Every finding on record at Leisure Glen Post Acute Care Center

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Resident 32, Resident 71, Resident 91) in accordance with the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered by failing to ensure: 1. Resident 32 who receives intradialytic parenteral nutrition [IDPN - nutrition that is given through the dialysis machine while receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed)] was addressed to determine interventions and monitoring needed while receiving the nutritional therapy 2. Resident 71, who was receiving Continuous Positive Airway Pressure (CPAP - continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) there was no care plan and interventions to indicate what complications or contraindications (a condition or circumstance that suggests or indicates that a particular technique or drug should not be used) while receiving CPAP. 3. Resident 91's who has depression (a feeling of severe sadness, hopelessness that affects the persons activity of daily living) had no care plan to address interventions related to resident's verbalization of wanting to end everything and wanted to die. These failure had resulted in Resident 32, Resident 71, and Resident 91 not to receive necessary care and services to achieve their highest potential and well being. Findings: 1. During a review of Resident 32's admission Record (AR), AR indicated that Resident 32 was originally admitted on [DATE], with diagnoses that included dementia (a progressive state of decline in mental abilities), End Stage Renal Disease (End Stage Renal Disease-irreversible kidney failure) dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool) dated 6/12/2026, the MDS indicated that Resident 32's cognition (the ability to process thoughts and information) was severely impaired and required substantial/maximal assistance (helper does more than half the effort) with putting on/taking off footwear, lower body dressing, shower/bathe self. During a review of Resident 32's Order Summary Report dated 4/7/2026, indicated Resident 32 has Dialysis treatment order three times a week on Monday, Wednesday and Friday. During a review of Resident 32's Laboratory Results Report, dated 5/4/2026, indicated Resident 32 had a glucose (simple sugar- the body's primary source of energy from food) result of 151 normal results (65-99). During a review of Resident 32's Dialysis Communication Record (communication between dialysis center and the facility) dated 6/17/2026, indicated that Resident 32 received IDPN 165 milliliters (ml-unit of measurement) on 6/19/2026, 6/22/2026, 6/24/2026, 6/26/2026, 6/29/2026 and on 7/1/2026 Resident 32 received IDPN 329 ml. During an interview on 7/2/2026 at 11:18 AM with Registered Nurse Supervisor (RNS )1 stated she was not aware Resident 32 was receiving IDPN on dialysis days, RNS 1 and IDPN was for and why it was given to Resident 32. RNS 1 also did not know Resident 32 was receiving IDPN at the Dialysis Center. RNS 1 stated that the purpose of the communication record between dialysis and the facility was to ensure the nurses were aware of medications and treatments that are administered at the Dialysis Center for continuous care and monitoring. RNS 1 stated she will contact the Dialysis Center to inquire what interventions are needed while Resident 32 is receiving IDPN. According to Provincial Standards & Guidelines (BC Renal) 2021, reference the IDPN complications that needed to be monitored included hyperglycemia (high blood sugar)/hypoglycemia (low blood sugar). During a review of the facility's (P&P) titled End Stage Renal Disease, Care of a Resident dated 9/8/2026, indicated that nursing staff will communicate in writing any changes of condition specific to the resident with each treatment. 2. During a review of Resident 71's admission Record (AR), AR indicated Resident 71 was originally admitted on [DATE], with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), pulmonary edema (a condition caused by too much fluid in the lungs), morbid obesity (a severe, chronic disease where carrying extreme excess weight begins to damage your overall health), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 71's MDS, dated [DATE], the MDS indicated Resident 71 has intact cognition (the ability to process thoughts and emotions), dependent (helper does all the effort) toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear. Substantial/maximal assistance in upper body dressing. The MDS also indicated that Resident 71 uses CPAP since admission. During a review of Resident 71's Physician Order indicated Resident 71 had a physician order on 4/29/2026 to apply CPAP at bedtime. During a concurrent observation and interview with Resident 71 on 6/29/2026 at 10:24 AM, Resident 71 had a CPAP machine next to his bed in his room, Resident 71 stated that he uses the CPAP machine daily at bedtime when he goes to sleep. Resident 71 was observed with snacks at bedside. During an interview on 7/2/2026 at 9:54 AM with the Director of Nurses (DON), DON stated that Resident 71 should not eat or drink for 2 hours before the use of the CPAP and that intervention should be in the residents' care plan and the resident should be aware of not eating food 2 hours prior to the use of the CPAP. DON also stated that a general assessment an overall evaluation of the residents' condition should be done with the purpose to identify any changes that require intervention and should be included in the residents' care plan. During a record review of the facility's policy and procedure (P&P) titled, CPAP/BIPAP Support dated 3/2015, indicated resident should be NPO (nothing by mouth) for at least 2 hours before using a full-face mask, monitor the oxygen saturation of the resident, general assessment (including vital signs, oxygen saturation, respiratory). 3. During a review of Resident 91's admission Record (AR), the AR indicated that the facility was admitted on [DATE] and readmitted Resident 91 on 5/27/2026 with diagnoses included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 91's MDS, dated [DATE], indicated that Resident 91's cognition (the ability to process thoughts) was intact. MDS also did not indicate Resident 91 had thoughts of wishing for death or attempting to harm self. During an observation on 6/29/2026 in Resident 91's bedroom resident was observed crying and verbalized to Certified Nurse Assistant (CNA 1) that he wanted everything to end and wanted to die. During an interview on 7/2/2026 at 9:29 AM, with Registered Nurse Supervisor (RNS 1), RNS 1 stated that any change of condition such as when Resident 91 verbalized he wanted everything to end and wanted to die, a care plan must be developed, which is a form of communication to the other staffs to indicate what the resident needed and how those interventions are going to be met. During a record review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 12/2016, indicated, that ongoing resident assessments should result in revisions to the comprehensive person-centered care plan when the residents condition changes. Also, the P&P indicated that care planning will include the resident and or representative incorporating the resident's personal and cultural preferences in developing the goals of care.

Based on observation, interview, and record review the facility failed to notify with resident's physician when one of three sampled residents (Resident 91) with depression (a mental illness resulting in feeling severe hopelessness, sadness affecting their daily life) had a significant change in condition, was found crying and verbalized to the facility staff that he wanted to end everything and wanted to die, in accordance with the facility's policy and procedure titled Change in a Resident's Condition or Status and the resident's care plan. This deficient practice resulted in delayed emotional and mental health care and treatment of Resident 1 that could result in worsening depression, suicide the action of killing oneself intentionally) and self-inflicted injury that could lead to hospitalization and death. Findings: During a review of Resident 91's admission Record (AR), the AR indicated that the facility was admitted on [DATE] and readmitted Resident 91 on 5/27/2026 with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 91's Minimal Data Set (MDS, a resident assessment tool), dated 4/2/2026, indicated that Resident 91's cognition (the ability to process thoughts and information) was intact. MDS also did not indicate Resident 91 had thoughts of wishing to die or attempting to harm self. During a review of Resident 91's care plan, dated 3/26/2026, titled Polypharmacy (having multiple medication therapy): Resident is at Risk for Adverse Reactions (undesired effect) from medication due to Polypharmacy indicated to monitor the resident for possible signs and symptoms of adverse drug reactions such as falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, agitation, depression. During a review of Resident 91's care plan, Antianxiety Med Use for Diagnosis Anxiety dated 3/26/2026, indicated to notify MD for significant decline in behavior for further intervention if behavior interferes with daily care of functioning. During a review of Resident 91's care plan, Resident had 2-9 mood interview on the MDS dated 3/27/2026, indicated to do 1:1 visit with social services as needed, arrange for psychology consult as necessary, allow resident to vent feelings and provide safe environment, monitor and document and report as necessary any risk for harm to self, sense of hopelessness or helplessness, safety awareness. During an observation on 6/29/2026 9:23 AM in Resident 91's bedroom resident was observed crying and verbalized to Certified Nurse Assistant (CNA 1) that he wanted everything to end and wanted to die. During an interview on 7/2/2026 at 9:15 AM with CNA 1, CNA 1 stated, I reported to the License Vocational Nurse 4 (LVN 4) on Monday 6/29/2026 that Resident 91 was crying and verbalized that he wanted to die. During an interview on 7/2/2026 at 9:22 AM with LVN 4, LVN 4 stated CNA 1 reported to her that Resident 91 was crying and verbalized wanting to die. LVN 4 stated she went to Resident 91's room and Resident 91 told her he was okay. LVN 4 stated she informed RNS 1 about Resident 91 verbalization of wanting to die on 6/29/2026. During an interview on 7/2/2026 at 9:29 AM with RNS 1, RNS 1 stated she did receive a report from LVN 4 that Resident 91 verbalized wanting to die on 6/29/2026. RNS 1 stated that on 6/29/2026 she talked to Resident 91 who verbalized that he was okay. RNS 1 stated Resident 1's primary physician was not informed about Resident 1's verbalization of wanting to die. RNS 1 also stated, it was important to implement the care plan and to communicate with all the staff the interventions are in place like frequently monitor resident's whereabouts. During an interview on 7/2/2026 at 9:35 with Social Services Director (SSD), SSD stated that Resident 91 was going to be seen by psychologist in the next couple of days and that she was not made aware of Resident 91, verbalizing he wanted to die stated that on 7/1/2026. The SSD was told by nursing that Resident 91 needed psychologist consult but was not told that Resident 91 had thoughts of wanted to die. SSD stated that it was extremely important for staff to communicate any change in condition in the residents to ensure prompt interventions and report to the primary physician. During an interview on 7/2/2026 at 9:44 with Director of Nurses (DON), DON stated that Resident 91's change of condition of having thoughts and verbalization of wanting to die should had been reported to the primary physician and responsible party and also communicated to all staff so that proper interventions and monitoring could be implemented such as when Resident 91 gets more depressed resulting in hurting himself. During a review of Resident 91's care plan titled, Communication Problem Due to Language Barrier dated 3/27/2026 indicated to monitor for/record confounding problems: decline in cognitive status, mood. During a review of the facility's Policy and Procedures (P&P) titled, Change in a Resident's Condition or Status dated 2/2021, indicated, The nurse will notify the resident's attending physician when there has been a significant change in the resident's physical/emotional/mental condition.

Based on interview and record review the facility failed to update the Minimum Data Set (MDS - a resident assessment tool) to accurately reflect resident's behaviors in the MDS for 1 of 3 sampled resident (Resident 50), who had a pattern of refusing prescribed medications and laboratory blood draws (a simple procedure where a healthcare professional uses a tiny needle to collect a small blood sample) which are behaviors identified in the resident's clinical record. This deficient practice had the potential to resulted in an inaccurate inappropriate care planning, identify and implement interventions necessary to address the Resident 50's refusal or medications and behavioral needs. Findings: During a review of Resident 50's admission Record (AR), the AR indicated Resident 50 was readmitted to the facility on [DATE] with a diagnosis that included dementia (impaired thinking) and encephalopathy (disease, damage, or malfunction of the brain). During a review of Resident 50's History and Physical (H&P) signed and dated 12/30/2025, indicated that Resident 50 did not have capacity to understand and make decisions. The H&P further indicated that Resident 50 had a history of refusing treatment. During a review of Resident 50's Change of Condition (COC - sudden or significant shift in a person's physical, mental, or functional health from their established baseline), dated 5/25/2026, the COC indicated that Resident 50 had refused to take her blood pressure (BP, the push of blood against the walls of blood vessels, normal BP is a reading of less than 120/80 mmHg [millimeters of mercury, unit of BP measurement]) medications unless Resident 50's Sinus Blood Pressure SBP (systolic BP, or the top number in a BP reading, which measures the push when the heart is actively squeezing or beating) was greater than 140. During a review of Resident 50's MDS, dated [DATE], the MDS indicated that Resident 50 had a moderately impaired cognition (thinking). The MDS further indicated that Resident 50 did not exhibit behaviors associated with rejection of evaluation or care (e.g. bloodwork and taking medications) that was necessary to achieve Resident 50's goals for health and wellbeing. During a review of Resident 50's COC, dated 6/19/2026, the COC indicated that Resident 50 refused labs for TSH (thyroid-stimulating hormone, the hormone that's mainly responsible for controlling the speed of the body's metabolism) and lipid panel (blood test that measures the fats in the blood). During a review of Resident 50's COC, dated 6/23/2026, the COC indicated that Resident 50 refused to take her medications (unspecified). During a concurrent interview and record review on 7/1/2026 at 9:19 AM with MDS coordinator (MDS 1), Resident 50's COC for 5/25/26, 6/19/26, and 6/23/26, were reviewed. MDS 1 stated that Resident 50 had a documented pattern of refusing treatment, including refusing prescribed medications and laboratory blood draws. During a concurrent interview and record review on 7/1/2026 at 9:35 AM with MDS 1, Section E0800 of Resident 50's MDS, dated [DATE], was reviewed. MDS 1 stated upon a review of Resident 50's MDS, Section E0800 indicated that Resident 50 did not exhibit the behavior of rejection care such as refusing blood work and taking medications. MDS 1 stated that Resident 50's COC documented multiple instances of the resident's refusals for medication administration and lab draws. MDS 1 stated Resident 50's behavior for refusing treatment was not coded accurately. MDS 1 stated that the Social Services Director (SSD) was responsible for completing the behavioral section of the MDS and should have reviewed the Resident 50's COC to ensure the resident's behavior was accurately coded. MDS 1 further stated that it was also her responsibility to review Resident 50's COC and oversee the accuracy of the SSD's MDS coding. MDS 1 stated that she did not ensure to accurately code the Resident 50's pattern of refusing treatment could result in an inaccurate assessment of the resident's needs, inappropriate care planning, and incorrect reimbursement. During a concurrent interview and record review on 7/1/2026 at 9:42 AM with the SSD, Resident 50's COC, dated 5/25/2026, 6/19/2026, and 6/23/2026, were reviewed. The SSD stated that Resident 50's COCs revealed that the Resident 50 had a documented pattern of refusing treatments, including refusing prescribed medications and laboratory blood draws. The SSD stated that she was responsible for coding in the MDS Section E0800 and coded it incorrectly. The SSD stated that by not inputting accurate behavior information in the MDS, Resident 50 would not receive accurate care for her behavior of refusing treatment. During an interview on 7/1/2026 at 10:14 AM with Registered Nurse (RN 1), RN 1 stated that Resident 50 had a documented pattern of refusing treatment, including prescribed medications and laboratory blood draws. RN 1 stated that the Resident 50's COC documented multiple instances of her refusals. RN 1 further stated that MDS 1 reviews the COCs to update the MDS assessment. RN 1 stated that when a COC occurs during the day shift, the licensed nurse should notify the MDS Coordinator to update the resident's MDS so that it accurately reflects the resident's condition and ensures the resident receives appropriate care. During a review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 1.20.1, dated October 2025, the manual indicated that rejection of care behavior that interrupts or interferes with the delivery or receipt of care. The RAI indicated that care rejection may be manifested by verbally declining or statements of refusal or through physical behaviors that convey aversion to or result in avoidance of or interfere with the receipt of care. The RAI indicated that a resident's rejection of care might be caused by an underlying neuropsychiatric, medical, or dental problem. The RAI indicated that this could interfere with needed care that is consistent with the resident's preferences or established care goals and in such cases, care rejection behavior may be a problem that requires assessment and intervention. During a review of the facility's policy and procedure (P&P) titled Behavioral Assessment, Intervention and Monitoring revised 3/2019, the P&P indicated that behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. The P&P indicated that the social service department will identify and document and inform nursing staff to notify the physician about specific details regarding changes in an individual's mental status. behavior, and cognition. including: onset, duration. intensity and frequency of behavioral symptoms: any recent precipitating or relevant factors or environmental triggers (e.g., medication changes, infection, recent transfers from hospital): and appearance and alertness of the resident and related observations

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and care in accordance with professional standards of practice (established guidelines or requirements for safe and accountable practice, protecting both the public and the profession's reputation) for one of three sampled residents (Resident 16), who had a change of condition and was diagnosed with acute respiratory failure (a sudden, life-threatening condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide). The facility failed to ensure Resident 16 was assessed and documented in the clinical record an evidence to indicate what prompted the staff to check Resident 16's vital signs (measurement of the blood pressure, respiratory rate, heart rate and body temperature) at 4:56 PM with significant changes in vital signs, mental status and ineffective breathing pattern (problems with breathing that does not provide adequate ventilation) respiratory function that required hospitalization on 4/16/2026, when Resident 16 was observed in stable condition at 3PM and 4PM. This deficient practice had the potential for Resident 16's deterioration of impaired respiratory function and wellbeing that could negatively impact on Resident 16's quality of life. Findings: During a review of Resident 16's admission Record (AR), the AR indicated that Resident 16 was initially admitted on [DATE] and recently readmitted on [DATE] with diagnoses including acute respiratory failure (a sudden, life-threatening condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from it), encephalopathy (a group of conditions that cause brain dysfunction), and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's Care Plan (CP) for the resident's risk of respiratory distress (difficulty or labored breathing), dated 3/14/2026, the CP indicated to monitor Resident 16 for signs and symptoms of respiratory distress and report to the physician as needed including but not limited to the following: increased respirations; decreased pulse oximetry; increased heart rate; restlessness; lethargy (sluggish or lacking energy); confusion. During a review of Resident 16's Weights and Vitals Summary (WVS), dated from 4/1/2026 to 4/16/2026, indicated there was no documentation of Resident 16's oxygen saturation during 7 AM to 3 PM shift from 4/4/2026 to 4/16/2026. The WVS indicated inconsistent documentation of the resident's oxygen saturation level, which was documented only once during 11 PM to 7 AM shift on 4/2/2026, 4/6/2026, 4/9/2026, 4/12/2026. During a review of Resident 16's Nursing Progress Notes (NPN) on 4/16/2026 timed at 3:42 PM the NPN documented by a Licensed Vocational Nurse (LVN 2), indicated that Resident 16 was asleep with even and unlabored respiration (breathing). The NPN did not indicate assessment of the level of consciousness (LOC) of Resident 16. During a review of Resident 16's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) documented by LVN 3, dated 4/16/2026, the SBAR indicated that on 4/16/2026 at 3 PM, Resident 16 was awake in bed with the vital signs of blood pressure (BP) 102/58, heart rate 88, respiration rate 15, temperature 97.7 Fahrenheit and O2 Sat 96% via room air. The SBAR indicated that on 4/16/2026 at 4 PM, Resident 16 was in bed asleep, and responsive to verbal and tactile stimuli (reacts to speech and physically or neurologically to touch, pressure, or texture). There was no documented evidence that vital signs were taken at 4 PM when Resident 16 was responsive to verbal and tactile stimuli, and the documentation did not describe what type of response (eye/verbal/motor response) the resident provided. During the same record review of Resident 16's SBAR, dated 4/16/2026, the SBAR further indicated that at 4:56 PM, Resident 16's charge nurse (unspecified) noted the resident's breathing was slow and shallow. The SBAR indicated Resident 16 remained responsive to verbal and tactile stimuli with the vital signs changed to BP of 88/60, HR of 93, RR of 10, O2 sat at 63% on RA. The SBAR indicated Resident 16's RP and primary physician were notified, and Resident 16 was transferred to GACH due to desaturation and hypotension. During the same record review of Resident 16's SBAR, dated 4/16/2026, indicated no documented evidence what prompted the staff to check Resident 16's vital signs at 4:56 PM with significant changes vital signs, ineffective breathing pattern (problems with breathing that does not provide adequate ventilation) impaired respiratory function that required hospitalization on 4/16/2026, when Resident 16 was observed in stable condition at 3PM and 4PM. During a review of Resident 16's Minimal Data Set (MDS- a resident assessment tool) dated 6/15/2026, the MDS indicated that Resident 16 had severely impaired cognition (rarely/never made decision). The MDS also indicated that Resident 16 required continuous oxygen therapy. During a concurrent record review and an interview on 7/2/2026 at 11:14 AM with LVN 3, Resident 16's SBAR and WVS were reviewed. LVN 3 stated that on 4/16/2026 she worked as a desk nurse from 3 PM to 11 PM. LVN 3 stated, she assisted in documenting Resident 16'a SBAR by receiving reports from the PM shift LVN and did not know the resident's actual condition. LVN 3 stated, around 5PM was when she heard about the resident's low O2 sat of 63%. LVN 3 stated, she documented based on what PM shift LVN reported to her. LVN 3 stated, the licensed nurse would not be able to know the resident's status without completing a thorough assessment, including measuring vital signs and assessing the resident's LOC. During a concurrent record review and an interview on 7/2/2026 with the Director of Nursing (DON), Resident 16's SBAR and NPN dated 4/16/2026, and WVS from 4/4/2026 to 4/16/2026 were reviewed. The DON stated the documentation about Resident 16's LOC at 4:00 PM and 4:56 PM in SBAR were documented no difference and the documented responsiveness could not determine whether Resident 16 already had COC that should have been identified. The DON also stated Resident 16 was at risk for respiratory distress however 7 AM to 3 PM licensed nurses from 4/4/2026 to 4/16/2026 did not check and document the resident's vitals. The DON further stated that residents' vitals were the signs that often could not be visualized by the appearance, so the routine vitals were supposed to be assessed as part of the licensed nurse's assessment. During a review of the facility's policy and procedures (P&P) titled Resident examination and Assessment revised in 2/2014. The P&P indicated for preparation of resident assessment included to review the resident's admission assessment and/or preliminary care plan to assess for any special situations regarding the resident's care. The P&P also indicated physical examination included vital signs, cardiovascular, respiratory, and neurological assessment.

Based on interview and record review the facility failed to ensure a resident received treatment, care and services for 2 of 3 sampled residents (Resident 8 and 58) in accordance with professional standards of practice, resident's care plan, physician's order and facility' s policy and procedures. 1. For Resident 8, who has MASD (Moisture-Associated Skin Damage, a broad term for skin inflammation, irritation, or sores caused by prolonged exposure to moisture [such as urine, sweat, wound fluids, or saliva]), and receiving lactulose (a prescription medication to treat constipation and certain liver diseases) with frequent loose stool, by failing to: a. Ensure TXN 1 developed an individualized repositioning schedule for Resident 8 in accordance with the care plan. b. Ensure TXN 1 contacted the resident's wound consultant as ordered so the resident could receive a physical assessment and appropriate wound care. c. Ensure IDT (Interdisciplinary Team- a coordinated group of medical professionals for plans of care and coordinating medical care) assessed Resident 8 and contacted the resident's responsible party (RP) to determine the cause and create individualized interventions to address the resident's noncompliance of reposition and incontinent care. These deficient practices resulted in Resident 8's wound delayed healing or worsened MASD and Resident 8 was sent to a general acute care hospital (GACH 1) on 6/28/2026 for further evaluation of worsening MASD and nonpitting edema (swelling caused by fluid buildup). These deficient practices placed the resident at risk for complications such as infection (the invasion and growth of germs in the body), bacterial overgrowth, pressure injuries (or pressure sores, localized damage to the skin and underlying tissue caused by prolonged or intense pressure-or pressure combined with rubbing [shear]). 2. For Resident 58 who was diagnosed with type 2 diabetes mellitus (DM - body does not produce enough insulin to control blood glucose [or blood sugar, the main sugar found in the bloodstream] levels) and receiving daily insulin therapy the facility failed to ensure the licensed nurses did not clarified with the physician the physician order for weekly blood sugar checks to appropriately monitoring the resident's blood sugar level. This deficient practice resulted in Resident 58 not receiving appropriate daily blood sugar monitoring needed to safely manage her DM. The deficient practice placed Resident 58 at risk for undetected hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), delayed intervention for abnormal blood sugar levels, inappropriate insulin management, and preventable diabetic complications. Findings: 1. During a review of Resident 8's admission Record (AR), the AR indicated that Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hepatic encephalopathy (brain dysfunction due to liver dysfunction), alcoholic cirrhosis of liver (a stage of alcohol-related liver disease where severe scarring of the liver impacts its ability to function), and obstructive and reflux uropathy (a blockage in the body that makes it difficult or impossible to urinate [pee] and condition of kidney damaged by the backward flow of urine into the kidney). During a review of Resident 8's Care Plan (CP) titled, Resident at risk for skin break/ulcer formation, dated 3/28/2026, the CP indicated Resident 8 was at risk for skin break/ulcer formation related to impaired mobility, incontinence, non-compliant with treatment/positioning, frequent loose stool, and episode of refusal of perineal care. The CP indicated the interventions that included: to assess, document & monitor for treatment effectiveness; assist and encourage resident to turn and reposition with turning schedule to redistribute weight and reduce the risk of skin break down; monitor/assess skin condition during care and notify MD (medical doctor); provide skin care frequently; turn and reposition every 2 hours & PRN (as needed). During a review of Resident 8's Order Summary Report (OSR), dated 4/27/2026, the OSR indicated that Resident 8 may have wound consultation for evaluation and treatment as needed. During a review of Resident 8's History and Physical (H&P), dated 4/29/2026, the H&P indicated Resident 8 does not have the capacity to understand and make decisions. During a review of Resident 8's Braden Scale for Predicting Pressure Sore Risk (BSPPSR), dated 5/18/2026, the BSPPSR indicated, Resident 8's skin was often moist, confined to bed with very limited mobility, and friction and shear are identified problems. The BSPPSR indicated that Resident 8 was at high risk for pressure sore. During a review of Resident 8's BSPPSR dated 6/10/2026, the BSPPSR indicated Resident 8's skin was kept moist almost constantly by perspiration, urine, etc. dampness was detected every time the resident is moved or turned; the resident was confined to bed, completely immobile with friction and shear problems identified. The BSPPSR indicated that Resident 8 was at high risk for pressure sore. During a review of Resident 8's CP titled, Skin: Recurred MASD on sacrococcyx area (the region at the very base of the spine) extending to bilateral buttocks (both sides of the bottom), related to: resident non-compliant with turning and repositioning, and preference of lay down on her back for prolonged times, dated 6/10/2026, the CP indicated the goal was for Resident 8 to be free from further skin breakdown, and the interventions included to identify potential causative factors; inform staff of causative factors and measures to prevent skin tears; keep skin clean and dry; monitor and document locations with size and treatment of skin tear; report abnormalities, failure to heal, maceration, etc. to MD. During a review of Resident 8's Minimal Data Set (MDS- a resident assessment tool) dated 6/25/2026, the MDS indicated that Resident 8 had severely impaired cognition (never/rarely made decision). The MDS indicated that Resident 8 required substantial/maximal assistance (helper does more than half the effort) on personal hygiene and rolling left and right. The MDS also indicated that Resident 8 was dependent (helper does all the effort) on toileting hygiene. During a review of Resident 8's physician order, dated 6/28/2026 at 2:28 PM, Resident 8 had a physician order to transfer to GACH 1 for further evaluation. During a review of Resident 8's Transfer Form (TF), dated 6/28/2026, the TF indicated Resident 8 was transferred to GACH 1 for worsening MASD in the sacrococcyx area extending to bilateral buttocks and nonpitting edema. During a concurrent record review and an interview on 7/2/2026 at 9:50 AM with the Treatment Nurse (TXN 1), Resident 8's clinical records since admission on [DATE], were reviewed. TXN 1 stated that he assessed Resident 8's skin on 6/10/2026 but did not notify Resident 8's physician or responsible party (RP) the resident's high risk for pressure sore. TXN 1 stated he developed the CP on 6/10/2026 to address Resident 8's noncompliance with turning and repositioning but did not assess the resident or contact the RP to determine the cause of the noncompliance or identify specific interventions to protect the resident's irritated skin. TXN 1 stated that he did not create an individualized repositioning schedule for Resident 8 and that the resident did not receive a wound consultation when her MASD presented on her sacrococcyx. TXN 1 further stated that he relied on certified nurse assistants (CNAs) to ensure Resident 8's skin was kept clean and dry after each incontinent care. During a concurrent interview and record review on 7/2/2026 at 11:50 AM with the Director of Nursing (DON), Resident 8's CP dated 6/10/2026, IDT dated 6/26/2026, were reviewed. The DON stated that TXN 1 should have developed an individualized repositioning schedule for Resident 8 in accordance with the CP. The DON stated that IDT should have assessed Resident 8 and contacted the resident's RP sooner to determine the cause and create individualized interventions to address the resident's noncompliance of reposition and incontinent care. The DON also stated Resident 8's skin issue should have been evaluated by a wound consultant for the resident's benefit and healing. During a review of the facility's policy and procedures (P&P) titled Prevention of Pressure Injuries revised in 4/2020, the P&P indicated the following: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. During the skin assessment, inspect: presence of erythema; temperature of skin and soft tissue; and edema. Skin care included to keep the skin clean and hydrated; clean promptly after episodes of incontinence; use incontinence products with high absorbency; use facility approved protective dressings for at risk individuals; Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team; Evaluate, report, and document potential changes in the skin; Review the interventions and strategies for effectiveness on an ongoing basis; 2. During a review of Resident 58's admission Record (AR), the AR indicated Resident 58 was readmitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (DM - body does not produce enough insulin to control blood sugar levels) and dementia (impaired thinking). During a review of Resident 58's History and Physical (H&P) signed and dated 5/13/2026, the H&P indicated that Resident 58 did not have capacity to understand and make decisions. The H&P further indicated that Resident 58 had a history of type 2 DM. During a review of Resident 58's MDS, dated [DATE], the MDS indicated that Resident 58 had a severely impaired cognition (thinking). During a review of Resident 58's Order Summary Report (OSR), dated 7/1/2026, the OSR indicated the following physician orders for Resident 58: - Started on 12/4/2024: Linagliptin (a medication used to lower blood sugar) 5 milligrams (mg – unit of measure) tablet administered orally (by mouth) once a day for DM. - Started on 9/30/2025: Lantus (a medication used to lower blood sugar) administered subcutaneously (under the skin) via a pen-injector at a concentration of 100 units per milliliter (unit of measure), with instructions to inject 15 units subcutaneously at bedtime for DM. - Started on 5/16/2026: finger-stick blood sugar test (a method of measuring blood sugar in the blood) every Saturday before breakfast. During a concurrent interview and record review on 7/1/2026 at 10:30 AM with RN 1, Resident 58's OSR, dated 7/1/2026, was reviewed. RN 1 stated that Resident 58 had an order for weekly blood sugar monitoring, Resident 58 was prescribed 15 units of Lantus subcutaneously at bedtime daily and received a bedtime snack. RN 1 stated that, based on the resident's daily insulin regimen, blood sugar monitoring should have been performed daily rather than weekly to monitor the resident's response to insulin therapy and identify potential hypo- or hyperglycemia. RN 1 stated that by not monitoring Resident 58's blood sugar on a daily basis it would be difficult to evaluate insulin effectiveness. RN 1 stated that daily blood sugar monitoring helps determine whether the prescribed insulin dose is appropriate and would prevent delayed identification of changes in condition: illness, weight changes, medications, or decreased oral intake can significantly affect blood sugar levels. During a concurrent interview and record review on 7/1/2026 at 11:00 AM with the Director of Nursing (DON), Resident 58's physician summary order report on 7/1/2026 was reviewed. The DON stated that Resident 58's physician orders included weekly blood glucose monitoring, a daily order for 15 units of Lantus administered subcutaneously at bedtime, and a bedtime snack. The DON stated that Resident 58's blood glucose should have been monitored daily rather than weekly because the resident was receiving 15 unit of Lantus insulin daily. The DON stated that without daily monitoring, hypo or hyper glycemia occurrences may not be recognized promptly. The DON stated that by not monitoring Resident 58's blood glucose daily, the resident had an increased risk of diabetic complications that would affect the kidneys, eyes, nerves, and cardiovascular system. During a review of the facility P&P titled Diabetes – Clinical Protocol revised 11/2020, indicated that for the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin (for example, before breakfast and lunch_ and as necessary); monitor 3 to 4 times a day if on intensive insulin therapy or sliding-scale insulin; monitor as indicated if the individual is fasting before a medical procedure, has returned to the facility after a significant absence, or has an acute infection or illness.

