [tenth] ribs. During a review of Resident 1's hospital medical record, the Final Report of a Progress Note dated 11/8/21, it indicated, Assessment: 1. Post trauma day #2, mechanical ground level fall with multiple left-sided rib fractures 6 through 10 and associated pulmonary contusion. During a review of Resident 1's medical record, the Falls Care Plan, initiated 10/8/21, indicated staff identified the following Approach[es] to reduce Resident 1's risk for falls: . use . floor mat as needed; bed at proper height for [Resident 1]. The record indicated an update to the care plan on 11/6/21 regarding an unwitnessed fall. The record indicated staff added a new Approach on 11/6/21 to reduce Resident 1's fall risk: placing Resident 1's bed in lowest position. The care plan did not indicate whether facility staff added the new approach before or after Resident 1's second fall, at or around 8:00 p.m. on 11/6/21. The facility's policy and procedure titled Falls and Fall Risk, Managing, revised 3/2018 indicated facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling. The facility's policy and procedure titled Assessing Falls and Their Causes, revised 3/2018, indicated When a resident falls, the following information should be recorded in the medical record: 1. The condition in which the resident was found . 2. Assessment data, including vital signs.4. Notification of the physician and family, as indicated. 5. completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls.

Based on interview and record review, the facility failed to protect one resident (Resident 1) from physical abuse when Unlicensed Staff C grabbed both of Resident 1's forearms and forcibly walked her backwards, and pushed Resident 1 into a chair. This failure caused Resident 1 to experience anger, sadness, and fear. This failure also had the potential to negatively impact Resident 1's emotional health and dignity. Findings: A review of Resident 1's medical record document titled DETAILED SUMMARY, not dated, indicated she was admitted on [DATE], with [DIAGNOSES REDACTED].' including verbal and physical aggression, wandering, and hoarding. These symptoms create patient and caregiver distress.), and Shared [MEDICAL CONDITION] (Presence of hallucination or delusions). During an interview with Assistant Director A and Charge Nurse F, on 4/23/20 at 8:45 a.m., Assistant Director A stated she was informed by Administrator B, on 4/22/20, at 3:45p.m., that Resident 1 might have been the victim of physical abuse by Unlicensed Staff C. Assistant Director A stated Administrator B told her that Staff E reported Resident 1 attempted to slap Unlicensed Staff C, who then grabbed both of Resident 1's forearms and forcibly walked her backwards, and pushed Resident 1 into a chair. Assistant Director A stated Administrator B observed Staff E was very upset that someone would treat Resident 1 in that manner. During the same interview on 4/23/20 at 8:45 a.m., Assistant Director A stated Administrator B asked her to investigate and identify the Unlicensed Staff who was involved. She stated she immediately went to Nursing Station Four to speak with Charge Nurse F about the incident. Charge Nurse F stated that Unlicensed Staff D reported to her that while she and Unlicensed Staff C were trying to direct Resident 1 to take her daily shower, Resident 1 became resistant and shouted to both of the unlicensed staff that she did not want to take a shower and to leave her alone. Charge Nurse F stated Unlicensed Staff D observed Resident 1 become very agitated and came towards Unlicensed Staff C, and that was when Unlicensed Staff C forcibly grab Resident 1's wrists and forced her to sit down in a chair. Charge Nurse F stated Unlicensed Staff D was very distressed, crying and stated she felt Unlicensed Staff C's actions were inappropriate. During an interview on 4/23/20 at 9 a.m., Supervisor G stated on 4/22/20 at around 3:45 p.m., she was doing nursing rounds in nursing station four, at change of shift, and observed Resident 1's face was extremely red, she was verbally angry saying loudly, don't touch me, don't touch me, get me out of here. Supervisor G stated that Resident 1 was usually very easy to redirect and stated she had never seen Resident 1 that angry before. Supervisor G stated she observed Unlicensed Staff D behind Resident 1. She stated Unlicensed Staff D looked distressed with a worried expression on her face. She stated Unlicensed Staff D started crying and described how Unlicensed Staff C grabbed Resident 1's arms and forcibly sat her down. She stated it made her feel very uncomfortable, and stated it just was not right to treat Resident 1 that way. During the same interview on 4/23/20 at 9 a.m., Supervisor G stated she confirmed the identity of Unlicensed Staff C with Staff E, and immediately communicated to Unlicensed Staff C she was being placed on Administrative Leave pending an abuse investigation. Supervisor G stated that Unlicensed Staff C stated she knew it was about how she treated Resident 1, and left the facility. Assistant Director A stated Unlicensed Staff C had been terminated after the investigation. During an interview with Manager H, on 4/23/20 at 11:42 a.m., she stated Staff E had come to her office on 4/22/20, at 4 p.m. to report a possible witnessed abuse incident around 3:37 p.m. on 4/22/20. She stated Staff E reported she was emptying the trash in (room number) in Nursing Station Four, when she witnessed Resident 1 yelling and very angry, saying I will kill you, I will kill you, to Unlicensed Staff C. She stated Staff E told her she observed Unlicensed Staff C pushing Resident 1 with both hands, forcing Resident 1 to walk backwards and then pushing her down into a chair and then Unlicensed Staff C immediately left the area. During an interview with Staff E, on 4/23/20, at 11:37 a.m., she stated she observed Unlicensed Staff C grab both of Resident 1's arms and push her backwards for 10-12 feet in the Nursing Station Four hallway, and then forced Resident 1 to sit in a chair. She stated Resident 1 was screaming and yelling very loudly and Resident 1 looked very scared. She stated Unlicensed Staff C did not treat Resident 1 respectfully and was very rough with her. Staff E stated the treatment of [REDACTED]. During an interview and record review, with Director J on 4/23/20 at 12:15 p.m., she stated every new employee had a job description that included information about patient rights, abuse and abuse reporting. She stated new employee orientation