Every finding on record at Lone Tree Post Acute

Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for 2 of 26 sampled residents (Resident 109, and Resident 4) when:Resident 109 did not have an order for the use of a Continuous Glucose Monitor (CGM - a device that continuously checks a person's blood sugar levels throughout the day and night without the need of a blood sample) and there was no facility policy to address the resident use of a CGM.A physician-ordered fluid restriction (limiting the amount of liquids a person can drink) was not implemented for Resident 4.These failures had the potential to result in inaccurate clinical assessment, improper treatment, and potential adverse health outcomes for Resident 109, and Resident 4 including hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), and fluid imbalance (the body has too much or too little fluid). Findings: 1. Review of Resident 109's admission RECORD, indicated Resident 109 was admitted to the facility with diagnoses of, but not limited to type 2 diabetes mellitus (DM- a condition where the body cannot control blood sugar levels), unspecified protein-calorie malnutrition (the body is not getting enough protein and calories from food), heart failure (a condition where the heart cannot pump blood as well as it should), weakness, chronic kidney disease (long term damage to the kidneys that makes them not work properly), and hypertension (high blood pressure). A review of Resident 109's clinical record titled, Order Summary Report, dated 4/29/26, indicated, .Dietary-Diet: CCHO [controlled carbohydrate diet (carbohydrates are broken down into sugar)] 7: Regular texture. Further review of Resident 109's Order Summary Report, indicated Resident 109 received two different insulins (medication given in units (a unit of measure) used to lower blood sugar levels) daily to control her DM including Humalog (a short acting insulin that starts working within 15 minutes) and Lantus (a long acting insulin that works steadily over 24 hours). A review of Resident 109's clinical record titled, Care Plan Report, date initiated 4/28/26, under the section titled, Focus, indicated, .Diabetes: Resident [Resident 109] has a diagnosis of diabetes and is at risk for complications manifested by Diabetic retinopathy [a serious eye complication of diabetes caused by high blood sugar damaging blood vessels in the eye] . and under the section titled, Interventions/Tasks, indicated, . Blood glucose checks as ordered. Report to physician if blood glucose is outside of set parameters.Education on medication action and potential side effects. A review of Resident 109's clinical record titled, Care Plan Report, date initiated 4/28/26, under the section titled, Focus, indicated, .Medication – Hypoglycemic: Resident [Resident 109] requires hypoglycemic medication related to Diabetes Humalog.for DM . and under the section titled, Interventions/Tasks, indicated, .Administer medication as ordered.Finger sticks [a small amount of blood obtained with a needle from the finger tip to test blood sugar] as ordered. Report abnormal findings to physician following set parameters. A review of Resident 109's clinical record titled, [Name of Corporate-MEDICATION ADMINISTRATION RECORD, for 4/2026, indicated Resident 109 had blood sugar reading taken four times per day, .Lantus.with BS [blood sugar [test]] at 2000 [8PM].Humalog with BS 0700 [7AM], BS 1200 [12PM], BS 1600 [4PM]. During a concurrent observation and interview on 4/28/26, at 10:59 AM, with Resident 109 in her room, Resident 109 stated that she was diabetic and emphasized the importance of managing her blood sugar levels. A blood glucose monitoring device was observed on top of Resident 109's bedside table. Resident 109 identified the device as her personal blood sugar monitor. While demonstrating its use Resident 109 placed the monitor close to the sensor attached to her left upper arm/shoulder area, after which the monitor displayed a blood sugar reading of 236. Resident 109 stated, Look, my blood sugar right now is 236, and added that her blood sugar levels usually ranged from 236 to 248. Resident 109 explained that controlling her diabetes was very important because she already had a diabetic ulcer (an open sore or wound that develops in a person with diabetes) on her left foot. When asked if facility staff also checked her blood sugar using the facility glucometer (used to test blood sugar levels) through finger-stick blood sampling, Resident 109 stated, No, and further stated, I hate being poked four times a day. Resident 109 stated that nursing staff would come into her room and she would simply show them the blood sugar readings displayed on her personal monitoring device. When asked if facility staff checked the quality, calibration, or accuracy of her personal blood sugar monitoring device, including performing any quality control checks, Resident 109 stated that she could not recall anyone checking the device since her admission to the facility. Resident 109 stated that her friend assisted her with changing the sensor approximately every two weeks and that the sensor currently in place had recently been changed by her friend. When asked how important it was to ensure the accuracy of her personal blood sugar monitoring device, Resident 109 stated that it was very important because she wanted to prevent complications related to diabetes. During a concurrent interview and record review on 4/30/26, at 7:59 AM, with Licensed Nurse (LN) 8, Resident 109's electronic health record was reviewed. LN 8 stated that she was aware Resident 109 was diabetic and required ongoing blood sugar monitoring and insulin administration. LN 8 confirmed that Resident 109 was using her own personal blood sugar monitoring device to check and monitor her blood sugar levels. During review of Resident 109's electronic Medication Administration Record (e-MAR - electronic chart that tracks what medicines a person receives), LN 8 stated that the documented blood sugar reading for the morning of 4/30/26 was 177 and clarified that the result was obtained from Resident 109's personal blood sugar monitor. LN 8 further stated that according to the e-MAR documentation, she administered a total of three units of insulin to Resident 109 that morning. LN 8 explained that one unit was the resident's routine scheduled insulin dose and an additional two units were administered based on the blood sugar reading displayed on Resident 109's personal monitoring device. LN 8 confirmed there were no physician orders, facility procedures, or documentation regarding quality control checks, verification of accuracy, calibration of Resident 109's personal blood sugar monitoring device, or orders regarding changing the sensor attached to the resident. LN 8 stated that it was important to ensure the accuracy and reliability of blood sugar readings because inaccurate results could directly affect insulin dosing and diabetic management. LN 8 further stated that there is no room for mistakes, especially for diabetic residents receiving insulin therapy, and emphasized the importance of preventing complications such as hypoglycemia or hyperglycemia. During an interview on 5/1/26, at 9:30 AM, with the Director of Nursing (DON), the DON stated that the facility followed the manufacturer's guidelines regarding the use of CGM's. The DON further stated the facility allowed residents to use their own CGM devices because some residents preferred not to undergo frequent finger-stick blood glucose checks. The DON stated that licensed nurses were expected to notify the physician and obtain a physician's order indicating that the resident preferred to use a personal continuous glucose monitor instead of the facility glucometer for blood sugar monitoring. The DON further stated that it was the facility's expectation for licensed nurses to follow the manufacturer's guidelines related to the operation, accuracy verification, calibration requirements if applicable, and quality control monitoring of resident-owned glucose monitoring devices, similar to the facility process for checking and validating facility-owned blood glucose monitoring equipment. The DON stated that ensuring the accuracy and reliability of blood glucose readings was very important because inaccurate readings could lead to incorrect insulin administration or inappropriate diabetic management. The DON further stated that licensed nurses were expected to supervise and monitor the changing of CGM sensors to ensure resident safety, infection prevention practices, proper device placement, and compliance with manufacturer guidelines. The DON explained that quality control checks and oversight of the device were important to ensure the glucose monitor was functioning correctly and to reduce the risk of inaccurate blood sugar readings that could potentially result in complications such as hypoglycemia or hyperglycemia. A review of a facility provided manufacturer guidelines titled, [Name of Company/Product – CONTINUOUS GLUCOSE MONITORING SYSTEM], dated 04/2022, indicated, . Indications for Use – The App and Sensor are designed to replace blood glucose testing in the self-management of diabetes, including dosing of insulin .The following Contraindication, Warnings and other safety information apply to the Sensor.Do not ignore symptoms that may be due to low or high blood glucose. If you have symptoms that do not match the Sensor glucose reading, or suspect your reading may be inaccurate, check the reading by conducting a fingerstick test using a blood glucose meter: If you are experiencing symptoms that are not consistent with your glucose readings, consult your healthcare professional .On rare occasions, you may get inaccurate Sensor glucose readings. If you believe your readings are not correct or are inconsistent with how you feel, perform a blood glucose test on your finger to confirm your glucose and check to make sure your Sensor has not come loose. If the problem continues or if your Sensor is coming loose, remove the current Sensor and apply a new one . 2. Review of Resident 4's admission RECORD, indicated Resident 4 was admitted to the facility with diagnoses of, but not limited to acute bronchiolitis due to respiratory syncytial Virus (RSV-a sudden lung infection caused by the RSV virus that makes the small airways in the lungs swollen and clogged), pneumonia (an infection in the lungs), acute and chronic respiratory failure (a serious breathing condition where the lungs are not working well enough both suddenly and over a long period of time), acute pulmonary edema (a sudden buildup of fluid in the lungs), chronic obstructive pulmonary disease (COPD - progressive lung condition that makes it hard to breathe because airflow into and out of the lungs get blocked) with acute exacerbation (a long-term lung diseases that suddenly became worse), heart failure (a condition where the heart cannot pump blood as well as it should), acute kidney failure (sudden kidney failure), and chronic kidney disease (long term damage to the kidneys that makes them not work properly). Review of Resident 4's clinical record titled, History and Physical, dated 4/9/26, indicated, .Hospital discharge summary/available records/labs reviewed/orders reviewed.long term resident [Resident 4] seen today after rehospitalization.due to.acute HFpEF [Heart Failure with preserved Ejection Fraction – a type of heart failure where the heart still pumps normally, but is too stiff to fill with blood properly] . Rehosp [Rehospitalization] again 4/2-4/6 for hematemesis [vomiting blood].Past Medical History.severe pulm [pulmonary-lungs] HTN [Hypertension – high blood pressure], chronic BLE [bilateral lower extremities] edema [swelling caused by too much fluid in the body tissues].Weight 204.8 lbs [pounds].Assessment/Plan.1. HFpEF – off furosemide [diuretic medication – a medicine that helps the body get rid of extra fluid by making a person urinate more], will write for fluid restriction.Discussed with Patient/Family/Nurse: Goals of care.Change in treatment. During a concurrent interview and record review on 4/30/26, at 11:47 AM, with LN 7, Resident 4's electronic health record was reviewed. LN 7 stated that Resident 4 was readmitted to the facility on [DATE] following an inpatient hospital stay from 4/2/26 through 4/6/26. LN 7 further stated that after the physician completed their assessment of the resident and wrote orders, it was the responsibility of the licensed nurses to review, verify, clarify if needed, and promptly carry out the physician's orders. LN 7 stated that if an order was unclear, nursing staff were expected to obtain clarification or verification from the physician before implementation. LN 7 further stated that prompt implementation of physician orders was important because the orders were based on the physician's assessment, evaluation, and identified clinical needs of the resident. LN 7 explained that delays or failure to carry out physician orders could potentially affect a resident's clinical condition, place the resident at risk for decline or change in condition, and potentially result in rehospitalization. LN 7 confirmed that the physician completed a History and Physical examination with an assessment and plan dated 4/9/26. LN 7 further confirmed that the physician included an order for fluid restriction in the treatment plan for Resident 4. LN 7 subsequently reviewed Resident 4's most current April 2026 current order summary report and stated that no physician order for fluid restriction was present. LN 7 reviewed the licensed nurses' progress notes and stated that no documentation was found indicating that the fluid restriction order had been addressed, clarified, implemented, or monitored. LN 7 stated that fluid restriction was very important for Resident 4 considering the resident's multiple medical diagnoses, which could affect fluid balance and overall clinical status. LN 7 requested assistance from the Medical Record Director to review additional hospitalization records and prior documentation; no additional documentation related to implementation or monitoring of fluid restriction was found. LN 7 stated that failure or delay in carrying out physician orders, including fluid restriction, could potentially negatively affect Resident 4's clinical condition and place the resident at risk for complications, including possible rehospitalization. During an interview on 5/1/26, at 9:35 AM, with the DON, the DON stated that it was her expectation that all physician orders written during physician visits or rounds would be promptly reviewed, transcribed if applicable, implemented, and carried out by licensed nurses without unnecessary delay. The DON further stated that failure to implement physician orders, including fluid restriction orders, could place residents at risk for potential complications, adverse effects, worsening clinical condition, and possible hospitalization or rehospitalization. A review of a facility policy and procedure (P&P) titled, admission Criteria, revised 3/23, indicated, .Policy Interpretation and Implementation.c. routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. A review of a facility P&P titled, Physician Services, dated 2001, indicated, .Policy Statement: The medical care of each Resident is supervised by a licensed physician. Policy Interpretation and Implementation: 1. A physician must recommend in writing that an individual be admitted to the facility. This can be accomplished through. a physician's admission orders for the resident's immediate care.3. Supervising the medical care of residents.h. overseeing a relevant plan of care for the resident.5. The attending physician will determine the relevance of any recommended interventions.