Based on observation, interview and record review, the facility failed to ensure one of 10 sampled residents (Resident 90) with an indwelling catheter (a flexible plastic tube inserted into the bladder [an organ that collected and stored urine until it was expelled from the body] that remains there to provide continuous urinary drainage) received proper care and services in accordance to the facility's policy and procedures titled Catheter Care, Urinary, by failing to: 1. Ensure Treatment Nurse (TXN) 1 accurately assess Resident 90's urine for sediments (urine appears cloudy or contain visible particles - such as cells, minerals, or bacteria [germs])) that settle at the bottom of a urine sample) in the indwelling catheter tubing and follow the physician's order to flush the catheter on 7/2/2026. 2. Ensure the licensed nurses followed the physician's order to flush Resident 90's indwelling catheter each shift from 6/28/2026 to 7/2/2026. These deficient practices had the potential to result in Resident 90 contracting urinary tract infection (UTI-a medical condition when bacteria get into the urinary system [organs that produce, store and expel urine in the body] and multiply) and lead to urosepsis (a potentially life-threatening complication of urinary tract infection). Findings: During a review of Resident 90's admission Record (AR), the AR indicated the facility admitted Resident 90 on 5/16/2025 with diagnoses that include neuromuscular dysfunction of bladder (a condition occurs when an injury or disease interrupts the electrical signals between the brain and the bladder [an organ to collect and store urine until it is expelled from the body]) and heart failure (a condition where the heart becomes too weak or stiff to effectively pump blood to the body). During a review of Resident 90's Minimum Data Set (MDS, a resident assessment tool), dated 5/4/2026, the MDS indicated Resident 90 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 90 had an indwelling catheter. The MDS indicated Resident 90 required setup or clean-up assistance with eating, oral hygiene and personal hygiene, and partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 90's Progress Notes (PN), dated 6/28/2026 time 2:48 PM, the PN indicated sediments in urine. During an observation on 6/29/2026 at 10:13 AM, Resident 90 was lying in bed with an indwelling catheter that hung on the bed frame. A moderate amount of white, cloudy sediment was observed in the urine within the indwelling catheter tubing. During a review of Resident 90's PN, dated 6/29/2026 timed 2:38 PM, the PN indicated still a few sediments noted in the urine. During a review of Resident 90's PN, dated 6/30/2026 timed 1:51 AM, the PN indicated slight sedimentation noted in the urine. During a review of Resident 90's PN, dated 6/30/2026 timed 2:44 PM, the PN indicated a few amounts of sediments present in the urine. During a review of Resident 90's Order Summary Report (OSR), dated 7/2/2026, the report indicated the physician ordered to flush the resident's indwelling catheter every shift with 50 Milliliter (ML, a measurement unit) of normal saline (NS, a mixture of salt and water) as needed if with sediments, starting on 6/28/2026. During an observation on 6/30/2026 at 12:40 PM, there was a moderate amount of white cloudy urine sediment in the urine in Resident 90's indwelling catheter tubing. During an observation on 7/1/2026 at 10:40 PM, there was a moderate amount of white cloudy sediment in the urine in Resident 90's indwelling catheter tubing. During a concurrent interview and record review on 7/1/2026 at 11:07 AM with Licensed Vocational Nurse (LVN) 1, Resident 90's OSR and SBAR (Situation, Background, Assessment and Recommendation, a tool for standardizing and improving interprofessional communication) Communication Form, dated 6/27/2026, were reviewed. LVN 1 stated on 6/27/2026, LVN 1 noticed a moderate amount of urine sediment in Resident 90's indwelling catheter tubing, and the physician ordered to flush the indwelling catheter with 50 ML of NS as needed. LVN 1 stated there was some sediment in Resident 90's urine as today. LVN 1 stated she did not flush Resident 90's indwelling catheter and it was the Treatment Nurse (TXN) 1 who would flush the indwelling catheter. During a concurrent interview and record review on 7/2/2026 at 10:29 AM with the TXN 1, Resident 90's Treatment Administration Record (TAR) for June and July 2026, and Resident 90's PN, dated from 6/28/2026 to 7/2/2026, were reviewed. TXN 1 stated he did not flush Resident 90's indwelling catheter on 6/29/2026, 6/30/2026, 7/1/2026 and 7/2/2026. TXN 1 stated there was no record of other nurses flushed Resident 90's indwelling catheter on 6/28/2026, 6/29/2026, 6/30/2026, 7/1/2026 and 7/2/2026. During a concurrent observation and interview on 7/2/2026 at 10:55 AM with TXN 1, there was a moderate amount of white cloudy urine sediment present in Resident 90's indwelling catheter tubing. TXN 1 stated he did not flush Resident 90's indwelling catheter as he believed the white cloudy particles in the urine were not sediment. During a concurrent observation and interview on 7/2/2026 at 10:57 AM with LVN 1, Resident 90's urine in the indwelling catheter tubing was observed, LVN 1 stated white cloudy sediment was present in Resident 90's urine, and that, per physician's order, licensed nurses should flush the indwelling catheter with NS to prevent the indwelling catheter from clogging and reduce the risk of UTI. During an interview on 7/2/2026 at 11:31 AM with the Director of Nursing (DON), the DON stated licensed nurses should be able to accurately assess the appearance of the urine and recognize abnormalities, such as sediments, to prevent UTI. The DON stated Resident 90's urine had sediments and the nurses should follow the physician order to flush the indwelling catheter with NS to ensure the patency of the indwelling catheter and prevent UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 8/2022, the P&P indicated catheter irrigation may be ordered to prevent obstruction in resident at risk for obstruction. The P&P also indicated to observe the resident for complications associated with urinary catheters for unusual urine appearance and signs and symptoms of urinary tract infection.

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 71) who received Continuous Positive Airway Pressure (CPAP - medical device and therapy that pumps steady, mild stream of pressurized air through a hose and face mask into the airway) was provided care in accordance with the facility's policy and procedure to ensure resident had nothing by mouth two hours before using a full-face mask, monitor the oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) of the resident, general assessment (including vital signs, oxygen saturation, respiratory prior to procedure. titled CPAP/BiPAP (Bilevel Positive Airway Pressure a type of non-invasive ventilator that helps keep airways open and makes breathing easier) Support. This deficient practice placed Resident 71, who had diagnoses that affect the respiratory system (the body's way of bringing in oxygen) at risk of experiencing complications associated with the use of the CPAP. Findings: During a review of Resident 71's admission Record (AR), the AR indicated that Resident 71 was admitted on [DATE], with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), pulmonary edema (a condition caused by too much fluid in the lungs), morbid obesity (a severe, chronic disease where carrying extreme excess weight begins to damage your overall health), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 71's Minimum Data Set (MDS - a resident assessment tool) dated 5/6/2026, the MDS indicated Resident 71 has intact cognition (the ability to process thoughts and emotions), dependent (helper does all the effort) toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear. Substantial/maximal assistance in upper body dressing. The MDS also indicated that Resident 71 used CPAP since admission to the facility. During a review of Resident 71's Physician Order indicated Resident 71 had a physician order on 4/29/2026 to apply CPAP Pressure of 8 CMH2O, F1O2 of 30 = 2.5 liters per minute, of oxygen, at bedtime. During a review of Resident 71's Respiratory Administration Record dated 6/1/2026 thru 6/30/2026, indicated Resident 71 was administered CPAP at bedtime. During a review of Resident 71's Care Plan, dated 4/30/2026, indicated, Resident is on CPAP for Obstructive Sleep Apnea, (OSA - a sleep disorder where sleep is interrupted by abnormal breathing) with the goal to maintain normal breathing pattern by maintaining normal respirations, normal skin color, and regular respiratory rate/pattern. During an interview on 7/1/2026 at 10:18 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated not to be she was not aware of any complications of using CPAP. LVN 4 stated there were no complications listed in the physician orders or the medication administration record (MAR). During a concurrent interview and record review on 7/1/2026 at 10:48 with Registered Nurse Supervisor (RNS 1), Resident 71's Progress Notes dated 6/30/2026 timed at 1:36 AM indicated Resident 72 was placed on the CPAP with the order setting, resident tolerated the procedure well. RNS 1 stated that the Progress Notes did not have an assessment of Resident 72's status while receiving CPAP to indicate if the resident was assessed for complications related to CPAP. During an interview on 7/2/2026 at 9:54 AM with the Director of Nurses (DON), DON stated that complications for the CPAP included nausea, vomiting, abnormal vital signs (measurement of the blood pressure (normal ranges between 120/80), pulse (heart rate per minute, normal range is 60-100), respiration rate (number of breaths per minute normal range is between 12 to 20) and temperature (body temperature typically ranges from 97 F to 99 F) facial trauma, altered mental status, and the resident should not eat food or drink food two hours before the procedure. DON state that aspiration (fluid enters the airway or lungs by accident) can happen if nursing does not assess the resident for any of these conditions. During a review of the facility's policy and procedure (P&P) titled CPAP/BiPAP Support dated 3/2015 the P&P indicated to review and follow manufacturer's instructions for CPAP machine setup, it also indicated that the resident should have not eaten two hours before using a full-face mask, monitor oxygen saturation (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage), and a general assessment including vital signs (measure of the basic functions of your body includes your body temperature, blood pressure, pulse and respiratory (breathing) rate), oxygen saturation, prior to the procedure. During a review of the CPAP user manual titled KMS BIPAP undated, indicated that complications for the CPAP includes low blood pressure, pneumothorax (when air gets inside your chest cavity and creates pressure against your lung) head trauma, bypassed upper airway (breathing through an artificial tube rather than their natural nose and throat.

Based on observation, interview and record review the facility failed to treat one of two sampled resident (Resident 1) in a manner that promoted respect and dignity, when the Certified Nurse Assistant (CNA) 1 was rough and loud to Resident 1 who spoke and understand a foreign language during care. CNA1 yelled and pushed Resident 1 to turn to the side when changing the resident's wet clothing and asked the resident why she was wearing a long gown that was hard to remove. This deficient practice resulted in Resident 1 to experienced fear and anxiety (fear of the unknown) towards CNA 1 during interactions. Resident 1 to immediately contacted Family Member 1 (FM 1) while crying to inform her about what had occurred. Resident 1 began to frequently calling FM 1 to contact facility staff to assist such as when turning and repositioning. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/23/2026 with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness, arthritis (swelling, pain, and stiffness in your joints, dementia(a progressive state of decline in mental abilities). During a review of Resident 1's care plan titled, Communication Problem due to Language Barrier dated 4/24/2026, indicated resident had concern with communication due to language barrier. The intervention included providing translator as necessary to communicate with the resident who spoke a foreign language, ask resident to repeat what has been said to confirm that the resident understood message, use low tone of voice and speak slowly to the resident and present one thought, idea, question or command at a time. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/27/2026, the MDS indicated Resident's 1 cognition (the ability to process thoughts) was severely impaired. The MDS also indicated that Resident 1 was dependent on staff to roll left and right (the ability to roll from lying on the back to the left and right side), dressing, shower/bathe self, toileting/hygiene, substantial/maximal assistance in personal hygiene, oral hygiene, and partial/moderate assistance in eating. During an interview on 5/9/2026 at 12:42 PM with Resident 1, Resident 1 stated last week (5/4/2026) a nurse (Certified Nurse Assistant 1 [CNA 1]) who was taking care of her raised her tone of voice towards her and pushing her to turn to her sides to change her wet and soiled clothes. Resident 1 stated CNA 1 knew that she could not turn to her side, but CNA 1 was yelling at her to turn on her side. Resident 1 stated she called FM 1 immediately about the incident. Resident 1 stated her roommate (Resident 2) who witnessed how CNA 1 treated her also called FM 1 on 5/4/2026 approximately 4:30 AM and made her aware of what CNA 1 did to her. Resident 1 stated FM 1 immediately called the facility and talked to the staff (unknown). Resident 1 stated, the incident make her feel anxious towards CNA 1. During an interview on 5/9/2026 at 12:53 PM with FM 1, FM 1 stated that she received a call from Resident 1 on 5/4/2026 at around 4:30 AM, who was crying on the phone and told her that CNA 1 was screaming and pushing her in bed. FM 1 stated she asked Resident 1 why CNA 1 was screaming and pushing her? Resident 1 replied that CNA 1 was complaining that her clothes were wet and tight which was difficult to remove. FM 1 stated she immediately called the facility and spoke to LVN 1 who informed her that she was going to look into this matter and that she will report the incident to Registered Nurse (RN) 1. FM 1 stated that Resident 2 called her on the phone to inform her that CNA 1 screamed at Resident 1 while changing her wet clothing and asking Resident 1 to turn to her side knowing that Resident 1 could not turn without assistance. FM 1 stated that following the incident with CNA 1, Resident 1 had been frequently calling her to request that FM 1 contact staff to assist to assist her in turning and repositioning. FM 1 stated that she is not sure if staff is not turning her or if Resident 1 is afraid to ask staff for assistance. FM 1 stated she was concern of Resident 1's ongoing apprehension about requesting assistance directly from staff, indicating a persistent sense of fear and anxiety. During an interview on 5/9/2026 at 1:09 PM with Resident 2, Resident 2 stated she was awakened when she heard Resident 1 (her roommate) calling for help and crying. When she opened the curtain between her and Resident 1, she saw CNA 1 yelling at Resident 1, questioning why she was not wearing a hospital gown. Resident 2 stated CNA 1 asked Resident 1 to turn because CNA 1 was having a hard time removing Resident 1's wet clothing. Resident 2 stated she told CNA 1 The lady can't turn on her own, she needs help. CNA 1 continued to change Resident 1's clothing while Resident 1 continued to cry and CNA 1 left Resident 1 crying. Resident 2 stated she heard CNA 1 tell Resident 1, You are going to give me a stroke. Afterward, Resident 2 advised Resident 1 to call louder for help next time. Resident 2 stated she called Resident 1's family immediately on 5/4/2026 at 5AM to make her aware that CNA 1 was screaming at Resident 1. Resident 2 stated she felt the situation was very bad and injustice. Resident 2 stated, two facility staffs later came into the room to question Resident 1. Resident 2 explained she did not report the incident to facility staff out of fear of retaliation. During a review of the facility's P&P titled, Dignity dated 2/2021, the Policy & Procedure (P&P) indicated it is the policy of the facility to support resident's in exercising their rights such as encouraging the resident to dress in clothing that they prefer. Staff are expected to always speak to residents respectfully. the P&P also indicated that residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with the facility.

Based on observation, interview and record review, the facility failed implement to implement the facility's policies and procedure titled Abuse Investigation and Reporting for one of two sampled resident (Resident 1) by facility to: 1. Investigate the allegation of abuse when Family (FAM 1) reported to Licensed Vocational Nurse (LVN) 1 that Certified Nurse Assistant (CNA) 1 was loud and rough to Resident 1 when changing the resident's wet clothing. CNA 1 was yelling at Resident 1 pushing the resident while turning to the side and complained that resident should not be wearing a long gown that was hard to remove. 2. Report the allegation of abuse to the state agency, police department and the ombudsman when FAM 1 reported to LVN 1 that CNA 1 was rough and yelling at Resident during care. 3. Protect Resident 1 from the alleged abuser (CNA1) continued to work at the facility 5/4/26 when FAM 1 reported the allegation of abuse to LVN 1. 4. Identify the alleged abuse as verbal and emotional abuse when LVN 1 informed the DSD and DON that FAM 1 reported to her that CNA 1 was yelling and rough with Resident 1 while being changed due to wet clothing. These deficient practices resulted in Residents 1 feeling anxious (fear of the unknown) towards CNA 1 during interactions, and frequently called FM 1 to ask staff to assist her except for CNA 1. In addition, this could lead to emotional decline and decreased quality of life of Resident 1 and other vulnerable residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/23/2026 with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness, arthritis (swelling, pain, and stiffness in your joints, dementia(a progressive state of decline in mental abilities). During a review of Resident 1's care plan titled, Related Risk Factors/DX Arthritis, Parkinson's, Dementia . dated 4/24/2026, indicated to assist Resident 1 to turn and reposition every two hours using a draw sheet or a lifting device to move the resident. During a review of Resident 1's care plan titled, Communication Problem due to Language Barrier dated 4/24/2026, indicated resident had concern with communication due to language barrier. The intervention included to provide translators as necessary to communicate with the resident who spoke a foreign language, use low tone of voice and speak slowly to the resident and present one thought, idea, question or command at a time. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/27/2026, the MDS indicated Resident's 1 cognition (the ability to process thoughts) was severely impaired. The MDS also indicated that Resident 1 was dependent on staff to roll left and right (the ability to roll from lying on the back to the left and right side), dressing, shower/bathe self, toileting hygiene, substantial/maximal assistance in personal hygiene, oral hygiene, and partial/moderate assistance in eating. During an interview on 5/9/2026 at 12:06 PM with the facility Administrator (ADM 1), ADM 1 stated there was no allegation abuse reported to her by the facility staff or any resident representatives. During an interview on 5/9/2026 at 12:42 PM with Resident 1, Resident 1 stated last week (5/4/2026) a nurse (Certified Nurse Assistant 1 [CNA 1]) who was taking care of her raised her tone of voice towards her and pushed her to turn to her sides to change her wet and soiled clothes. Resident 1 stated CNA 1 knew that she could not turn to her side, but CNA 1 was yelling at her to turn on her side. Resident 1 stated she called FM 1 immediately about the incident. Resident 1 stated her roommate (Resident 2) who witnessed how CNA 1 treated her also called FM 1 on 5/4/2026 approximately 4:30 AM and made her aware of what CNA 1 did to her. Resident 1 stated FM 1 immediately called the facility and talked to the staff (unknown). Resident 1 stated, the incident make her feel anxious towards CNA 1. During an interview on 5/9/2026 at 12:53 PM with FM 1, FM 1 stated that she received a call from Resident 1 on 5/4/2026 at around 4:30 AM, who was crying on the phone and told her that CNA 1 was screaming and pushing her in bed. FM 1 stated she asked Resident 1 why CNA 1 was screaming and pushing her? Resident 1 replied that CNA 1 was complaining that her clothes were wet and tight which was difficult to remove. FM 1 stated she immediately called the facility and spoke to LVN 1 who informed her that she was going to look into this matter and that she will report the incident to Registered Nurse (RN) 1. FM 1 stated that Resident 2 called her on the phone to inform her that CNA 1 screamed at Resident 1 while changing her wet clothing and asking Resident 1 to turn to her side knowing that Resident 1 could not turn without assistance. FM 1 stated that following the incident with CNA 1, Resident 1 had been frequently calling her to request that FM 1 contact staff to assist to assist her in turning and repositioning. FM 1 stated that she is not sure if staff is not turning her or if Resident 1 is afraid to ask staff for assistance. FM 1 stated she was concern of Resident 1's ongoing apprehension about requesting assistance directly from staff, indicating a persistent sense of fear and anxiety. During an interview on 5/9/2026 at 1:09 PM with Resident 2, Resident 2 stated on 5/4/2026 at around 4:30 AM., she was awakened when she heard Resident 1 (her roommate) calling for help and crying. When she opened the curtain between her and Resident 1, she saw CNA 1 yelling at Resident 1, questioning why she was not wearing a hospital gown. Resident 2 stated CNA 1 asked Resident 1 to turn because CNA 1 was having a hard time removing Resident 1's wet clothing. Resident 2 stated she told CNA 1 The lady can't turn on her own, she needs help. CNA 1 continued to change Resident 1's clothing while Resident 1 continued to cry and CNA 1 left Resident 1 crying. Afterward, Resident 2 advised Resident 1 to call louder for help next time. Resident 2 stated she called Resident 1's family immediately on 5/4/2026 at 5AM to make her aware the CNA 1 was screaming Resident 1. Resident 2 stated, two facility staffs later came into the room to question Resident 1. Resident 2 explained she did not report the incident to facility staff out of fear of retaliation. During an interview on 5/9/2026 at 3:46 PM with RN 1, RN 1 stated he was the nursing supervisor assigned on 5/4/2026 at night shift, RN 1 denied that LVN 1 and other staff reported any allegation of abuse to him or that FAM 1 reported any allegation of abuse during his working hours on 5/4/2026. During an interview on 5/11/2026 at 6:18 AM with CNA 2, CNA 2 stated RN 2 informed her that CNA 1 could not take care of Resident 1 because Resident 1 was complaining about CNA 1, but RN 2 did not explain why. During an interview on 5/11/2026 at 6:54 AM with LVN 2, LVN 2 stated, through a translator, Resident 1 informed him that the room assignment was changed due to Resident 1 not wanting CNA 1 to provide care because CNA 1 was not nice to her. LVN 2 stated he did not ask to why CNA 1 was not nice to her, so he did not ask the resident further question. LVN 2 did not report Resident 1's complaint about CNA 1 to the DON or ADM. LVN 2 stated when he came back to work after being off and the assignment was changed and thought the issues were already addressed. During an interview on 5/11/2026 at 8:31AM with LVN 1, LVN 1 stated FM 1 called her on 5/4/2026 around 5AM and informed her FM 1 told her that Resident 1 was told that she could not bring a sweater. LVN 1 did not explain why there was an issue with the sweater. LVN 1 stated that she did not know why CNA 1's assignment was changed and not assigned to Resident 1. LVN 1 denied that FM 1 reported to her that CNA 1 was yelling and rough to Resident 1. LVN 1 stated Resident 1 and Resident 2 did not report anything suspicious to her regarding CNA 1 and that Resident 1 did not report anything to her as well. During an interview on 5/11/2026 at 8:42 AM with DSD 1, DSD 1 stated that LVN 1 communicated to him on 5/4/2026 in the morning that LVN 1 had received a call from FM 1 regarding Resident 1's clothing and that LVN 1 thought CNA 1 had a miscommunication issue with Resident 1. DSD 1 stated that FM 1 thought the CNA 1 was upset regarding the clothing that got wet and was too tight on the resident. DSD 1 stated that based on that conversation he took it upon himself to remove CNA 1 from Resident 1's assignment. DSD 1 stated any type of grievance is written up and the administrator gets informed with the investigation and resolution. DSD 1 stated that he did not identify the situation as abuse, therefore he did not report the situation to the ADM and stated that he thought it was just a miscommunication issue. During an interview on 5/11/2026 at 9:04 AM with CNA 1, CNA 1 stated that around on 5/4/2026 at 4:30 AM she woke up Resident 1 to change her incontinent brief, she took the blanket off and saw that the resident's entire gown and sweater were all wet. CNA 1 stated that she had no choice but to sit Resident 1 at the edge of the bed because it was very difficult to remove the clothing while lying in bed. CNA 1 stated that she opened the door to see if there were any staff that could help change Resident 1 but couldn't find anyone to assist her. CNA 1 stated that she suggested Resident 1 to tell her family to bring a gown that had buttons or zipper. CNA 1 stated that the roommate Resident 2 was awake and was helping her in translating the information to Resident 1. CNA 1 stated that on 5/4/2026 at about 6AM, RN 1 walked toward her and told CNA 1 that the family had complaint about her being rough and loud with Resident 1. CNA 1 stated that the next day her assignment was change but was never given a reason and that based on the complaint she thought that maybe the family of Resident 1 did not want her to take care of Resident 1. CNA 1 stated on 5/9/2026 at the beginning of her shift around 4PM CNA 1 stated she was called to the office by the ADM 1 and DON and was told that the Health Department was at the facility and were investigating the complaint and that CNA 1 was suspended pending investigation. During a concurrent record review of CNA 1's Payroll Pay Period 5/1/2026 - 5/15/2026 with DSD 1, CNA 1 worked at the facility after alleged complaint on 5/4/2026 10:54 PM - 7:01 AM; 5/5/2026 10:58 PM - 7:00 AM; 5/6/2026 10:57 AM - 6:58 AM, 5/8/2026 2:57 PM -11:00 PM; 5/9/2026 3:04 PM-5:12 PM.DSD stated that the CNA was suspended the day the Health Department visited the facility. DSD stated that the process is that immediately when there is an allege abuse the CNA is suspended until their investigation is completed and that the CNA should have been suspended until the allege abuse investigation was completed. During an interview on 5/11/2026 at 10:42 AM with the Director of Nurses (DON), DON stated that any type of family grievance staff should complete a grievance report that is forwarded to the administrator (ADM). DON stated that there was no grievance report from the staff or investigation conducted for Resident 1's allegation of abuse. CNA 1 was not suspended after the allegation of abuse from FM1 and Resident 1 because the incident was not reported by LVN 1, LVN 2, DSD and RN 1 and other facility staffs to the DON or ADM. DON stated that when the staff Charge Nurse/Registered Nurse were made aware of the grievance the report should have been completed and forwarded to the administrator. During a review of facility's policy and procedure (P&P) titled, Resident Rights Guidelines for All Nursing Procedures dated 10/2010, the P&P indicated it is the policy of the facility that prior to having direct care responsibilities for residents, staff must have appropriate in-service training on resident rights such as preventing, recognizing and reporting resident abuse. During a review of facility's P&P titled, Abuse Investigation and Reporting dated 7/2017 indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The Administrator will keep the resident and his/her representative informed of the progress of the investigation. The Administrator will suspend immediately any employee who has been accused of resident abuse pending the outcome of the investigation. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented.