included at least a 4-hour training that included the mandated Department of Justice Video titled Your Legal Duty, about the types of abuse and how to report abuse. She stated new employee orientation included information about a patients right to refuse and options available to staff like trying to get patients to shower at a different time, alert another team member or distraction. If a patient refuses to shower and staff cannot get them to shower, they should document the patient refusal and contact the family. A review of Unlicensed Staff C employee file indicated completion of new employee Abuse Training on 2/4/20. During an interview with Director of Staff Development (DSD) I, on 4/23/20, at 12:35 p.m., she stated she provided education about Abuse Prevention during new employee orientation and annual education for staff. She stated during the education, each employee was taught about the different types of abuse, including physical abuse. She stated the difference between guiding a Resident with cognitive impairment and physical abuse was how the resident perceives the interaction. DSD I stated a resident with dementia communicated distress by being agitated, looking distressed or crying out. If the resident does not want to do something, you cannot force them. She stated the facility provided education to employees on how to provide resistant dementia residents with a distraction, try with different staff, options to guide patients to do something they are resistant to do. She stated employees should never try to force a resident to do something they do not want to do. A review of a record titled Interdisciplinary Notes, dated 4/22/20, at 4:51 p.m. for Resident 1, indicated This writer observed Res (Resident) to be in emotional distress @ 1540 (3:40 p.m.) and displaying emotions of anger and sadness r/t (related to) event on 4/22/20. Res was noted to be more anxious/distraut and trying to walk away from this writer when speaking. Once Res was able to calm down after a few minutes, she started repeating statements of help, get me out of here. A review of facility policy and procedure (P&P), titled Abuse Investigation and Reporting, revised 7/2017, indicated, If the investigation reveals that the allegations(s) of abuse are founded, the employee(s) will be terminated. A review of document titled Your Legal Duty .Reporting Elder and Dependent Adult Abuse, dated 2016, indicated Welfare and Institutions Code Section .63. Physical abuse means any of the following: . Use of a physical or chemical restraint or [MEDICAL CONDITION] medication (medication is used to treat mental illnesses) under any of the following conditions: .For punishment.For any purpose not authorized by the physician and surgeon.Examples of Physical Abuse: .A resident refuses to get out of bed when encouraged . The nurse then forcefully pulls the resident from a reclining to an upright position in his bed, pushes him out of his room, as the resident screams and cries to be left alone.

Based on observation, interview, and facility document review, the facility failed to ensure that five of five Licensed Nurses (LN) recognized and addressed a change of condition, when Resident 1 complained of pain 9/10 (Pain Level 7-10=Severe Pain; disabling; unable to perform ADLs) in her left knee; and two nurses failed to administer pain medication as ordered by Primary Care Physician (PCP) A, when it was given every four hours, but was ordered every eight hours. Licensed Nurse (LN) D, E, F, G, and H all became aware of Resident 1's high level pain complaint 9/10 reported on 6/7/19 at 9:00 a.m. None of the five LNs called PCP A to report it. Five nurses did not follow the facility policy for reporting change of condition, did not follow their job description, and did not practice according to professional standards. These failures caused Resident 1 to suffer with severe pain and crying, restricted movement, swelling, and discoloration of her left knee while staff continued to manipulate the left knee (with turning, positioning Resident 1 onto a bedpan, and moving her in or out of bed). PCP A did not initiate an assessment or intervention until 72 hours after Resident 1's initial complaint, during PCP A's regular rounds on Monday 6/10/19. It was four days from date of complaint 6/7/19 to date of X-ray report confirming a [MEDICAL CONDITION] knee on 6/11/19. Findings: During a record review from a local hospital, of Resident 1's Discharge Summary, dated 4/5/19 for service dates of 3/14/19 to 3/18/19 indicated: .Primary Discharge Diagnosis: [REDACTED].Urinary Tract Infection, .History of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) .came in with weakness to the emergency room , unable to pick her legs up. The patient had weakness . There was no [DIAGNOSES REDACTED]. During an interview on 6/13/19, at 3:50 p.m., Nurse Manager B was asked what happened to Resident 1, she stated that Resident 1 had a history of [REDACTED].=Severe Pain; disabling; unable to perform ADLs) on the morning of 6/7/19. Resident 1 received two doses of pain medication at 9:00 a.m., and 1:30 p.m. During the evening shift at 9:00 p.m., Resident 1 complained of pain again and swelling of the knee was noted. Nurse Manager B stated Resident 1 received pain medication, Family 2 and PCP A were called. During a record review on 6/13/19 for Resident 1, the Radiology Report, dated 6/10/19 (x-ray taken) with Radiologist signature of 6/11/19 (radiologist read it), indicated: .Results: There is a fracture involving left lateral tibial plateau with no displacement .