Based on interview, and record review, the facility did not maintain acceptable parameters of nutritional status for 3 of 26 sampled Residents (Resident 1, Resident 86, and Resident 96) when:1. Resident 96's unplanned weight loss in March of 2026 was not addressed,2. Resident 96's monthly weight was not completed for January 2026,3. Resident 86's monthly weights were not completed from January 2026 through March 2026; and,4. Resident 1's monthly weights were not completed from March 2026 through April 2026.These failures placed Resident 1, Resident 86, and Resident 96 at risk of ongoing unplanned weight loss.Findings: 1. A review of Resident 96's admission RECORD, indicated Resident 96 was admitted to the facility with diagnoses that included but not limited to dysphagia (difficulty swallowing), depression, and unspecified dementia (when a person shows clear signs of memory loss and cognitive decline that affect daily life). During a concurrent interview and record review on 4/30/26, at 3 p.m., with the Director of Nursing (DON), Resident 96's, Weights and Vitals Summary, dated 4/29/26, was reviewed. The DON confirmed that Resident 96 experienced weight loss on 3/3/26. The DON further confirmed that an assessment for Resident 96, and notification to the physician for Resident 96's weight loss was not done. The DON stated it was his expectation to see a progress note regarding any change in condition, an assessment completed by licensed nursing staff, and notification to the responsible party and physician. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2001, indicated, .Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the residents medical/mental condition and/or status.A significant change of condition is a major decline or improvement in the resident's status that.will not normally resolve itself without intervention by staff .requires interdisciplinary review.If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. 2. During a concurrent interview and record review on 4/30/26, at 9:47 a.m., with the Registered Dietitian (RD), Resident 96's, Weights and Vitals Summary, dated 4/29/26, was reviewed. The RD confirmed a monthly weight was not obtained for Resident 96 for January 2026. The RD stated it was her expectation weights are obtained at least monthly, to determine the nutritional status of residents. The RD further stated if monthly weights are missed there is a risk for unwanted and ongoing weight loss or weight gain. A review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention dated 9/2008, indicated, .The nursing staff will measure residents weights on admission, the following Tuesday, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 3. During an interview on 4/29/26, at 4:10 p.m., with Licensed Nurse (LN) 1, LN 1 stated it was important to obtain monthly weights for Resident 86 because he had the tendency to retain fluid (too much fluid in the body's bloodstream or tissues) and it was important to ensure he was not retaining too much fluid in a short amount of time. During a concurrent interview and record review on 4/29/26, at 4:18 p.m., with the DON, Resident 86's, Weights and Vitals Summary, dated 4/30/26, was reviewed. The DON confirmed Resident 86's weight was not obtained from January 2026 to March 2026. The DON stated it was important to obtain monthly weights for Resident 86 due to complications associated with potential weight gain. 4. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses that included malnutrition (poor nutrition resulting in weight loss and decline in health), weakness, and depression (a condition that may cause sadness, loss of interest, and decline in daily activities).Review of Resident 1's Weights and Vitals, indicated the following documented weights: 2/4/26 – 130.8 pounds (lbs- unit of measurement for weight) 2/11/26 – 131.4 lbs. 2/18/26 – 132.8 lbs. 3/3/26 – 129 lbs. 3/10/26 – 123 lbs. No additional weights were documented from 3/10/26 through 4/28/26. The record further indicated Resident 1 experienced a 6.4% unplanned weight loss from 131.4 lbs. on 2/11/26 to 123 lbs. on 03/10/26, which met the facility's criteria for significant weight loss within a one-month period.During a concurrent interview and record review on 4/29/26, at 3:22 p.m., with the RD, Resident 1's weights and Order Summary were reviewed. The RD confirmed Resident 1's weights were missed and confirmed the last documented weight in the resident's electronic health record was entered on 3/10/26. The RD further confirmed there was no standing order for weights in the resident's order summary. The RD acknowledged Resident 1 had a history of significant weight loss and continued a weight decline over several weeks. The RD stated missed weights placed the resident at risk for malnutrition, missing delayed identification, and intervention for additional weight loss. During a concurrent interview and record review on 4/29/26, at 4:03 p.m., with the DON, Resident 1's weights and Order Summary were reviewed. The DON confirmed the order for weights had been missed for Resident 1. The DON further confirmed the resident's weight changed from 130.8 pounds on 2/4/26 to 123 pounds on 3/10/26, representing a significant weight change of 6.4%. The DON acknowledged the missed weight monitoring placed the resident at risk for undetected nutritional decline and delayed intervention.Review of the facility policy titled, Weight Assessment and Intervention, revised September 2008, indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.2. Weights will be recorded in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment, Registered Dietitian will be notified .Review of the facility policy titled, Nutrition (Impaired)/Unplanned Weight Loss – Clinical Protocol, revised September 2012, indicated, .1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. 4. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake .

Based on interview, and record review, the facility failed to ensure non-pharmacological interventions (without the use of medication or drugs) were implemented and documented for 3 of 5 sampled residents (Resident 1, Resident 71, and Resident 106) reviewed for unnecessary medications when the facility administered psychotropic medications (mind altering drugs) to Resident 1, Resident 71, and Resident 106 without evidence of individualized non-pharmacological interventions to address the residents' behavioral symptoms, or mood-related concerns prior to or in conjunction with medication use.This failure had the potential to result in unnecessary psychotropic medication use, adverse side effects, excessive sedation (difficult to stay awake), and medication dependency.Findings:a. Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses that included malnutrition (poor nutrition resulting in weight loss and decline in health), weakness, and depression (a condition that may cause sadness, loss of interest, and decline in daily activities).Review of Resident 1's physician order summary indicated Resident 1 received psychotropic medications (mind altering drugs) for depression. Physician orders included Duloxetine Hydrochloride (HCl) 30 milligrams (mg- unit of measurement), give one capsule by mouth every morning and at bedtime for depression, and Mirtazapine 7.5 mg, give one tablet by mouth at bedtime for depression. Further review of Resident 71's medical record did not identify physician-ordered, care planned, or documented individualized non-pharmacological interventions related to the resident's mood, behavioral symptoms, anxiety, or distress.b. Review of Resident 71's admission RECORD, indicated Resident 71 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), anxiety (a condition that may cause excessive worry, nervousness, fear, or restlessness affecting daily activities), and depression.Review of Resident 71's physician order summary indicated Resident 71 received psychotropic medications for depression and anxiety. Physician orders included Escitalopram Oxalate 10 mg, give one tablet by mouth daily for depression; Hydroxyzine HCL 25 mg, give one tablet by mouth every eight hours as needed for anxiety; and Trazodone HCL 50 mg, give 25 mg by mouth at bedtime for depression. Further review of Resident 71's medical record did not identify physician-ordered, care planned, or documented individualized non-pharmacological interventions related to the resident's mood, behavioral symptoms, anxiety, or distress.c. Review of Resident 106's admission RECORD, indicated Resident 106 was admitted to the facility with diagnoses that included anxiety, depression, and dementia (a condition where memory and thinking abilities gradually decline over time).Review of Resident 106's physician order summary indicated Resident 106 received psychotropic medications for depression and anxiety. Physician orders included Fluoxetine 40 mg, give one capsule by mouth daily for depression; Buspirone HCL 5 mg, give one tablet by mouth daily for anxiety; Risperidone 0.5 mg, give one tablet by mouth at night for anxiety; and Trazodone HCL 50 mg, give one tablet by mouth every 24 hours as needed for depression. Further review of Resident 106's medical record did not identify physician-ordered, care planned, or documented individualized non-pharmacological interventions related to the resident's mood, behavioral symptoms, anxiety, or distress.During a concurrent interview and record review on 5/1/26, at 11:14 a.m., with the Assistant Director of Nursing (ADON), the physician order summaries and electronic medical records for Resident 1, Resident 71, and Resident 106 were reviewed. The ADON confirmed there were no physician orders, care planned approaches or documented individualized non-pharmacological interventions for the residents receiving psychotropic medications. The ADON acknowledged psychotropic medications should not be the sole intervention used to address resident symptoms and stated alternative non-pharmacological approaches should be utilized when appropriate. The ADON stated psychotropic medications could place residents at risk for adverse side effects and medication dependency.During an interview on 5/1/26, at 11:51 a.m., with the facility Pharmacy Consultant (PC), the PC stated non-pharmacological intervention orders were important to assist the facility and physician in evaluating gradual dose reductions and determining whether psychotropic medications remained necessary for the residents. The PC further stated documentation of non-pharmacological interventions in the resident's medical record assisted staff in identifying alternative interventions prior to the continued use of psychotropic medications and helped reduce unnecessary medication use.A review of the facility policy titled, Psychotropic Medication Use, revised February 2025, indicated, .1. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction.3. A. Documentation must include that behavioral (non-pharmacological) interventions were attempted but not successful, and these interventions were deemed clinically contraindicated.A review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, indicated, .3. Current guidelines recommend the use of non-pharmacological interventions for BPSD (Behavioral or Psychological Symptoms of Dementia).9. Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms .

Based on observation, interview, and record review the facility failed to store, prepare, and serve food per food safety standards when:The reach-in refrigerator in the dry storage area of the kitchen had missing entries on the temperature log.The reach-in refrigerator in the dry storage area of the kitchen had several strawberries with mold.A vent in the dry storage area of the kitchen had dust.Two vents in the food prep area were dusty and with rust.The ceiling above the tray line was cracked approximately three feet in length.These failures had the potential to lead to cross contamination and food borne illness for the 94 residents eating facility prepared meals.Findings: 1.During the initial kitchen tour with the Dietary Manager (DM) on 4/28/26, at 8:30 a.m., the temperature log of the reach-in refrigerator in the dry storage area was reviewed. The DM confirmed the log had a missing temperature entry on 4/24 at 1:30 p.m., and on 3/27 at 1:30 p.m.During an interview at 9:10 a.m., with the DM, the DM stated it was important to monitor and log the reach in refrigerator temperatures to ensure the food that was stored did not go bad.During an interview on 4/30/26, at 3:00 p.m., with the Registered Dietitian (RD), the RD stated it was important to monitor the temperature of the refrigerators to ensure food was not stored in the refrigerator above 41 degrees Fahrenheit (F, a unit of measurement) to reduce the risk of foodborne illness.During a review of the facility's policy and procedure (P&P) titled, Food Storage dated 2023, the P&P indicated, Food will be stored at appropriate temperatures and by methods designed to prevent contamination.Temperatures for refrigerators should be between 35 to 39 degrees F.Check for proper functioning of the unit at all times.2.During the initial kitchen tour with the DM on 4/28/26, at 8:30 a.m., the DM confirmed several strawberries were stored with mold in the reach-in refrigerator in the dry storage area.During an interview on 4/29/26, at 10:00 a.m., with the RD, the RD stated keeping strawberries with mold was a risk of food borne illness to the residents if used.During a review of the facility's P&P titled, Food Storage dated 2023, the P&P indicated, .Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing.3. During the initial kitchen tour with the DM on 4/28/26, at 8:30 a.m., the DM confirmed a vent in the dry storage area was dusty.During an interview on 4/29/26, at 10:00 a.m., with the RD, the RD stated vents with dust could potentially contaminate food stored and was not sanitary.During a review of the facility's P&P titled, Food Storage dated 2023, the P&P indicated, .Food will be stored in an area that is clean, dry and free of contaminants.4. During the initial kitchen tour with the DM on 4/28/26, at 8:30 a.m., the DM confirmed two vents in the food prep area were covered with dust and rust.During an interview on 4/29/26, at 10:00 a.m., with the RD, the RD stated the vents that were dusty and had rust had the potential risk of affecting the quality of the food being prepared and risked contamination.5. During the initial kitchen tour with the DM on 4/28/26, at 8:30 a.m., the DM confirmed there was a crack in the ceiling approximately 3 feet in length above the tray line area.During a concurrent observation and interview on 4/28/26, at 9:23 a.m., with the DM, the crack in the ceiling above the tray line area was observed. The DM stated that the same spot in the ceiling had fallen in the past and stated there was the potential of paint chipping onto the food prep area.During a concurrent observation and interview on 4/29/26, at 10:00 a.m., with the RD, the crack in the ceiling above the tray line area approximately 3 feet in length was verified with the RD. The RD stated there was risk of the ceiling coming down, the paint, and anything above the ceiling landing on the food being prepared to serve.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 94 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 4 errors out of 27 opportunities which resulted in a facility wide medication error rate of 14.81% in three out of six residents (Resident 68, Resident 40, Resident 28) during medication administration observation when:Resident 68 omeprazole (a medication used to protect the stomach lining), 10 mg (mg-milligram a unit or measurement) Delayed Release Oral Capsule was not given as ordered by the doctor; Resident 40 Folic Acid 1mg (a supplement used to help blood production in the body) dosage was not given as ordered by the doctor; Resident 28 Folic Acid 1mg dosage was not given as ordered by the doctor; andResident 28 Ferrous Sulfate (Iron), 324mg Delayed Release oral tablet was not given as ordered by the doctor. These failures resulted in unsafe use of medication, medication errors, and not following the physician's orders.Findings:1.During a medication observation with Licensed Nurse (LN) 2, on 4/29/26 at 8:30 AM, LN 2 obtained a small cup to place the medication that will be used to administer the medications to Resident 68. While preparing the medications LN 2 used the Medication Administration Record (MAR- A place where medication and treatment orders are placed for staff to view and administer as indicated). LN 2 removed one capsule from a bottle titled, Omeprazole Delayed Release Capsules. and placed that capsule in the small cup with the rest of Resident 68's medication that was added according to the MAR. LN 2 then poured a cup of water and administered the medication to Resident 68. A review of Resident 68's electronic medical record, titled Medication Administration Record, dated 4/2026, indicated an order as follows: Omeprazole Capsule Delayed Release 20 MG; (MG- is a milligram a unit of measure) Give 1 capsule by mouth one time a day for acid indigestion (stomach unable to digest food and medicine) DO NOT CRUSH/give before meals.02/14/2026During a concurrent interview and record review on 04/29/2026 at 2:39 PM, with LN 2 of Resident 68's MAR, dated 4/2026, LN 2 verified the doctor's order for Omeprazole Delayed Release capsule for Resident 68 which indicated to take the medication prior to having his meals. LN 2 verified that at the time of the medication administration Resident 68 had already eaten his breakfast. LN 2 stated the medication was indicated to help Resident 68 with digestion.2. During a medication observation with LN 2, on 4/29/26 at 8:32 AM, LN 2 prepared and poured Resident 40's medication in a small cup for administration from the bottle. LN 2 did this while looking at Resident 40's Medication Administration Record (MAR), to the small cup LN 2 added one tablet from a bottle titled, .Folic Acid 400 mcg [micrograms-a unit of measurement] .During a record review of Resident 40's electronic medical record, titled .Medication Administration Record., dated 4/2026, indicated an order as follows: .Folic Acid Tablet 1 MG [Milligram- a unit of measurement] Give 1 tablet by mouth one time a day for supplements.During a concurrent interview and record review on 4/29/26 at 2:44 PM, with LN 2 of Resident 40's MAR, dated 4/2026, LN 2 verified the doctors order for Resident 40 indicated, .Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for supplements., LN 2 then opened his medication cart and obtained the bottle of folic acid and confirmed the bottle indicated each tablet was 400mcg. LN 2 verified he administered Resident 40 one tablet which was not her adequate dosage that was ordered. LN 2 stated the importance of following the doctor's orders wasto preserve the well-being of the residents life.3. During a medication observation with Licensed Nurse (LN) 4, on 4/29/26 at 9:01 AM, LN 4 prepared and poured medications in a small cup, once the medications were removed from the bottle LN 4 while reviewing Resident 28's Medication Administration Record (MAR), added one tablet from a bottle titled, .Folic Acid 400 mcg.A record review of Resident 28's electronic medical record, titled .Medication Administration Record., dated 4/2026, indicated an order as follows: .Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for supplements.During a concurrent interview and record review with LN 4 on 4/29/26 at 2:33 PM, and review of Resident 28's MAR record dated 4/2026, LN 4 verified the doctors order for Resident 28 indicated, .Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for supplements., LN 4 then opened his medication cart and noted his cart contained the bottle of folic acid 400mcg that he administered to Resident 28. LN 4 confirmed he administered folic acid 400 mcg not realizing the order was for 1 mg. 4. During a medication observation with LN 4, on 4/29/26 at 9:01 AM, LN 4 poured the medications in a small cup for Resident 28, once the medications were removed from the bottle LN 4 while reviewing Resident 28's Medication Administration Record (MAR), added one tablet from a bottle titled, .IRON FERROUS SULFATE 325 mg.During a concurrent interview and record review with LN 4 on 4/29/26 at 2:33 PM, and review of Resident 28's MAR record dated 4/2026, the MAR indicated, .Ferrous Sulfate Tablet Delayed Release 324 MG Give 1 Tablet by mouth one time daily for supplement . LN 4 verified he administered ferrous sulfate 325 mg tablet instead of the ordered form of delayed release ferrous sulfate 324mg tablet. LN 4 stated he misread the medication bottle label and administered the wrong form of the iron pill. During an interview with the Director of Nurses (DON) on 4/30/2026 at 12:53 PM, the DON stated his expectations were for the residents to receive their medication as ordered and if not the residents were at risk of the medication not reaching its desired effect. A record review of the facility's policy and procedure titled, Administering Medications dated April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescribers orders.The individual administering the medication checks the label THREE (3) times to verify the.right dosage.of administration before giving the medication .

Based on observation, interview, and record review, the facility failed to ensure respiratory care (care and treatment provided to help a person breathe better) was provided in accordance with professional standards of practice for 3 of 26 sampled residents (Resident 4 and Resident 106) when:A physician-ordered Continuous Positive Airway Pressure (CPAP - a machine that helps a person breathe by gently blowing air through a mask while sleeping) therapy was not carried out.Resident 106's nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen directly into a patient's nostrils) was not labeled/dated to identify when the equipment was last changed. Physician orders for supplemental oxygen (extra oxygen given to help a person breathe and maintain healthy oxygen levels) and head of bed orders for Resident 71 were not followed.These failures had the potential to result in inadequate ventilation (not getting enough air in and out of the lungs), decreased oxygenation (lower than normal oxygen levels in the body), and adverse respiratory outcomes (harmful or negative breathing-related problems or complications) for Resident 4, Resident 106, and Resident 71.Findings:1. Review of Resident 4's clinical record titled, admission RECORD, indicated Resident 4 was admitted to the facility with diagnoses of, but not limited to acute bronchiolitis due to respiratory syncytial virus (a sudden lung infection that makes the small airways in the lungs swollen and clogged), pneumonia (an infection in the lungs), acute and chronic respiratory failure (a serious breathing condition where the lungs are not working well enough both suddenly and over a long period of time), acute pulmonary edema (a sudden buildup of fluid in the lungs), chronic obstructive pulmonary disease (COPD- progressive lung condition that makes it hard to breathe because airflow into and out of the lungs get blocked) with acute exacerbation (a long-term lung diseases that suddenly became worse), and heart failure (a condition where the heart cannot pump blood as well as it should).Review of Resident 4's clinical record titled, [Name of Hospital] Inter-Facility Transfer Report, dated 4/6/26, indicated, .Additional Orders: CPAP at night.During a concurrent observation and interview on 4/28/26, at 4:33 PM, with Resident 4, in her room, Resident 4 was observed lying on her back in bed with the head of bed elevated. Resident 4 was observed receiving oxygen via a nasal cannula connected to an oxygen concentrator (a machine that provides extra oxygen to help a person breathe) located at the right bedside area. A CPAP machine was also observed placed on top of Resident 4's nightstand located at the upper right side of the bed. During the interview, when asked if she used the CPAP machine, Resident 4 nodded her head yes. When further asked if the nurses apply the CPAP for her use, Resident 4 again nodded her head yes. Resident 4 remained in bed throughout the observation with the CPAP machine present at bedside and oxygen therapy ongoing.During a concurrent interview and record review on 4/30/26, at 11:26 AM, with Licensed Nurse (LN) 7, LN 7 stated that Resident 4 had multiple hospitalizations and was most recently readmitted to the facility on [DATE] following a hospitalization related to a change in condition. LN 7 further stated that on 4/2/26, Resident 4 experienced oxygen desaturation (a drop in the oxygen level in the blood) and was subsequently transferred to the hospital for further evaluation and treatment. LN 7 explained that prior to a resident's return to the facility, the hospital case manager typically communicated with the receiving facility regarding the resident's care needs and required medical equipment, including respiratory equipment such as a CPAP machine. LN 7 confirmed the presence of a CPAP machine in Resident 4's room and stated that the CPAP was intended for resident use. LN 7 stated that the facility's readmission process included review and verification of all interfacility transfer documents, reconciliation of hospital discharge orders, obtaining clarification from the attending physician when needed, and implementation of all physician orders upon admission/readmission. During review of Resident 4's Interfacility Transfer records and comparison with the facility admission orders entered into Resident 4's electronic health record at the facility, no active physician order for CPAP implementation was identified. LN 7 stated she did not see an order for the CPAP machine carried over into Resident 4's facility admission orders from the hospital. LN 7 further stated that CPAP therapy was important for Resident 4 due to the resident's multiple respiratory and medical diagnoses and explained that timely and accurate implementation of physician orders, including respiratory treatments and equipment, was important to prevent further respiratory decline and potential rehospitalization.During an interview on 5/1/26, at 9:45 AM, with the Director of Nursing (DON), the DON stated that based on facility policy and the facility's readmission process, it was his expectation that licensed nurses reviewed all hospital discharge and interfacility transfer orders upon a resident's return to the facility, verify the completeness and accuracy of the orders, clarify any discrepancies with the attending physician as needed, and ensure all physician orders were accurately and timely carried out. The DON further stated that respiratory equipment orders, including CPAP, were important components of a resident's treatment plan and should not be missed during the readmission reconciliation process. The DON stated that failure to carry out physician orders, including CPAP therapy, could place Resident 4 at risk for respiratory decline, worsening condition, oxygen desaturation, and potential rehospitalization. The DON stated, Not carrying out an order like CPAP can definitely put the resident at risk for another change in condition or rehospitalization. A review of a facility policy and procedure (P&P) titled, Admissions Policies, dated 2021, indicated, .Policy Interpretation and Implementation. 3. The objectives of our admission policies are to. e. assure that appropriate medical.records are provided to the facility prior to or upon the resident's admission.A review of a facility P&P titled, admission Criteria, revised 3/23, indicated, .Policy Statement: Our facility admits only residents whose medical and nursing care can be met. Policy Interpretation and Implementation.5. Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least.b. medication orders, including (as necessary) a medical condition or problem associated with each medication; and c. routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan.2. Review of Resident 106's admission RECORD, indicated Resident 106 was admitted to the facility with diagnoses that included anxiety (a condition that may cause excessive worry, nervousness, fear, or restlessness affecting daily activities), depression (a condition that may cause sadness, loss of interest, and decline in daily activities), and dementia (a condition where memory and thinking abilities gradually decline over time).During a concurrent observation and interview on 4/28/26, at 2:10 p.m., with LN 10, Resident 106 was observed receiving oxygen from a nasal cannula. The nasal cannula was observed without a label, date and staff initials. LN 10 confirmed the nasal cannula was not labeled or dated and stated labeling the nasal cannula was important to identify when the equipment was last changed and for infection control purposes.During an interview on 4/30/26, at 4:37 p.m., with the DON, the DON stated staff were expected to label and date nasal cannulas. The DON further stated proper labeling assisted staff in monitoring equipment changes and helped reduce the risk of infection transmission.Review of the facility policy titled, Policies and Practices - Infection Control, revised October 2018, indicated, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. b. Maintain a safe, sanitary and comfortable environment. 3. Review of Resident 71's admission RECORD, indicated Resident 71 was admitted to the facility with diagnoses that included respiratory failure with hypercapnia (condition causing elevated carbon dioxide levels in the blood due to inadequate breathing), COPD, and pleural effusion (fluid buildup around the lungs that may impair breathing).Review of Resident 71's physician order dated 3/28/26 and 4/16/26 indicated Resident 71 was to receive oxygen at 2 liters (a unit of measure) per minute (LPM) via nasal cannula and maintain the head of the bed elevated due to shortness of breath when lying flat, every shift.During an observation on 4/28/26, at 5:27 p.m., Resident 71 was observed in bed with the head of the bed in a flat position and receiving oxygen above the physician-ordered 2 LPM.During a concurrent observation, interview, and record review on 4/28/26, at 5:28 p.m., LN 9 confirmed Resident 71's physician orders included oxygen at 2 LPM via nasal cannula and to keep the head of the bed elevated due to shortness of breath when laying flat. LN 9 further confirmed Resident 71's head of bed was flat during the observation and confirmed the oxygen setting was greater than the ordered 2 LPM. LN 9 stated it was important for staff to follow physician orders to ensure resident safety and proper care. LN 9 further stated failure to follow physician orders could place Resident 71 at risk for complications related to Resident 71's respiratory condition and overall well-being.During a concurrent interview and record review on 4/30/26, at 4:30 p.m., with the Director of Nursing (DON), Resident 71's physician orders were reviewed. The DON confirmed the physician ordered oxygen at 2 LPM via nasal cannula and to keep the resident's head of bed elevated due to SOB (shortness of breath) when lying flat. The DON stated staff were expected to follow physician orders as written. The DON further stated failure to follow physicians orders had the potential to place Resident 71 at risk for respiratory distress and increased shortness of breath. Review of the facility policy titled, Physician Services, revised on February 2021, indicated, .The medical care of each resident is supervised by a licensed physician.Physician orders and progress notes are maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act- federal nursing home regulations) regulations and facility policy .Review of the facility policy titled, Oxygen Administration, revised on October 2010, indicated, .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.8. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .

Based on observation, interview, and record review, the facility failed to ensure adequate pain management was provided to one of twenty-six sampled residents (Resident 83) when Resident 83's pain was not assessed appropriately by staff and non-pharmacological pain interventions (interventions that do not involve the use of medications to treat pain) were not implemented for Resident 83These failures resulted in unmanaged, increased pain, and hindered Resident 83's participation in rehabilitation services and recovery.Findings:Review of Resident 83's undated admission RECORD indicated that Resident 83 was admitted to the facility with diagnoses which included, presence of right artificial knee joint (a right knee replacement), chronic pain (pain that last longer than the standard healing time usually greater than 6-months), chronic obstructive pulmonary disease (COPD- an incurable lung disease that restricts the air way and causes difficulty when breathing), muscle wasting and atrophy (loss of muscle mass), and a history of falling. Review of Resident 83's Brief Interview for Mental Status (BIMS- is a standardized screening tool used primarily in long-term care facilities to assess cognitive function upon admission), dated 4/14/2026, indicated Resident 83's cognitive function was intact with a score of 15, indicating Resident 83 demonstrated a strong cognitive ability with no evidence of cognitive impairment in the areas that were tested. Review of Resident 83's medical record titled, Pain Assessment Interview [a standardized, resident-centered tool designed to identify the presence, frequency, functional impact, and intensity of pain over the last 5 days prior to the questioning], dated 4/14/2026, indicated Resident 83 denied receiving any non-pharmacological interventions to support the pain she experienced. This assessment indicated Resident 83 stated she considered her pain as moderate (pain that is constantly distracting and interferes significantly with daily activities and concentration) and the pain occasionally interrupted her sleep at night.During a concurrent observation and interview on 4/28/26 at 10:06 AM, Resident 83 was observed with facial grimacing (facial wrinkling usually signaling pain), and pale skin, with her body leaning to one side. Resident 83 stated she had constant pain in her right leg. Resident 83 stated she recently had a total right knee replacement and shortly after the surgery she fell and landed on that same knee. Resident 83 stated since the fall the pain had progressed. Resident 83 stated her regular pain medication was ineffective and the pain remained constant. Resident 83 stated when she reported her pain level sometimes she was told that she had to wait because it was not time for her medication. Resident 83 stated she received her pain medication a short time prior to this interview, and her current pain level according to a numerical scale (a series of numbers used to rate pain intensity on scale of 1 being mild pain and 10/10 being the worst pain felt), was 8/10. Resident 83 further stated the pain would keep her up at night.Review of Resident 83's Medication Administration Record (MAR) indicated, Resident 83 was given, .HYDROCODONE-ACETOMINOPHEN 10-325 [a strong pain medication used to treat moderate to severe pain] 1 tablet by mouth every 4 hours as needed for moderate to severe pain.on 4/28/2026 at 8:06 AM for a pain level of 8/10.During a concurrent observation and interview on 04/28/2026 at 5:34 PM, with Resident 83 at the residents dining room during dinner time, Resident 83 was seated at the table with two other residents. Resident 83's face was grimaced, and her body was leaning more to the right on the table. Resident 83 expressed that she did not want to eat her dinner and felt nauseous due to the pain. Resident 83 stated her pain was 8/10. Resident 83 became emotional and got into a disagreement with her table mates then stated to them she was in a lot of pain and did not want to talk. Resident 83 stated everything was no longer funny to her. Resident 83 then requested for a staff member to return her to her bedroom. Review of Resident 83's care plans on 4/28/2026 indicated a pain care plan was not developed for Resident 83. During an interview on 4/30/26 at 9:01AM, with Licensed Nurse (LN) 4, LN 4 stated Resident 83 was constantly requesting pain medication for pain in her right knee. LN 4 stated the pain medication was not helping Resident 83's pain because soon after it was administered Resident 83 would state that she was still in pain. LN 4 stated Resident 83 constantly reported to be in severe pain with no relief. LN 4 stated Resident 83 had been going to bed early and was not active in activities like she used to be. LN 4 stated Resident 83 should be further evaluated by a medical provider and given medication that will be helpful in managing her pain because once her pain started it would only get worse. LN 4 confirmed he did not notify the doctor of Resident 83's ineffective pain management.During a concurrent interview and record review of Resident 83's medical record on 4/29/26 at 4:17 PM, with LN 3, LN 3 stated Resident 83's primary location of pain was her right lower leg. LN 3 stated when a resident was in constant pain then she would notify the doctor, and document the pain in the resident's medical record, and update the care plan. Resident 83's medical record indicated Resident 83's numerical pain level on 4/20/26 at 5:06 AM, was 9/10, a follow up pain level at 8:44 AM was 9/10, another follow up pain level at 8:50 AM, was reported as 9/10. Resident 83's pain level on 4/20/26 1:53 PM, was 8/10, a follow up pain level at 2:50 PM, was 6/10. On 4/21/26 at 9:10 AM, pain level was 7/10, follow up pain scale at 11:03 AM pain was 5/10, on 4/21/26 at 1:59 PM, pain level was 7/10, follow up pain scale at 2:58 PM, was 5/10, On 4/22/26 at 10:40 AM pain level was 8/10, a follow up pain scale at 12:58 PM 5/10. LN 3 confirmed Resident 83 was in pain frequently. LN 3 reviewed Resident 83's medical record and confirmed there was no evidence of staff attempting to alleviate Resident 83's pain when she remained in pain after the follow up pain level was reported. LN 3 was unable to find any documentation, other than administered medications, to show anything else was attempted to alleviate Resident 83's pain. LN 3 stated the doctor for Resident 83 should have been notified due to pain level reports and how ineffective the current pain medication has been in managing her pain. LN 3 verified there was not a pain care plan developed for Resident 83's until today (4/29/26). LN 3 stated the care plan needed more interventions that included nonpharmacological interventions such as repositioning her and hot and cold therapy.During an interview on 5/1/2026 at 11:17AM, with the Assistant Director of Nursing (ADON), the ADON stated not adequately assessing and providing care to Resident 83 placed her at risk for experiencing further pain and discomfort. The ADON stated it would have been important for the staff to try and figure out the cause of the worsening pain by contacting the doctor and anticipating an X-Ray (pictures of your bones and organs inside your body) image. The ADON stated a further assessment on the primary site of complaint which was Resident 83's right knee was expected but not initiated by the staff. The ADON stated the staff could have referred Resident 83 to pain management while also providing nonpharmacological interventions such as stretching, ice application and/or heating packs. The ADON stated when she interviewed Resident 83, she informed her of her pain level and stated the pain has continuously gotten worse since she was admitted .During a concurrent interview and record review of Resident 83's MAR on 4/30/2026 at 12:53 PM, with the Director of Nursing (DON), the DON confirmed the MAR did not have any non-pharmacological interventions, and the documentation of Resident 83's pain scale showed significant fluctuations from 0/10 to 8/10 and sometimes 10/10. The DON confirmed the follow up pain levels (after medication has been given) remained in the moderate pain level range. The DON stated the doctor should have been notified to review the medication. During a concurrent interview and record review of Resident 83's care plan, the DON stated the facility's process and his expectations was for the care plan to be created when the resident was admitted into the facility. The DON stated in addition to notifying the doctor his expectations were for the non-pharmacological interventions to be implemented by the staff and added to the care plan. The DON confirmed there was no documentation of non-pharmacological interventions being implemented.During a review of the facility's policy and procedure titled, Pain Assessment and Management dated 10/2022, indicated, .The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of pain;.g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. For stable chronic pain the residents pain and consequences of pain are assessed at lease weekly.Recognizing Pain. somnolence.Assessing Pain 1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing or for whom pain may be anticipated during specific procedures, care, or treatment.2. Monitor the resident for the presence of pain and the need for further assessment when there is a change in condition. 3. Assess the resident whenever there is suspicion of new or worsening of existing pain.a. History of pain and its treatment including pharmacological and non-pharmacological interventions. c. Characteristics of pain.Identifying the Causes of Pain 1. Residents may experience pain from several different causes simultaneously. surgical incision.Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: environmental- adjusting the room temperature, smoothing the linens, providing a pressure reducing mattress, repositioning etc.physical- ice packs, cool or warm compresses, baths, .exercises- range of motion exercises to prevent muscle stiffness and contractures.Contact the prescriber immediately if the residents pian or medication side effects are not adequately controlled. 6. If pain has not been adequately controlled, the multidisciplinary team including the physician, shall reconsider approaches and make adjustments as indicated.