Based on observation, interview, and record review, the facility failed to provide safe and hazard free environment and interventions for safety and supervision for four of four sampled residents (Residents 7,69,102, and 79) the facility failed to: 1.Ensure Resident 7's bed alarm was in the working condition. 2.Provide adequate supervision and safety measures to ensure safety to Residents 69 and 102 who are at risk for elopement (leaving the facility without permission) keeping the patio gate closed and not kept opened with a wire. 3a.Ensure Certified Nurse Assistants 3 and 4 maintain Resident 79, environment free from accidents/hazards, by using caution during transfers and bed mobility, to prevent striking the resident's arms, legs, and hands against any sharp or hard surface to prevent bruising/bleeding for Resident 79, who was assessed at risk for bleeding and bruising due to Lovenox (an anticoagulant) medication, in accordance with the resident's developed care plans. 3b. Ensure that LVN 6 notified Resident 79's representative (RP 1) of Resident 79's accident that resulted to an open ecchymosis and bleeding on the right dorsal forearm on 6/13/25, in accordance with the facility's policy and procedure (P&P) titled Safety and Supervision of Residents. 3c. Ensure Resident 79's information recorded in the resident's record titled Situation Background Report (SBAR) report was accurately documented to include that RP 1 was notified of Resident 79's open ecchymosis and bleeding to the right dorsal forearm on 6/13/25, in accordance with the facility's policy and procedure (P&P) titled Safety and Supervision of Residents. 3d. Ensure Resident 79's information recorded in the resident's record titled Situation Background Report (SBAR) report was accurately documented to include that Resident 79's open ecchymosis was bleeding on the right dorsal forearm on 6/13/25, as reported by Resident 79 and CNA 4, in accordance with the facility's policy and procedure (P&P) titled Safety and Supervision of Residents. LVN 6 verbalized on 6/27/25 at 11:22 AM during an interview that Resident 79's right forearm skin tear was bleeding on 6/13/25, but the SBAR documentation indicated No bleeding noted. LVN 6 verbalized on 6/27/25 at 11:22 AM during an interview that she did not notify RP 1 of Resident 79's skin tear to the right dorsal forearm, but the SBAR documentation indicated [RP 1] was made aware. These deficient practices had placed the residents: Resident 7 at risk for fall and injury. Resident 69 and 102 to be at risk for elopement and potential harm, which could lead to serious injury and decline in the resident's well-being. and for Resident 79 to be at risk for injury and harm. Findings: 1. During a review of Resident 7's admission Record (AR), the AR indicated the facility originally admitted Resident 7 on 7/22/2022 and readmitted on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and repeated falls. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 7 had severely impaired memory and cognition (ability to think and reasonably). The MDS indicated Resident 7 required partial/moderate assistance with eating and oral hygiene, and substantial/maximal assistance with personal hygiene, toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 7's Order Summary Report, dated 6/24/2025, the Report indicated the physician ordered sensor bed alarm (a device placed on or under a bed that alerts caregivers when someone starts to get up or get out of bed) for safety every shift, starting on 1/9/2024. During a review of Resident 7's Care Plan, dated 1/9/2024, the Care Plan indicated interventions for a sensor pad in bed for safety was implemented to prevent falls. During a review of Resident 7's Quarterly Risk Assessment and Assessment Outcomes, dated 4/9/2025, the assessment indicated Resident 7 had a total score of 14 for fall risk, which represented high risk for fall. During a concurrent observation and interview on 6/24/2025 at 9:29 AM with Registered Nurse (RN) 1 in Resident 7's room, Resident 7's bed alarm monitor was observed on the floor next to Resident 7's bed, with the sensor pad plug disconnected from the sensor mat jack. RN 1 inserted the sensor pad plug into the sensor mat jack on the monitor and hung the sensor pad on the bed rail, but the sensor pad plug fell out the sensor mat jack. on the monitor. RN 1 stated, the sensor pad plug was loose, and since the sensor mat plug could be easily disconnected, the bed alarm monitor was not in good working condition. RN 1 stated, Resident 7 was at risk for falls and the resident could get out of bed without staff's knowledge, which could lead to fall and injury. During an interview on 6/24/25 at 11:04 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she did not check Resident 7's bed alarms this morning (6/24/25) and did not know Resident 7's bed alarm monitor's sensor plug was loose. CNA 1 stated, if the bed alarm was not working, the bed alarm would not trigger to alert facility staff that Resident 7 attempted to get out of bed. CNA 1 stated the bed alarm monitor was used to assist and aid in the prevention of fall. when the resident was trying to get out of bed in time to prevent fall. During an interview on 6/27/25 at 9:24 AM with the Director of Nursing (DON), the DON stated staff must check and make sure bed alarms were in place and working properly every shift. The DON stated, if the resident's bed alarm was not working properly, it could place the resident at risk for fall and injury. During a review of the undated facility's policy and procedures (P&P) titled, User Manual, the P&P indicated to insert the sensor pad's telephone style plug into the ‘sensor Mat' jack on the monitor until you hear or feel the ‘click' of the plug locking in place. During a review of the facility's P&P titled, Falls-Clinical Protocol, dated 3/2018, the P&P indicated Based on the proceeding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.Examples of such interventions may include.use of bed and wheelchair alarm. 2a. During an observation of the facility's outdoor patio on 6/25/2025 at 4:35 PM, a visitor was observed exiting through patio get that was held open. The patio gate held open by gray wire that was tied onto nearby bush. Patio exits gate leads to main residential street. During a concurrent observation of the open patio gate and interview on 6/25/2025 at 4:37 PM, treatment nurse (TN) 2 confirmed patio gate was left open and tied onto a nearby bush with a gray wire. TN 2 stated he did not know who tied the wire to the bush to hold the patio gate open. TN 2 stated the gate was not locked from the inside (patio area) and there was no alarm to indicate the patio gate was open. TN 2 stated the patio gate was locked from the outside so no one can enter. During a concurrent observation of the open patio gate and interview on 6/25/2025 at 4:47 PM, the Administrator (ADM) confirmed patio gate was left open and tied onto a nearby bush with a gray wire. The ADM stated the gate is kept unlocked from the patio for fire safety and remains locked from the outside so no one can get in. The ADM stated she did not know who would tie a wire on the bush. The ADM stated the patio gate should be kept closed because someone can come into the patio area. During an observation of the facility's outdoor patio on 6/26/2025 at 11:36 AM, a family member (FM) 2 was observed trying to exit through patio gate. Door alarm was heard as patio door was pushed. During an interview on 6/26/2025 at 11:39 AM, FM 2 stated she was trying to go through the patio gate exit to smoke. FM 2 stated the patio gate never had an alarm before and now they are saying we cannot use this exit and must go around. FM 2 stated the alarm was never there before and would often use the patio gate as an exit gate. FM 2 stated she has seen the patio gate held open before. During an interview on 6/26/2025 at 11:46 AM, FM 3 stated the door alarm was new. FM 3 stated she has never used the patio gate as an exit before but had seen nursing students use the exit gate through the patio. FM 3 stated she has seen the patio gate open a few times and the gate was even held open by a wire. FM 3 stated she has seen the wire. During a review of Resident 69's admission Record indicated Resident 69 was initially admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (change in how the brain works due to an underlying condition), unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). During a review of Resident 69's History and Physical (H&P) dated 3/27/2025 indicated Resident 69 did not have the capacity to understand and make decisions. During a review of Resident 69's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 6/19/2025, indicated the resident had severely impaired cognitive skills for decision making. During a review of Resident 69's active care plans, had no documented evidence of a care plan or interventions were created to prevent the resident from elopement for elopement risk. During a review of Resident 69's Quarterly Risk assessment dated [DATE] indicated resident walked frequently with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. During a concurrent interview and record review of Resident 69's Quarterly Risk Assessments dated 6/19/2025 on 6/26/2025 at 1:24 PM, MDSN 1 stated the evaluation for elopement risk should have been filled out correctly. MDSN 1 stated this was so you have a proper idea of where the residents are, functionally. MDSN 1 stated because of this, there was a discrepancy on the MDS, the MDS provides an overview of what kind of care the resident needs. MDSN 1 stated the assessment needs to be accurate so the facility knows who would need individualized care. b. During a review of Resident 102's admission Record indicated Resident 102 was initially admitted to the facility on [DATE], with diagnoses that included unspecified dementia, muscle wasting and atrophy and cognitive communication deficit. During a review of Resident 102's History and Physical (H&P) dated 8/14/2024 indicated Resident 102 did not have the capacity to understand and make decisions. During a review of Resident 102's MDS, dated [DATE], indicated the resident had severely impaired cognition. During a review of Resident 102's active care plans, had no documented evidence of a care plan or interventions created for elopement risk. During a review of Resident 102's Quarterly Risk assessment dated [DATE] indicated resident walked occasionally with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. During a review of Resident 102's Quarterly Risk assessment dated [DATE] indicated resident walked occasionally with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. During a review of Resident 102's Quarterly Risk assessment dated [DATE] indicated resident walked occasionally with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. During a concurrent interview and record review of Resident 102's Quarterly Risk assessment dated [DATE] on 6/26/2025 at 12:43 PM, MDSN 2 confirmed Resident 102's elopement risk evaluation was not completed. MDSN 2 stated when documenting Resident 102's elopement risk she did not think dementia could be a risk for elopement and misinterpreted the question. During a concurrent interview and record review of Resident 102's Quarterly Risk assessment dated [DATE] on 6/26/2025 at 1:46 PM, MDSN 1 confirmed Resident 102's elopement risk was incorrect and should have been filled out correctly. MDSN 1 stated need to make sure documentation was accurate to get a proper picture of the resident and what their activity levels and needs are. During an interview on 6/27/2025 at 1:36 PM, the Director of Nursing (DON) stated the patio gate was not an exit and should not be used as an exit. The DON stated the patio gate should only be used for fire safety. The DON stated if the patio gate is left open it becomes a safety issue for the residents. During an interview on 6/27/2025 at 1:38 PM, the Director of Nursing (DON) stated the elopement risk assessment should have been accurate and filled out completely. The DON stated this was to provide an accurate intervention for resident. The DON stated if a resident was a high risk for elopement they need to have appropriate placement. The DON stated if there was a resident who tried to elope, the facility needs to provide intervention right away and look for placement because the facility was not an appropriate place for resident who was at high risk for elopement. A review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents dated 7/2017 indicated the facility strives to make the environment free from accident hazards as possible, resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 3a. During a review of Resident 79's admission Record (AR), the AR indicated the facility originally admitted the resident on 12/10/2024 and readmitted on [DATE] with diagnoses that included muscle weakness (a reduced ability of one or more muscles to exert force), Acute pulmonary edema (APE- A condition caused by excess fluid in the lungs). During a review of Resident 79's History and Physical [H&P] dated 12/11/2024, the H&P indicated Resident 79 does not have the capacity to understand and make decisions. During a review of Resident 79's care plan for Potential for bleeding/bruising due to anticoagulant therapy for DVT prophylaxis, initiated on 1/25/25, the care plan interventions included a goal to monitor the resident for signs of bleeding. During a review of Resident 79's Order Summary Report, dated 6/1/25, the Order Summary Report indicated the following orders: a. Lovenox (an anticoagulant, or blood thinner, meaning it helps prevent the formation of blood clots) injection solution prefilled syringe 40 milligrams (a unit of measure), inject subcutaneously in the morning for Deep vein thrombosis (DVT- is a condition where a blood clot forms in a deep vein) prophylaxis. b. Monitor for signs and symptoms of bleeding for anticoagulant use: blood in urine, blood in stool, coffee ground emesis, bleeding gums, confusion, cols clammy skin and notify primary care practitioner if present, document Y= with symptoms and N=no symptoms every shift. During a review of Resident 79's previously developed care plan initiated on 6/01/25 for Skin: left lower extremity redness related to recent hospitalization ., the care plan indicated as an intervention to use caution during transfer and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. During a review of Resident 79's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/12/2025, the MDS indicated Resident 79 had severely impaired memory and cognition (ability to think and reasonably). The MDS indicated Resident 79 is dependent (helper does all of the effort) on staff with toileting, shower and putting on and taking off footwear. The MDS indicated Resident 79 required partial/moderate assistance with upper body dressing, The MDS indicated Resident 79 required supervision (helper provided verbal cues) when eating in addition the MDS indicated Resident 79 required set up (helper sets up or cleans up) for oral hygiene. During a review of the SBAR communication form authored by Licensed Vocational Nurse (LVN 6), dated 6/13/2025 for Resident 79, the SBAR indicated Resident [79] is alert and oriented X 4, no change in level of consciousness noted. During rounding noted resident with open ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) on right dorsal (relating to the upper side) forearm, 2.5 centimeters. No bleeding noted. No sign and symptoms of infection noted. Asked resident what happened, the resident stated that I accidently hit on the side rail when reaching to my side table, it wasn't that hard, but I still got this. Resident [79] denied pain and discomfort. Resident [79] is on Lovenox daily which predispose the resident for easy bruising. Good skin care provided, and first aid done.Called Nurse Practitioner and made aware with no new orders at this time. Resident [79]'s representative made aware. During a review of Resident 79's care plan for Open ecchymosis on right dorsal forearm initiated in 6/13/2025, the care plan did not include resident specific interventions to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces, in accordance with Resident 79's previous history of accidents/injuries incurred during bed mobility. During an interview on 6/24/25 at 10:05 AM with Resident 79, and in the presence of Resident 79's Resident Representative (RP 1), Resident 79 stated a few weeks ago, two Certified Nursing Assistants (CNAs), Whammed me [Resident 79] against the bed rail, it happened last week at night. Resident 79 stated she was banged against the bed and the wall. Resident 79 further stated After we (Resident 79 and the two CNAs) saw blood dripping [from Resident 79's arm], the CNAs called the charge nurse (LVN 6) to come in. Resident 79 stated LVN 6 came inside her room and wiped off the blood from her arm (right arm) and put a band aid on top of it. During the same interview, RP 1 stated the incident happened a couple weeks ago. RP 1 stated he was not notified by any facility staff of Resident 79 having a skin tear due to hitting her arm against the bed side rails, that night. RP 1 stated he found out about the incident, the following day (6/13/25 AM shift) when he came to visit Resident 79 at the facility, on 6/13/25 and was informed by Resident 79 about the incident. During a review of a facility provided document signed and dated 6/27/2025, the document indicated This letter is a follow up letter regarding an allegation incident that occurred on 6/13/2025, approximately at 1:10 AM. Resident 79 reported on 6/27/25 at 3 pm to the Social Worker and Assistant Director of Nursing that at approximately 1:10 AM, on 6/13/25, two female Certified Nursing Assistants (CNA) came into her [Resident 79] room and while changing her [Resident 79], they turned her to the right side and her right forearm accidently hit the side rail causing an open ecchymosis During an interview on 6/27/25 at 11:22 AM with LVN 6, LVN 6 stated that on 6/13/25, she was asked by CNA 3 to go look at Resident 79 and stated that the resident's skin was open like a skin tear. LVN 6 stated, she went to Resident 79's room to do an assessment and cleaned the bleeding wound (skin tear) with saline solution then put antiseptic and covered the wound. LVN 4 stated she could not recall if it was Resident 79 or CNA 3, who explained to her how the incident (skin tear) occurred. LVN 4 stated she documented in Resident 79's record that she notified Resident 79's RP (RP 1) but she actually did not notify RP 1. LVN 6 stated she actually endorsed the RP notification to another Licensed Vocational Nurse (LVN 3) and Treatment Nurse 1. During an interview on 6/27/25 at 1:36 PM with CNA 4, CNA 4 stated, she was asked by CNA 3 for assistance in changing Resident 79 on 6/13/25. CNA 4 stated she observed CNA 3 changed Resident 79 while lying in bed and when they turned Resident 79, she heard Resident 79 yell out Ouch. CNA 4 stated she asked Resident 79 What happened Mama and Resident 79 proceeded to show her arm, which was bleeding. CNA 4 stated CNA 3 immediately left the room to call LVN 6. CNA 4 stated when CNA 3 returned to the room with LVN 6, CNA 3 left as she had her assigned residents to care for. CNA 4 stated she did not report the actual cause of Resident 79's skin tear to LVN 6, because she assumed CNA 3 informed LVN 6 what had occurred and no one from the facility had called her to ask how or what had occurred to Resident 79. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, with a revision date of July 2017, the P&P indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy further indicated 4. Employees shall be trained on potential accident hazards and demonstrate knowledge on how to identify and report accident hazards and try to prevent avoidable accidents.

Based on observation, interview, and record review, the facility to failed to provide respiratory care to ensure four of 4 sampled residents (Resident 15, 99, 75, and 213) who were receiving oxygen therapy were provided care in accordance with the professional standard of practice and facility's policy and procedure by failing to: 1.Ensure Resident 99 was monitored to ensure the resident wears the nasal cannula (a tube inserted into the nostril used to deliver oxygen into the lungs) to received continuous oxygen as ordered by the physician ordered for oxygen administration. 2.Ensure Resident 15's oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was placed in designated plastic bag when not in use. 3. Facility failed to provide a working/ functioning BIPAP (a type of non-invasive ventilation that helps people breathe by providing two different levels of air pressure through a mask) machine for one of one sampled resident (Resident 213) with a diagnoses of sleep apnea upon admission and for 7 days after (7/17/2025-7/24/2025). 4.Ensure the nasal cannula (NC-a flexible tube used to deliver supplemental oxygen to people through the nostrils) was changed every seven (7) days for Resident 75 and to ensure to label the oxygen humidifier bottle (a device used to add moisture to oxygen gas, making it more comfortable and less drying for patients who require supplemental oxygen therapy) with the date it was opened and used for Resident 75. These deficient practices placed Residents 15, 99, 75, and 213 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues), respiratory infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility which can lead into serious injury or death. Findings: 1. During a review of Resident 99's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included fusion of spine lumbar region (surgical procedure that joins two or more vertebrae in the lower back, aiming to stabilize the spine and reduce pain), acute respiratory failure, and muscle wasting and atrophy (partial or complete wasting away of a part of the body). During a review of Resident 99's History and Physical (H&P), dated 6/20/2025, indicated the resident had the capacity to understand and make decisions. During a review of Resident 99's Order Summary Report dated 6/13/2025, indicated a physician order to administer Oxygen at 2 to 3 LPM (liters per minute) via nasal cannula continuously for acute respiratory failure (ARF-failure of the lungs to meet the body's oxygen demand), may titrate up to 5 LPM via nasal cannula and if oxygen saturation still < 95% may titrate up to 6-10 LPM via non-rebreather mask (a mask used to deliver high flow and concentrated oxygen)to keep oxygen saturation > 95% with humidifier for 2 to 3 L per resident and responsible party request every shift. During an observation in Resident 99's room on 6/24/2025 at 8:56 AM, Resident 99's was talking on the phone and not wearing nasal cannula with the oxygen concentrator on. Resident 99 stated the nasal cannula was behind her head. During a concurrent observation and interview in Resident 99's room on 6/24/2025 at 9:09 AM, verified with RN 1 of Resident 99 was not wearing the nasal cannula. RN 1 reminded Resident 99 to wear oxygen via nasal cannula. During an interview with the DON on 6/27/2025 at 1:35 PM, the DON stated if resident does not wear oxygen nasal cannula as ordered it should be documented, and care plan should be revised. The DON stated the nurse should notify the physician. The DON stated if the resident does not wear oxygen, there could be a decrease in oxygen saturation. 2. During a review of Resident 15's admission record indicated the resident was readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), chronic obstructive pulmonary disease (COPD, lung disease causing restricted airflow and breathing problems) with (acute) exacerbation (worsening of a disease or an increase in its symptoms), and intervertebral disc degeneration lumbar region (breakdown of the discs between the vertebrae [back bones] in the lower back) with discogenic back pain (type of low back pain that originates from a damaged or degenerated intervertebral disc). During a review of Resident 15's History and Physical (H&P), dated 6/10/2025, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 15's Order Summary Report dated 4/11/2025, indicated a physician order to administer Oxygen at 2 to 3 liters (L, unit of measure) per minute (PM) via nasal cannula continuous for COPD, may titrate up to 5 LPM via nasal cannula and if oxygen saturation still < 95 may titrate up to 6-10 LPM via non-rebreather mask to keep oxygen saturation > 95% every shift. During an observation in Resident 15's room on 6/24/2025 at 9:01 AM, Resident 15's oxygen tubing and nasal cannula was observed on resident's soiled bed and oxygen machine still on. Resident 15 was not in the room. During a concurrent observation and interview in Resident 15's room on 6/24/2025 at 9:09 AM, verified with registered nurse (RN) 1 of Resident 15's oxygen tubing and nasal cannula on the resident bed, not in use. RN 1 stated the oxygen tubing and nasal cannula should be in the plastic bag and not on the bed because of infection control. During an interview with the Director of Nursing (DON) on 6/27/2025 at 1:34 PM, the DON stated when oxygen was not in use, the oxygen tubing and nasal cannula should be placed in the designated bag due to infection control. DON stated resident would be at risk for respiratory infection. A review of the facility's policy and procedure (P&P) titled Oxygen Administration dated 2001 indicated to provide guidelines for safe oxygen administration. 3. During a review of Resident 213's admission Record (AR), the AR indicated the facility admitted Resident 1 on 6/17/2025 with diagnoses that included acute respiratory failure (failure of the lungs to meet the body's oxygen demand) with hypercapnia (a condition where the lungs cannot adequately remove carbon dioxide (CO2) from the blood), obstructive sleep apnea (sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage in the upper airway). During a review of Resident 213's History and Physical [H&P] dated 6/18/2025, the H&P indicated the resident has the capacity to understand and make medical decisions. During a review of Resident 213's Order Summary Report, indicated the physician ordered on 6/17/2025 for BIPAP for obstructive sleep apnea at least 12 hours at bedtime. During a review of Resident 213's Progress notes dated 6/18/2025 timed at 11PM, indicated BIPAP not used due to missing parts, applied oxygen inhalation at 3 liters (unit of measurement) via nasal canula (a device that delivers extra oxygen through a tube and into your nose) authored by Licensed Vocational Nurse (LVN 4). During a review of Resident 213's Progress notes dated 6/19/2025. timed at 12:20 AM indicated, CPAP noted missing parts no strap, hose doesn't fit mask. Staff to follow up on missing parts at appropriate time. authored by LVN 4. During a review of Resident 213's Progress notes dated 6/23/2025 timed at 9:30 PM indicated awaiting mask strap, will apply when available authored by LVN 4. During a review of Facility provided document titled delivery receipt that included billed to Resident 213, dated 6/18/2024, indicated the following items were delivered to the facility: 1.Full face mask quantity 1.2. Headgear for CPAP/BiPAP quantity 1.3. Tubing 6 feet quantity 1,4. Enrichment FOR CPAP quantity 1 ,5. BIPAP G3 [NAME] quantity 1,6. BIPAP Humidifier G3 [NAME] quantity 1. During a review of Facility provided document titled delivery receipt that included billed to Resident 213, dated 6/24/2024, indicated the following items were delivered to the facility: 1.Full face mask quantity 1, 2. Headgear for CPAP/BiPAP quantity 1 , 3. Tubing 6 feet quantity 1, 4. Enrichment FOR CPAP quantity 1 During an interview on 6/24/2025 at 9:11 AM with Resident 213, Resident 213 stated he has sleep apnea and needs a CPAP in order to sleep at night. Resident 213 stated the day he was admitted to the facility they ordered a CPAP machine on admission but it wasn't working. Resident 213 stated the nurse who was helping me put it on said it was missing pieces and it was leaking, she said they would order a new one. Resident 213 stated with out his CPAP machine he can't sleep at night. Resident 213 stated a few days ago I woke up and I couldn't breathe it felt like I couldn't catch my breath. Resident 213 stated he asked his nurse again few days after admission but she told him they are still waiting for the missing parts. Resident 213 stated he is very tired during the day because he is not able to get quality sleep and wakes up feeling like he's choking at night. Resident 213 stated last night another nurse came and tried putting the same machine back on him and also said it wasn't working and that the facility would re- order a new one. During a telephone interview on 6/27/2025 at 9:37 AM with License Vocational Nurse (LVN 4), LVN 4 stated she was Resident 213's on admission [DATE]) when Resident 213 informed them he uses a CPAP to sleep at night. LVN 4 stated RN supervisor that evening ordered the machine. When the machine came in that same evening LVN 4 stated she put the machine together and fitted the mask to the resident at bedtime but the straps were not the correct ones as they did not fit Resident 213 and the machine would leak when it was on from the hose part, it sounded like air was leaking. LVN 4 stated she informed the charge nurse that night of the issue. LVN 4 stated on 3/23/25 Resident 213 told her he needed to use his CPAP machine at bedtime. LVN 4 stated she called the RN supervisor to fit the mask on Resident 213 and it still didn't fit correctly then RN supervisor told Resident 213 they were going to order a new machine. LVN 4 stated she forgot to follow up with anyone up after 6/18/25 until 6/23/225 when Resident 213 asked for the machine again at bedtime. During an interview and record review on 6/27/2025 at 2:04 PM with Director of Nursing (DON), DON stated there was no record that the facility followed up on Resident 213's BIPAP machine after 6/18/2025 when it was initially found defective by LVN 4. DON stated it is important to follow up and make sure the Resident's have the correct equipment available to prevent any respiratory distress. DON stated facility should have had the equipment available in functioning matter for the resident. 4. During a review of Resident 75's admission Record (AR), the AR indicated the facility admitted Resident 75 on 3/26/2024 with diagnoses that included chronic pulmonary edema (a condition where fluid builds up in the lungs, making it difficult to breathe) and congestive heart failure (a condition where the heart doesn't pump blood as efficiently as it should, leading to a buildup of fluid in the body). During a review of Resident 75's Minimum Data Set (MDS, a resident assessment tool), dated 6/16/2025, the MDS indicated Resident 75 had intact memory and cognitive (ability to think and reasonably). The MDS indicated Resident 75 required partial/moderate assistance with eating, shower/bathe self, and chair/bed-to-chair transfer. During a review of Resident 75's Order Summary Report, dated 6/24/2025, the Report indicated a physician's order for oxygen at two (2) to three LPM [liters (unit of volume) per minute (unit of time)] via NC at bedtime for comfort, may titrate up to five (5) LPM via NC. The Report indicated, if oxygen saturation (O2 sat, a measure of how much oxygen is carried in your blood) is still less than 95 %, may titrate up to six (6) to 10 LPM via non re-breather mask (a medical device used to deliver high concentrations of oxygen to patients) to keep O2 sat greater than 95 %, starting on 3/12/2025. The Report also indicated to change NC/mask every 7 days on Thursday 7 AM- 3 PM shift and as needed when soiled, starting on 3/13/2025. During a review of Resident 75's Care Plan dated 3/13/2025, the Care plan indicated interventions for Resident 75's use of oxygen was to change the resident's NC/mask every 7 days on Thursday. During a concurrent observation and interview on 6/24/2025 at 10:21 AM with Resident 75 in Resident 75's room, Resident 75's NC tubing, which was connected to the oxygen concentrator (a medical device that provide oxygen supplement), was labeled and dated 6/12/2025. An oxygen humidifier (a device used to add moisture to oxygen gas before it is inhaled by a patient) bottle, which was attached to the oxygen concentrator (a medical device that provides supplemental oxygen) did not have a label to indicate when the oxygen concentrator was changed. During a concurrent observation and interview on 6/24/2025 at 10:26 AM with Licensed Vocational Nurse (LVN) 1 in Resident 75's room, LVN 1 stated Resident 75's NC tubing was dated 6/12/2025 and there was no label on the oxygen humidifier with the date the humidifier was started. on the oxygen humidifier. LVN 1 stated, the staff did not change Resident 75's NC tubing on the seventh day, which was supposed to be on 6/19/2025, per policy. LVN 1 stated, the staff did not label the oxygen humidifier with the date when it was opened and used, so facility staff would not know for how long the oxygen humidifier had been used. LVN 1 stated, the humidifier bottle should be replaced every 7 days. LVN 1 stated, Resident 75 would be at risk of infection when the NC tubing or the oxygen humidifier was not changed every 7 days. During an interview on 6/24/2025 at 10:36 AM with the Central Supply (CS), the CS stated he was responsible to change the residents' NC tubing and oxygen humidifier every Thursday. The CS stated, he did not change Resident 75's NC tubing on 6/19/2025 when it was due to change. The CS stated, he did not label the oxygen humidifier with the date when it was opened and used for Resident 75. The CS stated as a result, Resident 75 was at risk for respiratory illness and infection. During an interview on 6/27/25 at 9:23 AM with the Director of Nursing (DON), the DON stated according to the facility's policy, NC tubing and oxygen humidifier bottles should be labeled with the date started to prevent infection to the residents. During a review of the facility's P&P titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated 6/2011, the P&P indicated Single used items such as nebulizer tubing, oxygen tubing's, humidifiers, suction tubing. These tubing are replaced every 7 days, labeled with the date started.