(A tibial plateau fracture is a break of the upper part of the tibia (shinbone) that involves the knee joint. Symptoms include pain, swelling, and a decreased ability to move the knee) .Conclusion: Tibial plateau left knee fracture as described above. [MEDICAL CONDITION]. The age is unclear and should be correlated with site of pain and timing of injury. During an observation and interview on 6/13/19, at 4:16 p.m., Resident 1 was sitting up in her lounge chair with her legs up. Resident 1 was alert and oriented with a very soft voice. Resident 1 required time to process the question before answering it, usually about 10 to 15 seconds. When asked what happened, Resident 1 stated that it was on Tuesday about 2 a.m. when her knee began to hurt. It was painful when she hit the blanket while turning. Resident 1 stated the CNA (Certified Nursing Assistant) did not stop when she complained of pain. When asked if she remembered the name of the CNA, Resident 1 did not remember. When asked if she told anyone, Resident 1 stated No, they were around. When Resident 1 was asked, what she meant, she did not respond. During an interview on 6/13/19, at 4:20 p.m., LN [NAME] stated that on 6/6/19, the last day she worked before the incident, Resident 1 was comfortable, alert, oriented, a 1-person assist (needing guidance due to her poor vision) to get up out of bed or transfer from bed to chair using the transfer pole in her room. LN [NAME] stated that on 6/8/19, day shift staff endorsed to her that Resident 1 complained of soreness with touching, and was getting pain medication every shift. During an interview on 6/13/19, at 4:40 p.m., Certified Nursing Assistant (CNA) K stated Resident 1 could turn herself and was a 1-person assist before she complained of pain at 9/10 in her left knee. CNA K stated after the complaint was made of 9/10 in her left knee, she became a 2-person assist for transfers, and could not bear weight on the left leg. During an observation on 6/13/19, at 5:20 p.m., Resident 1's left leg, the outer aspect of it, was severely bruised with discoloration of black, purple, and blue. The discoloration extended on the outer aspect of the left knee about four inches above the knee joint, and six inches below the knee joint. Resident 1 did have some discomfort noted by facial grimace during observation when staff manipulated her left knee for observation. During an interview on 6/24/19, at 11:45 a.m., CNA I stated she worked on 6/6/19, and on 6/7/19 the day before and the day of the incident with Resident 1's complaint of pain 9/10 in her left knee. CNA I stated that Resident 1 was a 1-person assist, but after the complaint was a 2-person assist and needed the hoyer lift (a mechanical device used to lift residents who were non-ambulatory) to transfer Resident 1 from bed to chair or chair to bed. CNA I stated that Resident 1 was in a lot of pain with any movement and could not extend her left leg without pain. During an interview on 6/24/19, at 10:20 a.m., PCP (Primary Care Physician) A was on rounds, but had not seen Resident 1 yet. PCP A stated he was informed during rounds on Monday, (MONTH) 10, 2019 that Resident 1 was having knee pain. When asked what he knew of the chronic knee pain, PCP A stated he did not know of any chronic knee pain. When asked what the criteria was to notify him of patient condition change, PCP A stated that staff typically called him when needed. During an interview on 6/26/19, at 4:15 p.m., LN D stated she became aware of the complaint of pain in Resident 1's left knee with report from staff on 6/8/19. LN D stated she was told a request for x-ray had been faxed to PCP [NAME] LN D stated Resident 1 received as needed medications for pain. When asked if she had done a nursing assessment of Resident 1's left knee, LN D stated that it was done during medication pass. LN D stated the left knee was not swollen, red, or warm to the touch. During an interview on 6/27/19, at 1:37 p.m., CNA J stated she worked day shift on 6/10/19 and reported Resident 1's complaint of pain and discoloration of her left knee to LN D. CNA J stated she saw redness and displacement of the bone at the side of Resident 1's leg. CNA J stated that when she told LN D what she had observed, she was told an x-ray was up-coming. During an interview on 6/27/19, at 1:50 p.m., LN G stated she worked on 6/7/19 and 6/8/19. LN G stated Resident 1 was in pain but that she thought it was probably arthritis, joint pain, or maybe contractures (the shortening or stiffening of muscles, skin, or connective tissues that results in decreased movement and range of motion). LN G stated Resident 1 continued to complain of pain after receiving the medication for pain. LN G stated she saw and spoke to PCP A on 6/10/19, who after reviewing the faxes checked the request for x-ray as yes. When asked why she did not call the doctor, LN G stated, .Well it really wasn't an emergency. During an interview on 7/2/19, at 8:00 a.m., CNA M stated she received report on 6/7/19 at 11:00 p.m., from the evening shift staff that there was some discoloration, and bruise on Resident 1's left knee. When asked what was observed, CNA M stated she saw purple color on the left knee. CNA M stated both the pain (Resident 1 winced and frowned with movement), and the bruised area of Resident 1's knee was reported to LN H. During an interview on 7/2/19, at 1:17 p.m., LN H stated he worked nights and was working the night of 6/7/19. LN H stated that Resident 1 was in pain, he noted Resident 1's non-verbal indications of pain: facial grimacing, whining with movement, and transitioning to a 2-person assist when she had been a 1-person assist for turning, positioning on the bed-pan, or getting up out of bed. When asked why he did not call the physician, LN H stated that it was a judgement call, as the nurse. During a review of Resident 1's Interdisciplinary Notes (where nurses and CNAs document care of residents), dated 6/7/19, LN F worked the 7 a.m. to 3 p.m. shift and received the complaint from Resident 1 of pain. LN F did not document her assessment or interventions. LN G worked the 3 p.m. to 11 p.m. shift, received report from LN F and CNA K of Resident 1's pain. LN G did not document her assessment or interventions. The time of the first note from nursing staff was 11:14 p.m. Resident 1's complaint of pain 9/10 in her left knee happened at 9:00 a.m. During an interview on 7/8/19, at 11:36 a.m., LN F stated she received the complaint of pain level 9/10 from Resident 1 on 6/7/19 at 9:00 a.m When asked what her assessment of Resident 1 included, LN F stated that she asked Resident 1 if she had hurt herself. LN F stated that she did not see any disfigurement or discoloration of the left knee. When asked why she did not call PCP A, LN F stated that she endorsed to the next shift to send a fax to PCP [NAME] When asked why there was no documentation of her assessment, LN F stated that she had 12 patients that day, was overwhelmed, and forgot. LN F stated that she had consulted with Family 2 and was told it would be acceptable to wait to notify the doctor, but there was no documentation of that conversation in the medical record. During an interview on 7/8/19, at 1:30 p.m., Family 2 stated that when she arrived on Saturday, (MONTH) 7, 2019, Resident 1 was sitting in the wheelchair and was wet (as if she had come from a shower). Family 2 stated that Resident 1 was crying, and stated her knee hurt. Family 2 stated Resident 1 