Based on observation, interview, and record review, the facility failed to provide an environment free of accidents and hazards for 1 of 26 sampled residents (Resident 62) when Resident 62 was found carrying a cigarette lighter without staff supervision.This failure had the potential for burn related injuries due to the risk associated with Resident 62 carrying a lighter (ignition and combustion of materials).Findings: A review of Resident 62's, admission RECORD indicated Resident 62 was admitted to the facility with diagnoses that included but not limited to unspecified dementia (when a person shows clear signs of memory loss and cognitive decline that affect daily life), muscle weakness, altered mental status, and lack of coordination.During a concurrent interview and record review on 4/29/26, at 4:18 p.m., with Licensed Nurse (LN) 1, Resident 62's, SMOKING OBSERVATION/ASSESSMENT dated 11/25/26, was reviewed. LN 1 verified that Resident 62 was required to have supervision when wanting to smoke. LN 1 further stated Resident 62 should not have had a lighter on his person since he required staff supervision with smoking activity.During a concurrent observation and interview on 4/30/26, at 8:40 a.m., with certified nurse assistant (CNA) 1, CNA 1 verified Resident 62 had a lighter stored in an empty cigarette box in his pocket.During a concurrent interview and record review on 4/30/26, with LN 2, Resident 62's, Order Summary was reviewed. LN 2 verified Resident 62 had a PRN (as needed) order for supplemental oxygen and there was a sign that indicated oxygen was in use posted outside of Resident 62's room (Oxygen-enriched environments [e.g., supplemental medical oxygen] make materials that do not normally burn in air become combustible, while flammable materials burn intensely).During an interview on 4/30/26, at 9:20 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 62 was not able to smoke independently due to a cognitive impairment and Resident 62 was previously observed putting cigarette ashes onto himself while smoking. A review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents dated 10/2023, the P&P indicated, .this facility has established and maintains safe resident smoking practices.Residents without independent smoking privileges may not have or keep any smoking items.except under direct supervision.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer prevention interventions were implemented in accordance with professional standards of practice for 2 of 15 sampled residents (Resident 26 and Resident 3) when Low Air Loss (LAL - a special mattress that helps prevent and treat bed sores by blowing gentle air through the mattress) mattresses were in use without a physician's order.This failure placed Resident 26 and Resident 3 at risk for ineffective pressure redistribution, development of pressure injuries, or worsening of existing skin conditions.Findings:Review of Resident 26's clinical record titled, admission RECORD, indicated Resident 26 was admitted to the facility with diagnoses of, but not limited to Parkinson's disease (a condition that affects movement and makes it harder for the body to move normally), unspecified protein-calorie malnutrition (the body is not getting enough protein and calories from food, but the exact type or severity is not clearly defined), dementia (a condition that affects the brain and causes problems with memory, thinking, and daily activities), and adult failure to thrive (overall physical and mental decline in older adults).Review of Resident 26's clinical record titled, Care Plan Report, dated 9/20/23, under the section titled, Focus, indicated, .[Resident 26] has a potential/actual impairment to skin integrity r/t [related to] incontinence of the bowel and bladder [lack of control of bowel and bladder] . and under the section titled, Interventions/Tasks, indicated, .[Resident 26] needs,: pressure relieving/reducing mattress.to protect the skin while in bed.Follow facility protocols for treatment of injury .Implement wound care protocols as prescribed.Review of Resident 26's clinical record titled, Care Plan Report, dated 9/19/23, under the section titled, Focus, indicated, .Skin .[Resident 26] is at risk for skin breakdown related to bedbound status . and under the section titled, Interventions/Tasks, indicated, . Administer treatments as ordered.Air mattress as ordered.During an observation on 4/28/26 at 2:30 PM, in Resident 26's room, Resident 26 was observed lying in bed using a Comfort Zone Alternating Pressure mattress with low air loss (LAL) feature. During a concurrent interview and record review on 4/30/26 at 11:07 AM, with Licensed Nurse (LN) 4, LN 4 confirmed that Resident 26 was using a LAL mattress. LN 4 stated that the LAL mattress was being used as an intervention to help prevent pressure ulcers because Resident 26 was bedbound and totally dependent on staff for care and activities of daily living (ADLs). LN 4 explained that use of an LAL mattress required a physician's (MD) order because it was a treatment intervention related to pressure ulcer prevention and skin integrity management. LN 4 stated that the MD order was important to ensure nurses could properly monitor the mattress and verify that the settings were appropriate for the resident, including adjustment of the settings based on the resident's current weight. LN 4 added that the LAL mattress should be used together with other pressure ulcer prevention interventions, including routine turning and repositioning. During review of Resident 26's electronic health record (EHR), including the Order Summary Report section, LN 4 stated she did not see an order for the LAL mattress. When asked regarding potential risks, LN 4 stated that without an MD order, the intervention would not appear on the electronic Medication Administration Record (eMAR) or electronic Treatment Administration Record (eTAR), resulting in the inability of licensed nurses to consistently monitor, document, and follow through with the intervention. LN 4 stated that unmonitored use of the LAL mattress could place Resident 26 at risk for improper settings, ineffective pressure relief measures, and potential development or worsening of skin impairment or pressure ulcers.Review of Resident 3's clinical record titled, admission RECORD, indicated Resident 3 was admitted to the facility with diagnoses of, but not limited to displaced intertrochanteric fracture of right femur (a broken right hip bone where the broken pieces moved out of place), unspecified protein-calorie malnutrition, weakness, muscle wasting and atrophy (loss or shrinking of muscle size and strength), need for assistance with personal care, and cerebral infarction (Stroke - a part of the brain gets damaged because it did not receive enough blood and oxygen).Review of Resident 3's clinical record titled, Order Summary Report, dated 4/29/26, indicated, . TX [Treatment]: Unstageable Pressure Ulcer [a severe bedsore where the full depth of the wound cannot be seen because it is covered by dead tissue]: Cleanse NS [Normal Saline-wound cleaner], pat dry, apply Medi Honey [a medical-grade honey used on wounds] and Alginate [a soft wound dressing] with Dry Dressing every day shift for Unstageable Pressure Sacrum [lower back area near the tailbone].Review of Resident 3's clinical record titled, Care Plan Report, dated 4/21/26, under the section titled, Focus, indicated, Skin: Resident [Resident 3] has a pressure ulcer to (enter site) and is at risk for further breakdown and/or slow, delayed healing related to decreased mobility, impaired circulation, impaired nutrition . TX [Treatment]: Unstageable Pressure Ulcer: . for Unstageable Pressure Sacrum, and under the section titled, Interventions/Tasks, indicated, . Air mattress. Pressure reduction mattress for bed.During a concurrent observation and interview on 4/28/26 at 2:03 PM, with Resident 3, in his room, Resident 3 was observed lying in bed and using a low air loss (LAL) mattress. When asked regarding the purpose of the LAL mattress, Resident 3 stated that it was possibly for the wound in my bottom, and added that he recently had surgery related to a broken right hip. Resident 3 further stated that the mattress felt comfortable and helped him while lying in bed.During a concurrent interview and record review on 4/30/26 at 8:50 AM, in Resident 3's room, with LN 1, LN 1 greeted Resident 3 and informed him regarding his scheduled wound treatment for the day. During the interaction, LN 1 asked Resident 3 if he was experiencing pain. Resident 3 stated yes and rated his pain at approximately 6 to 7 on a 0-10 (0 being no pain with 10 being the worst pain) pain scale. When asked by LN 1 regarding the location of the pain, Resident 3 stated the pain was in his bottom. At the time of the observation, Resident 3 was observed lying in bed on a low air loss (LAL) mattress. The LAL mattress was observed to be turned off. LN 1 confirmed that the mattress was off while Resident 3 remained in bed. LN 1 stated that the LAL mattress .should be on at all times when the resident is in bed . to provide pressure relief and assist with prevention and management of pressure ulcers. LN 1 further stated that she needed to verify the physician's order and confirm the resident's current weight because the effectiveness and settings of the LAL mattress were dependent on the resident's weight. During review of Resident 3's electronic health record (EHR) with LN 1, including the Order Summary Report, no physician (MD) order for the LAL mattress was identified. LN 1 explained that the LAL mattress was an important intervention used together with turning and repositioning to reduce pressure and protect skin integrity. LN 1 told Resident 3 that the pain in his buttocks area could possibly be related to the mattress being turned off, stating that if the LAL mattress was off, .it's not doing its purpose . and .not doing what it's supposed to do . LN 1 stated that all staff entering the room, including licensed nurses and certified nursing assistants (CNAs), were responsible for ensuring that the LAL mattress remained turned on while the resident was in bed. LN 1 stated that failure to ensure the mattress was functioning properly could place Resident 3 at risk for worsening of existing pressure ulcers or development of new pressure-related skin impairment.During an interview on 5/1/26 at 9:15 AM with the Director of Nursing (DON), the DON stated that it was his expectation that a nursing assessment be conducted prior to placing any resident on a low air loss (LAL) mattress in order to determine whether the intervention was clinically indicated based on the resident's condition, risk factors, skin integrity, and pressure ulcer status. The DON stated that once the need for an LAL mattress was identified, licensed nurses were expected to notify the physician (MD) so that an appropriate MD order could be obtained prior to implementation of the intervention. The DON further stated that the resident's current weight was an important factor in determining the correct LAL mattress settings to ensure the mattress functioned effectively and provided the intended pressure relief. The DON explained that inaccurate settings could reduce the effectiveness of the intervention and place the resident at risk for skin breakdown or worsening pressure ulcers. The DON also stated that the use of the LAL mattress, including monitoring and related interventions, should be reflected in the resident's comprehensive care plan to ensure continuity of care and staff awareness regarding the resident's pressure ulcer prevention and treatment needs.A review of a facility policy and procedure (P&P) titled, Physician Services, dated 2001, indicated, Policy Statement: The medical care of each Resident is supervised by a licensed physician. Policy Interpretation and Implementation .3. Supervising the medical care of residents. h. overseeing a relevant plan of care for the resident. 5. The attending physician will determine the relevance of any recommended interventions .A review of a facility P&P titled, Prevention of Pressure Injuries, dated 2001, indicated, Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors.Support Surfaces and Pressure Redistribution - 1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice.

Based on interview, and record review, the facility failed to develop a comprehensive care plan for 2 of 26 sampled residents (Resident 83 and Resident 96), when:1. Resident 83 did not have a care plan to address her chronic pain (pain that lasts longer than the standard healing time, usually greater than 6-months); and,2. Resident 96 did not have a care plan to address his weight loss.These failures had the potential for Resident 83 and Resident 96's needs to not be met and a delay in implementing interventions. Resident 83 was at risk for increased pain and discomfort and Resident 96 was at risk for ongoing weight loss. Findings: 1. Review of Resident 83's admission RECORD, indicated that Resident 83 was admitted to the facility early 2026 with diagnoses which included, presence of right artificial knew joint (a right knee replacement), chronic pain, and a history of falling. Review of Resident 83's Brief Interview for Mental Status (BIMS- is a standardized screening tool used primarily in long-term care facilities to assess cognitive function upon admission), dated 4/14/26, indicated Resident 83's cognitive function was intact. Resident 83 demonstrated a strong cognitive ability with no evidence of cognitive impairment. During an concurrent interview and record review on 4/29/26, at 4:17 PM, with Licensed Nurse (LN) 3, Resident 83's medical record titled, Care Plan Report, was reviewed. LN 3 confirmed Resident 83's care plan for pain was not implemented prior to 4/29/26. LN 3 stated the care plan reviewed was not customized to Resident 83's medical needs. LN 3 further stated Resident 83's care plan lacked nonpharmacological interventions such as repositioning and hot and cold therapy. LN 3 stated that due to Resident 83's pain, other interventions would be necessary in managing the resident's pain in addition to the medication. During a concurrent interview and record review on 4/30/26, at 12:53 PM, with the Director of Nursing (DON), Resident 83's medical record titled, Care Plan Report, was reviewed. The DON confirmed Resident 83's admission date and that Resident 83's pain care plan was initiated on 4/29/26. The DON stated his expectation was for the care plan to be created when the resident was admitted into the facility. The DON further stated that the time difference of the resident admission and care plan initiation did not meet his expectations. Further review of Resident 83's care plans, the DON stated his expectation was for the non-pharmacological interventions to be in the resident's care plan and implemented by the staff. The DON confirmed there was no documentation of non-pharmacological interventions being implemented to manage Resident 83's pain. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. A review of the facility's P&P titled, Pain Assessment and Management, dated 10/2022, indicated, .The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.The pain management interventions are consistency with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, type and severity of pain.Pain management interventions shall address the underlying cause of the resident's pain. 2. A review of Resident 96's admission RECORD, indicated Resident 96 was admitted to the facility with diagnoses that included but not limited to dysphagia (difficulty swallowing), and unspecified dementia (when a person shows clear signs of memory loss and cognitive decline that affect daily life). During a concurrent interview and record review on 4/30/26, at 3 p.m., with the Director of Nursing (DON), Resident 96's Weights and Vitals Summary, dated 4/29/26, was reviewed. Further review of the document indicated Resident 96 experienced a weight loss of 11.6% in March 2026. The DON confirmed Resident 96 lost weight in March 2026 and a care plan was not updated to reflect the weight loss. The DON stated Resident 96's care plan should have been updated and that the care plan served as a guide to determine the plan of care for Resident 96. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs in developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to submit a new Level I Preadmission Screening and Resident Review (PASRR- a screening for mental illness and treatment to ensure the facility coordinates with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services appropriate to their needs) for 1 of 26 sampled residents (Resident 12), when a level I PASRR was not completed for Resident 12.This failure had the potential to result in unmet specialized service needs for Resident 12 and the lack of appropriate evaluation and care plan interventions. Findings:Review of Resident 12's admission RECORD, indicated Resident 12 was admitted to the facility with diagnosis of, but not limited to depression unspecified (a condition where a person is feeling very sad, down or emotionally low), unspecified psychosis not due to a substance abuse or known physiological condition (a mental condition where a person may have trouble knowing what is real and what is not), vascular dementia unspecified severity with anxiety (memory and thinking problem caused by poor blood flow to the brain, along with feelings of worry or nervousness), other schizoaffective disorders (a mental health condition that includes symptoms of schizophrenia [a serious mental illness that affects how a person thinks, feels, and understands reality] and mood disorder [a condition that affects a person's emotions or mood]), and generalized anxiety disorders (a condition where a person worries too much or feels anxious most of the time).Review of Resident 12's Order Summary Report, dated 4/29/26, indicated, .Monitor episodes of restlessness or agitation for anxiety.order date 12/8/24.Monitor for side effects of Ativan [anti-anxiety medication].order date 1/24/23.Monitor for side effects of Klonopin [anti-anxiety medication]. order date 2/19/26.Monitor for the following side effects of Mirtazapine [antidepressant medication].order date 4/7/25.Monitor for the following side effects Trazodone [antidepressant medication].order date 4/7/25.Monitor number of hours of sleep for depression m/b [manifested by] inability to sleep .order date 4/7/25.clonazepam [anti-anxiety medication] oral tablet.for anxiety m/b restlessness agitation.order date 3/1/26.Lorazepam tablet.as needed for anxiety m/b restlessness.order date 3/9/26.traZODone HCl oral tablet.for depression m/b inability to sleep/restlessness.order date 8/28/25.Review of Resident 12's clinical record titled, Care Plan Report, dated 5/5/23, under the section titled, Focus, indicated, .[Resident 12] uses anti-anxiety medication; clonazepam/lorazepam r/t [related to] anxiety m/b inability to relax., and under the section titled, Interventions/Tasks, indicated, .Give anti-anxiety medications ordered by physician.Review of Resident 12's clinical record titled, Care Plan Report, date initiated 1/20/23, under the section titled, Focus, indicated, .09/07/2022 - Depakote sprinkles.for unspecified mood d/o [disorder] m/b pacing/exit seeking and mood lability., and under the section titled, Interventions/Tasks, indicated, Administer medications as ordered. Anticipate and meet the resident's [Resident 12] needs.Provide a program of activities that is of interest and accommodates residents [Resident 12] status.Review of Resident 12's clinical record titled, Care Plan Report, date initiated 12/17/25, under the section titled, Focus, indicated, .The resident [Resident 12] uses antidepressant medication.Trazodone.for depression m/b inability to sleep/restlessness., and under the section titled, Intervention/Tasks, indicated, .Administer ANTIDEPRESSANT medications as ordered by physician.Review of Resident 12's clinical record titled, Care Plan Report, dated 5/5/23, under the section titled, Focus, indicated, .The resident [Resident 12] uses anti-anxiety medications.Lorazepam . r/t Anxiety disorder., and under the section titled, Interventions/Tasks, indicated, .Administer ANTI-ANXIETY medications as ordered by physician.Review of Resident 12's clinical record titled, Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 12/26/21, indicated, . Level I - Negative.Reason Code: 30-Day Exempted Hospital Discharge.Case State: Closed.Resolution: LII - Not Required.Review of Resident 12's clinical record titled, Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 5/2/22, indicated, . Level I - Positive.Reason Code: Suspected MI [Mental Illness].Section III Serious Mental Illness Screen.12. The individual [Resident 12] has been prescribed psychotropic medications for mental illness.Quetapine [antipsychotic medication] 25 mg [milligram- unit of measurement] daily, Mirtazapine 7.5 mg at hs [bedtime].Review of Resident 12's clinical record titled, [Name of Department], dated 5/2/22, indicated, .Re: Positive Level I Screening Indicates a Level II Mental Health Evaluation is Required.Review of Resident 12's clinical record titled, [Name of Department], dated 5/2/22, indicated, .UNABLE TO COMPLETE LEVEL II EVALUATION.After reviewing the Positive Level I Screening and speaking with staff, a level II Mental Health Evaluation was not scheduled for the following reason: The individual [Resident 12] has no serious mental illness (SMI). The case is now closed. To reopen, please submit a new Level I Screening.During a concurrent interview and record review on 4/30/26, at 12:18 PM, with the Assistant Director of Nursing (ADON), Resident 12's electronic health record (EHR) was reviewed. The ADON stated that she was the staff member primarily responsible for the facility's PASARR process. The ADON further stated the PASARR process included from the time of admission, completion of the initial Preadmission Screening (PAS), and the need for a Resident Review (RR) when a resident experienced a significant status change. The ADON stated status changes that required PASARR review could include the development of a new psychiatric diagnosis or initiation of psychotropic medications such as antidepressants, antianxiety medications, antipsychotics, or hypnotics. The ADON stated the PASRR form consisted of yes and no questions, and a yes response could trigger the need for additional review or referral for a Level II evaluation. The ADON further stated that Resident 12 was originally admitted to the facility in 2021 with a PASARR completed on 12/26/21 showing Level I - Negative, indicating that a Level II Mental Health Evaluation was not required at that time. The ADON stated that another PASARR was completed on 5/2/22 which showed Level I - Positive due to yes responses related to the resident's use of psychotropic medications including Quetiapine and Mirtazapine, indicating that a Level II Mental Health Evaluation was required. The ADON acknowledged there was documentation of the Level II evaluation outcome stating UNABLE TO COMPLETE LEVEL II EVALUATION, with remarks indicating Resident 12 did not meet criteria for Serious Mental Illness (SMI). Further review of Resident 12's EHR indicated that during Resident 12's current stay at the facility, the resident developed new psychiatric-related diagnoses including other schizoaffective disorders dated 1/22/26, Unspecified Psychosis dated 9/9/22, and Generalized Anxiety Disorder dated 7/17/23. Medication review further revealed physician orders for psychotropic medications including Clonazepam with order date 3/1/26, Lorazepam with order date 3/9/26, and Trazodone with order date 8/28/25. The ADON stated the addition of new psychiatric diagnoses and psychotropic medications represented a significant status change and that a new PASARR should have been completed for Resident 12. The ADON stated that completing a new PASARR was important to determine whether the resident required a Level II evaluation, additional mental health services, specialized supports, or other interventions based on the resident's current condition and care needs. The ADON further stated that failure to complete a new PASARR could place Resident 12 at risk for unmet mental health needs, lack of appropriate evaluation, delayed services, and inadequate care planning.During an interview on 5/1/26, at 8:58 AM, with the Director of Nursing (DON), the DON stated that it was his expectation that a new PASARR should be completed whenever a resident experienced a significant status change, such as the development of a new psychiatric diagnosis, worsening psychiatric symptoms, or initiation of new psychotropic medications including antipsychotics, antidepressants, antianxiety medications, or hypnotics. The DON further stated that changes in a resident's mental health condition or treatment regimen could indicate the need for further PASARR review and possible Level II evaluation. The DON stated that completion of a new PASARR evaluation was important to determine whether the resident remained appropriately placed in the facility and to ensure the resident received the necessary care, treatment, mental health services, and specialized supports based on the resident's current condition and needs. The DON further stated that failure to complete a new PASARR after a significant status change could place the resident at risk for unmet psychiatric needs, inadequate care planning, delayed mental health evaluation, and failure to identify or provide appropriate services and interventions.A review of a facility policy and procedure (P&P) titled, admission Criteria, revised 3/23, indicated, .Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation.9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.d. The state PASARR representative provides a copy of the report to the facility.e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services.

Based on interview, and record review, the facility failed to notify the physician of a change of condition for 1 of 26 sampled residents (Resident 96), when Resident 96 experienced an unplanned weight loss in March 2026.This failure resulted in a delayed physician response and delayed interventions to address Resident 96's change of condition. This failure also had the potential to impact Resident 96's health.Findings: A review of Resident 96's admission RECORD, indicated Resident 96 was admitted to the facility with diagnoses that included but not limited to dysphagia (difficulty swallowing), depression, and unspecified dementia (when a person shows clear signs of memory loss and cognitive decline that affect daily life).During a concurrent interview and record review on 4/30/26, at 9:47 a.m., with the Registered Dietitian (RD), Resident 96's Weights and Vitals Summary, dated 4/29/26, was reviewed. The RD confirmed that Resident 96 weighed 165.3 pounds (Lb, a unit of measurement) in December 2025 and then weighed 146.8 Lb in March 2026, which was an 11.2% weight loss.During a concurrent interview and record review on 4/30/26, at 3 p.m., with the Director of Nursing (DON), Resident 96's Weights and Vitals Summary, dated 4/29/26, was reviewed. The DON confirmed that Resident 96 experienced weight loss on 3/3/26, and notification to the physician about Resident 96's weight loss for Resident 96 was not done. The DON stated it was his expectation to see a progress note regarding any change in condition, an assessment by licensed nursing staff, and notification to the responsible party and physician. The DON further stated notifying the physician was important for the physician to evaluate and assess Resident 96 timely.A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2001, indicated, .Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the residents medical/mental condition and/or status.A significant change of condition is a major decline or improvement in the resident's status that. will not normally resolve itself without intervention by staff.requires interdisciplinary review.If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.A review of the facility's P&P titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revision date on 9/2012, indicated, .The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 2 of 26 sampled residents (Resident 108 and Resident 54).This failure limited Resident 108 and Resident 54's ability to request assistance and had the potential risk for unmet needs, falls, and injury.Findings:a. Review of Resident 108's admission RECORD, indicated Resident 108 was admitted to the facility with a diagnosis of, but not limited to unspecified fall, unspecified injury of head, weakness, need for assistance with personal care, repeated falls, dementia (a condition that affects the brain and causes problems with memory, thinking, and daily activities) and cerebral infarction (stroke - a part of the brain gets damaged because it did not receive enough blood and oxygen).A review of Resident 108's clinical record titled, Care Plan Report, initiated on 4/22/26, in the section titled, Focus, indicated, Falls: Resident [Resident 108] is at risk for falls with or without injury related to altered balance.history of falls, unsteady gait. Further review of the document under the section titled, Interventions/Tasks, initiated on 4/22/26, indicated, .Anticipate and meet needs.resident [Resident 108] to call for assistance with all transfers.Keep call light within reach.During a concurrent observation and interview on 4/28/26, at 9:53 AM, Resident 108 was observed lying in bed with her call light hanging down on the left side of the bed and was not within the resident's reach. Resident 108 was unable to locate her call light and stated, Where is it? Resident 108 stated she used the call light when she needed assistance. During a concurrent observation and interview on 4/28/26, at 9:55 AM, in Resident 108's room, Licensed Nurse (LN) 5 confirmed that Resident 108's call light was not within reach. LN 5 stated it was everyone's responsibility to ensure residents' call lights were within reach. LN 5 further stated the call light was the resident's means of communicating and requesting assistance. LN 5 stated that if the call light was not within reach, Resident 108 could attempt to reach for items or get assistance independently, which could potentially result in a fall. LN 5 further stated the call light was also important for resident safety.b. Review of Resident 54's admission RECORD, indicated Resident 54 was admitted to the facility with a diagnosis of, but not limited to mechanical complication of indwelling ureteral stent (the urine drainage tube inside the body is not working properly or has developed a physical problem), chronic pain (pain that lasts for a long time or keeps coming back over time), gout (a type of arthritis caused by a buildup of uric acid crystals in the joints), flank pain (pain on the side of the body between the ribs and the hip), unspecified osteoarthritis (wear and tear arthritis in a joint, but the exact joint or type was not clearly identified), and low back pain.A review of Resident 54's clinical record titled, Care Plan Report, initiated on 4/28/26, in the section titled, Focus, indicated, .Falls: Resident [Resident 54] is at risk for falls with or without injury related to altered balance while standing and/or walking, decreased muscular coordination, history of falls . Further review of the document under the section titled, Interventions/Tasks, indicated, .Anticipate and meet needs. Educate /remind resident [Resident 54] to call for assistance with all transfers.Keep call light within reach.During a concurrent observation and interview on 4/28/26, at 10:56 AM, in Resident 54's room, Resident 54 was observed lying in bed and stated she was waiting for her pain medication. Resident 54's call light was observed on the floor on the right side of the bed and partially covered by the curtain. Resident 54 stated she was unable to locate her call light. Resident 54 further stated she needed the call light, especially when requesting pain medication. Resident 54 stated, Without my call light close to me, how can I follow up on my requested pain medication?During a concurrent observation and interview on 4/28/26, at 10:58 AM, in Resident 54's room, LN 5 confirmed that Resident 54's call light was on the floor and not within reach. LN 5 stated it was important for Resident 54 to always have her call light within reach because it was her means of communicating her needs to staff, including requests for pain medication. LN 5 further stated that not having the call light within reach may affect the Resident 54's comfort level and pain management.During an interview on 5/1/26, at 8:48 AM, with the Director of Nursing (DON), the DON stated it was his expectation that residents' call lights should always be kept within reach. The DON further stated that not only nursing staff, but all staff conducting room rounds, were responsible for ensuring call lights were accessible to residents. The DON stated that call lights were very important because they were the resident's primary means of communicating needs and requesting assistance. The DON further stated that if call lights were not within reach, residents could experience unmet needs or attempt to get assistance on their own, which could place them at risk for falls or other injuries.A review of the facility policy and procedure titled, Call Light Response, revised 7/24, indicated, .Policy Statement: Call lights are a method of notification for those in need of assistance, be it in the form of medical, social, or other. All employees are to ensure proper response time and service to call lights initiated. Policy Interpretation and Implementation: 1. Employees and contractors are required to respond quickly and appropriately to address the needs made known by a call light.2. The following standards of call light response are required.b. Ask what the reason for the call light is.Respond in a timely manner.8. Department directors and supervisors are to oversee call light response and ensure the needs of the residents are being met.