Based on observation, interview, and record review, the facility failed to enforce the facility's policy and procedure to ensure a visitor was monitored and instructed not obtain the cups, spoons, juice and water pitchers from medication cart for 1 of 3 sampled resident (Resident 15). This deficiency has the potential to result in cross contamination (the process by which bacteria or other microorganism unintentionally transfer from one object to another with harmful effect) and spread of infection in the facility. Findings: During a medication pass observation on 6/25/2025 at 12:51 PM with Licensed Vocational Nurse (LVN 5), LVN 5 was preparing to dispense medication from medication cart - when a facility visitor (Visitor 1) grabbed multiple cups and pulled out a cup from the middle of the cup stack on top of the medication cart and then proceeded to pour juice and water in the presence of LVN 5. LVN 5 did not inform the visitor that she could not get cups, pour juice and water from the cart then take to the resident's room. During a concurrent medication pass observation on 6/25/2025 at 12:52 PM with LVN 5 facility Visitor 1 was observed exiting a Resident 15's room approach the medication cart again to grab spoons. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 4/11/2025 with that included acute respiratory failure (failure of the lungs to meet the body's oxygen demand) with hypoxia, type 2 diabetes mellitus (DM2 - a condition that results in too much sugar circulating in the blood). During an interview on 6/27/2025 at 7:39 AM with Infection Prevention Nurse (IPN), IPN stated the facility does not allow for visitors or residents to grab cups, spoons, juice or water from the medication carts because it can cause contamination as we do not know if they did hand hygiene. Standard Precautions, Enhanced Barrier Precautions and Transmission Based precautions indicated, purpose of the policy: to provide guidelines for infection control practices to reduce the potential for transmission of pathogens including Covid-19 and multi-drug-resistant organisms and viruses. Furthermore, the policy indicated J. Residents, visitor, volunteers shall be educated and instructed in hand hygiene protocols, PE use, and other infection control practices.

Based on observation, interview and record review, the facility failed to provide a homelike environment for one of one sampled resident (Residents 11) by not ensuring Resident 11 was provided a functional wall clock in the room. This deficient practice had the potential to cause disorientation and Resident 11 verbalizing feelings of frustration. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 4/14/2025 with diagnoses that included dementia (progressive decline in cognitive function, memory, and thinking abilities that can impact daily life), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and muscle wasting. During a review of Resident 11's History and Physical Examination (H&P), dated 4/16/2025, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 4/18/2025, the MDS indicated Resident 11 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, substantial/maximal assistance (helper does more than half the effort) with bathing and dressing, and dependent (helper does all the effort) with toileting. During a concurrent observation and interview on 6/24/2025 at 9:30 AM with Resident 11 and Certified Nurse Assistant (CNA) 2, in Resident 11's room, Resident 11 was observed staring at the wall clock that indicated the current time as 6:05 (shorthand pointed at #6 and long hand pointed at #1). Resident 11 stated, the time on the wall clock was wrong, and that Resident 11 was frustrated since she had to ask facility staff for the current time. CNA 2 stated the time on the wall clock was wrong and she would inform the maintenance right away to fix Resident 11's wall clock since it caused confusion and frustration to Resident 11. During an interview on 6/24/2025 at 9:37 AM with license Vocational Nurse (LVN)2 in Resident 11's room, LVN 2 stated, it was important to ensure residents' wall clocks indicated the accurate time to help with her orientation and to minimize frustration. LVN 2 stated having a functional clock that indicates the accurate time was part of providing a homelike environment to Resident 11. During an interview on 6/25/2025 at 10:59 AM with the Director of Nurses (DON), DON stated, to create a homelike environment for the residents would include having a wall clock that indicated the accurate time in every room. DON stated, not having an accurate time on Resident 11's wall clock had the potential for disorientation and resulted in frustration, and not a homelike environment. A review of the facility's policy and procedure (P&P) titled, , Homelike Environment, revised 5/2017 indicated: a) Residents are provided with a safe, clean , comfortable and homelike environment, b) staff shall provide person-centered care that emphasizes the residents comfort , independence and personal needs and preferences and, c) the facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting.

Based on observation, interview and record review, the facility failed to ensure a prompt response to address grievances for one of one sampled resident (Resident 5) Resident Representative (FAM 1), when FAM 1 reported missing clothing items belonging to Resident 5. This deficient practice delayed the process of investigating Resident 5's missing clothing items and violated the residents' right to have grievances addressed promptly. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the facility originally admitted Resident 5 on 4/26/2023 and readmitted on [DATE] with diagnoses that included dementia (progressive decline in cognitive function, memory, and thinking abilities that can impact daily life), atherosclerotic heart disease (thickening or hardening of the arteries), and chronic kidney disease (a condition in which the kidneys are damaged and can't filter blood as well as they should). The AR indicated Resident 5 had a Representative for her care (FAM 1). During a review of Resident 5's History and Physical Examination (H&P), dated 6/12/2025, the H&P indicated Resident 5 does not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 4/18/2025, the MDS indicated Resident 5 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, substantial/maximal assistance (helper does more than half the effort) with bathing and dressing and dependent (helper does all the effort) with toileting. During an interview on 6/24/2025 at 1:45 PM with FAM 1, FAM 1 stated when Resident 5 was discharged home on 6/3/2025, FAM 1 informed Social Service Assistant (SSA) that Resident 5 was missing two pants and a blouse. FAM 1 stated the facility had not informed FAM 1 regarding the outcome of the missing clothing for Resident 5. FAM 1 stated, the facility was aware that she does the laundry, and FAM 1 was concerned that Resident 5's clothing would get lost again. During an interview on 6/24/2025 at 2:28 PM with SSA, SSA stated Resident 5 was discharged to home on 6/3/2025 and readmitted to the facility on [DATE]. SSA stated, she was aware that family did Resident 5's laundry, and prior to Resident 5's discharge from the facility on 6/3/2025, FAM 1 informed SSA that Resident 5 was missing some clothes. SSA stated she thought FAM 1 would come to the facility to find Resident 5's missing clothing. SSA stated, she did not initiate a grievance report nor did SSA follow up with FAM 1. SSA stated she should have initiated a grievance report when FAM 1 informed the SSA of Resident 5's missing clothes. SSA stated it was a violation of resident's rights that a grievance report was not initiated when the facility became aware of Resident 5's missing clothing items. During a concurrent interview and record review, on 6/24/2025 at 4:27 PM with SSA, the facility document titled Concern/Grievance Log, dated June/2025 was reviewed. The Log did not indicate any grievance initiated from Resident 5 and/or FAM 1. SSA stated, grievance from FAM 1 was not initiated, and that with any grievances filed the DON (Director of Nurses) and the Administrator should have been informed. During an interview on 6/25/2025 at 10:53 AM with DON, DON stated SSA should have reached out to FAM 1 regarding Resident 5's missing clothing, and that a grievance report should have been initiated. DON stated not promptly addressing Resident 5 and/or FAM 1 grievance violates resident rights. During an interview on 6/25/2025 at 2:20 PM, with the Administrator (ADM), ADM stated, she was not aware Resident 5's clothes were missing. The ADM stated a grievance report should have promptly been initiated in accordance with the facility's policy and procedure, and by not promptly conducting a grievance report violated residents rights. A review of the facility's policy and procedure (P&P) titled, Grievances/Complaints, Filing, revised 4/2017 indicated; a)Residents and their representative have the right to file grievances, either orally or in writing to the facility staff or to agency designated to hear grievances, b) the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative, c) resident representative may file grievance or complaint regarding resident stay in the facility, and d) all grievances concerning resident care will be considered and actions on the issues will be responded to in writing, including rationale for the response. A review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 12/2016 indicated: a) employees shall treat all residents with kindness, respect and dignity, b) resident rights include voice grievances to the facility and have the facility respond to his or her grievances.

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS, a federally mandated standardized assessment and care-screening tool) and Quarterly Risk Assessment was accurate for two (2) of 2 sampled residents (Resident 69 and 102) who had a diagnosis of dementia and was not evaluated for elopement risk. These deficient practices had the potential to result in Resident 69 and 102 not receiving appropriate treatment and/or services. Findings: 1. A review of Resident 69’s admission Record indicated Resident 69 was initially admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (change in how the brain works due to an underlying condition), unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Alzheimer’s disease (progressive disease that destroys memory and other important mental functions). During a review of Resident 69’s Admission/readmission Initial assessment dated [DATE] indicated resident walked frequently (walks outside room at least twice a day and inside room at least once every two hours during waking hours) with no limitation. The MDS assessment indicated an evaluation of resident elopement risk was not completed. The evaluation of resident elopement risk indicated resident was not independently mobile. During a review of Resident 69’s History and Physical (H&P) dated 3/27/2025 indicated Resident 69 did not have the capacity to understand and make decisions. During a review of Resident 69’s MDS dated [DATE], indicated Resident 69 was independent with indoor mobility (walking from room to room [with or without a device such as a cane, crutch, or walker]). During a review of Resident 69’s Quarterly Risk assessment dated [DATE] indicated resident walked frequently with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. The evaluation of resident elopement risk indicated resident was not independently mobile. During a review of Resident 69’S MDS dated [DATE] indicated Resident 69 required partial/moderate assistance to walk 10 feet and walk 50 feet with two turns. During a concurrent interview and record review of Resident 69’s Admission/readmission Initial assessment dated [DATE] on 6/26/2025 at 12:03 PM, Registered Nurse (RN) 2 stated she should have documented Resident 69 walked occasionally instead of frequently because resident was only walking inside the room. RN 2 stated the level of activity should have been documented accurately because the admission assessment is the baseline of the resident. During an interview on 6/26/2025 at 12:28 PM, Minimum Data Set Nurse (MDSN) 2 stated she has seen Resident 69 walk and exercise around the facility. MDSN 2 stated Resident 69 was able to walk around to activities room, facility patio, and resident rooms to speak with other residents. During a concurrent interview and record review of Resident 69’s Quarterly Risk Assessments dated 6/19/2025 on 6/26/2025 at 12:37 PM, MDSN 2 confirmed she did not complete the evaluation for elopement risk. MDSN 2 stated she used her own judgment that Resident 69 was not a “wanderer” (moving from one place to another aimlessly) and selected “no” for the first question “is the resident independently mobile.” MDSN 2 stated she misinterpreted the question and chose “no” because from her understanding, Resident 69 was not an elopement risk. MDSN 2 stated she knew Resident 69 was independently mobile and she was just focused on the elopement risk and decided Resident 69 was not an elopement risk. MDSN 2 stated it was important for documentation to be accurate so the whole facility knows that Resident 69 could have potential to wander or elope. During the same interview on 6/26/2025 at 12:43 PM, MDSN 2 stated when documenting the quarterly evaluation of Elopement Risk, she always thinks about elopement, “I didn’t really think dementia could be a risk for elopement and misinterpreted the questions.” MDSN 2 stated residents with dementia repeat themselves, are agitated and irritable, only remember certain things and are forgetful. MDSN 2 stated when she was doing the quarterly assessment, she would see the residents and assess them from head to toe, ask other staff like certified nursing assistants, charge nurses about the resident. MDSN 2 stated she should have been answering questions for the quarterly risk assessment as a cumulative of the resident’s current status. During an interview on 6/26/2025 at 1:18 PM, MDSN 1 stated she focuses on resident admission when they are admitted to facility and oversees MDSN 2 who focuses on quarterly assessments when residents are in long term care. MDSN 1 stated she has to review and sign off MDSN 2’s quarterly risk assessments. During a concurrent interview and record review of Resident 69’s Quarterly Risk Assessments dated 6/19/2025 on 6/26/2025 at 1:24 PM, MDSN 1 confirmed the evaluation for elopement risk should have been filled out correctly. MDSN 1 stated this was “so you have a proper idea of where the residents are, functionally.” MDSN 1 stated because of this, there was a discrepancy on the MDS, the MDS provides an overview of what kind of care the resident needs. MDSN 1 stated the assessment needs to be accurate so the facility knows who would need individualized care. During the same interview on 6/26/2025 at 1:30 PM, MDSN 1 stated MDSN 2 documents residents quarterly risk assessment and quarterly MDS. MDSN 1 stated she reviews MDSN 2’s documentation. MDSN 1 stated “I was not focusing on elopement because we know our patients here. MDSN 2 misinterpreted the question, I trust her, and I didn’t check.” MDSN 1 stated she reassessed all the residents of the facility yesterday. MDSN 1 stated she should be reviewing for accuracy so that it would be a correct reflection of the resident and to show that MDSN 2 was competent in assessing. MDSN 1 stated this showed MDSN 2’s failure to accurately assess residents. During an interview on 6/27/2025 at 1:38 PM, the Director of Nursing (DON) stated the elopement risk assessment should have been accurate and filled out completely in order to provide an accurate intervention for resident. The DON stated if a resident was high risk for elopement they need to have appropriate placement. The DON stated if there was a resident who tried to elope, the facility needs to provide intervention right away and look for placement because the facility was not an appropriate place for resident who was at high risk for elopement. 2. A review of Resident 102’s admission Record indicated Resident 102 was initially admitted to the facility on [DATE], with diagnoses that included unspecified dementia, muscle wasting and atrophy and cognitive communication deficit. During a review of Resident 102’s History and Physical (H&P) dated 8/14/2024 indicated Resident 102 did not have the capacity to understand and make decisions. During a review of Resident 102’s MDS dated [DATE], indicated Resident 102 was independent with indoor mobility (walking from room to room [with or without a device such as a cane, crutch, or walker]). During a review of Resident 102’s Quarterly Risk assessment dated [DATE] indicated resident walked occasionally with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. The evaluation of resident elopement risk indicated resident was not independently mobile. During a review of Resident 102’s Quarterly Risk assessment dated [DATE] indicated resident walked occasionally with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. The evaluation of resident elopement risk indicated resident was not independently mobile. During a review of Resident 102’s Quarterly Risk assessment dated [DATE] indicated resident walked occasionally with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. The evaluation of resident elopement risk indicated resident was not independently mobile. During a review of Resident 102’s MDS dated [DATE] indicated Resident 102 required partial/moderate assistance to walk 10 feet and walk 50 feet with two turns. During a concurrent interview and record review of Resident 102’s Quarterly Risk assessment dated [DATE] on 6/26/2025 at 12:43 PM, MDSN 2 confirmed Resident 102’s elopement risk evaluation was not completed. MDSN 2 stated when documenting Resident 102’s elopement risk she “did not think dementia could be a risk for elopement and misinterpreted the question.” During a concurrent interview and record review of Resident 102’s Quarterly Risk assessment dated [DATE] on 6/26/2025 at 1:46 PM, MDSN 1 confirmed Resident 102’s elopement risk was incorrect and should have been filled out correctly. MDSN 1 stated need to make sure documentation was accurate to get a proper picture of the resident and what their activity levels and needs are. A review of the facility’s policy and procedure (P&P) titled “Resident Assessments” dated 12/2024 indicated risk assessments will be conducted on admission, quarterly, and as needed to include fall, elopement, pain, Braden scale, bowel and bladder and dehydration risk assessments. The P&P indicated all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. The P&P indicated the results of the assessments are used to develop, review, and revise the resident’s comprehensive care plan. A review of the facility’s P&P titled “Charting and Documentation” dated 7/2017 indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to ensure the care plan was revised for two of two sampled residents (Resident 69 and 102) who had an active care plan for a diagnosis for dementia (a progressive brain disorder that results in a decline in memory and thought process).This deficient practice had the potential result in Resident 69 and 102 no receiving appropriate interventions and treatment and/or services. Cross Referenced to F641 and F744 Findings: 1. A review of Resident 69’s admission Record indicated Resident 69 was initially admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (change in how the brain works due to an underlying condition), unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Alzheimer’s disease (progressive disease that destroys memory and other important mental functions). During a review of Resident 69’s History and Physical (H&P) dated 3/27/2025 indicated Resident 69 did not have the capacity to understand and make decisions. During a review of Resident 69’s MDS dated [DATE], indicated Resident 69 was independent with indoor mobility (walking from room to room [with or without a device such as a cane, crutch, or walker]). During a review of Resident 69’s Dementia Care plan dated 3/17/2025 did not indicate resident specific behaviors to monitor. During an interview on 6/26/2025 at 11:53 AM, Registered Nurse (RN) 2 stated Resident 69 stated in the past 2 weeks resident has become more mobile. RN 2 stated if Resident 69 had a behavior of going into the wrong resident room she would tell the charge nurses and Certified Nursing Assistants (CNAs) to monitor for when Resident 69 goes into other resident rooms. RN 2 stated a care plan should be created for this to protect other residents' privacy. RN 2 stated the care plan is developed to ensure specific interventions for her tailored to her and her behaviors. RN 2 stated this should be added to Resident 69’s care plan. RN 2 stated licensed nurses can update or create care plan. During an interview on 6/26/2025 at 12:28 PM, Minimum Data Set Nurse (MDSN) 2 stated she has seen Resident 69 walk and exercise around the facility. MDSN 2 stated Resident 69 was able to walk around to activities room, facility patio, and resident rooms to speak with other residents. During an interview on 6/26/2025 at 1:35 PM, MDSN 1 stated for residents with dementia care plan would include medication, activities, and reorienting the resident if needed. MDSN 1 stated the care plan should be created on admission and updated quarterly or as needed if there was a change. MDSN 1 stated when staff notice behaviors, they should notify the charge nurse, and the care plan should be updated specific to Resident 69. MDSN 1 stated if Resident 69 walks into another resident’s room, there could be a “terrible altercation” if the other resident does not want Resident 69 in the room. During a concurrent interview and record review of Resident 69’s Dementia Care Plan on 6/27/2025 at 11:14 AM, MDSN 1 stated there was no actual behavior indicated to increase monitoring for Resident 69. MDSN 1 stated the care plan was not resident specific. 2. A review of Resident 102’s admission Record indicated Resident 102 was initially admitted to the facility on [DATE], with diagnoses that included unspecified dementia, muscle wasting and atrophy and cognitive communication deficit. During a review of Resident 102’s History and Physical (H&P) dated 8/14/2024 indicated Resident 102 did not have the capacity to understand and make decisions. During a review of Resident 102’s MDS dated [DATE] indicated Resident 102 required partial/moderate assistance to walk 10 feet and walk 50 feet with two turns. During a review of Resident 102’s Dementia Care plan dated 8/12/2024 did not indicate the specific resident’s behaviors to be monitor. During a concurrent interview and record review of Resident 102’s Dementia Care Plan on 6/27/2025 at 11:16 AM, MDSN 1 stated there was no actual resident behavior to monitor for Resident 102. MDSN 1 stated the care plan was not resident specific. During an interview on 6/27/2025 at 1:40 PM, the Director of Nursing (DON) stated the residents care plan should have specific behavior so that licensed nurses and staff could be aware of residents' specific behaviors and interventions for the behaviors to ensure everyone was aware of what was going on and what to do. The DON stated care plan should be revised to show patient specific behaviors to monitor. A review of the facility’s policy and procedure (P&P) titled “Care Plans, Comprehensive Person-Centered” dated 12/2016 indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs was developed and implemented for each resident. The P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents’ conditions change. The P&P indicated the interdisciplinary team must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview, observation and record review, the facility failed to set the Alternating Pressure Mattress (APM, mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation and physicians orders for one of [three] residents (Resident 94). This deficient practice had the increased potential for Resident 94 to develop new pressure ulcer or injury (skin injury due to prolonged unrelieved pressure or skin friction) and/or delay the resident's wound to heal. Findings: During a review of Resident 94's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/22/2008 with diagnoses that included fracture of unspecified part of neck of right femur [the section of the thigh bone (femur) that connects the femoral head (the ball of the hip joint) to the femoral shaft (the main part of the thigh bone)], muscle wasting and atrophy (loss of muscle mass and strength), type 2 diabetes mellitus (DM2 – a condition that results in too much sugar circulating in the blood). During a review of Resident 94’s History and Physical (H&P), dated 2/24/2025, the H&P indicated the Resident 94 did not have the capacity to understand and make decisions. During a review of Resident 94’s Order Summary Report (OSR), the OSR indicated the physician ordered on 2/26/2025, without an end date, indicated that Resident 94 may have Low Air Loss mattress (LALM-a type of the APM) for skin management and to monitor for function and settings every shift. During a review of Resident 94’s “Pressure Ulcer Assessment,” dated 3/4/2025, the assessment indicated Resident 94 had a healed unstageable right sacrococcyx [a single bony structure formed by the fusion of the sacrum (a large, triangular bone at the base of the spine) and the coccyx (also known as the tailbone)] due to Deep Tissue Injury (DTI, damage to the tissues beneath the skin, often caused by sustained pressure and/or shear forces). The assessment indicated Resident 94 remained at risk for further skin breakdown due to recent hospitalization and the preventive measures included a LAL mattress. During a review of Resident 75's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/1/2025, the MDS indicated Resident 94’s cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 94 needed set up/clean up assistance in eating and oral hygiene; and needed moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) in toileting hygiene and shower. During a concurrent observation and interview on 6/24/2025 at 9:26 AM with Licensed Vocational Nurse (LVN 3) in Resident 94’s room, Resident 94 was lying in bed in supine position with the head of bed slightly elevated and the LAL mattress setting was set at 350 lbs. There was a yellow circle sticker with Resident 94’s room and bed number with 120-180 lbs. written on it. LVN 3 confirmed Resident 94’s mattress setting was at 350 lbs. LVN 3 stated, she did not know what the correct setting for Resident 94’s LALM was supposed to be as the Treatment Nurse (TN) was the one who is in charge of adjusting the LALM settings for the residents. During a concurrent interview and observation on 6/24/2025 at 9:56 AM with TN 1 in Resident 94’s room, the TN 1 stated Resident 94’s LAL mattress should always be in the correct setting according to the resident’s weight range as indicated in the yellow sticker pasted on Resident 94’s LALM. TN 1 stated, Resident 94’s LALM setting should be between 120-180 pounds maximum to help Resident 94 prevent further pressure injury as Resident 94 was not mobile and had a previous sacrococcyx pressure injury in the past. TN 1 stated, she did not know why the LALM was set at 350 lbs., which was not the correct setting for the Resident 94. During a review of manufacture’s guidelines for Drive-Med Aire Melody control unit, indicated the following: - The Med Aire Melody Alternating Pressure and Low Air Loss Mattress is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. - Operating instructions Step 6: Determine the patients' weight and set the control knob to that weight setting on the control unit.