was in a lot of pain, and when Family 2 asked her what happened, Resident 1 stated 'somebody fell on me'. Family 2 stated that there was no discussion with LN F in regard to delaying call to PCP [NAME] Family 2 stated that she was told by nursing staff (no names given) the doctor had been called. During an interview on 7/8/19, at 5:45 p.m., CNA L stated that Resident 1 complained of pain both vocally, and with facial expressions, when she said 'my knee hurts' while frowning, but Resident 1 could not tell her what happened. CNA L stated because she did not see any injury to Resident 1's left knee, she reported the pain to LN F and moved Resident 1 from bed to shower chair for her shower, while in pain. CNA L stated Resident 1 was not able to bear weight on her left leg. During a review of the facility documents titled Licensed Nurse Skills and Competencies, dated 12/23/18, for LN F, included: a three page check-off list of skills, a four page check-off list on orientation, a two-page test on accidents and falls, a one-page test on use of Mechanical Lifts, a one-page test on Abuse, a four-page check-off list for orientation, for a total of 15 pages with the subject of Resident Change of Condition mentioned once, as a check-off item. During a record review for Resident 1, a document titled Medication Administration Record [REDACTED]. During the month of April, 2019, Resident 1 had no documented levels of pain on day, evening, or night shifts, but received as needed pain medication on 4/5/19 and 4/10/19. During the month of May, 2019, Resident 1 had no documented levels of pain on day, evening, or night shifts, and received no medication for pain. During the month of June, 2019, Resident 1 had complaint of pain 9/10 in her left knee on 6/7/19 at 9:00 a.m. Resident 1's pain restricted her movement of the extremity, she was given as needed pain medication, and at the next assessment for pain (4 hours later), the pain level was 7/10 (Pain Level 7-10 Severe Pain (disabling; unable to perform ADLs), but PCP A was not called to report this change of patient status . For more than 60 days prior to 6/7/19 Resident 1 had no complaint of pain greater than 4/10 (Pain Level 4-6 Moderate Pain (interferes significantly with ADLs). During a record review for Resident 1, a document titled Medication Administration Record, [REDACTED]. LN E, and LN F gave the as needed pain medication every 4 hours on 6/7/19 and 6/8/19 without an order from PCP [NAME] On 6/10/19 PCP A changed the as needed dose time to every 4 hours. During a review of the American Journal of Nursing article titled, Assessing and Managing Acute Pain, dated (MONTH) (YEAR), indicated: Acute pain, which is usually sudden in onset .The authors call on nurses to assess and manage acute pain in accordance with evidenced-based guidelines .Nurses assume an essential role in caring for patients with acute pain and in preventing that pain from transitioning to chronic pain. Nurses must advocate for patients to receive optimal treatment of [REDACTED]. The facility document titled Job Analysis and Description for Charge Nurse, LVN and RN dated January, (YEAR), indicated: .14. Consults with the residents physician in planning residents care, treatment, and rehabilitation. 15. Notifies the residents attending physician and next of kin when there is a change of resident's condition . The facility policy and procedure titled Pain Assessment and Management, dated March, (YEAR), indicated: General Guidelines: .Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . The facility policy and procedure titled Change of Status Notification, dated, (MONTH) (YEAR), indicated: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition .1. The nurse will notify the resident's Attending Physician or physician on call when there has been an. a. accident or incident involving the resident b. discovery of injuries of an unknown source .A significant change in the resident's physical, metal or psychosocial status .c. A need to alter treatment significantly .Except in medical emergencies, notifications will be made within twenty-four hours of a change .

Based on observation, interview, record review, and document review, the facility failed to ensure adequate supervision and assistive devices for 4 of 15 sampled residents (Resident 61, Resident 159, Resident 274, and Resident 209) who had multiple falls and made multiple attempts to get out of bed/chair unassisted and who had no effective interventions to prevent further falls from occurring resulted in Resident 61 sustained a left [MEDICAL CONDITION], Resident 274 sustained a left femur fracture, Resident 159 had seven falls in a 3 month period of time, and Resident 209 had four falls within a 2 month period of time. In addition, facility failed to assess Resident 159's ability to use a sit stand lift that resulted in bruising on Resident 159's chest. Findings: 1. Resident 61, a [AGE] year old female, was admitted to the facility on [DATE]. On Resident 61's Nursing Care Plan, her diagnoses, dated 9/26/16, included [MEDICAL CONDITION], abnormalities of gait and mobility, scoliosis (lateral or sideways curvature of the spine), and urinary and fecal incontinence. The care plan also indicated a history of falling. In a phone interview on 4/11/18 at 10:10 a.m., Family Member J stated that (Named Resident) had a history of [REDACTED]. Other concerns Family Member J discussed include Resident 61's history of being a very independent and private person, such that she will not always ask for help when she needs it. First Fall: An incident report faxed to Resident 61's physician on 1/5/18 indicated that Resident 61 had an unwitnessed fall on 1/5/18, during the night shift. Resident 61 was found by a CNA (Certified Nursing Assistant) on the floor by her bed and was confused and combative. The post fall risk assessment dated [DATE] indicated a risk score of 16 (a resident who scores 10 or higher is at risk for falling). There were no evaluations of the fall with interventions documented in the nursing plan of care for preventing Resident 61 from future falls. On the incident report faxed to the resident's physician on 1/5/18, staff wrote, Will continue to monitor. In an interview on 04/12/18 at 11:10 a.m. with the facility DON, regarding the absence of interventions on the fall risk assessment for Resident 61, the DON stated, The interventions we have are on the care plan, and Interdisciplinary Team (IDT) and management staff usually write the interventions. In addition, the