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for 1 of 26 sampled residents (Resident 32), when Resident 32's Foley catheter (a thin, flexible tube used to drain urine from the bladder) drainage bag was left uncovered and visible.This failure did not promote a dignified environment and had the potential to compromise Resident 32's privacy, autonomy, and dignity.Findings:Review of Resident 32's admission RECORD, indicated Resident 32 was admitted to the facility with a diagnosis of, but not limited to acute kidney failure (sudden kidney failure), and benign prostatic hyperplasia (an enlarged prostate gland that is not cancer).A review of Resident 32's Order Summary Report, dated 4/29/26, indicated, .Indwelling urinary (Foley) catheter is in privacy bag and catheter leg strap/leg bag on at all times.A review of Resident 32's Care Plan Report, date initiated on 4/19/26, under the section titled, Focus, indicated, .Bladder: At risk for complications with urinary system related to Benign Prostatic Hyperplasia (BPH), indwelling catheter, Obstructive uropathy [a condition in which the flow of urine is blocked], and under the section titled, Interventions/Tasks, indicated, Indwelling Catheter: provide catheter care.During a concurrent observation and interview on 4/28/26, at 10:11 AM, in Resident 32's room, Resident 32 was observed lying in bed with Resident 32's family member (FM) 2 seated at bedside. Resident 32's foley catheter drainage bag was observed hanging on the right side of the bed near the foot area and was visible from the doorway, containing yellow-colored urine. Resident 32 stated that he preferred the Foley catheter drainage bag to be placed inside a privacy bag, similar to when he was up in his wheelchair, to maintain his privacy and dignity.During an interview on 4/28/26, at 10:13 AM, with Resident 32's family member (FM) 2, FM 2 stated that she agreed with Resident 32's preference for the Foley catheter drainage bag to be placed inside a privacy bag. FM 2 further stated that keeping the drainage bag covered would prevent it from being easily seen by others entering the room. FM 2 stated the privacy bag would provide more privacy and dignity for Resident 32, and make the drainage bag appear more secure and protected. FM 2 further stated that having the drainage bag exposed made the resident feel uncomfortable and less dignified.During a concurrent observation and interview interview on 4/28/26, at 10:20 AM, with Licensed Nurse (LN) 5, in Resident 32's room, LN 5 confirmed that Resident 32's Foley Catheter drainage bag was not placed inside a privacy bag and was visible from the doorway. LN 5 stated that the facility's process was for Foley catheter drainage bags to be kept inside a privacy bag to help maintain the resident's privacy, dignity and comfort. LN 5 further stated that it was not acceptable for a Foley Catheter drainage bag to be left exposed in a plain view, especially where it could easily be seen by visitors or individuals entering the room. LN 5 acknowledged that the drainage bag should have been properly covered to protect Resident 32's privacy and dignity.During an interview on 5/1/26, at 8:48 AM, with the Director of Nursing, (DON), the DON stated it was his expectation for staff to follow the facility's process of placing Foley catheter drainage bags inside a privacy bag to maintain resident dignity, privacy, and respect. The DON stated that Foley catheter drainage bags should not be left exposed in plain view and that staff were expected to ensure privacy measures were consistently maintained for residents with urinary drainage devices.A review of the facility policy and procedure (P&P) titled, Resident Rights, dated 2001, indicated, .Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents.These rights include.a. a dignified existence; b. be treated with respect, kindness, and dignity.A review of the facility P&P titled, Dignity, dated 2001, indicated, .Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. A review of the facility P&P titled, Catheter Care, Urinary, dated 2001, indicated, .Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications.General Guidelines.4. Ensure the catheter remains secured.Infection Control.2. Be sure the catheter tubing and drainage bag are kept the floor.Steps in the Procedure.6. Provide privacy.

Based on observation, interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staff and supervised by a qualified social worker which affected all 98 residents.This failure resulted in all residents receiving social services care from unqualified staff.During an interview on 4/9/26, at 1:24 p.m., with the Social Services Director (SSD), SSD stated they were the primary staff responsible for the social services department. SSD stated they had bachelor's degree in engineering.During a concurrent interview and record review on 4/10/26, at 9:40 a.m., with Human Resources (HR), SSD's two job descriptions both titled, Job Description: Social Services Director, dated 3/2017 and 2/2024 was reviewed. HR stated after review of the job descriptions, both job descriptions indicate a minimum education requirement of Bachelor's Degree in Social Work or Human Services. HR stated they did not have record of SSD's past education but stated SSD had a bachelor's degree in engineering.During an interview on 4/10/26, at 3:50 p.m., with the administrator (ADM), the ADM stated they were aware SSD did not meet the qualifications based the facility job description and the facility did not have a qualified social worker to supervise or direct the department. The ADM stated SSD possessed a bachelor's degree but the subject of study did not meet the job requirement.During a review of facility assessment titled, [Facility] Facility Assessment, dated 2/26, the facility assessment indicated the facility staffing plan included a full-time social worker.During a review of facility policy and procedure (P&P) titled, Social Services, dated 2001, the P&P indicated the facility provides medically related social services.the director of social services is a qualified social worker.During a review of California state regulation titled, Title 22 S72433, the state regulation indicated 'Social Work Service' means those services which assist.a patient and a patient's family to understand and cope with.personal, emotional and related health and environmental problems.During a review of California state regulation titled, Title 22 S72105, the state regulation indicated a Clinical Social Worker was person who is a licensed clinical social worker by the Board of Behavioral Sciences.During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants.

Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents (1-8), the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered). 2. The facility failed to ensure, between 9/1/23 through 12/31/23, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system was incomplete (all documents available) and inaccurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).1. During an interview, on 4/9/26 at 9:15 a.m. with Medical Records Director (MRD), MRD was requested to describe the scheduled medication record system. Her description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest. The Shipping Manifest was the documentation that the scheduled medication was delivered and received by the facility. She further described that the Shipping Manifests were retained by the facility. She stated that the CDR for each scheduled medication prescription was completed by the nurse and retained by the facility. She was requested to provide the Shipping Manifests and CDRs from 9/1/23 through 12/31/23.During a concurrent interview and record review, on 4/9/26 at 9:50 a.m. MRD identified the requested Shipping Manifests and CDRs. MRD stated that not all the requested Shipping Manifests were located.During a concurrent observation and interview, on 4/9/26 at 12:35 p.m. at medication cart (stores medication) A1, Licensed Vocational Nurse (LVN 1) was requested to describe the scheduled medication record system. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The medication was locked in the medication cart. The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medications and the CDR were sent to the Director of Nursing.Durning a concurrent interview and record review, on 4/10/26 at 10:35 a.m. Assistant Director of Nursing (ADON) identified the Shipping Manifests for the Residents listed below.Resident 1, 4834441 Oxycodone (narcotic pain reliever) 5 mg (milligram) tablet #26 date 12/23/23Resident 2, 4838317 Hydrocodon (narcotic pain reliever) Acetamin (acetaminophen) 5-325 mg #88 date 12/28/23Resident 3, 4836437 Hydrocodone-Acetamin 5-325 mg #18 date 12/26/23ADON stated the facility could not located the corresponding CDRs for the above Shipping Manifests.Continuing the concurrent interview and record review, on 4/10/26 at 10:35 a.m. ADON identified CDRs and corresponding MARs. ADON inspected the CDRs and MARs. ADON stated the CDRs and MARs did not match at the dates and times listed below. Resident 4, 4704215.01 Hydrocodone-Acetamin 5-325 mg #56 date 9/11/239/14/23 08459/17/23 1015Resident 5, 4717560 Hydrocodone-Acetamin 5-325 mg #60 date 9/9/239/20/23 015710/6/23 44010/9/23 170010/11/23 0340Resident 6, 4790551 Hydrocodone-Acetamin 10-325 mg #30 date 11/11/2311/14/23 14011/15/23 085811/19/23 0200Resident 7, 4757090 Oxycodone (narcotic pain reliever) 5 mg tablet #30 date 10/12/2310/14/23 100010/16/23 83010/16/23 213010/22/23 211210/29/23 2000Resident 8, 4763608 Hydrocodone-Acetamin 10-325 mg #30 date 10/18/2311/4/23 183011/5/23 1002Continuing the concurrent interview and record review, on 4/10/26 at 10:35 a.m. ADON acknowledged the facility did not have the Shipping Manifests that match the CDRs as documented above. She further acknowledged that information was inaccurate between CDRs and corresponding MARs as documented above. She stated that it was the facility's expectation that all documents were to be available and accurate. Durning a concurrent interview and record review, on 4/10/26 at 11:07 a.m. ADON identified the policy for Controlled Substances. She reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be complete and accurate (monitored and reconciled). An administrative record review of the facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 2. The system of reconciling the receipt (Shipping Manifest) dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage (CDR, destruction log): b. Medication administration records (MAR): c. Declining inventory records (CDR): and d. Destruction, waste and return to pharmacy records.An administrative record review of the facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. During an interview, on 4/9/26 at 9:15 a.m. Medical Records Director (MRD) was requested to describe the scheduled medication record system. Her description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest. The Shipping Manifest was the documentation that the scheduled medication was delivered and received by the facility. She further described that the Shipping Manifests were retained by the facility. She stated that the CDR for each scheduled medication prescription was completed by the nurse and retained by the facility. She was requested to provide the Shipping Manifests and CDRs from 9/1/23 through 12/31/23. During a concurrent interview and record review, on 4/9/26 at 9:50 a.m. MRD identified the requested Shipping Manifests and CDRs. MRD stated that not all the requested Shipping Manifests were located. During a concurrent observation and interview, on 4/9/26 at 12:35 p.m. at medication cart (stores medication) A1, Licensed Vocational Nurse (LVN 1) was requested to describe the scheduled medication record system. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The medication was locked in the medication cart. The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medications and the CDR were sent to the Director of Nursing. Durning a concurrent interview and record review, on 4/10/26 at 10:35 a.m. Assistant Director of Nursing (ADON) identified the Shipping Manifests for the Residents listed below.Resident 1, 4834441 Oxycodone (narcotic pain reliever) 5 mg (milligram) tablet #26 date 12/23/23Resident 2, 4838317 Hydrocodone (narcotic pain reliever) Acetamin (acetaminophen) 5-325 mg #88 date 12/28/23Resident 3, 4836437 Hydrocodone-Acetamin 5-325 mg #18 date 12/26/23ADON stated the facility could not located the corresponding CDRs for the above Shipping Manifests. Continuing the concurrent interview and record review, on 4/10/26 at 10:35 a.m. ADON identified CDRs and corresponding MARs. ADON inspected the CDRs and MARs. ADON stated the CDRs and MARs did not match at the dates and times listed below.Resident 4, 4704215.01 Hydrocodone-Acetamin 5-325 mg #56 date 9/11/239/14/23 08459/17/23 1015Resident 5, 4717560 Hydrocodone-Acetamin 5-325 mg #60 date 9/9/239/20/23 015710/6/23 44010/9/23 170010/11/23 0340Resident 6, 4790551 Hydrocodone-Acetamin 10-325 mg #30 date 11/11/2311/14/23 14011/15/23 085811/19/23 0200Resident 7, 4757090 Oxycodone (narcotic pain reliever) 5 mg tablet #30 date 10/12/2310/14/23 100010/16/23 83010/16/23 213010/22/23 211210/29/23 2000Resident 8, 4763608 Hydrocodone-Acetamin 10-325 mg #30 date 10/18/2311/4/23 183011/5/23 1002Continuing the concurrent interview and record review, on 4/10/26 at 10:35 a.m. ADON acknowledged the facility did not have the Shipping Manifests that match the CDRs as documented above. She further acknowledged that information was inaccurate between CDRs and corresponding MARs as documented above. She stated that it was the facility's expectation that all documents were to be available and accurate. Continuing the concurrent interview and record review, on 4/10/26 at 10:35 a.m. ADON was requested to provide the Pharmacist inspection reports for 9/1/23 through 12/31/23. ADON identified the Pharmacy QAPI (Quality Assurance and Performance Improvement, process to improve resident safety and compliance) Report, Q4 2023, October, November, December and Pharmacy QAPI Report, Q1 2024, January, February, March. She inspected the reports and stated they did not document issues with incomplete or inaccurate scheduled medication records. Durning a concurrent interview and record review, on 4/10/26 at 11:04 a.m. ADON identified the Consultant Pharmacist Policy for Pharmacy Services-Role of the Consultant Pharmacist. She stated that it was the facility's expectation that issues with scheduled medications should have been identified. Durning a concurrent interview and record review, on 4/10/26 at 11:07 a.m. ADON identified the policy for Controlled Substances. She reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be complete and accurate (monitored and reconciled). An administrative record review of the Facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 2. The system of reconciling the receipt (Shipping Manifest) dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage (CDR, destruction log): b. Medication administration records (MAR): c. Declining inventory records (CDR): and d. Destruction, waste and return to pharmacy records. An administrative record review of the facility's Policy for Controlled Substances (November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. An administrative record review, of the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019) showed, Policy Interpretation and Implementation, 3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to:, a. develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services.