Based on interview and record review, the facility failed to ensure two of two licensed nurses (Minimum Data Set Nurse [MDSN] 1 and 2) were trained and with sufficient competency to conduct and coordinate the development and completion the residents MDS assessment by failing to: Ensure MDSN 1 and MDSN 2 conducted an accurate MDS assessment of Resident 69 and 102's elopement risk. Ensure MDSN 2 had an updated competency skills to conduct annual evaluation used for MDS assessment. This deficient practice placed residents at risk for not receiving appropriate services, treatments, and unsafe level and type of care necessary for the resident population. Cross Referenced to F641 Findings: 1. A review of Resident 69's admission Record indicated Resident 69 was initially admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (change in how the brain works due to an underlying condition), unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). During a review of Resident 69's Admission/readmission Initial assessment dated [DATE] indicated resident walked frequently (walks outside room at least twice a day and inside room at least once every two hours during waking hours) with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. The evaluation of resident elopement risk indicated resident was not independently mobile. During a review of Resident 69's History and Physical (H&P) dated 3/27/2025 indicated Resident 69 did not have the capacity to understand and make decisions. During a review of Resident 69's MDS dated [DATE], indicated Resident 69 was independent with indoor mobility (walking from room to room [with or without a device such as a cane, crutch, or walker]). During a review of Resident 69's Quarterly Risk assessment dated [DATE] indicated resident walked frequently with no limitation. The assessment indicated an evaluation of resident elopement risk was not completed. The evaluation of resident elopement risk indicated resident was not independently mobile. During a review of Resident 69'S MDS dated [DATE] indicated Resident 69 required partial/moderate assistance to walk 10 feet and walk 50 feet with two turns. During a concurrent interview and record review of Resident 69's Admission/readmission Initial assessment dated [DATE] on 6/26/2025 at 12:03 PM, Registered Nurse (RN) 2 stated she should have documented Resident 69 walked occasionally instead of frequently because resident was only walking inside the room. RN 2 stated the level of activity should have been documented accurately because the admission assessment is the baseline assessment of the resident. During an interview on 6/26/2025 at 12:28 PM, Minimum Data Set Nurse (MDSN) 2 stated she has seen Resident 69 walk and exercise around the facility. MDSN 2 stated Resident 69 was able to walk around to activities room, facility patio, and resident rooms to speak with other residents. During a concurrent interview and record review of Resident 69's Quarterly Risk Assessments dated 6/19/2025 on 6/26/2025 at 12:37 PM, MDSN 2 confirmed she did not complete the evaluation for elopement risk. MDSN 2 stated she used her own judgment that Resident 69 was not a wanderer (going to one place to another aimlessly) and selected no for the first question is the resident independently mobile. MDSN 2 stated she misinterpreted the question and chose no because from her understanding, Resident 69 was not an elopement risk. MDSN 2 stated she knew Resident 69 was independently mobile and she was just focusing on the elopement risk. MDSN 2 stated she decided Resident 69 was not an elopement risk. MDSN 2 stated it was important for documentation to be accurate so the whole facility knows that Resident 69 had the potential to wander or elope. During the same interview on 6/26/2025 at 12:43 PM, MDSN 2 stated when documenting the quarterly evaluation of Elopement Risk, she always thinks about elopement, I didn't really think dementia could be a risk factor for elopement and misinterpreted the questions. MDSN 2 stated residents with dementia repeat themselves, are agitated and irritable, only remember certain things and are forgetful. MDSN 2 stated when she was doing the quarterly assessment, she would see the residents and assess them from head to toe, ask other staff like certified nursing assistants, charge nurses about the resident. MDSN 2 stated she should be answering questions for the quarterly risk assessment as a cumulative of the resident's current status. During an interview on 6/26/2025 at 1:18 PM, MDSN 1 stated she focuses on resident admission when they are admitted to facility and oversees MDSN 2 who focuses on quarterly assessments when residents are in long term care. MDSN 1 stated she has to review and sign off MDSN 2's quarterly risk assessments. During a concurrent interview and record review of Resident 69's Quarterly Risk Assessments dated 6/19/2025 on 6/26/2025 at 1:24 PM, MDSN 1 confirmed the evaluation for elopement risk should have been filled out correctly. MDSN 1 stated this was so you have a proper idea of where the residents are, functionally. MDSN 1 stated because of this, there was a discrepancy on the MDS, the MDS provides an overview of what kind of care the resident needs. MDSN 1 stated the assessment needs to be accurate so the facility knows who would need individualized care. During the same interview on 6/26/2025 at 1:30 PM, MDSN 1 stated MDSN 2 documents residents quarterly risk assessment and quarterly MDS. MDSN 1 stated she reviews MDSN 2's documentation. MDSN 1 stated I was not focusing on elopement because we know our patients here. MDSN 2 misinterpreted the question, I trust her, and I didn't check. MDSN 1 stated she reassessed all the residents of the facility yesterday. MDSN 1 stated she should be reviewing for accuracy so that it would be a correct reflection of the resident and to show that MDSN 2 was competent in assessing. MDSN 1 stated this showed MDSN 2's failure to accurately assess residents. During an interview on 6/27/2025 at 1:38 PM, the Director of Nursing (DON) stated the elopement risk assessment should have been accurate and filled out completely. The DON stated this was to provide an accurate intervention for resident. The DON stated if a resident was high risk for elopement they need to have appropriate placement. The DON stated if there was a resident who tried to elope, the facility needs to provide intervention right away and look for placement because the facility was not an appropriate place for resident who was at high risk for elopement. 2. A review of Resident 102's admission Record indicated Resident 102 was initially admitted to the facility on [DATE], with diagnoses that included unspecified dementia, muscle wasting and atrophy and cognitive communication deficit. During a review of Resident 102's History and Physical (H&P) dated 8/14/2024 indicated Resident 102 did not have the capacity to understand and make decisions. During a review of Resident 102's MDS dated [DATE], indicated Resident 102 was independent with indoor mobility (walking from room to room [with or without a device such as a cane, crutch, or walker]). During a review of Resident 102's Quarterly Risk Assessments dated 11/14/2024, 2/13/2025 and 5/15/2025 indicated resident walked occasionally with no limitation and the evaluation of resident elopement risk was not completed. The evaluation of resident elopement risk indicated resident was not independently mobile. During a review of Resident 102's MDS dated [DATE] indicated Resident 102 required partial/moderate assistance to walk 10 feet and walk 50 feet with two turns. During a concurrent interview and record review of Resident 102's Quarterly Risk assessment dated [DATE] on 6/26/2025 at 12:43 PM, MDSN 2 confirmed Resident 102's elopement risk evaluation was not completed. MDSN 2 stated when documenting Resident 102's elopement risk she did not think dementia could be a risk for elopement and misinterpreted the question. During a concurrent interview and record review of Resident 102's Quarterly Risk assessment dated [DATE] on 6/26/2025 at 1:46 PM, MDSN 1 confirmed Resident 102's elopement risk was incorrect and should have been filled out correctly. MDSN 1 stated need to make sure documentation was accurate to get a proper picture of the resident and what their activity levels and needs are. A review of MDSN 1's Competency Skills Checklist dated 5/12/2025 indicated MDSN 1 was satisfactory in following established protocols for completing and submitting MDS Assessments ensuring accuracy and compliance in regulatory requirements. A review of MDSN 2's Competency Skills Checklist dated 11/24/2023 indicated MDSN 2 was satisfactory in accurate documentation. A review of the facility's job description for Resident Care Coordinator (MDSN 1) dated 8/2006 indicated major duties and responsibilities included: to conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment; ensure that quarterly and annual assessments and care plans reviews are made in a timely basis; inform all team members of the requirements for accuracy and completion of the resident assessment (MDS). The job description indicated the MDSN 1 was supervised by the DON. A review of the facility's policy and procedure (P&P) titled Competency of Nursing Staff dated 3/2025 indicated licensed nurses employed by the facility will demonstrate specific competencies and skills sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.

Based on interview and record review, the facility failed to post the nurse staffing information of the number of Registered Nurses (RN), License Vocational Nurse (LVN)/ License Practical Nurse (LPN) and Certified Nursing Assistant (CNA)/Nursing Assistant (NA) per shift in a prominent location in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice had the potential to not inform and cause misleading information to the residents and the visitors of the nursing care provided to the residents. Findings: During an observation on 6/24/2025 at 8:30 AM, one page of the Census and Direct Care Service Hours per Patient Day (DHPPD), dated 6/24/2025, was posted on the wall by the facility entrance near Nursing Station 2. There was no other nursing staff information posted. During an observation on 6/25/2025 at 2:40 PM, only the DHPPD, dated 6/25/2025 was posted on the wall by each nursing stations. there was no information posted indicating how many RN ' s, LVN ' s and CNA ' s were on shift for 6/25/25. During a concurrent observation and interview on 6/25/2025 at 2:44 PM with the Staffer, the Staffer removed the DHPPD from the wall sign holder and revealed a second page of paper behind the DHPPD. The Staffer stated the nursing staffing information of the number of RNs, LVNs, and CNAs was on the second page behind the DHPPD, which was not visible to the residents and visitors. The Staffer stated she had worked as the Staffer for three months and had always placed the posting that way. The Staffer stated the nursing staffing information should be posted in clear view and visible to all residents and the visitors. During an interview on 6/27/25 at 9:25 AM with the Director of Nursing (DON), the DON stated facility staff did not post the entire nursing staffing information for the RNs, LVNs, and CNAs per shift which could result in the residents and the visitor did not know the actual number of nursing staff working to provide care to the residents and cause misleading information of nursing care that the residents received. During a review of the facility ' s policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, dated 8/2022, the P&P indicated; a)the facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to resident, b) within two hours of the beginning of each shift the number of licensed nurses (RNs, LPNs, and LVNs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in clear and readable format.

Based on interview, and record review, the facility failed to complete a performance review by completing the Annual Core Clinical Competencies (ACCC, an assessment and training on the Certified Nurse Assistant(s) (CNA) the ability to perform clinical nursing care). In addition, the facility did not have a system in place to keep track of the CNA's performance evaluation to ensure three of five CNAs (CNA 1, CNA 2 and CNA 3) were evaluated for their competencies annually and provided training based on the outcome of the review for each of the CNAs. This failure had a potential to result in the facility's resident's population based on the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents) not to receive quality care services from CNAs with insufficient skills and competencies. Findings: A review of the facility's undated Tracking log, indicated there was no tracking for the facility's CNA's ACCC that indicated which CNA required the training. During an interview on 6/13/2024 at 2:08 PM with Registered Nurse (RN) 1, RN 1 stated, she used to assist the facility as the Director of Staff Development (DSD) and has been helping to train the new DSD. RN 1 stated, all CNAs were required to have yearly clinical skills competency check. RN 1 stated, she based on the CNAs month of hire for the CNA's ACCC due date. RN 1 stated, once completed, she would file the CNAs' ACCC to the Administrator (ADM)'s office for records. RN 1 stated, there was no tracking system available to know if any CNA's ACCC was not completed or up to date. During an observation and record review on 6/13/2024 at 2:22 PM in the ADM's office, the DSD, RN 1 and ADM were observed checking the records for five sampled CNAs. The records indicated: 1. CNA 1 was hired on 10/22/1996 and the last competency date was 9/1/2022. 2. CNA 2 was hired on 8/9/2016 and the last competency date was 4/19/2021. 3. CNA 3 was hired on 8/19/20 and the last competency date was 8/23/2023. During an interview on 6/13/2024 at 2:57 PM with the DSD, the DSD stated, CNAs were supposed to have yearly clinical skills competency check based on the facility's CNA Core Clinical Competencies check list to assess for their competency and to refresh their knowledge on how to provide appropriate care to the residents. The DSD stated, she just started the DSD position about eleven weeks ago and she did not have a system to log and keep track of the CNAs' ACCC. The DSD stated, if the CNAs' skills were not checked annually, the CNAs could miss important details care that could affect the residents' overall health. During an interview on 6/13/2024 at 3:45 PM with the Infection Control Nurse (IPN), the IPN stated, she held an in-person lesson in July and August 2023, which was considered as an annual ACCC for all CNAs. The IPN stated, all facility's CNAs were required to attend and watch a video with post test given. The IPN stated, some CNAs but not all of them were called to demonstrate the skills after watching the video. During a concurrent record review and interview on 6/19/24 at 4 PM with the IPN, the facility's record Lesson Plan, with the title of Certified Nursing Assistant IPC (Infection Prevention) Curriculum, undated, was reviewed. The IPN stated, the lesson plan was used for the in-person lesson in July and August 2023. The IPN stated, not all skills listed in the facility's CNA Core Clinical Competencies were included in the lesson plan. A review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, revised May 2019, indicated the following: a. Licensed nurses and nursing assistants employed by the facility will demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents. b. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. c. Facility and resident-specific competency evaluations will include lecture with return demonstration for physical activities; demonstrated ability to use tools, devices, or equipment used to care for residents; demonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform.

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 12 of 12 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) by failing to: 1. Place a physical barrier to separate the COVID-19 area (Red Zone, area for residents who tested positive for COVID-19) from the suspected COVID-19 area (Yellow Zone, area for persons undetermined illness). 2. Dedicate Licensed Vocational Nurses 1 (LVN 1) to care for confirmed COVID-19 residents (Residents 1, 2, 3, 4, 5, and 6) and negative COVID-19 residents (Residents 7, 8, 9, 10, 11, and 12) at the same time. 3. Screen Surveyor 1 (S 1) and Physician Assistant 1 (PA 1) for signs and symptoms of COVID-19, history of travel and contact with positive COVID-19 persons upon entering the facility. 4. Place signages in front of the residents' rooms in the Yellow and Red Zone to remind staff to wash their hands, don (put on) and doff (take off) Personal Protective Equipment (PPE - gown, gloves, mask and face shield) before and after providing care to the residents. These deficient practices had the potential to result in the spread of COVID-19 from Residents 1, 2, 3, 4, 5, 6, 7 placing Residents 8, 9, 10, 11, 12, and staff at risk for COVID-19 infection that could lead to severe respiratory illness, hospitalization and/or death. On 8/13/20 at 5:10 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm impairment or death to a resident) was identified in the presence of the Director of Nursing (DON) and Infection Control Nurse 1 (ICN 1- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment). The IJ was called in the presence of the Administrator (ADM), DON and ICN 1 regarding the facility's failure to implement interventions to prevent the spread of COVID-19 infection that threatened the health and safety of the residents and staff. On 8/14/20 at 5:50 p.m., the IJ was lifted after the facility submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices); the surveyor verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the ADM, DON, ICN 1 and Registered Nurse Consultant (RNC). The ADM provided an acceptable POA as follows: 1. On 8/13/20 at 6:00 p.m., facility's staff placed a plastic barrier for the purpose of separation of COVID and Non-COVID residents. 2. The facility's ADM followed the Acute Communicable Disease Control Manual ([DIAGNOSES REDACTED]-M) updated on 8/11/20 to dedicate a single staff if possible and should refrain from moving staff back and forth between cohorts. If staff does need to move between cohorts, they should organize their work schedule so that they move from the Green Zone (Non COVID area for residents tested negative for COVID-19) to the Yellow Zone and to the Red Zone, but never the other way around. PPE must be changed per each resident contact. 3. ICN 1 provided an in-service to Greeter 1 (GR1-person who screens staff and visitors) on 8/13/20 at 6:10 p.m., which included asking staff and visitors for signs and symptoms of respiratory illness, contact with positive COVID-19 persons and history of travel. 4. On 8/13/20 at 6:10 p.m. facility's staff placed signages for donning/doffing PPEs and hand hygiene/washing in the hallways and by the doors in the YELLOW and RED zones. Findings: A review of Resident 1's Face Sheet indicated the facility admitted the resident on 7/16/20 with [DIAGNOSES REDACTED]. A review of Resident 1's laboratory (lab/test) result, dated 7/9/20, indicated the resident tested positive for COVID-19. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 7/29/20 with [DIAGNOSES REDACTED]. A review of Resident 2's lab result, dated 7/21/20, indicated the resident tested positive for COVID-19. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 7/29/20 with [DIAGNOSES REDACTED]. A review of Resident 3's lab result, dated 7/19/20, indicated the resident tested positive for COVID-19 A review of Resident 4's Face Sheet indicated the facility admitted the resident on 7/31/20 with [DIAGNOSES REDACTED]. A review of Resident 4's lab results, dated 7/27/20, indicated the resident tested positive for COVID-19. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 8/7/20 with [DIAGNOSES REDACTED]. A review of Resident 6's Face Sheet indicated the facility admitted the resident on 7/31/20 with [DIAGNOSES REDACTED]. A review of Resident 6's lab result, dated 7/24/20, indicated the resident tested positive for COVID-19. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 8/12/2020 with [DIAGNOSES REDACTED]. A review of Resident 8's Face Sheet indicated the facility admitted the resident on 7/28/20 with [DIAGNOSES REDACTED]. A review of Resident 8's lab result, dated 8/3/20, indicated the resident tested negative for COVID-19. A review of Resident 9's Face Sheet indicated the facility admitted the resident on 7/28/20 with [DIAGNOSES REDACTED]. A review of Resident 9's lab result, dated 8/3/20, indicated the resident tested negative for COVID-19. A review of Resident 10's Face Sheet indicated the facility admitted the resident on 7/31/20 with [DIAGNOSES REDACTED]. A review of Resident 11's Face Sheet indicated the facility admitted the resident on 8/6/20 with [DIAGNOSES REDACTED]. A review of Resident 11's lab result, dated 7/15/20, indicated the resident tested negative for COVID-19. A review of Resident 12's Face Sheet indicated the facility admitted the resident on 8/7/20 with [DIAGNOSES REDACTED]. A review of Resident 12's lab result, dated 8/10/20, indicated the resident tested negative for COVID-19. 1. During the initial observation with ICN 1 on 8/13/20, at 11:10 a.m., Residents 1's, 2's, 3's, 4's, 5's, 6's, 7's, 8's, 9's, 10's, 11's, and 12's' Rooms were located in the same hallway of Unit 100, designated as Red and Yellow Zones. There was no physical barrier to separate the Red and Yellow Zones. A concurrent interview was conducted; ICN 1 stated there was no physical barrier to separate the Red and Yellow Zones. ICN 1 stated Residents 1's, 2's, 3's, 4's, 5's, 6's, and 7's rooms with opened doors are in Yellow Zone. ICN 1 stated Residents 8's, 9's, 10's, 11's and 12's rooms with closed doors and a red sticker are in the Red Zone. During an observation of the Yellow and Red Zones on 8/13/20, at 11:25 a.m., LVN 1 walked out of Resident 2's room (Red Zone) into Resident 11's room (Yellow Zone). LVN 1 spoke with Resident 11, then walked back to the Nursing Station 1, in front of Resident 2's room. A concurrent interview was conducted; LVN 1 stated there was no barrier or separation between the Yellow and the Red Zones. LVN 1 stated the facility used the residents' room doors as barriers. LVN 1 stated residents' rooms in the Yellow Zone had opened doors while residents' rooms in the Red Zone had closed doors. During a telephone interview on 8/13/20 at 2:10 p.m., Public Health Nurse 1 (PHN 1, local public health nurse who was assigned to work with the facility) stated she did not know facility's staff were using residents' room doors as a barrier between Yellow and Red Zone. PHN 1 stated closing of the residents' room doors is not enough as barriers. PHN 1 stated she recommended for the facility's Administrator to place clear barriers between the Yellow, Green, and Red Zones. During a review of the PHN's recommendation, dated 4/28/2020, indicated based on the Health Officer Order (HOO, measures taken to preserve the health of the public) residents who tested positive for COVID-19 or displayed symptoms associated with COVID-19 must be physically separated from those who do not have confirmed or suspected COVID-19. During an interview with the Administrator on 8/13/20 at 2:40 p.m., she stated Residents 1's, 2's, 3's, 4's, 5's, 6's 7's rooms are designated for confirmed COVID 19 residents (Red Zone). The Administrator stated Residents 8's, 9's 10's, 11's 12's and other rooms' in the same hallway were designated for the Yellow Zone. The ADM stated he assumed closing residents' room doors was enough to use as a barrier between the Yellow and Red Zones. During an interview with the DON on 8/14/20 at 4:50 p.m., she stated a barrier should have been placed to separate the Yellow from the Red Zone. The DON stated separation is needed to avoid the spread of infection and for residents' safety. The DON stated a barrier or divider is needed to distinguish the different zones to prevent intermingling (mixing) of the positive COVID-19 residents (Red Zone) from the non-COVID-19 residents (Green Zone) and the suspected COVID-19 resident (Yellow Zone). A review of the facility's undated Mitigation Plan, under the section Designation of Space for COVID-19 Positive and Suspected for COVID-19, indicated for the facility to have a designated space (COVID Unit) to care for residents with confirmed COVID- 19. The designated space ideally will be self-contained and easily definable by its barriers (e.g. Fire Doors). The MP indicated the barriers are used to limit movement in and out of COVID area to other non-COVID areas. 2. During an observation of the Yellow and Red Zones on 8/13/20, at 11:25 a.m., LVN 1 walked out of Resident 2's room (Red Zone) into Resident 11's room (Yellow Zone). LVN 1 spoke with Resident 11, then walked back to the nursing station in front of Resident 2's room. A concurrent interview was conducted; ICN 1 stated LVN 1 was assigned to care for residents in both Yellow and Red Zones. During an interview on 8/13/20 at 11:35 a.m., LVN 1 stated she was assigned by the DON to care for all residents in Unit 100 where both Yellow and Red Zones are located. LVN 1 stated Unit 100 housed Residents 1, 2, 3, 4, 5, 6, 7 who tested posited for COVID-19 and Residents 8, 9, 10, 11, and 12, who tested negative for COVID-19. During a telephone interview on 8/13/20 at 2:10 p.m., PHN 1 stated she recommended to the facility's Administrator that there should be no sharing of staff between COVID and Non-COVID residents. A review of the facility's Shift Assignment, dated 8/14/20, indicated one LVN was assigned to Unit 100 to take care of residents from both Yellow and Red Zones per each shift. During a review of the facility's Shift Assignment, dated 8/14/20 and a concurrent interview with the Administrator on 8/14/20 at 4:50 p.m., she stated LVN1 was assigned to care for both suspected COVID and confirmed COVID residents. The ADM stated mixing staff can be a source of spreading infection to the residents who had not yet confirmed with COVID-19. A review of the facility's undated Mitigation Plan, under section Designation of Space for COVID-19 Positive and Suspected for COVID-19, indicated the facility will have a designated Health Care Provider to work in COVID Unit. The MP indicated staffing with at least a nursing assistant and a Licensed Nurse will be assigned to care for the residents. A review of the facility's policy, titled Facility Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus (COVID-19) in Skilled Nursing Facility, dated 4/13/2020, indicated for facility to have assigned staff specially to care for only suspected or confirmed COVID-19 residents. 3. During an observation at the facility's entrance area on 8/13/20 at 11:00 a.m., Greeter 1 (GRT1) requested Surveyor 1's name and type of visit. GRT 1 checked Surveyor 1's temperature and did not screen for signs and symptoms of COVID 19. GRT 1 then proceeded to take PA 1's temperature who was next person in line. A review of the facility's Visitor Log, dated 8/13/20 for the 7 a.m. - 3 p.m. shift, indicated screening questions for signs and symptoms of COVID-19 including respiratory illness, fever, chills, contact with positive COVID-19 residents, international travel, were left blank for Surveyor 1 and the PA 1. During an interview on 8/14/20 at 3:30 p.m., GRT 1 stated she filled out the blank sections on the Visitor Log dated 8/13/20 from the 7 a.m. -3 p.m. shift later although she did not ask the screening questions because she did not want to get in trouble. GRT1 stated she was aware that she should carefully screen staff and visitors prior to entering the facility. During an interview with ICN 1 on 8/14/20 at 4:30 p.m., she stated GRT 1 need to ask all visitors and surveyors the screening questions prior to entering the facility. ICN 1 stated careful screening is a source of control of who comes in and out of the facility to prevent COVID 19 and or other diseases from spreading in the facility. A review of the facility's undated job description for Health Screener/Greeter indicated the health screeners need to check temperature and ask basic health screening questions to all employees and visitors before they enter the facility daily. 4. During initial tour of the Yellow and Red Zones on 8/13/20 at 11:10 a.m., there were no signages posted to remind facility's staff to perform hand washing, don and doff PPEs for infection control precautions. A concurrent interview was conducted; ICN 1 stated there were no signages in front of the resident's room in the Yellow and Red Zones. During an interview on 8/13/20 at 2:35 p.m., ICN 1 stated residents in the Yellow or Red Zones are on contact and droplet isolation (used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing). ICN 1 stated signages or reminders are important for staff to help control the spread of infection. A review of the facility's undated Mitigation Plan, titled Designation of Space for COVID-19 Positive and Suspected for COVID-19, indicated for COVID Unit to have clear signages at the entrance and exit to instruct HCP to don and doff proper PPE and perform hand washing or apply Alcohol-Based Hand Sanitizer Procedures.