DON stated, A while back, interventions were also written on the fall risk assessment, but then it was decided that it would be redundant to repeat them on both (the care plan and the assessment). Concerning documentation questions about specific fall risk care plans for this resident (e.g., For this resident, what did you do differently from one fall to the next? and What did work? and What didn't work?), the DON stated, I see what you're saying. However, no resident-specific care plans were provided. Second Fall: The facility reported to the Department on 2/20/2018 that Resident 61 had an unwitnessed fall on 2/13/18 at 11:30 p.m. in her room. She was found on the floor and was initially unable to recall what she was doing at the time of the fall. The resident later informed hospital staff that she was reaching down for a piece of candy. While still at the facility, she was assessed for injuries, and according to the facility report, She denied any pain initially but flinched and said ouch when left hip and leg were moved for neurological check. Resident 61 was then sent to the ER for further evaluation, which at first identified no displaced fracture or malalignment of the hips on a radiology report dated 2/14/18 at 2:59 a.m. However, the resident continued to experience pain, and a subsequent radiology study was done on 2/16/18. On that same day, Resident 61 was discharged from the hospital and returned to the facility, where staff received a fax from the hospital indicating the resident did sustain a left [MEDICAL CONDITION], described on the radiology report as a minimally displaced left obturator ring fracture complex (fracture in which two ends of the broken ring area of the pelvic bone, or hip girdle bones, are slightly separated) and a minimally displaced left sacral alar fracture (slightly separated ends of a break in the wing-like projections at the side of the sacrum, or lowest triangular-shaped bone on the spine). The post fall risk assessment dated [DATE] indicated a risk score of 24 (a resident who scores a 10 or higher is at risk for a falling). Again, no interventions, evaluation of the effectiveness of interventions, or follow-up nursing care plans were documented for preventing Resident 61 from falling, and no resident-specific interventions or revisions were found in Resident 61's nursing care plan. On 2/14/18 a general repeated goal of Will have no further injury from fall was documented on the nursing care plan. Third Fall: A third unwitnessed fall was documented in the facility's Interdisciplinary Notes for 2/25/18. This fall occurred on 2/25/18 at 5:00 p.m. when Resident 61 was found on the floor of her room. The Interdisciplinary Notes indicated that Resident 61 asked why she cannot get out of bed and use the bathroom by herself. In addition, the report states, Continue to orient resident that she had a L (left) [MEDICAL CONDITION] from previous fall. Frequently rounded. Safety measures maintain(ed). Call light within reach, even though the Facility Reported Incident (FRI) report indicated that Resident 61 does not call for help and ask for assistance. The fall risk assessment dated [DATE] indicated a score of 20 (a resident who scores a 10 or higher is at risk for falling). In the nursing care plan dated 4/10/18 (during the week of this survey), under S/P (meaning status [REDACTED].g., frequent monitoring, anticipate resident's needs, scheduled toileting, supervised when toileting), but no further description of how these interventions would be or had been implemented or evaluated. In an interview with a Licensed Nurse (Nurse C) on 4/11/18 at 2:15 p.m., Nurse C stated Resident 61 is very independent, so she might not realize she needs help. Nurse C stated that facility staff provide supervision with frequent checks on Resident 61. They encourage and help Resident 61 to activities where she will be supervised or resident will hang out at the nurses' station. Nurse C also stated if the resident is napping, staff will keep her door open and check on her frequently, defined as every hour. In an observation on 4/11/18 at 3:30 p.m., Resident 61's door was closed. In addition, there is a general nursing care plan in place for safety/falls for Resident 61 on the Electronic Health Record (EHR) but no resident-specific interventions. In a second interview with Nurse C on 4/12/18 at 9:38 a.m., Nurse C stated the resident knows how to use the call light but is not consistent with it. Nurse C stated that Resident 61 has a history of being very independent and will at times take off her brief herself and urinate on the floor. Nurse C stated Resident 61 might have slipped on her own urine. Resident 61's door was closed during this interview. Nurse C was told that Resident 61's door was closed, and Nurse C showed no response. Care plan and risk assessment review revealed no resident-specific interventions. The facility's Policy and Procedure for Safety and Supervision of Residents revealed statements about evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. A care plan intervention documented on 2/7/18 after the resident's first fall (on 1/5/18) stated as a goal: Minimize risk of falls and injuries daily. Then on 2/14/18, after the resident's second fall (on 2/13/18), an addition to the care plan stated a new goal: Will have no further fall or injury from fall. There was no documentation of implementation measures, evaluation of effectiveness, or modification/ replacement of interventions noted in the care plan. 2. Resident 159, a [AGE] year old female, was admitted to the facility on [DATE]. On Resident 159's nursing plan of care, dated 12/21/17, her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool), dated 12/29/17, indicated Resident 159 had moderately impaired cognition, unsteady balance, and required extensive assistance with bed mobility, transfers, walking in her room, dressing, and toilet use. Resident 159 uses two assistive devices for mobility: a four-wheeled walker and a wheelchair. During an interview on 4/10/18 at 10:09 a.m., Family Member H stated that (Named Resident) was admitted to the facility due to a history of falls at home and that since her admission to the facility, Resident 159 has had a number of falls. Family Member H also stated that an unwitnessed fall resulted in an abrasion (scrape-like injury) to Resident 159's lower spine area. Other unexplained injuries were discovered by staff and are described in the following findings. First Fall: A Fax to Physician, dated 1/11/18, reported an unwitnessed fall incident for Resident 159, who was found sitting on the floor by her bed. Resident 159 was not able to tell the nurse how she fell or what she was trying to do at the time of the fall. An Interdisciplinary Note, dated 1/11/18 indicated that the resident was reminded and highly encouraged to use the call light and to not stand up without assistance from staff. The Interdisciplinary Note also stated, Will continue to closely monitor. In an interview on 4/12/18 at 9:45 a.m. with Health Care Staff F (HCS-F) stated Resident 159 does not use the call light. HCS-F also stated she continues to make the call light available to Resident 159, even though the resident does not use it, because she learned in her training that it is better for the resident to have it than to not have it, in case of a sudden change in mental status. HCS-F stated Resident 159 is assisted with toileting every two hours routinely and HCS-F checks on Resident 159 frequently, meaning whenever I walk by her room. When asked specifically, How often is frequently?, HCS-F stated, We were told every hour, but that was a while ago and did not know if the guidelines had changed since then. Second Fall: A Fax to Physician, dated 1/13/18 at 10:49 (no a.m. or p.m. noted) indicated that facility staff found Resident 159 sitting on her bedroom floor. The report indicated, Resident (159) stated she was trying to go to the bathroom. She did not call for help. On 1/16/18, the physician's response to the faxed report stated, Monitor, and Inform MD if change in mental status. The corresponding Interdisciplinary Note, dated 1/13/18, indicated that Resident 159 was transferred to bed with two person extensive assist. On 3/9/18, an Interdisciplinary Note indicated that Resident 159 has not been ambulating with RNA (Rehabilitative Nursing Assistant) and noted decline with mobility. The report also stated, She (Resident 159) is currently 2 (two) person assist with mobility. Third Fall: In a Fax to Physician, dated 1/14/18 at 4:00 a.m., facility staff observed Resident 159 sitting on the floor near her bed. The physician's response to the report stated, Monitor, and Inform MD if change in mental status. An Interdisciplinary Note, dated 1/14/18, stated, Resident (159) was able to stand back up with assistance from 2 (two) staff. Resident (159) was reminded and highly encouraged to use the call light and to not stand up without assistance from staff. Resident (159) was reoriented to using call light for assistance. Will continue to closely monitor, with frequent visual checks. There was no documentation found in the nursing care plan of new fall interventions pertaining to this fall. Fourth Fall: On 1/18/18 (no time stamp indicated), a Fax to Physician stated, Resident (159) does not sleep well during the night and keeps trying to stand up/get out of bed. She looks restless and exhausted. She also seems to be confused . Also, can we have PRN (as needed) medicine for inability to sleep? She has PRN [MEDICATION NAME] 25 mg 1 (one) tab @ HS (at bedtime) for itching/anxiety. Please advise. In an Interdisciplinary Note on 1/18/18 at 3:51 p.m., facility staff reported observing Resident 159 crawling on the floor of her room. A subsequent Interdisciplinary Note, dated 1/19/18 and related to the same fall on 1/18/18, reported that the resident stated, I have to go to the bathroom. The note also indicated, Plan scheduled toileting. Again, there was no indication in the care plan of evaluation for the effectiveness of this intervention in preventing Resident 159 from falling. Fifth Fall: In an Interdisciplinary Note, dated 1/24/18, facility staff observed Resident 159 sitting on the floor next to her bed and wheelchair. Resident 159 stated she was trying to get to the hallway to see her husband. A Fax to Physician report, dated 1/24/18 and sent on 1/25/18 at 12:04 (no a.m. or p.m. indicated), a facility staff person states, Will continue to monitor. On the same report, a response from the physician, dated 1/25/18, reads, Yes, please continue to observe. There were no indications on the care plan of new fall interventions pertaining to this fall. Sixth Fall: In the Interdisciplinary Note for 2/10/18, at 12:00 noon, facility staff reported finding Resident 159 lying on her back on the floor, and a CNA got her back into the wheelchair. At noon, Resident 159 denied pain. A later entry (4:32 p.m.) to the Interdisciplinary Notes reports that at 1:00 p.m., Resident 159 complained of knee pain at an intensity of 5 (on a scale of 1-10, with 10 representing the most severe pain). A Fax to Physician, dated 2/10/18 and sent on 2/11/18 at 1:18 a.m., indicated that Resident 159 had a fall, facility staff observed swelling to her right knee, and Resident 159 complained of pain at a level 6. The report reads, We've tried getting order from (provider) for stat (immediate) x-ray for both knees but we're unable to obtain the order from facility's Medical Director. Attached is the result (no x-ray report available). An addition to the Nursing Care Plan on 2/10/18 titled, actual fall, indicated a goal of no complication from fall. New interventions documented on the care plan pertaining to this fall included, discuss safety issues and concerns such as calling for assistance, etc. No documentation of implementation or evaluation for the effectiveness of these goals and interventions was found. Seventh Fall: In a Fax to Physician, dated 3/30/18 and sent on 3/30/18 at 2:56 p.m., facility staff reported observing Resident 159 sitting on the floor next to her bed. Resident 159 stated she was trying to get out of bed. The Interdisciplinary Notes for 3/30/18 indicated that Resident 159 stated, I was trying to stand up. The report also stated, Call light placed within reach of pt. (patient). A nursing care plan entry for 3/31/18 states, Resident (159) will ask for assistance to get out of bed and Discuss safety issues and concerns with Resident (159). The Nursing Care Plan, dated 3/30/18, indicated a goal of No complications from fall' and get resident up out of bed and in the wheelchair when she wakes up early am (a.m.). However, during an interview with Resident 159 and her husband on 4/10/18 at 10:09 a.m., Resident 159 was lying in bed in her pajamas. The Nursing Care Plan for 3/30/18 also indicated a goal of Resident (Resident 159) will ask for assistance to get out of bed. In addition, the care plan documented Discuss safety issues and concerns with Resdident. No documentation of implementation or evaluation for the effectiveness of these goals and interventions was found. The facility's Policy and Procedure for Safety and Supervision of Residents revealed statements about evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. In Resident's 159's care plan, there was no indication of documentation of effective, resident-specific interventions or evidence of how or if interventions were implemented, nor was there an evaluation of the effectiveness of implementation. 