Based on observation, interview and record review, the facility failed to accurately assess and provide the necessary care and services (wound treatments) by the physician, the physician designee (NP, Nurse Practitioner), the Director of Nursing (DON), the registered nurses, and the licensed vocational nurses (treatment nurses); after a resident sustained [REDACTED]. Cross Reference F 689. This deficient practice resulted to a wound infection of [MEDICAL CONDITION] ([MEDICAL CONDITION], an organism difficult to treat due to resistance to commonly used antibiotics) to resident's injury. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility, on 10/22/18, with [DIAGNOSES REDACTED]. blocked). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 11/3/18, indicated resident was able to understand others and express her needs and wants, and required extensive assistance (resident involved in activity, staff provide weight bearing support) with two person physical assistance with bed mobility and transfers. A review of Resident 1's SBAR (Situational Background Assessment Report) Communication Forms, dated 12/13/18 timed at 10 a.m. by Licensed Vocational Nurse 3 (LVN 3), indicated, a Certified Nursing Assistant 1 (CNA 1) reported to the charge nurse that Resident 1 sustained right lower leg skin tear with skin flap and bleeding when the resident bumped leg on the footrest of Resident 1's wheelchair while transferring from the wheelchair to the bed and sustained a skin tear (a wound cause by shear, friction, and/or [MEDICATION NAME] force resulting in separation of skin layers) measuring 4.5 centimeter (cm) in length x (by) 1 cm. A review of Resident 1's Physician Order, dated 12/13/18, indicated to clean the right shin skin tear with Normal Saline (water with salt used to retard the growth of bacteria), pat dry, apply sterile strips (dressing strips that keep the tissues intact) and cover with dry dressing for 21 days then reevaluate. A review of Resident 1's Clinical Documentation-Skin Integrity Condition, dated 12/19/18 at 2:20 p.m. by LVN 2, indicated, Resident 1 wound size increased to length 3.8 cm x width 5.8 cm. x depth 0.3 cm. A review of Resident 1's Physician Order, on 12/19/18, indicated to clean the right shin skin tear with Normal Saline pat dry, apply triple antibiotic (medication used to treat infection) ointment and cover with dry dressing for 21 days then reevaluate. A review of Resident 1's medical records indicated no documented evidence that the NP assessed the wound prior to changing the wound treatment, dated 12/19/18, when the LVN 2 reported to the NP that the wound was not improving. A review of the Resident 1's Progress Notes, dated 12/19/18 timed at 12:33 p.m., LVN 2 documented received change in order. The note did not describe what order received, or why the order was changed. On 12/31/18 at 10:15 a.m., during a wound treatment observation in Resident 1's room with LVN 1, Resident 1 was observed grimacing. The wound observed on the right leg had pink tissue with bright red blood oozing from an open deep wound. On 12/31/18 at 10:18 a.m., during an interview, LVN 1 explained, she initially assessed Resident 1's wound, as a Skin tear, because the wound had a skin flap, however, the wound had increase in size and was now deeper. LVN 1 stated Resident 1 sustained the wound from a sharp edge metal on the side of resident's wheelchair during a transfer from a wheelchair to bed two weeks ago. On 12/31/18 at 11:19 a.m., during an observation in Resident 1's room and concurrent interview with the DON, the DON stated she had never seen or assessed the wound on 12/13/18. The DON stated the wound did not look like a skin tear. The DON stated the wound was a laceration (a cut or jagged wound). The DON stated a registered nurse and a physician should have assessed the wound to ensure accurate assessment for immediate interventions to prevent complication such as infection. On 12/31/18 at 11:47 a.m., during an interview, LVN 2 stated the wound treatment using the steri-strip was not working and the wound was not getting better. LVN 2 stated LVN 2 called the Nurse Practitioner (NP), on 12/ 19/18, for new treatment order. LVN 2 stated the NP changed the order to apply triple antibiotics to the wound. LVN 2 stated the NP did not physically assess Resident 1's wound on 12/19/18. On 12/31/18 at 1:10 p.m., during an interview, the NP stated she had not assessed Resident 1's skin tear on the right leg. The NP stated the staff reported Resident 1's skin tear was not improving, and the treatment was changed to triple antibiotic. The NP stated she did not order any laboratory test to check for infection of the wound or assessed the skin tear prior to changing the treatment. A review of Resident 1's Clinical Documentation-Skin Integrity Condition, dated 12/31/18 timed at 1:31 p.m. by LVN 2, indicated Resident 1 had a skin tear on the right anterior (front) lateral leg measuring 3 cm in length x 5.5 cm in width x 0.6 cm in depth. On 12/31/18 at 2:05 p.m., during an interview with the DON and concurrent review of Resident 1's medical records, there were no documented evidence that the Interdisciplinary Team (IDT, team of facility staff responsible to assess and plan the care of the residents) discussed with the responsible party and a care plan for resident's skin tear. The DON stated the IDT should have assessed the resident and developed a care plan. A review of the Physician's Progress Record, dated 1/2/19, indicated Resident 1 had painful right leg ulceration/laceration from a skin rupture (separate) with a wheelchair. The progress notes indicated the wound was infected and with [DIAGNOSES REDACTED] (redness), measured 2 cm x 3.5 x 1 cm that was cleaned with Dakins Solution (diluted bleach used as strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION]) and applied wet to dry dressing. A review of Resident 1's Surgical Consult, dated 1/7/19, indicated a right anterior lower leg debridement (the removal of damaged tissue) performed by surgical excision due to 75 % wound slough (dead tissue, usually cream or yellow in color). The wound measured on length 3.0 cm x width 4.0 cm x depth described as unstageable tissue damage (UTD). A review of Resident 1's Laboratory Report, result date 1/8/19, indicated Resident 1's right leg skin tear was infected [MEDICAL CONDITION]. A review of Resident 1's Physician Order, dated 1/9/19 at 6:56 a.m., indicated to place Resident 1 on Contact Isolation [MEDICAL CONDITION] of the right lower leg wound, and to administer [MEDICATION NAME] (medication used to treat infection) for ten days for [MEDICAL CONDITION] infection. A review of Resident 1's Laboratory Report, result date 1/15/19, indicated Resident 1's right leg skin tear continued to be infected [MEDICAL CONDITION]. A review of Resident 1's Surgical Consults, dated 1/21/19 and 2/11/19, indicated resident had repeat wound debridement. On 3/1/19 at 10:36 a.m., during a telephone interview, the facility's Medical Director (MD 1) stated for reported skin tear, he wound find out what happened, assess the wound, administer antibiotics, consult with the wound consult, and refer to the surgeon if needed. MD 1 stated MD 1 observed the treatment nurses (no specified date given), and stated, The treatment nurses did not know what they were doing. A review of the undated facility's job description, titled, Treatment Nurse, indicated the primary job position of a treatment nurse was to provide primary skin care to residents under the medical direction and supervision of the DON, attending physician, and the Medical Director. A review of the undated facility's job description, titled, Director of Nursing, indicated the DON will provided close supervision and direction to the nurses to continually improve the nursing care of the residents and will assume ultimate responsibility for coordinating plans for the total care of each residents, which comply with physician's orders [REDACTED]. A review of the facility's policy and procedure, dated 8/06, titled, Physician's Services, indicated the resident's attending physician participated in resident assessment, care planning, monitoring changes, in resident's medical status, and providing consultation and treatment when called by the facility.

Based on observation, interview and record review, the facility failed to prevent an accident and provide a safe, hazard free wheelchair when the wheelchair had a sharp edge, transfer by two-person assistance, and there was no investigation on the cause of the resident's injury from the wheelchair for one of three sampled residents (Resident 1). Resident 1 sustained a laceration (a deep cut or jagged wound) on the right lateral leg, on 12/13/18, from a sharp edge on the side of resident's wheelchair when a staff rushed to assist resident to avoid a fall. This deficient practice resulted to resident's wheelchair remained a hazard and the Director of Nursing (DON) did not assess Resident 1's injury sustained from the wheelchair until 12/31/18 (18 days after the injury). Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility, on 10/22/18, with [DIAGNOSES REDACTED]. blocked). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 11/3/18, indicated Resident 1 was able to understand others and express her needs and wants, and required extensive assistance (resident involved in activity, staff provide weight bearing support) with two person physical assistance with bed mobility and transfers. A review of Resident 1's SBAR (Situational Background Assessment Report) Communication Forms, dated 12/13/18 timed at 10 a.m. by Licensed Vocational Nurse 3 (LVN 3), indicated, a Certified Nursing Assistant (CNA 1) reported to the charge nurse that Resident 1 sustained right lower leg skin tear (a wound caused by shear, friction, and/or [MEDICATION NAME] force resulting in separation of skin layers) with skin flap and bleeding when the Resident 1 bumped leg on the footrest of while transferring from the wheelchair to the bed and sustained a skin tear measuring 4.5 centimeter (cm) in length x 1 cm. A review of Resident 1's Physician Order, dated 12/13/18, indicated to clean the right shin skin tear with Normal Saline (water with salt used to retard the growth of bacteria), pat dry, apply sterile strips ( strips that keep the tissues intact) and cover with dry dressing for 21 days then reevaluate. A review of Resident 1's Clinical Documentation-Skin Integrity Condition, dated 12/19/18 at 2:20 p.m. by LVN 2, indicated, Resident 1 wound size increased to length 3.8 cm x width 5.8 cm. x depth 0.3 cm. A review of Resident 1's Physician Order, on 12/19/18, indicated to clean the right shin skin tear with Normal Saline pat dry, apply triple antibiotic (medication used to treat infection) ointment and cover with dry dressing for 21 days then reevaluate. On 12/31/18 at 10:15 a.m., during a wound treatment observation with LVN 1, Resident 1 observed grimacing when interviewed Resident 1 stated she had pain on the wound site but refused to take pain medication. The wound observed on the right leg had pink tissue with bright red blood oozing from an open deep wound. A review of Resident 1's Clinical Documentation-Skin Integrity Condition, dated 12/31/18 timed at 1:31 p.m. by LVN 2, indicated Resident 1 had a skin tear on the right anterior lateral leg measuring 3 cm in length x 5.5 cm in width x 0.6 cm in depth. On 12/31/18 at 2:00 p.m., during an interview and concurrent record review with the DON of Resident 1's medical records, the DON stated there was no documented evidence Resident 1 skin injury was investigated. The DON stated she should have investigated the incident of the exact cause of the skin injury such as checking the sharp edge on the wheelchair to determine the appropriate care. On 12/31/18 at 2:05 p.m., during an interview and concurrent record review with the DON of Resident 1's medical records, the DON stated resident's laceration was reported during the stand-up meeting that resident had a skin tear. The DON stated she did not observe or investigate the exact cause of the skin tear. The DON stated she was responsible to investigate any type of resident injury. On 12/31/18 at 2:22 p.m. during an observation and concurrent interview with LVN 3 and CNA 1, Resident 1 observed sitting on the wheelchair. CNA 1 stated Resident 1 sustained a Skin tear, and pointed at the side of resident's wheelchair that had a sharp edge without a rubber cap. CNA 1 stated the resident's wheelchair was the same wheelchair that caused the injury to resident's leg on 12/13/18. CNA 1 stated she transferred Resident 1 alone, and she should have had another staff to assist her. CNA 1 stated resident was heavy. CNA 1 stated the resident stood up, started losing balance, and had to move the resident into the bed right away to prevent the resident from falling. On 12/31/18 at 2:58 p.m. during an observation of Resident 1's wheelchair and interview, the DON stated the side of the wheelchair should have had a rubber cap to cover the sharp edge. The DON stated no one inspected the wheelchair after resident was injured to ensure the sharp edge was covered. A review of the facility's policy and procedure, dated 12/07, titled Safety and Supervision of Residents, indicated the facility will provide safety and supervision to residents to prevent accidents. The policy and procedure indicated safety risk and environmental hazards were identified on an ongoing basis, and when an accident hazards were identified, and the Quality Assurance and Safety Committee (group of facility staff from different healthcare disciplines) shall evaluate and analyze the cause of the hazards and develop strategies to remove the hazards.

Based on observation, interview, and record review, the facility failed to prevent and have preventative measures in place to prevent worsening of pressure ulcers (injuries (PI)/areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore) prominence as a result of pressure) for three of five sampled residents with pressure injuries (Resident 22, 76, and 151) in a total resident sample of 24. 1. For Resident 22, the resident had a facility acquired deep tissue injury (DTI an injury under the intact skin due to prolonged unrelieved pressure) PI to the left heel. The facility failed to: a. Ensure weekly skin assessment were done on 12/17/18, and 12/24/18, in accordance with the facility's policy and procedures. b. Notify the physician of Resident 22's change in condition to the left foot PI. The left foot was swollen. c. Ensure Resident 22 was monitored on multiple days to relieve constant pressure on the left heel (offload the heel) as indicated in the plan of care. d. Notify the physician of the facility's policy and procedures regarding treatment for [REDACTED]. 2. Resident 151, skin assessment was not properly assessed to reflect the resident's pressure injury on the left heel and the facility failed to start preventative measures on admission. 3. Resident 76, with a DTI on the right heel was treated with [MEDICATION NAME] (or [MEDICATION NAME]-iodine is solution used to eliminate bacteria to prevent infection) These deficient practices put the resident at risk for further skin breakdown that could have been prevented. Findings: 1. A review of Resident 22's record titled, Resident Face Sheet, undated, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 22's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 10/1/18, indicated the resident was able to express ideas and wants. The MDS indicated Resident 22 required extensive assistance (staff provided support with bearing weight, at times full staff performance of activity) from staff with activities of daily living ((ADLs) such as toileting, personal hygiene, and bed mobility) and had a pressure reducing device while in bed and chair. A review of Resident 22's Treatment Administration History, dated 12/1/18 to 12/27/18, indicated a physician's order on 12/10/18, to cleanse the left heel DTI with normal saline (salt solution), pat dry, paint with [MEDICATION NAME], then cover with dry dressing every day. During an observation on 12/26/18, at 11:22 a.m., Resident 22 was in the room on a wheelchair with no footrest. Resident 22 was wearing non-skid socks and both feet were resting directly on the floor. During an observation on 12/27/18 at 10:46 a.m., Resident 22 was in the room on a wheelchair wearing non-skid socks with both feet resting directly on the floor. During an interview with the Director of Nursing (DON) at that time, the DON stated Resident 22 had a facility acquired DTI PI to the left heel. During an inspection of Resident 22's left heel, there was no dressing, the foot was swollen, and an area was observed with dark purple discoloration. The DON verified the wheelchair had no footrest and Resident 22's feet were directly on the floor. The DON stated Resident 22 was mostly on the wheelchair and was able to self- propel using her feet and was unable to use her arms due to weakness. When asked about the interventions provided to residents with PI, the DON stated the feet needed to be offloaded to prevent pressure and worsening of the PI. During an interview on 12/27/18, at 10:55 a.m., with Certified Nursing Assistant 3 (CNA 3) in the presence of Resident 22, CNA 3 stated Resident 22 refused the foot rest. At the same time Resident 22, stated when she is on the wheelchair, it takes a long time to move and prefers to use her feet. On 12/27/18, at 10:57 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), when asked if she was aware Resident 22 refused the foot rest, LVN 1 stated the CNAs have not reported to her that Resident 22 did not like the footrest. LVN 1 stated a resident with PI to the feet when on a wheelchair should have their feet offloaded and not resting on the floor. A review of Resident 22's care plan, Left Heel Deep Tissue Injury, dated 12/10/18, indicated the wound should heal within 30 days and the following interventions: 1. Assess skin every day and as needed. 2. Provide pressure relieving surfaces to bed and wheelchair. 3. Encourage weight shifting while in wheelchair. A review of Resident 22's care plan, Allergic to IV Dye, dated 3/26/18, indicated resident will be free of any allergic reactions. During a review of Resident 22's care plan on 12/27/18, at 11 a.m., and concurrent interview, the DON verified the care plan for DTI of the heel indicated an intervention to provide pressure relieving device when on a wheelchair and should have heel protectors. The DON stated Resident 22 was not provided heel protectors and have her feet offloaded. During an interview on 12/27/18, at 11:05 a.m., LVN 2 (treatment nurse) verified Resident 22 had no dressing to the PI. LVN 2 stated there was no wound consult (a wound specialist that assess and provide treatment) obtained to evaluate Resident 22's facility acquired PI since 12/10/18. During an interview on 12/27/18, at 11:06 a.m., the DON stated the procedures for facility acquired PI were the following: 1. Facility staff should notify the physician for the change in condition (facility acquired PI). 2. Obtain a treatment order according to facility's policy. 3. Treatment nurse should monitor the wound every day and ensure the nursing interventions are provided according to the care plan. 4. Develop a care plan for PI. 5. Make an incident report regarding facility acquired PI. During the same interview, when asked when the facility staff obtains a wound consult, the DON stated a resident with acquired PI should have a wound consult. During a concurrent review of Resident 22's clinical record, the DON verified that Resident 22, who acquired a left heel DTI on 12/10/18, had no documentation that the physician was notified of the allergy to iodine, swelling and treatment order not according to facility policy. The DON stated there was no physician order obtained for a Doppler (test done to assess blood circulation for healing) study or wound consult. The DON verified there were no weekly skin assessments for Resident 22 and stated residents with a PI should have weekly skin assessments. During an interview on 12/27/18 at 11:32 a.m., and concurrent record review, the DON stated Resident 22 had an initial assessment on 12/10/18, that indicated Resident 22 developed a left heel DTI, measuring 3.5 centimeters (cm) in length by 4 cm in width, the depth was unable to determine. The DON verified there were no other assessments done on a weekly basis for 12/17/18, and 12/24/18. During an interview on 12/27/18, at 11:49 a.m., the DON and LVN 2 verified there were no weekly assessments done on 12/17/18, and 12/24/18, per facility policy. The DON stated that currently, LVN 2 was the only treatment nurse in the facility due to the other treatment nurse being on leave. Both LVN 2 and LVN 7 were the treatment nurse that would conduct the weekly assessments and treatments for residents with wounds during the week (Mondays-Fridays). During a concurrent review of Resident 22's Treatment Administration Record (TAR), dated 12/18, the DON and LVN 2 verified the TAR indicated Resident 22 had an allergy to IV dye. When LVN 2 was asked for the treatment bottle for Resident 22, LVN 2 removed an open bottle from the treatment cart labeled [MEDICATION NAME] Iodine 10 percent (%) with no open date label. LVN 2 stated he had no knowledge of the possible allergic reaction to iodine and IV dye. The DON stated she would call the physician and notify him of Resident 22's allergy and swelling to the left foot. During an observation on 12/27/18, at 3:26 p.m., Resident 22 was in a side lying position in bed. The DON and LVN 2 verified Resident 22 had a heel protector to the left heel and none to the right foot. Resident 22 had a pillow between the feet with the right heel on top of the pillow that was over the left heel wound. The DON was notified of the positioning of pillow on the left foot; pressure was applied to the left heel wound. The DON verified the position of the pillow was not on the calf to allow for the offloading of the feet. During an interview on 12/28/18, at 5:15 a.m., CNA 4 stated she was told to offload Resident 22's feet. During a concurrent observation, Resident 22 was lying on her back with one pillow under the resident's calves with both heels directly pressing on the mattress, not offloading. CNA 4 stated she will add another pillow to elevate the feet. During an interview on 12/31/18, at 1:31 p.m., the DON and LVN 4 stated [MEDICATION NAME] was not a current treatment for [REDACTED]. The DON stated the residents that were being cared by the wound consult did not have [MEDICATION NAME] as a wound treatment for [REDACTED]. During an interview on 12/31/18 at 2:56 p.m., the DON stated according to the facility's nurse consultant, a DTI PI followed the protocol for a Stage 4 PI (full thickness tissue loss wound). A review of the facility policy and procedures titled, Pressure Ulcer Treatment, dated 10/10, indicated the treatment for [REDACTED]. A review of the facility policy and procedures titled, Pressure Ulcer Risk Assessment, dated 10/10, indicated the monitoring of the skin should have weekly assessments to identify any changes. According to National Pressure Ulcer Advisory Panel (NPUAP) handbook on Prevention and treatment of [REDACTED]. In addition, NPUAP guidelines for PI care included a caution that iodine products should be avoided in individuals with iodine sensitivity due to the risk of systemic absorption. 2. A review of Resident 151's Resident Face Sheet indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 151's MDS dated [DATE], indicated Resident 151 had clear speech and was able to make needs known. Resident 151 needed extensive assistance, staff providing weight-bearing support, for transferring and dressing. During an interview and concurrent record review, on 12/28/18, at 8:43 a.m., the DON stated, Resident 151 was admitted with a left heel DTI from the hospital on [DATE]. The DON stated, the facility started the treatment on the wound on 12/22/18, but did not order the heel protectors until 12/27/18. The DON stated, they should have ordered the heel protectors on admission to prevent worsening of the wound. A review of Resident 151 admission skin assessment, the nurse documented there was a mid chest old surgical scar and bilateral foot [MEDICAL CONDITION] (both feet swelling). There was no documentation on admission regarding the left heel DTI. The DON was unsure why the admitting nurse did not have any documentation of the left heel DTI. A review of the facility form titled, Clinical Documentation-Skin Integrity, dated 12/21/18, indicated Resident 151 had a mid chest old surgical scar and bilateral foot [MEDICAL CONDITION]. A review of Resident 151's physician's order dated 12/21/18, indicated to cleanse the left heel DTI with normal saline (salt water), paint with [MEDICATION NAME], wrap with Kerlix (gauze) daily. A review of Resident 151's physician's order dated 12/27/18, indicated may use floater on left heel every shift as tolerated for wound management. A review of the facility P&P titled, Pressure Ulcer Treatment, dated 10/2010, indicated the pressure ulcer treatment program should focus on the following strategies: Assessing the resident and the pressure ulcer. Managing tissue loads. Pressure ulcer care. Managing bacterial colonization and infection. Operative repair of the pressure ulcer(s). Educating and quality improvement. 3. A review of the Resident Face Sheet indicated Resident 76 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 76 was usually able to understand others and express ideas and wants and required total dependence with one-person assistance for bed mobility. On 12/29/18, at 9:43 a.m., during an observation and concurrent interview, Resident 76 was observed with left foot wrapped with Kerlix dressing and was wearing a boot. LVN 2 stated, Resident 76 had a DTI on the left heel and was being treated with [MEDICATION NAME]. A review of the physician's order, dated 12/5/18, indicated to treat Resident 76's left heel DTI with normal saline, pat with [MEDICATION NAME] and wrap with Kerlix daily for thirty days. On 12/31/18, at 2:10 p.m., in an interview, the DON stated, according to the facility protocol, [MEDICATION NAME] was not the treatment of [REDACTED]. A review of the facility P&P dated 10/2010, titled, Pressure Ulcer Treatment, did not include [MEDICATION NAME] for treatment of [REDACTED]. According to National Institute of Health, the care of pressure ulcer was to keep the wound clean and prevent infection and do not use iodine cleanser as it can damage the skin. Reviewed: 5/12/18 https://medlineplus.gov/ency/patientinstructions/ 0.htm

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 2) who was admitted to the facility with [DIAGNOSES REDACTED]. 1. Failure to assess Resident 2's behavior of hitting a table with her hands and fingers, and identify, address, and resolve the cause of the behavior. 2. Failure to notify the physician of Resident 2's behavior of hitting the table. 3. Failure to follow the physician order [REDACTED]. 4. Failure to provide redirection and diversional activities in a language that Resident 2 understands in accordance with the care plan for mood, behavior, and psychosocial health, dated 11/10/17. 5. Failure to implement the care plan for cognition and communication, dated 11/10/17, to provide a safe and secure environment. These deficient practices resulted for Resident 2 to sustain a fourth right finger displaced fracture (the two ends of the broken bone are separated from one another) on 11/19/17, when the resident repeatedly hit a table with her hands and fingers, that required a splint (a firm material used for supporting and immobilizing a broken bone); administration of [MEDICATION NAME] (pain relief medication) 50 milligrams (mgs) every eight hours; and the separation of the spouses (Resident 1 and 2) when Resident 2 had a lateral transfer (movement to the same type of facility) to another skilled nursing facility. The separation of Resident 2 from Resident 1 (Resident 2's spouse) caused emotional distress to Resident 1. Findings: During an observation on 12/7/17 at 6:14 a.m., Resident 1 (Resident 2's spouse) was awake and lying in bed. During an interview with the assistance of Certified Nursing Assistant 1(CNA 1) who translated for Resident 1, Resident 1 stated he missed Resident 2 not being in the facility and he was concerned about Resident 2 because Resident 2 was transferred to a different facility. A review of Resident 1's Minimum Data Set ((MDS) a resident assessment and care screening tool), dated 11/7/17, indicated the resident needed an interpreter, had clear speech, was moderately impaired in cognitively skills (the ability to think, read, learn, remember, reason, and pay attention), and was totally dependent on staff for bed mobility, transfers, and locomotion on and off unit (how resident moves between locations). A review of Resident 2's Record of Admission indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Physician admission orders [REDACTED]. A review of Resident 2's Psychosocial Assessment, dated 11/15/17, indicated the resident was to sit close to the nursing station to be monitored by staff. A review of Resident 2's Minimum Data Set, dated dated [DATE], indicated that the resident needed an interpreter, had unclear speech, and that sometimes understood others. The MDS indicated that Resident 2 was severely impaired in cognitively skills, required extensive assistance (resident involved in activity; staff provide weight bearing support) for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair) requiring two persons to assist, and was totally dependent on staff locomotion on and off unit. The MDS indicated the resident exhibited a behavioral symptom not directed toward others, for example, physical symptoms such as hitting or scratching self or verbal/vocal symptoms like screaming and disruptive sounds. A review of Resident 2's care plan titled, Mood/Behavior/Psychosocial Wellbeing, dated 11/10/17, indicated that the resident had alteration in mood, behaviors and psychosocial well-being related to anxiety agitation. The interventions included redirecting behavior as needed, attempting to determine cause of upset and try to resolve, providing diversional activities as needed to redirect behavior, and psych consult and follow up as needed. A review of Resident 2's care plan titled, Cognition/Communication, dated 11/10/17, indicated that Resident 2 had altered cognition related to [DIAGNOSES REDACTED]. The interventions included providing a safe and secure environment. A review of Resident 2's SBAR (Situation, Background, Assessment Recommendation - a tool to share patient information in a clear, complete, concise and structured format; improving communication efficiency and accuracy) Communication Form, dated 11/19/17, and timed at 12 p.m., indicated that the resident was noted with swelling to her right fourth finger, with increased agitation, striking out, and hitting the table. A review of Resident 2's Final X-Ray Report, dated 11/19/17, indicated that the resident had moderate soft tissue swelling and had a minimally displaced fracture involving the shaft (central part of a long bone) of the proximal (nearest to a point of reference ) right fourth phalanx (a bone of the finger). A review of Resident 2's Physician's Telephone Orders, dated 11/19/17, and timed at 4:40 p.m., indicated to place a splint on Resident 2's fourth finger. A review of Resident 2's Interdisciplinary Progress Notes, dated 11/20/17, and timed at 10:45 a.m., indicated that the resident was very agitated, and that the resident had a right fourth finger fracture, and that on 11/19/17, in the morning she (Resident 2) hits around the table, so it caused the fracture. The notes indicated that the resident is very agitated and was not appropriate for this facility, and that the Social Worker would find an appropriate facility. A review of Resident 2's untimed Physician's Telephone Orders, dated 11/20/17, indicated for Resident 2 to receive [MEDICATION NAME] 50 mg by mouth every 8 hours for pain for seven days. A review of Resident 2's Licensed Personnel Progress Notes, dated 11/28/17, and timed at 11:15 a.m., indicated that Resident 2 was transported to another facility. During an interview, on 12/7/17 at 6:26 a.m., CNA 1 stated that Resident 2 was very confused and would get agitated when staff did not talk to her in Armenian, a language she (Resident 2) could understand and that it was difficult to care of her. During an interview, on 2/28/18 at 12:40 p.m., the Director of Nursing (DON) stated that Resident 2 was not evaluated by the psychiatrist as ordered on [DATE], by Resident 2's physician. During an interview on 2/28/18 at 1:14 p.m., the Social Services Director (SSD), stated that Resident 2 was transferred to another facility (same services offered as the facility) due to Resident 2's agitation that was hard to control. The SSD stated the facility was not appropriate for Resident 2 and that the resident needed to be in a dementia unit. The SSD stated Resident 2 was transferred to the same type of facility because We just could not care for her here. During an observation, on 2/28/18 at 11:12 a.m., six residents were sitting in wheelchairs in front of the nursing station with no facility staff present. This was the same area where Resident 2 sustained a fourth right finger displaced fracture on 11/19/17 and a fall on 11/22/17. During an interview, on 2/28/18 at 1:47 p.m., a Licensed Vocational Nurse (LVN 1) stated that Resident 2 was always sitting in a wheelchair by the table in the nursing station and hit the table every day, prior to Resident 2 sustaining a fourth right finger displaced fracture. LVN 1 stated that Resident 2 had the tendency to hit her (Resident 2's) hands and fingers against the table. LVN 1 stated that the nurses were supposed to assess the resident behavior and create a care plan to prevent injury. LVN 1 stated that she did not notify Resident 2's physician regarding resident's behavior. During the interview, LVN 1 stated that on 11/19/17 prior to 12 p.m., she (LVN 1) saw Resident 2 hitting the table. LVN 1 stated that she did not remove Resident 2 from the table when she (LVN 1) saw the resident hitting the table. LVN 1 stated that at 12 p.m., she saw Resident 2 with swollen right fourth finger while she was passing medications. During an interview, on 2/28/18 at 2 p.m., LVN 2 stated that Resident 2 was very confused and was placed daily at the nursing station and that the resident would bang on the table to get attention from people. LVN 2 stated that Resident 2 would be bored or something. LVN 2 stated that she would speak to Resident 2 in the language (Armenian) the resident would understand and the resident would calm down. A review of the facility's policy and procedure titled, Dementia, with a revised date of (MONTH) 2010, indicated that the staff and physician would review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. The policy indicated that individuals with dementia could also have a personality disorder, mental illness, [MEDICAL CONDITIONS], depression, adverse drug reactions, or other conditions causing or contributing to impaired cognition and problematic behavior and as needed, the physician could obtain a psychiatrist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications. The policy indicated that the staff would monitor the individual with dementia for changes in condition and decline in function and would report these findings to the physician. A review of the facility's policy and procedure titled, Behavior Assessment and Monitoring, with a revised date of (MONTH) 2007, indicated that problematic behavior would be identified and managed appropriately and that the nursing staff would identify, document, and inform the physician about an individual's mental status, behavior, and cognition.