3. Resident 274, an [AGE] year old female was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Data Set (MDS, an assessment tool), dated 5/31/17 and the most recent quarterly MDS, dated [DATE], indicated Resident 274 had short term and long term memory impairment and moderately impaired cognitive skills for decision making capacity. Resident 274 had an unsteady gait, required extensive assistance with transfers, walking within the room, dressing and using the toilet and was at risk for falls due to a history of fall. The Resident Admission Evaluation and Interim Care Plan dated 5/24/17 indicated Resident 274 had problems walking, complicated by her left [MEDICAL CONDITION], had short term memory loss, confusion and was at risk for falls. A Nursing Plan of Care for Falls, dated 5/24/17, documented 1) Give resident verbal reminders not ambulate/transfer without assistance, 2) Keep call light in reach at all times The goal was Resident 274 would remain free from injury. The MDS dated [DATE] indicated that Resident 274 was unable to walk and had to use a manual wheelchair First Fall: Resident 274's nursing notes dated 7/1/17 at 9:30 a.m., indicated that Resident 274 was found on the ground, dated 7/4/17 (time unknown) Resident had a fall (description of event was not found) and dated 7/11/17 at 12:30 p.m., the resident was found on the floor by staff. This resulted in a femur fracture and transfer to a hospital for further treatment and surgical repair. The nursing post fall assessment, dated 7/1/17 at 9:30 a.m., Resident 274 was observed on ground next to bed by staff, Resident attempting to transfer self after breakfast. Post fall assessment indicated that a Neurological Assessment Flow Sheet was initiated and continued for the next 72 hours. A Fall Risk Evaluation dated 7/1/17, provided no new information in comparison to the original evaluation dated 5/27/17. The Resident's plan of care was updated to include, status [REDACTED]. The nursing plan of care lacked specificity of how Resident 274 was going to call for help, when she required cueing and supervision and did not reflect interventions to prevent the Resident from falling. Second Fall: Nurse's Note dated 7/4/17 indicated that the Resident had a fall, (no time given or description of event) the resident was documented in the Nurses' Note to have neurological checks within normal limits and no change in level of consciousness. The nurses' note dated 7/4/17 at 7:40 p.m. indicated that the Resident continues to need staff assistance with activities of daily living to maintain safety and to help prevent falls and Resident reminded to use call light for assistance. The Resident's plan of care was updated to reflect status [REDACTED]. There were no effective interventions addressing adequate supervision considered to prevent Resident 274 from further falls. Third fall: Nursing note dated 7/11/17 at 12:55 p.m. noted that, resident observed sitting on the floor at 12:30 p.m. beside her bed. Nursing notes described the event, Resident stated she was wanting to use the toilet, no call light used, non-slip socks on wheelchair noted at bedside. The resident complained of left hip pain dated 7/11/17 at 5:30 p.m. the doctor was notified of the pain and requested an x-ray of the left hip. The plan of care was updated on 7/11/17 to include status [REDACTED]. The nursing notes dated 7/11/17 at 9:30 p.m. indicated that the Resident was being transferred to the hospital for management of a left femur fracture. The facility's Policy and Procedure for Safety and Supervision of Residents indicated evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions. 4. Resident 209, a [AGE] year old male, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Data Set (MDS, an assessment tool), dated 2/27/18, and the most recent quarterly MDS, dated [DATE], indicated Resident #209 had mild cognitive impairment, required extensive assistance with bed mobility, transfers, toilet use and had to be supervised while walking. During an interview on 04/11/18 at 03:36 p.m., Health Care Staff 2, stated that staff check on Resident 209 every twenty to thirty minutes. Health Care Staff 2 also stated that Resident # 209 is able to use the call light when he needs help, but often forgets to use it. A Nursing Plan of Care for falls dated 11/1/17 indicated 1) Keep call bell, fluids, and personal items within reach; 2) Provide constant safety reminders (Resident 209 is hard of hearing and has short-term memory deficits); 3) Remind and encourage use of assistive device; 4) Provide proper foot wear. The goal was to minimize the risk for falls and injuries daily. First Fall: The initial nursing post fall assessment, dated 2/26/18 at 3:57 p.m., indicated Resident 209 had an unwitnessed fall on 2/26/18, No RN on duty for initial assessment. Resident was noted on the floor by CNA. Another nursing post fall assessment, dated 2/27/18 at 9:07 a.m., indicated, Per resident, he was trying to go in circles and did not fall. No injury noted. Neuro checks initiated. MD and RP were notified. Plan-frequent checks. The post fall Nursing Plan of Care indicated 1) Provide assurance for his safety; 2) Keep call light within reach; 3) Maintain low bed; 4) Frequent monitoring for his safety. There is no quantitative data stating how often Resident 209 should be checked. The goal of the post fall Nursing Plan of Care indicated, Resident will have no complications from fall. Second Fall: The nursing post fall assessment dated [DATE] at 9:05 a.m., indicated Resident 209 had a fall on 3/7/18, Resident was found crawling on the floor trying to get to his wheelchair. No injury noted. Neuro checks completed. MD and RP were notified.-Plan bed at proper height, keep wheelchair close to bed, scheduled toileting every 2 hours, keep bedroom door open The post fall Nursing Plan of Care indicated 1) Frequent rounding; 2) Schedule toileting every 2 hours; 3)Discuss safety issues and concerns; 4) Keep call light and belongings within reach. The new intervention is Schedule toileting every 2 hours. The goal of of the post fall Nursing Plan of Care indicated, (Resident 209) will have no complications from fall. The Nursing Plan of Care did not indicate the frequency in which the staff would provide adequate supervision. Third Fall: The nursing post fall assessment dated [DATE] at 11:23 p.m., indicated Resident #209 had a fall on 3/31/18, Writer heard someone yell from their room at 2030 (10:30 p.m.) and found resident alone and sitting in front of his toilet on the ground with wheelchair near by. Denied hitting his head. Denies any pain. When asked what happened, Resident 209 stated, I just slipped from the toilet. A post fall assessment dated [DATE] at 9:02 a.m., indicated, Plan-assist resident to toilet at HS. The post fall Nursing Plan of Care indicated, 1) Discuss safety issues and concerns; 2) Keep call light and belongings within reach; 3) Frequent rounding by staff; 4) Keep room well lit. The goal of the post fall Nursing Plan of Care indicated, No complications from fall. There were no new interventions. The interventions did not address specific frequency in which adequate supervision was provided, as Resident #209 did not only fall on night shift. Fourth Fall: The nursing post fall assessment dated [DATE] at 9:01 a.m., indicated Resident 209 had a fall on 4/10/18, Resident was observed on the floor in his room on 4/10/18. No injury noted. Per resident, he was in a hurry to use the toilet and he slipped out of his wheelchair. Neuro checks initiated and continued. Plan-have staff sit out of resident room for direct visual on during shift. The post fall Nursing Plan of Care indicated, 1) Remind resident to use call light to ask for assistance at all times and keep call light within reach; 2) Monitor frequently for his safety; 3) N[NAME] shift staff to sit in hallway near residents door to increased visualization of resident; 4)Staff to monitor for pain/discomfort related to fall. The goal of the post fall Nursing Plan of Care indicated, Resident will be free from injuries related to fall. The Nursing Plan of Care did not address the specific frequency at which adequate supervision was provided. During an interview on 4/11/18 at 3:10 p.m., with Nurse Supervisor, she was unable to define frequent monitoring, and stated it was simply frequent rounding. She was asked specifically how often Resident 209 is required to be monitored. Nurse Supervisor could not state a specific quantitative timeframe for frequent monitoring of the resident During an interview on 4/12/18 at 10:18 a.m., DON stated the facility does not have a specific timeframe to check on Resident 209. However, they have two CNAs (Certified Nursing Assistants) and one licensed staff at all times in Station Four where Resident 209 lives. DON also stated that they have a lot of traffic in that Station during day shift such as housekeeping and dietary staff who are able to observe the residents. She confirmed that housekeeping and dietary staff are not direct care staff. During an interview and concurrent record review on 4/12/18 at 3:55 p.m., DON reviewed the nursing care plans after falls for Resident 209 and agreed the care plans were incomplete and lacked specific interventions to prevent Resident 209 from future falls. She also confirmed that the interventions did not apply to Resident 209 given his cognitive status, since he would be unable to remember directions such as using the call light when he needs help. According to facility's policy titled Safety and Supervision of Residents revised (MONTH) of 2007, When accident hazards are identified, the QA & A/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 5. A facility fax sent to Resident 159's physician dated 2/28/18 indicated that staff noticed purplish discoloration on right anterior arm that measured 13 centimeters (cm) by 4 cm. Resident 159's right lateral chest had plurplish discoloration that measured 20 cm. by 9 cm. Resident 159 was unaware of how she obtained it. A Nurse Practitioner's (NP) progress note dated 3/15/18 at 3:16 p.m., indicated that Resident 159 does not ambulate and staff need to use hoyer lift for transfers. During an interview on 04/12/18 0945, CNA F was asked if she used the hoyer lift, CNA F stated Resident 159 does not like the hoyer lift, so nursing staff transfer her with two-person assist with resident moving from sitting to standing position. CNA F stated they use the sit stand lift. When asked who instructed her to use the lift, CNA F stated the licensed nurses do. During an interview and concurrent record review, the Interdisciplinary team note dated 4/12/18, reviewed the discolorations. Resident 159 uses sit to stand mechanical lift requiring a sling that wraps around the upper body. IDT note concluded that the discolorations were caused by the use of the sit to stand lift. The Restorative Nurses Aide (RNA) attempted to work with Resident 159 with resident ambulation both lower extremities (BLE) strengthening to decrease use of sit stand lift. Resident 159 was unable to participate multiple times with restorative nurses aide. During an interview and concurrent record review on 4/13/18 at 11:20 a.m., MDS Coordinator stated that the transfer screening dated 3/23/18 was from information that they received from Nurse C. Resident 159 required assistance with one or two staff and pivot to toilet. Resident 159 sustained chest bruising from sit stand lift. It was not idenified until 4/12/18 what the root cause was (sit stand lift). NP noted that Resident 159 does not ambulate and needs to use hoyer lift for transfers. During interview on above date and time, MDS Coordinator further stated that you can stand but may not be able to ambulate and the facility wanted Resident 159 to achieve the highest level of functioning. Resident 159 sustained bruises from sit stand lift, while trying to achieve the highest level of functioning, this placed Resident 159 at risk for serious injury and harm and sustained bruising. MDS Coordinator was not aware that CNAs were using sit stand lift and was not aware of the Nurse Practitioners note in record even though she conducts nursing assessments. She stated that it was up to staff to notify her of changes or if the Nurse Practitioner writes in the record. MDS Coordinator further stated that the licensed nurse should be reading the record and notifying the management of changes or clarifying with the NP. MDS Coordinator stated that the sit stand or hoyer lift was not on the nursing care plan.