Based on observation, interview, and record review, the facility failed to ensure that each resident received appropriate supervision to prevent falls and injuries of two sampled residents (Residents 1 and 2) including: 1. Failure to ensure, Resident 1, who was assessed as at risk for fall and injury, with history of falls, impaired cognitive skills (when a person has trouble remembering, learning new things, concentrating, or making decisions), and required total assistance from staff in transferring (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), and locomotion on and off the unit (how resident moves between locations) and locomotion, was provided supervision and assistance to prevent Resident 1 from falling twice from his wheelchair on 11/26/17 and on 12/24/17. 2. Failure to ensure Resident 2, who was assessed as at risk for fall, with impaired cognitive skills, and required extensive to total assistance from staff for transfers and locomotion, was provided supervision and assistance to prevent Resident 2 from falling from her wheelchair on 11/22/17. This deficient practice resulted in Resident 1 sustaining a re-fracture (the breaking of a bone that has united after a previous fracture) of his left hip, lacerations (deep cut or tear in skin or flesh) of the left forehead, face, and left arm. Resident 1 was transferred to a general acute care hospital (GACH) for treatment, and had a left hip arthroplasty (surgical procedure used to replace all or part of a patient's hip joint with a prosthetic hip) under general anesthesia (a medically induced coma), and had the potential for Resident 2 to sustain injuries. Findings: On 12/7/17 at 5:57 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding residents sustaining falls in the facility. 1a. During an observation on 12/7/17, at 6:14 a.m., Resident 1 was lying in bed awake. During a concurrent interview in Armenian with Resident 1, in the present of Certified Nursing Assistant 1 (CNA 1), Resident 1 stated on 11/26/17 he called staff for assistance, but the staff did not come to help him. Resident 1 stated he fell from his wheelchair, inside his room, while he was trying to go back to his bed. During an interview on 12/7/17 from 6:26 a.m. to 6:32 a.m., CNA 1 stated Resident 1 spoke Armenian and that some of the staff did not speak Resident 1's language. CNA 1 stated Resident 1 was dependent on staff for transfers. CNA 1 stated when she arrived on duty; she would find Resident 1's and other residents' call lights (a device used by a patient to signal his or her need for assistance) not within the residents' reach. During a telephone interview on 3/22/18 at 8:52 a.m., CNA 3 stated it was hard to attend to Resident 1's needs due to the resident required supervision and that she had other residents who were totally dependent. 1b. During an observation on 2/28/18, at 11:12 a.m., six residents were sitting on wheelchairs in front of the nursing station (same area where Resident 1 fell on [DATE]) with no activities conducted and no staff present. During an interview on 1/10/18, at 12:12 p.m., Registered Nurse 1 (RN 1) stated Resident 1 sustained a fall on 12/24/17 and was transferred to a GACH for further evaluation. During a telephone interview, on 3/21/18, at 2:51 p.m., CNA 2 stated that Resident 1 was little alert, and did not follow instructions. CNA 2 stated on 12/24/17, at approximately 10:30 a.m., she placed Resident 1 sitting on a wheelchair in front of a nursing station. CNA 2 stated she left Resident 1 by the nursing station due to the residents, who were at risk for falls, needed to be placed near the nursing station so that any nurse at the nursing station or any staff that passing by the nursing station was responsible to supervise the residents. CNA 2 stated no particular staff was assigned to supervise the residents who were placed by the nursing station. During a telephone interview on 3/22/18, at 11:42 a.m., RN 2 stated on 12/24/17, at 10:50 a.m., she found Resident 1 face down on the floor by the nursing station. RN 2 stated residents who were at risk for falls such as Resident 1 was placed by the nursing station, and no particular staff was assigned to supervise the resident. RN 2 stated whoever was the nurse sitting by the nursing station or whoever passed by the hallway was responsible to supervise the resident. A review of Resident 1's Record of Admission indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Client [DIAGNOSES REDACTED]. A review of Resident 1's history and physical examination [REDACTED]. A review of Resident 1's Clinical Health Status, dated 10/26/17, indicated that resident was at risk for falls. A review of Resident 1's Care Plan dated 10/26/17, indicated the resident was at risk for fall injury secondary to history of falls, recent fall with fracture, and [MEDICAL CONDITION]. The nursing intervention was to reposition the resident every two hours or as needed (PRN). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/7/17, indicated the resident needed an interpreter, had clear speech, was moderately impaired in cognitively skills (when a person has trouble remembering, learning new things, concentrating, or making decisions). The MDS indicated Resident 1 was totally dependent on staff for bed mobility (how resident moves to and from lying position, turns side to side, positions body while in bed), transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), locomotion on and off unit (how resident moves between locations), toileting, and personal hygiene. A review of Resident 1's care plan, dated 10/26/17, indicated the resident was at risk for potential injury from tremors and involuntary movements due to [MEDICAL CONDITION]. The goal was for Resident 1 to have no injuries within three months. The nursing interventions were to monitor environment for possible padding of side rails, and special chair needs if involuntary movements put resident at risk for injury. A review of Resident 1's Change of Condition Report, dated 11/26/17, and timed at 2 p.m., indicated Resident 1 was found lying face down on the floor mattress next to his bed, inside his room, and that the interventions after the fall were to provide the resident with frequent supervision. A review of Resident 1's Change of Condition Report, dated 12/24/17, and timed at 10:45 a.m., indicated Resident 1 was found face down on the floor in a hallway by the nursing station and that Resident 1 had localized pain, redness, bleeding, swelling, a bump on his forehead, and a skin tear to the left forearm. A review of Resident 1's Licensed Personnel Progress notes, dated 12/24/17, indicated that at 10:35 a.m., RN 2 saw Resident 1 sitting on his wheelchair at a nursing station, and at 10:50 a.m. (15 minutes after) RN 2 overheard a sound of a fall. The notes indicated Resident 1 was found on the floor face down with the resident's legs between the wheelchair footrests. The notes indicated Resident 1 had a bump on the left forehead measuring 2.2 by 2.0 centimeters (cm), a skin tear to his left forehead measuring 1.2 by1 cm. and a small amount of blood, and a left skin tear on the left posterior forearm measuring 2 by 1 cm. A review of Resident 1's Licensed Personnel Progress Notes, dated 12/24/17, indicated at 11 a.m., Resident 1 complained of pain 5/10 (0 being no pain, 10 being the worst pain you can imagine, and 5 being moderately strong pain) to his forehead. The notes indicated at 11:30 a.m., Resident 1's Physician ordered for Resident 1 to be transferred to a GACH for further medical evaluation. A review of Resident 1's GACH Discharge Summary Notes, dated 1/22/18, and timed at 12:37 a.m., indicated the resident was diagnosed with [REDACTED]. A review of Resident 1's GACH Surgery and Procedure Reports, dated 12/29/17, and timed at 5:07 p.m., indicated the resident was taken to the operating room and was placed under general anesthesia for a conversion to the left hip arthroplasty, bone graft (surgical procedure that replaces missing bone) of severe acetabular (the cup-shaped socket of the hip joint which is a key feature of the pelvis) defect, and resection (is the surgical removal of part or all of a damaged organ or structure) of heterotopic [DIAGNOSES REDACTED] (the presence of bone in soft tissue where bone normally does not exist). During an interview with LVN 3/MDS nurse, on 2/28/18, at 2:32 p.m., she stated Resident 1 was totally dependent on staff for transfers, and locomotion off unit. LVN 3 stated Resident 1 required one person to assist for propelling and repositioning while the resident was in the wheelchair. LVN 3 sated Resident 1 needed to be supervised to prevent falls. 2. During an interview on 12/7/17 at 6:26 a.m., CNA 1 stated Resident 2 was no longer at the facility. CNA 1 stated Resident 2 was confused and that it was difficult to care for her. A review of Resident 2's Record of Admission indicated that resident was admitted to the facility on [DATE]. A review of Resident 2's Client [DIAGNOSES REDACTED]. A review of Resident 2's History and Physical, dated 11/19/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident had severe impairments in cognitively skills and required extensive assistance with two persons-assist for transfers, bed mobility, and was totally dependent on staff for locomotion on and off the unit. A review of Resident 2's Fall Injury Potential Care plan, dated 11/10/17, indicated the resident was at risk for fall or injury. The staff's interventions were to provide safe, secure environment and to transfer resident with two persons-assist. A review of Resident 2's Licensed Personnel Progress Notes, dated 11/22/17, and timed at 9 a.m., indicated the resident was found lying on the floor with a student holding the wheelchair. A review of Resident 2's Change in Condition Report-Post Fall Trauma, dated 11/22/17, and timed at 9 a.m., indicated that resident was sitting on the wheelchair at the nursing station at 8:30 a.m., at 9 a.m. the student reported he was with the resident when she fell . The report indicated that the student reported Resident 1 insisted to get up from the wheelchair. During an interview, on 2/28/18 at 2:13 p.m., RN 2 stated that on 11/22/17 at 9 a.m., a CNA student (unidentified) reported to RN 2 that Resident 2 fell by the nursing station (same station as Resident 1). RN 2 stated that the licensed nurses were supposed to be supervising the residents not the students and that no other staff was with Resident 2 at the time of Resident 2's fall. A review of the facility's policy and procedure titled Safety and Supervision of Residents, with a revised date of (MONTH) 2007, indicated that the facility strived to make the environment as free from accident hazards as possible and that resident safety and supervision and assistance to prevent accidents were the facility's wide priorities. The policy indicated that the type and frequency of resident supervision could vary among residents and over time for the same resident and that staff should use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. A review of the facility's policy and procedure titled Falls-Clinical Protocol, with a revised date of (MONTH) 2013, indicated that as part of the initial assessment, the licensed nurse would help identify individuals with a history of falls and risk factors for subsequent falling. The policy indicated that if an individual continued to fall, the staff and the physician would re-evaluate the situation and consider other possible reasons for the residents falling besides those that were already identified, and would re-evaluate the continued relevance of current interventions.

Based on interview and record review, the facility failed to ensure residents were free from accident hazards and provided adequate supervision for one of three sampled residents (Resident 1). For Resident 1, who was assessed as a high fall risk and had poor safety awareness, the facility failed to ensure CNA 1 transferred Resident 1 with a two person extensive assist, per the Minimum Data Set (MDS - an assessment and care planning tool). Resident 1 was left unattended sitting on the wheelchair and the resident was found on the floor by facility staff. This deficient practice resulted in Resident 1 sustaining a fall with injuries, which included a fracture to the right clavicle (collar bone). Findings: A review of the clinical record indicated Resident 1 was readmitted to the facility, on 1/30/16, with [DIAGNOSES REDACTED]. A review of the Fall Risk Evaluation, dated 12/21/15, indicated Resident 1 was a high risk for falls with a score of 15 (a total score of 10 or above represents high risk). The fall evaluation form indicated Resident 1 had 1-2 falls in the past three months and had balance problem while standing and walking. A review of Resident 1's Minimum Data Set (MDS - an assessment and care planning tool), dated 2/11/16, indicated the resident was assessed alert, able to express verbally, and had the ability to understand others. The resident required extensive assistance with transferring from bed to chair or wheelchair with two person assist, and was totally dependent with toilet use and personal hygiene. The MDS indicated Resident 1 was not steady, and only able to stabilize with staff assistance when moving from seated to standing position. A review of Resident 1's Potential for Falls/Injury care plan, dated 1/30/16, indicated the resident was at risk for fall or injury related to history of stroke, right sided weakness, poor safety awareness, impaired gate and balance, non-compliance with safety measures, and impaired cognition. The care plan interventions included for facility staff to provide a safe, secure environment, provide cueing and supervision as needed, use simple direction to establish and maintain consistent routine, monitor changes in level of alertness and increasing lethargy, and handle gently. The care plan did not indicate Resident 1 required two person extensive assistance with transferring. A review of the Cognition and Communication care plan, dated 1/30/16, indicated Resident 1 had altered cognition related to [DIAGNOSES REDACTED]. The care plan interventions indicated to provide a safe and secure environment for the resident and to establish and maintain consistent routine. A review of Resident 1's Licensed Personnel Progress Notes, dated 2/21/16, at 11:30 a.m., indicated the licensed vocational nurse (LVN 1) was informed by the certified nursing assistant (CNA 1) that the resident fell on the floor. LVN 1 walked in the resident's room and found the resident facing down on the right side side with wheelchair flipped over. Resident 1 informed LVN 1 she hit her head when she fell . The progress notes indicated, at 11:45 a.m., LVN 1 called and left a message with the Nurse Practitioner, and at 12:15 p.m., the physician was notified with an order for [REDACTED]. At 1:45 p.m., Resident 1 was transferred to the acute care hospital. A review of the Final Report, dated 2/21/16, at 4:27 p.m., from the acute hospital indicated Resident 1 had a distal right clavicle fracture (a complete or incomplete break in the outer third of the collarbone (clavicle) near where it attaches to the shoulder blade, tendency to heal slowly or not at all). A review of the Licensed Personnel Progress Notes, dated 2/21/16, at 8:30 p.m., indicated Resident 1 returned to the skilled nursing facility from the acute care hospital. A review of Physician's Progress Record, dated 2/22/16, indicated Resident 1 had a right shoulder distal clavicle fracture requiring a right shoulder immobilizer. A review of the Medication Administration Record (MAR) indicated on 2/23, 2/24, and 2/25/16, Resident 1's pain was assessed to the right shoulder with a pain rating of 4-5 out of 10 (1-4 mild, 5-7 moderate, 10 worst possible pain). The MAR indicated Tylenol 325 milligrams, 2 tablets were provided. During an interview, on 2/26/16, at 2 p.m., CNA 1 stated on the day of the incident at 11:30 a.m., CNA 1 brought Resident 1 to the bathroom to use the, toilet via wheelchair. CNA 1 then transferred the resident back to the wheelchair after using the bathroom and left the resident outside Room 12 in the hallway. This indicated CNA 1 transferred Resident 1 without a two person extensive assist, per the MDS. CNA 1 stated the resident in Room 9 was calling out for help needing to go to the, toilet. CNA 1 left Resident 1 in the hallway to assist the resident in room 9. CNA 1 stated she did not inform any staff members that Resident 1 was left in the hallway. CNA 1 then stated she found Resident 1 on the floor, face down in the resident's room near the resident's bed. CNA 2 put a pillow under the resident's head while CNA 1 looked for the charge nurse (LVN 1). LVN 1 was alerted and assessed the resident in the room. On 2/26/16, at 2:23 p.m., an interview was conducted with LVN 1 who stated on the day of the incident, at noon, LVN 1 arrived in Resident 1's room and found the resident face down with wheelchair flipped over the resident's legs. LVN 1 stated the resident was placed back to bed and denied pain. LVN 1 stated he notified the Medical Director to report the incident, received orders to transfer Resident 1 to the emergency room , and informed family who visited the resident during that time regarding the incident. On 2/26/16, at 2:42 p.m., an interview was conducted with the Director of Nursing (DON) who stated Resident 1 was a fall risk due to the history of stroke. The DON stated there was no method for staff, who were not directly caring for the resident, to identify those who are at high risk for falls. The DON stated it was the facility's practice to have facility staff leave residents in the hallway as a way of supervising them. A review of the facility's policy and procedure for Falls-Clinical Protocol does not indicate evidence it is the facility's protocol to have facility staff leave residents in the hallway unattended as a way of supervising residents.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was admitted to the facility with pressure sore (a localized injury to the skin and / or underlying tissue, usually over a bony prominence, as a result of pressure), and was identified as a risk for developing pressure sores, was provided necessary treatment and services for prevention and promote healing of pressure sores by failing to assess Resident 1's skin per plan of care and upon re-admission. This deficient practice resulted in Resident 1 developing a Stage III pressure sore. Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 8/6/15, with [DIAGNOSES REDACTED]. A review of the Nursing Admission Assessment, dated 8/6/15, indicated Resident 1 had a 7 centimeter (cm) by 5 cm (7 cm x 5 cm) redness to the sacrococcyx area (pertains to both the sacrum and coccyx or the tailbone). A review of Resident 1's admission Minimum Data Set (MDS - an assessment and care planning tool), dated 8/13/15, indicated Resident 1 had a Stage 1 pressure sore (intact skin with non-blanchable redness), received a pressure reducing device for bed and received pressure sore / ulcer care. A review of the quarterly MDS, dated [DATE], indicated Resident 1 currently did not have a Stage 1 pressure sore and was at risk for developing a pressure sore. A review of the care plan, dated 8/7/15 and re-evaluated 2/1/16, indicated Resident 1 had a potential for impaired skin integrity and the goal indicated to minimize skin breakdown for 90 days. The care plan approach / intervention indicated nursing to assess skin everyday, as needed, and to report impaired integrity to the physician. A review of clinical records with body diagrams (untitled), dated 8/28/15, 9/3/15, 10/3/15, 11/30/15, on the 3 p.m. - 11 p.m. shift and 11/30/15, on the 11 p.m. - 7 a.m. shift indicated Resident 1 had no skin breakdown, no redness or sores / ulcers. During an interview with Assistant Director of Nursing (ADON), on 1/7/16, at 2 p.m., he stated the body diagram records (the Skin Alerts) were completed by Certified Nursing Assistants (CNA). A review of Resident 1's Licensed Personnel Progress Notes, dated 11/30/15, at 4:50 p.m., indicated Resident 1 was transferred to the acute hospital for a post fall evaluation. A review of the general acute care hospital's Wound and Ongoing Pressure Ulcer Photographic Record, dated 12/1/15, indicated Resident 1 had a Stage III (full thickness skin loss) pressure sore located on the left buttock and a Stage I pressure ulcer to the sacral area. A review of Resident 1's Weekly Progress Note from the skilled nursing facility, dated 12/1/15, 7 a.m. - 3 p.m. shift, indicated under skin assessment, pressure sore / ulcer remained blank. The progress note, under care plan problems, did not indicate Resident 1 had a Stage III pressure sore to the left buttock or a Stage 1 pressure sore to the sacral area. During an interview, on 1/7/16, at 1:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was admitted to the facility with redness to the sacrococcyx area and when a resident had skin redness, it should be documented on the nursing assessment sheet, if the redness was blanchable (skin loses redness with pressure) or not. LVN 1 stated the physician should be notified if redness was assessed and a low air loss mattress was typically ordered. A review of the clinical record indicated there was no nursing assessment sheet complete for Resident 1 regarding pressure sores. On 1/7/15, at 2:15 p.m., a record review and interview was conducted with the ADON, who stated a Nursing Admission Assessment should have been completed when Resident 1 returned to the skilled nursing facility on 12/1/15, at 1 a.m., which would indicate any skin breakdown, and the resident's medical condition after returning from the general acute care hospital. There was no documented evidence a Nursing Admission Assessment was completed by licensed nursing staff. A review of the facility's policy and procedure titled, Pressure Ulcer Risk Assessment, dated October 2010, indicated a pressure risk assessment would be completed upon admission, with each additional assessment; quarterly, annually, and with significant changes. Skin would be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. The policy indicated staff would maintain a skin alert, performing routine skin inspections daily or every other day as needed. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The policy indicated the admission evaluation helped define those initial care approaches.

Based on interview, and record review, the facility failed to identity and and evaluate accident risks and hazards and did not develop and / or implement care plan interventions when necessary (release and reposition every two hours, assess at least quarterly for continued use of self release belt), and the facility failed to ensure a resident received adequate supervision and assuasive devices to prevent accidents for one of three sampled residents (Resident 1). For Resident 1, who had severely impaired cognition and a history of falls, was assessed as high risk for fall due to disorientation, the resident was not assessed for the safe use of the self release belt and there was no identification / evaluation of adverse effects of medications which may increase risk for fall. This deficient practice resulted in Resident 1 falling and sustaining a left hip fracture (a break in the upper quarter of the femur (thigh) bone). Findings: A review of the admission record indicated Resident 1 was admitted to the facility, on June 23, 2015, with [DIAGNOSES REDACTED]. A review of the Physical Restraint/Device Assessment, dated September 25, 2015, indicated Resident 1 used a lap buddy restraint which was changed to a self release seat belt, because the lap buddy increased restlessness and yelling. The Physical Restraint/Device Assessment did not indicate whether the resident was safe to use the self release seat belt, with Resident 1 having severely impaired cognition. In addition, there was no documented evidence the resident was assessed for the use of self release belt, or any monitoring of the effectiveness of the self release belt, since September 25, 2015 (over four months). A review of the physician's orders [REDACTED]. A review of the plan of care, developed on September 29, 2015, for the use of self release seat belt while in the wheel chair indicated the approaches were to assess Resident 1's response to restraints, to release and reposition every two hours, and to assess at least quarterly for continued use of restraint. A review of the resident's clinical record indicated there was no documented evidence Resident 1 was released and repositioned every two hours. The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated November 26, 2015, indicated Resident 1 was severely impaired in cognitive skills for daily decision making, rarely/never understand others, and rarely/never able to make self understood. The resident required extensive to total assistance from staff with activities of daily living (ADLs), but did not have functional limitation in range of motion on both upper and lower extremities. A review of the Fall Risk Assessment, dated November 26, 2015, indicated Resident 1 had a history of [REDACTED]. The fall risk assessment indicated the resident's level of consciousness / mental status was scored 2, which indicated the resident was disoriented times three, at all times. The assessment also indicated Resident 1 received 3 to 4 medications currently and / or within the past last seven days. A review of the risk of fall or injury plan of care for Resident 1, updated November 26, 2015, indicated the goal was to minimize risk for fall / injury and shall have no major injury every day for 90 days. The care plan approaches / interventions was to receive a low bed, and place a self release seat belt with alarm when in wheel chair. The fall care plan indicated medications as ordered, but did not include to monitor for adverse drug effects / reactions. A review of the physician's orders [REDACTED]. However, there was no care plan for Nuedexta. According to Drugs.com, 2016, the physician would need to check the resident's progress on a regular basis to help determine how long to treat with Nuedexta. Drugs.com indicated this medication may impair your thinking or reactions, avoid getting up too fast from sitting position, or you may feel dizzy and weak. Side effects such as confusion may be more likely in older adults. A review of Resident 1's Medication Administration Record (MAR), dated January 2016, included Keppra a neuroleptic, anticonvulsant drug with drowsiness and dizziness as side effects, Amlodipine used to treat high blood pressure or chest pain (angina), one of the side effects was dizziness, and Lisinopril used to treat high blood pressure or congestive heart failure, with a common side effect of dizziness. A review of the facility's Verification of Investigation, dated January 25, 2016, indicated Resident 1 fell from a wheelchair after she released her seat belt. The alarm sounded, staff responded, and Resident 1 was laying on her left side next to the wheelchair. The verification of investigation form indicated Resident 1 verbalized she had pain on her left hip, was transferred to the emergency room , and had a confirmed left hip fracture on January 26, 2016. On February 5, 2016, at 10:10 a.m., during an interview with Assistant Director of Nursing (ADON), he stated he was not able to provide documentation regarding if Resident 1 was assessed for safety with the use of the self release seat belt, and was not able to provide the documented evidence the resident was reassessed for the use of self release seat belt after September 25, 2015. The ADON stated Resident 1 should have been reassessed for the use of self release seat belt at least quarterly to evaluate any hazards or risks. During an interview, on February 12, 2016, at 3:40 p.m., the Director of nursing (DON), stated she was not able to provide the documented evidence Resident 1 was released and repositioned every two hours while the resident was in the wheelchair with the self release seat belt. The DON stated the care plan was not developed for the use of Nuedexta and it should have been developed, due to potential hazard /risk to resident. The DON stated Resident 1 should have been assessed whether the resident was able to release the seat belt. The DON also stated Resident 1 should have been released and repositioned every two hours while in the wheelchair with the self release seat belt, as indicated in the care plan. A review of the facility's policy titled, Falls and Fall Risk, Managing, revised December 2007, indicated based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also indicated in conjunction with the consultant pharmacist and nursing staff, the attending physician would 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 prevent actual urinary tract infection [MEDICAL CONDITION] and urosepsis (3), and the potential for UTI and incontinence related complications (12) and failed to provide bladder training to restore as much normal bladder function as possible following the discontinuation of an indwelling catheter (2) for three out of 18 sample residents (3, 12, 2) by failing to: 1. Ensure Resident 3 (a female resident) who had a history of [REDACTED]. 2. Ensure that Resident 3 who was assessed at risk for dehydration was adequately hydrated to prevent UTI that progressed to a urosepsis (a systemic infection with an accumulation of pus-forming bacteria or their toxins in the blood originating in the urinary tract leading to overwhelming bacteremia (bacteria in the blood) and septic shock (a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure). Resident 3 was transferred to the general acute care hospital (GACH) two hours after an order was issued by the physician. Resident 3 was diagnosed as having a UTI, urosepsis, and dehydration, hospitalized four days and treated for [REDACTED]. 3. Ensure Resident 12 was provided timely incontinent care when the resident requested assistance after she was soiled with urine and to prevent incontinence related skin complication manifested by maceration of the skin due to delayed incontinent care and services and prolonged use of soiled incontinent briefs (12), 4. Ensure that Resident 2 was placed on scheduled toileting and bladder training program following the discontinuation of an indwelling catheter to restore as much bladder function as possible. Findings: a. According to the admission record, Resident 3 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. It affects memory, thinking, language, judgment, and behavior). A review of the registered dietician's (RD's) assessment (Nutritional Assessment), dated April 22, 2011, indicated the resident's fluid need was 1,980 cubic centimeters (cc). The successive quarterly and annual RD assessments, dated June 4, 2012, September 5, 2012, December 5, 2012, did not indicate a change in the resident's fluid need per day. During an interview with the RD on April 11, 2013 at 9:35 a.m., he stated on average, the resident would receive approximately 2,000 cc per day from food, water and other beverages served. However, there was no documented evidence in the clinical record to verify the RD's assertion that the resident had consumed 2,000 cc of fluid and beverages served per day. The Minimum Data Set (MDS- a standardized comprehensive assessment of the resident's problems and conditions), dated December 4, 2012, indicated the resident's cognitive patterns were moderately impaired and needed extensive assistance from staff members for eating, toilet use, and personal hygiene. The resident was always incontinent of bowel and bladder. A review of the care plan for incontinence that was last updated on December 4, 2012, indicated the resident was totally incontinent for bowel and bladder and had functional incontinence. The goal of the care plan stated the resident will be continent at least during the day time and will be kept clean and dry after each incontinence episode. The approaches (interventions) included to keep resident clean and dry, provide good perineal care for every episode of incontinence, assist resident to the toilet at least before meals and/or after meals. On April 10, 2013 at 10:15 a.m. Certified Nurse Assistant 1 (CNA 1) was observed providing incontinent care to Resident 3. During the care, CNA 1 first removed the resident's incontinent brief soiled urine with gloved hands. The resident was observed with fecal material in the skin folds around the genitalia. CNA 1 after she removed the resident's incontinent brief, proceeded to cleanse Resident 3's perineal region around her genitalia with gloved hands in an up and down motion using a wash cloth soaked with soapy water. While cleansing the resident's genitalia CNA 1 did not use the appropriate cleansing technique in that she used an up and downward, back and forth motion contaminating the resident's urethral meatus that caused the potential for UTI. According to the accepted standard of nursing practice cleaning the perineal region and genitalia should be done using gentle downward [MEDICAL CONDITION] from the front to the back of the perineum to prevent intestinal organisms from contamination of the urethra or the vagina. Avoid the area around the anus and use a clean section of the washcloth for each stroke by folding each used section inward (Lippincott's Visual Encyclopedia of Clinical Skills, 2009, Pages 383-384). On April 10, 2013 at 10:30 a.m., during the incontinent care observation, CNA 1 during an interview, when asked, stated that she should have cleansed the resident's genital region using a one stroke top to bottom technique and not to use the same wash cloth. A review of the resident's clinical record indicated the resident had recurrent urinary tract infection manifested by positive urinalysis, microscopic urine tests, and urine culture and sensitivity tests. For example: A review of the laboratory test results on a specimen taken on March 6, 2012 at 3:15 a.m., indicated Resident 3 had a UTI as follows: 1. The urinalysis test result indicated the urine was cloudy (reference range-clear) and had moderate amount of blood- (reference range-negative), 2. The microscopic urine test result indicated the presence of WBC (white blood cells) 5-10 (reference range- 0-2), RBC (red blood cells) 2-5 (reference range 0-2), many bacteria (reference range-none), 3. The urine culture and sensitivity test results indicated the presence of Escherichia coli (gram-negative, facultative anaerobic, rod-shaped bacterium that is commonly found in feces and in the lower intestine) >100,000 cfu (colony formation unit). The resident was treated for [REDACTED]. A review of another care plan for dehydration dated December 4, 2012, indicated- potential for dehydration secondary to dementia. The goal of the care plan was for the resident to be well hydrated as evidenced by but not limited to moist mucous membranes, good skin turgor, etc. for 90 days. The approaches/interventions included in the care plan included: to monitor for signs and symptoms of insufficient fluid intake such as dry skin, dry mucous membranes, cracked lips, poor skin turgor, thirst, fever, and watch for concentrated urine, to monitor laboratory values and to notify the physician, the family and the registered dietitian if above symptoms occur and intake and output (I&O) if necessary. However, there was no documented evidence that indicated the resident was provided adequate fluid as assessed by the dietician in order to prevent UTI secondary to dehydration. A review of the resident's laboratory test results had indicators for dehydration as follows: 1. On March 6, 2012, the resident had an elevated level of blood urea nitrogen (BUN) of dated was 29 mg/dL (reference range 5-20 mg/dL) and a creatinine of 0.6 mg/ dl (reference range 0.7-1.5 mg/dL). The BUN/Cr Ratio was 48. A BUN/Cr. ration of more than 20 indicates dehydration (Nursing Care Ready Reference: Resident Assessment Protocol, Pages 53-55). There was no documented evidence such as an intake and output record that indicated the resident was provided the volume of fluid (1980 cc per day) as assessed by the dietician in order to prevent UTI secondary to dehydration. A review of the resident's laboratory test results revealed Resident 3 had indicators for dehydration as follows: 1. On March 6, 2012, the resident had an elevated level of blood urea nitrogen (BUN) of 29 mg/dL (milligrams per deciliter reference range 5-20 mg/dL) and a creatinine of 0.6 mg/dl (reference range 0.7-1.5 mg/dL). The BUN/Cr Ratio was 48. A BUN/Cr. ratio of more than 20, indicates dehydration (Nursing Care Ready Reference: Resident Assessment Protocol, Pages 53-55). 2. On December 4, 2012: BUN was 19 mg/dl and the Cr. was 0.5 mg/dl. The BUN/Cr ratio was 38. 3. On February 3, 2013, the resident had an elevated sodium level of 152 mEq/L (reference range 135-145 mEq/L), and an elevated BUN of 32 mg/dL and the Cr was 0.7 mg/ dl. The BUN/Cr ratio was 46 ratio. On April 10, 2013 at 10:40 a.m., during an interview with Licensed Vocational Nurse 2 (LVN 2), she stated the resident only drinks small sips of water when she was offered water. There was no plan of care to give specified amount of fluids at a specified time intervals to be provided to the resident to meet the daily requirement of 1980 cc per day. A review of the licensed nurse progress note, dated February 3, 2013 at 12 a.m., indicated the resident had a change of condition that included a fever of 101.2 degrees Fahrenheit (?F normal 98.6 ?F), blood pressure of 180/110 (normal 120/80), and an elevated fasting blood glucose of 493 milligram (mg per deciliter (dl) reference range 65- 99 laboratory test mg/dl). On the same date at 10 a.m., the resident's vital signs were: blood pressure (BP) was 200/98, pulse rate was 98 beats per minute (normal 60-100), respiratory rate of 18 per minute (normal 14-18). The resident was responsive to verbal commands and showed weakness in extremities. The physician was notified of the resident's change of condition and orders for laboratory tests were obtained. A review of the laboratory test results dated February 3, 2013, indicated Resident 3 had a UTI as following: 1. The urinalysis test result on a specimen taken at 3:15 a.m. on February 3, 2013, indicated the color of the urine was orange (reference range- straw-yellow), slightly cloudy (reference range-clear), blood- moderate amount (reference range- negative), protein 100 mg/dL (reference range-negative), glucose >1000 mg/d/L (reference range- negative). 2. The microscopic urine test result indicated the presence of WBC 5-10 (reference range- 0-2), RBC 2-5 (reference range 0-2), many bacteria (reference range-none), 3. The urine culture and sensitivity test results indicated the presence of [DIAGNOSES REDACTED] Pneumonia (gram-negative, non-motile, encapsulated organism) >100,000 cfu (colony formation unit), resistance to two out of 15 antibiotics tested . On February 3, 2013 at 8:30 a.m., a physician order [REDACTED]. On February 3, 2013 at 10:30 a.m., after a two hour delay, the resident was transferred to the acute care hospital by an ambulance. A review of the clinical record, dated February 3, 2013, obtained from the GACH indicated the resident presented a chief complaint of altered level of consciousness had been having decreasing mental status and worsening weakness and difficulty even with eating at the skilled nursing facility. A review of the emergency room (ER) physician's documentation, dated February 3, 2013, indicated the resident was an [AGE] year old female admitted with a fever of 100.7 ?F, pulse of 97 beats per minute, respiration 31 breaths per minute and a blood pressure of 230/110. A review of the ER history and physical examination [REDACTED]. The laboratory test results indicated [MEDICAL CONDITION]- elevated Sodium in the blood of 151 mEq/L milliequivalent/liter (one thousandth of 1 equivalent of a specific substance dissolved in 1 liter of solution or plasma. [MEDICAL CONDITION] is almost always an indicator for excessive fluid depletion; it usually occurs with inadequate fluid intake and increased water loss), an elevated BUN of 38 mg/dl, 3+ white blood cells in the urine, elevated white blood cells count greater than 100 red blood cell count. The resident was diagnosed with [REDACTED]. Resident 3 was admitted to the GACH and was treated with an intravenous (IV) fluid therapy for dehydration and antibiotics for urinary tract infection and urosepsis. The resident was hospitalized for [REDACTED]. According to the ER physician note dated February 3, 2013, Resident 3's UTI was treated with two different antibiotics -[MEDICATION NAME] 1 gram and [MEDICATION NAME] 3.375 gram to cover possible [MEDICAL CONDITION] and urinary pathogens (harmful microorganisms) and discharged to the facility on [DATE]. According to the readmission record, the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. b. According to the admission record, Resident 12 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the care plan for Potential for Skin Integrity dated February 4, 2013, indicated potential for impaired skin integrity secondary to [MEDICAL CONDITION], incontinence, [MEDICAL CONDITION], arthritis, [MEDICAL CONDITION], and normal progression of disease process with an unavoidable/predictable decline expected. The goals included to minimize skin breakdown every day for 90 days. The approaches/interventions included to assess skin every day plus as necessary (PRN) and report impaired integrity to the physician and keep clean and dry. The Minimum Data Set (MDS - a standardized comprehensive assessment of the resident's problems and conditions) assessment, dated February 9, 2013, indicated the resident's cognitive patterns were severely impaired, was totally dependent from staff members for all activities of daily living and needed one to two person assist for activities of daily living support. The resident was always incontinent for bowel and bladder and was at risk for developing pressure ulcers. A review of the Care Area Assessment Documentation Notes, dated February 9, 2013, indicated urinary incontinence was triggered. The indicators were modifiable factors contributing to transitory urinary incontinence such as medications and environmental factors with restricted mobility, other factors that contribute to incontinence such as urinary urgency and need for assistance in toileting, type of incontinence: functional (cannot get to the toilet in time due to physical disability). A review of the Bladder Assessment Form, dated February 10, 2013, indicated the resident was incontinent of bladder and that the resident had functional urinary incontinence. The bladder assessment summary indicated that toileting was not appropriate due to impaired cognition and mobility secondary to multiple medical conditions. The plan was to provide incontinence care after each episode to prevent skin problems. However, there was no scheduled toileting program planned in order to prevent the resident from becoming wet in his incontinent brief for prolonged period and to prevent incontinence complication manifested by maceration of the skin. On April 9, 2013 at 11:20 a.m., Resident 12 was observed sitting in the wheelchair in his room. Two staff members, Certified Nursing Assistant 2 (CNA 2) and Restorative Nursing Assistant 1 (RNA 1), were assisting Resident 12's roommate. While the two staff members were helping his roommate, Resident 12 verbalized that he wanted to be helped to go back to his bed and be changed (replace his soiled incontinent briefs). After 15 minutes at 11:30 a.m., the Surveyor observed Resident 12 was still sitting in the wheelchair with soiled and wet pants around his groin region that caused the potential for the development of UTI. Resident 12's call light was not within his reach and the resident continued to verbalize for help in a loud voice. On April 9, 2013 at 11:35 a.m., during an interview Resident 12, he stated that he had been waiting for help for hours and hours, "Please don't desert me." At 11:45 a.m., during an observation, RNA 2 went to help Resident 12. He told Resident 12 that he will get somebody to help and transfer him to the bed. On April 9, 2013 at 11:50 a.m., during an interview with RNA 2, he stated the resident was wet and he will get somebody to help him transfer the resident to his bed. According to RNA 2, he needed a hydraulic lift (a lifting device) since the resident was heavy. On April 9, 2013 at 11:55 a.m., during an observation, Resident 12 was transferred from the wheelchair to the bed using the hydraulic lifting device. The resident's incontinent brief was soaking wet with urine and his soiled incontinent brief was changed. While Resident 12 received perineal care, the skin in the perineal and coccyx area were observed reddened and macerated. According to the State Operations Manual (SOM) dated October 2010, pages 238 to 239, skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. One form of early skin breakdown is maceration or the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes "soggy" texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe [MEDICAL CONDITION] or skin erosion. Skin erosion is the loss of some or all of the epidermis (comparable to a deep chemical peel) leaving a slightly depressed area of skin. On April 10, 2013 at 7:45 a.m. RNA 2 during an interview stated that RNA 1 called him from the hallway to help transfer a resident. RNA 1 got the hydraulic lift device and assisted the resident to bed. RNA 2 further stated Resident 12 was very upset because he wanted to go back to bed so bad and his pants were soaking wet. The resident had been up in the wheelchair before breakfast and was not followed up by the CNA taking care of him to ensure that the resident was not wet or soiled. On April 10, 2013 at 8:30 a.m., CNA 2 during an interview was asked why she did not provide incontinent care or ask anybody to help when Resident 12 asked for help. CNA 2 stated she was busy and wanted to finish Resident 1's care (his roommate) first before attending Resident 12. She also stated she did not ask for help from other staff because everybody was busy taking care of eight residents and giving showers. The night shift (11 p.m. to 7 a.m. shift) staff member changed the resident's incontinent brief before getting him out of bed for breakfast. The facility's policy and procedure titled "Perineal Care" dated October 2010, indicated the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The nursing staff did not provide timely incontinence care when the resident requested assistance to be transferred to bed and changed his incontinent brief to prevent skin related complications such as maceration of the skin surrounding the anus area due to delayed incontinent care and services of the nursing staff. The facility also failed to follow its care plan to keep the resident dry and clean. c. According to the admission record, Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. It's caused by conditions or changes in the brain), and [MEDICAL CONDITION] disorder (is a psychiatric [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated November 7, 2012, indicated the resident's cognitive patterns were severely impaired, needed total dependence from staff members for locomotion on and off the unit, dressing, and had an indwelling catheter. The Minimum Data Set (MDS) assessment, dated February 7, 2013, indicated the resident's cognitive patterns were severely impaired, needed total dependence from staff members for locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing, and was always incontinent for bowel and bladder. According to the physician's orders [REDACTED]. However, the licensed nursing staff did not assess the resident for bladder training program and the physician's orders [REDACTED]. On April 11, 2013 at 10:15 a.m., during an interview with Registered Nurse 1 (RN 1), she stated Resident 2 should have been assessed for voiding pattern, monitored and evaluated for the need of the toileting program. RN 1 during the interview also stated the resident should have been assessed for bladder training in order to implement the physician's orders [REDACTED]. A review of the Bladder Assessment Form, dated February 7, 2013, indicated the resident had a functional urinary incontinence with affecting factors of mobility/manual dexterity impairments, lack of toilet or toilet substitute, use of restraints, medications such as sedative, hypnotic, and diuretics; it also indicated that the resident was verbally responsive, totally incontinent of bowel and bladder function; toileting program is not appropriate due to multiple medical conditions such as dementia, [MEDICAL CONDITIONS], and confusion. It also indicated to provide incontinence care after each episode to prevent skin breakdown, bladder infections, preserving quality of life and preserving dignity. The indwelling catheter was discontinued and the resident was able to urinate without difficulty. However, the decision not to provide the resident with the appropriate bladder and/or scheduled toileting was made before the resident was accurately assessed for the voiding pattern. A review of the care plan for Bladder Elimination dated February 7, 2013, indicated potential for alteration in bladder function related to impaired cognition/communication, diuretic therapy, use of psychoactive medications and incontinent. The goal was for the resident not to have complaints of pain, increased frequency and increased odor daily. The approaches/interventions indicated were to observe for signs and symptoms of urinary tract infection [MEDICAL CONDITION] such as cloudiness, amount, malodor, sediment, dysuria (painful urination), and chills. Encourage fluid intake as much as possible. Intake and output monitor as per protocol. Assess bladder function at least quarterly. A review of the clinical record revealed the resident was not assessed for the pattern of the bowel and bladder function before placing the resident on a scheduled toileting plan. There was no documented evidence that the resident was assessed and monitored for urine output after the removal of the indwelling catheter and was not assessed and monitored for UTI and there was no care plan developed for UTI. In addition, there was no documented evidence that the scheduled toileting plan was followed and implemented. A review of the facility's undated Indwelling Catheter Justification/Decision Program guideline, indicated under the post catheter removal interventions included to monitor urinary output and bladder status for 72 hours to observe for decreased urinary output, complete a bowel/bladder voiding evaluation as per the incontinence guideline, and implement an individualized toileting plan for the resident. On April 10, 2013, between the hours of 9:25 a.m. and 10:50 a.m., during an observation and interview, Resident 2 was observed in bed and was alert and oriented. When asked, Resident 2 stated that she had to hold her urine until the staff members came to assist her because she cannot go to the bathroom by herself. According to Resident 2, she can use the bathroom provided she gets assistance from staff members otherwise, she soils herself. The resident further stated when she cannot hold it anymore (the urine); she tried to go to the bathroom and had an incident of a fall because she was not assisted. A review of the facility's undated guideline titled "Incontinence Management/Bladder Function Guideline." indicated the purpose of the bladder management program is to avoid possibility of urinary infection, restore the resident's dignity, manage urinary incontinence, and restore or maintain as much normal bladder function as possible. General guideline for working to retrain bladder function included to provide a bedside commode if necessary, develop a schedule of toileting times specific to the resident, observe and record the resident's voiding pattern and revise the toileting schedule to meet the resident's toileting needs.

Based on observation, interview, and record review, the facility failed to ensure that residents received adequate fluids to prevent actual dehydration (3) and potential dehydration (7) for two out of 18 sample residents (3, 7) by failing to: 1. Ensure that Resident 3 who had a [DIAGNOSES REDACTED]. 2. Ensure that Resident 3 at risk for dehydration was monitored for hydration status by means of an intake and output (I&O) record as indicated in the facility's policy and procedures (3) Resident 3 was transferred to the general acute care hospital (GACH) two hours after an order was issued by the physician. Resident 3 was diagnosed as having a UTI, urosepsis, and dehydration. Resident 3 was hospitalized for [REDACTED]. 3. Ensure that Resident 7 who had skin conditions that included Stage III pressure ulcers was provided the volume of fluid as assessed by the RD and monitored for adequate hydration. Findings: a. According to the admission record, Resident 3 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. It affects memory, thinking, language, judgment, and behavior). A review of the registered dietician's (RD's) assessment (Nutritional Assessment) dated April 22, 2011, indicated the resident's fluid needs were 1,980 cubic centimeters (cc). The successive quarterly and annual RD assessments dated June 4, 2012, September 5, 2012, December 5, 2012, did not indicate a change in the resident's fluid needs per day. During an interview with the RD on April 11, 2013 at 9:35 a.m., he stated on average, the resident would receive approximately 2,000 cc per day from food, water and other beverages served. However, there was no documented evidence in the clinical record to verify the RD's assertion that the resident had consumed 2,000 cc of fluid and beverages served per day. The Minimum Data Set (MDS - a standardized comprehensive assessment of the resident's problems and conditions) dated December 4, 2012, indicated the resident's cognitive patterns were moderately impaired and needed extensive assistance from staff members for eating, toilet use, and personal hygiene. The resident was always incontinent of bowel and bladder and had a weight and height of 144 pounds and 62 inches respectively. A review of another care plan for dehydration dated December 4, 2012, indicated - potential for dehydration secondary to dementia. The goal of the care plan was for the resident to be well hydrated as evidenced by but not limited to moist mucous membranes, good skin turgor, etc. for 90 days. The approaches/interventions included in the care plan included: to monitor for signs and symptoms of insufficient fluid intake such as dry skin, dry mucous membranes, cracked lips, poor skin turgor, thirst, fever, and watch for concentrated urine, to monitor laboratory values and to notify the physician, the family and the registered dietitian if above symptoms occur and intake and output (I&O) if necessary. There was no documented evidence such as an intake and output records that indicated the resident was provided the volume of fluid (1980 cc per day) as assessed by the dietician in order to prevent UTI secondary to dehydration. A review of the resident's laboratory test results had indicators for dehydration as follows: 1. On March 6, 2012, the resident had an elevated level of blood urea nitrogen (BUN) of was 29 mg/dL (reference range 5-20 mg/dL) and a creatinine of 0.6 mg/ dl (reference range 0.7-1.5 mg/dL). The BUN/Cr Ratio was 48. A BUN/Cr. ratio of more than 20 indicates dehydration (Nursing Care Ready Reference: Resident Assessment Protocol, Pages 53-55). 2. On December 4, 2012: BUN was 19 mg/dl and the Cr. was 0.5 mg/dl. The BUN/Cr ratio was 38. 3. On February 3, 2013, the resident had an elevated sodium level of 152 mEq/L (reference range 135-145 mEq/L), and an elevated BUN of 32 mg/dL and the Cr was 0.7 mg/dl. The BUN/Cr ratio was 46 ratio. While the above lab test results indicated the resident had the indicators for dehydration, the facility did not ensure the resident had received 1,980 cc of fluid per day assessed by the dietitian. In addition, a review of the interdisciplinary team (IDT) conference record did not indicate the resident's hydration status was assessed and monitored by means of an I & O record as stated in the plan of care. A review of the facility's policy and procedure titled "Residents to Place on Intake/Output" dated November 2012, indicated for residents identified /assessed with [REDACTED]. However, the facility did not implement its policy and procedures. A review of another facility's policy and procedure titled "Resident Hydration and Prevention of Dehydration", dated December 2011, indicated the facility will endeavor to provide adequate hydration and to prevent and treat dehydration. Nursing will assess for signs and symptoms of dehydration during daily care. Nurses' Aides will provide and encourage intake at bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1,200 ml/day to nursing staff. If the potential for inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. The activities of daily living (ADL) status, diagnosis, individual preferences, habits and cognitive and medical status will be considered in all interventions. "Encourage fluids" is not an adequate order. The dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. If laboratory results are consistent with actual dehydration, the physician may initiate intravenous (IV) hydration. Interdisciplinary Team will update care plan and document resident's response to interventions until team agrees that fluid intake and relating factors are resolved. However, these policy and procedures were also not implemented. A review of the Certified Nursing Assistant - Activities of Daily Living Tracking Form for the month of January 2013, indicated the resident had received fluids ranging from 300 cc to 560 cc per day. The record however, did not consistently document the volume of fluid to assure the resident had received a total of 1980 cc per day the assessed by the dietitian. A review of the licensed nurse progress note dated February 3, 2013 at 12 a.m., indicated the resident had change of conditions that included a fever of 101.2 degrees Fahrenheit (?F), blood pressure of 180/110 and an elevated fasting blood glucose was 493 milligram (mg per deciliter (dl reference range 65- 99 mg/dl). On the same date at 10 a.m., the resident's vital signs were: blood pressure was 200/98, pulse rate was 98 beats per minute, respiratory rate of 18 per minute. Resident was responsive to verbal commands and showed weakness in extremities. The physician was notified on the same date the following orders were obtained: 1. Administer 8 units of [MEDICATION NAME]once, for the elevated blood sugar level. 2. Administer Tylenol 650 mg every four hours as necessary for temperature above 100 degrees Fahrenheit. 3. Administer oxygen inhalation two liters per minute by nasal cannula for shortness of breath. 4. Chest x-ray in the morning (a.m.) and to monitor blood pressure every shift and inform the physician if systolic BP is above 160 times three days. On April 9, 2013 at 9:30 a.m., Resident 3 was observed sitting in the wheelchair in her room and was unable to reach for her water cup. The resident was not fully interview-able and responded with a yes or no answers to questions asked. On April 10, 2013, at 10:40 a.m., during an interview with Licensed Vocational Nurse 2 (LVN 2), she stated the resident only drank small sips of water when she was offered water. There was no plan of care to give specified amount of fluids at a specified time intervals to be provided to the resident to meet the daily requirement of 1980 cc per day. On April 11, 2013 at 9:35 a.m., during an interview with the Registered Dietitian (RD), he stated on average, the meal trays of the resident would receive approximately 2,000 cc of water from beverages a day whether the resident consumes it or not. However, there was no documented evidence in the clinical record to verify the RD's assertion that the resident had consumed approximately 2,000 cc of fluid and beverages served per day. According to the RD it is the nurses' responsibility to verify the volume of fluid consumed by the resident and record it in the chart. On February 3, 2013 at 8:30 a.m., another physician's orders [REDACTED]. On February 3, 2013 at 10:30 a.m. two hours after the physician's orders [REDACTED]. On February 3, 2013 at 9:45 a.m., during an interview Registered Nurse 1 (RN 1), stated the nurses should have assessed the resident for dehydration. When asked, RN 1 was unable to provide an explanation why the resident's hydration status was not monitored for by means of an intake and output record. A review of the clinical record dated February 3, 2013, obtained from the GACH indicated the resident presented a chief complaint of altered level of consciousness had been having decreasing mental status and worsening weakness and difficulty even with eating at the skilled nursing facility. A review of the emergency room (ER) physician's documentation indicated the resident was an [AGE] year old female admitted with a fever of 100.7 ?F, pulse of 97 beats per minute, respiration 31 breaths per minute, blood pressure 230/110, increased white blood cells count, with [MEDICAL CONDITION] and elevated blood sugar as) of 151 mEq/L. ([MEDICAL CONDITION] is almost always an indication of excessive fluid depletion; it usually occurs with inadequate fluid intake and increased water loss). BUN 38 mg/dl, 3+ white blood cells in the urine, elevated white blood cell count (WBC), greater than 100 red blood cell count (RBC). The resident was diagnosed with [REDACTED]. Resident 3 was admitted to the GACH treated with an intravenous (IV) fluid therapy and antibiotics and hospitalized for [REDACTED]. According to the readmission record the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. b. According to the admission record, Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated April 3, 2013, indicated the resident was assessed as having moderately impaired cognitive skills for daily decision making and required from extensive to total assistance from staff in activities of daily living. According to the Wound Healing Record, dated March 25, 2013, the resident had skin conditions ranging from tissue injuries of various from, a deep tissue injury, unstageable pressure sores to a Stage III pressure sores. According to the Nutritional Assessment, dated March 26, 2013, the resident's estimated fluid need was 1950 to 2275 cubic centimeters (cc) daily. There was a plan of care dated March 29, 2013, for a potential for dehydration. One of the interventions was to encourage adequate fluid intake. There was another plan of care dated March 25, 2013, for the impairment in skin integrity. One of the interventions was to encourage fluids. A review of the intake and output (I&O) record from March 23 to April 8, 2013, indicated the resident's fluid intake ranged from 950 cc to 2200 cc daily, which was less than the volume of fluid indicated in the Nutritional assessment by a range of 75 cc to 1000 cc. The I&O record also indicated the resident's output was greater than intake. For example, according to the weekly I&O evaluation the average daily fluid intake was 1800 cc and average daily output was 2300 cc. On April 9, 2013 at 1 p.m., a review of the resident's clinical record and an interview with the Assistant Director of Nursing (ADON) revealed that there was no documented evidence that nursing staff had encouraged adequate daily fluid intake as stated in the plan of care in order to ensure the resident's fluid output would not exceed the fluid intake and thus prevent the potential for dehydration (dehydration a deficit of body water that results when the output of water exceeds intake may lead to dehydration). Adequate hydration is important in wound healing as dehydrated skin is less elastic, more fragile and more susceptible to breakdown. Dehydration will also reduce efficiency of blood circulation, which will impair the supply of oxygen and nutrients to the wound. One of the main risk factor for dehydration is poor oral intake (Manual of Nursing Practice, Spring House, third edition, 2010).