Based on observation, interview and document review, the facility failed to post direct care daily staffing data on a daily basis. This failure resulted in nurse staffing data not being posted in a visible and prominent place where it was accessible to residents and visitors. Findings: During multiple observations on 4/7/25, and 4/8/25, there was no staffing data posted in facility's reception, nursing station and/or hallways area. During an interview and record review on 4/9/25 at 12:07 p.m., with the Staff Scheduler (SS 1), facility's Nursing Staff Sign in Binder was reviewed. The binder had a document titled the census and direct care services hours per patient day (DHPPD). DHPPD had the estimated and actual total direct care hours for direct care staff (Registered Nurse, (RN), Licensed Vocational Nurses (LVN), Certified Nurse Assistant (CNAs) and beginning patient census, for day, evening and night shift. SS 1 stated the DHPPD was only kept in a binder, and was not posted anywhere in the facility; and the binder was kept at the nurse's station. During an observation and interview on 4/9/25 at 12:21 p.m., SS1 stated she was working as facility's staffing scheduler for past five years. SS 1 stated she was responsible for creating the DHPPD document on a daily basis. SS 1 stated she had never posted and or had seen the DHPPD being posted on facility's premises. SS1 then walked around the facility's hallways, including nursing station, and looked through glass doors into facility's reception area. SS 1 stated she was unable to find the DHPPD being posted anywhere. SS 1 stated since she was responsible for creating the DHPPD, she would be responsible to post it. SS 1 also stated she was not even aware of such requirement that DHPPD must be posted in an area visible to residents and visitors. During a concurrent observation and interview on 4/9/25 at 12:28 p.m., with Director of Nursing (DON), facility's notice board with licensing information was reviewed. The DON stated he had seen DHPPD data posted on the notice board, but he could not recall when was the last time he had seen it being posted. The DON stated he was unable to find the DHPPD posting on the notice board. The DON stated SS 1 must know about DHPPD posting. A record review of facility's Policy and Procedure titled 'Posting Direct Care Daily Staffing Numbers dated 2001, indicated, within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form. The charge nurse, or designee, completes the form and places the staffing information in the location (s) designated by the administrator. the form may be typed or handwritten.If the information is handwritten, it must be legibly printed in black ink and written so that staffing data can be easily seen and read by residents, staff and visitors who are interested in our facility's daily staffing information.

Based on observations, interviews, and record reviews, facility failed to ensure one of four sampled residents (Resident 83) received a combination tablet of Calcium and Vitamin D per physician's order and Fluticasone nasal spray per manufacturer's recommendation. 1.Licensed Vocational Nurse (LVN) 1 administered 600mg+400 units of Calcium + Vitamin D instead of 600mg +200 units of Calcium + vitamin D. 2.LVN 1 did not shake and/or prime (remove the air from the applicator/nasal piece and fill the applicator/nasal piece with medication) prior to administering the nasal spray. Facility's medication error rate was 6.6.%. This failure resulted in Resident 83 not receiving Calcium/ Vitamin D supplement per physician's orders and placed Resident 83 at risk of not receiving the correct dose and concentration of the nasal spray. Findings: A record review of Resident 83's admission Record (record with residents' basic personal information) indicated Resident 83 was admitted to the facility on [DATE]. A review of Resident 83's Physician orders dated 04/2025 indicated Resident 83 was to receive Calcium-Vitamin D Tablet 600-200 mg-units [mg=milligrams] one tablet by mouth two times day for supplementation and Fluticasone Propionate Nasal Suspension 50 mcg/act two spray in each nostril one time a day for nasal allergy. During a medication administration observation on 04/08/25 at 08:11 a.m., with LVN 1, LVN 1 administered Calcium 600 mg + Vitamin D 10 [micrograms] mcg (10 mcg containing 400 units of Vitamin D) one tablet by mouth to Resident 83. LVN 1 also brought a new bottle of Fluticasone Propionate (Flonase) nasal spray from her medication cart into Resident 83's room. After removing the plastic seal from the spray applicator, without shaking and priming the nasal spray, LVN 1 administered two sprays into Resident 83's nostril. During an observation on 04/08/25 at 10:50 a.m., with LVN 1, medication cart containing Resident 83's medication was inspected. LVN 1 stated she did not have correct and prescribed dose of Calcium and Vitamin D supplement/ medication for Resident 83, stocked in the medication cart. During an interview on 04/09/25 at 10:01 a.m., LVN 1 stated that she should prime the new bottle and gently shake the Flonase bottle before administration. During an interview with the Director of Nursing (DON) on 04/09/25 at 09:51 a.m., DON stated that nurses should gently shake the Flonase bottle and prime a new nasal spray applicator before administration to ensure the resident received the correct dose of medication. During an interview and record review on 04/10/25 at 10:16 a.m., with Assistant Director of Nursing (ADON), pharmaceutical instructions for Flonase nasal spray were reviewed. The ADON stated the instructions emphasized the need to gently shake the Flonase bottle before each use. The ADON stated that failure to shake the bottle could result in the resident receiving either overly diluted or overly concentrated medication, potentially compromising its effectiveness. During review facility's policy and procedure titled Administering Medications dated 04/2019, indicated Medications are administered in accordance with prescriber orders.

Based on observation, interview and record review, facility failed to ensure one of one medication storage room, had unexpired resident care and treatment supplies. Expired items including two wound swab tubes, six blood test tubes, three syringes, and two covid test kits, five packs of Intravenous Antibiotics (IV ATB- medication used to treat infections, given directly into the veins) medication for a discharged resident, were kept with ready to use supplies. This failure placed facility's residents at risk for getting exposed to expired treatment supplies, inaccurate lab test results. Findings: During an observation and interview, in facility medication storage room on [DATE] at 10:29, with Director of Nursing (DON), following items were found stored in medication storage cabinets around the room: 1. Six light purple-top vacutainers (a sterile glass or plastic test tube with a color-coded stopper that creates a vacuum seal inside, allowing a predetermined volume of blood to be drawn directly into it), with expiration date on [DATE]. 2. Two BD Eswab transport system (a tool used in medical labs to collect and move samples from a patient to the lab for testing), with expiration date on [DATE]. 3. Three five (5) cc syringes (without needles) with expiration date on [DATE]. 4. Two Covid test kits with expiration date on [DATE]. 5. A ziplock bag with five piggy bags of Invanz (an ATB medication for infection) IV one gram/100 mellites (1gm/100ml), with Resident 347's name on it. The ziplock bag did not indicate if medication belonged to an active resident or a discharged resident. During an interview on [DATE] at 10:40 a.m., DON stated using expired vacutainers, syringes may cause inaccurate test results, contamination, and potentially impacting patient care. The DON stated Resident 347 was discharged from the facility on [DATE] and the IV Invanz medication should not be kept in the medication storage room. The DON grabbed all the expired items and placed in the bin designated for discontinued/discarded medication kept in the medication storage room. The DON stated government had issued a memorandum that even expired covid test kits were usable beyond their expiration date; however, was unable to provide any supporting guidance for that. During review facility policy titled Storage of Medication revised on [DATE], indicated The nursing staff is responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner, and Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observations, interviews, and record reviews, the facility failed to prepare, distribute, serve food in a safe, clean, and sanitary manner for 97 out of 97 residents, not following professional standards for food service safety and not following their facility policy and procedures, when: 1. staff failed to wear hair covering in the food preparation (the series of operational processes involved in prepping foods for serving, such as: washing, mixing ingredients, cutting, slicing, washing etc ) area. 2. Kitchen staff failed to use and maintain cutting board in a good condition to chop up and prepare food for the residents. 3. Facility did not maintain the kitchen ceiling in good, repaired condition. 4. Facility failed to maintain ceiling vent above tray line area in a clean condition, free from dust and other air particles. 5. Staff placed contaminated soiled rag, personal drinking cup, personal phone and charger on the food preparation area. 6. Staff did not follow correct cleaning and (sanitation) process when cleaning the food preparation area (kitchen counter tops and shelves). These failures had the potential for residents to get foodborne illnesses (illness caused by ingestion of contaminated food or beverages), cross contamination (the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils) of diseases, spread of infection, and possible hospitalization. Findings: 1.During an observation on 04/07/2025 at 09:09 AM, Certified Nursing Assistant (CNA) 5 came into the food prep area, past the red line marked on the floor (that means staff should not go beyond without hair net covering), and was standing by the coffee stands, near the tray line area, in-between the food shelves areas without hair net covering. During an interviewed on 4/7/2025 09:09 a.m., with CNA 5 and Dietary Manager (DM), CNA 5 stated red line means do not cross. CNA 5 also stated she does not have her hair net on, and she was supposed to have put one on because it's food area. DM stated [NAME] means staff should not cross that line because of sanitation, so that hair does not get into the food. 2.During an observation on 4/10/2025 at 09:53 a.m., Kitchen [NAME] (KC) was cutting lettuce and carrots on a worn out (unrepaired) cutting board for lunch preparation. 3.During an observation on 4/7/2025 at 09:05 a.m., with DM, ceiling area around the kitchen hood cracked on different angles and open on one spot above the stove. The cracked ceiling had some patch work to it. The open part on the ceiling was where the patch work had been done. During an observation on 4/7/2025 at 11:22 a.m., ceiling around kitchen hood had cracked areas at different angles and an open area on one spot above the stove where staff was cooking beef stew. During an interview with the DM, the DM stated she and the facility Administrator (Admin), are aware of the cracked ceiling. DM stated Maintenance had done the patch work to the ceiling some few months ago. DM stated the reason the cracked ceiling should be fully repaired to a good condition is because the stove is right below the cracked area, anything can fall from it, into the meal being prepared for residents, and also because it's open. 4.During an observation and interview on 4/10/2025 at 09:36 a.m., with Admin and DM, vent area right above the tray line area had cracked lines on it, and had dust, and cluster of dust particles attached and dangling from the vent Admin stated he had been informed about the cracked ceiling first week of February 2025. DM stated the vent above the tray line is called a swap cooler, and the facility uses the swap cooler to get air from outside to the inside. During a review of facility's document emailed on 4/16/2025, titled E&G Handyman . Project Proposal, dated 4/7/2025, the project proposal had no schedule date and receipt of payment to repair the facility's kitchen. 5.During an initial observation and an interview on 4/7/2025 at 08:42 a.m., with the Dietary Manager (DM), Kitchen Chef (KC), in the kitchen, a used cup half filled with water, placed on the same food prep counter, near the mixing bowl filled with wiped cream. A staff's personal phone and charger placed on food prep area, near the microwave used for reheating resident's meals. KC stated he had used the cup to take his medication and had left the cup on the counter. DM stated the used cup was not supposed to have been placed near the food mixer or on the food preparation area/counter, for sanitation purposes. DM also stated the microwave was used to reheat resident trays, drinks, or meals that facility hold in the kitchen, like a late tray if they had gone out of the facility for medical appointments or like for dialysis. During an observation and an interview on 4/7/2025 at 08:42 a.m., with DM, soiled, wet rag was placed on the food prep counter right next to the open food mixer filled with wiped cream. The DM stated the wet rag was used to wipe down the kitchen counter during food prep. 6.During an observation and an interview on 4/7/2025 at 2:17 p.m., with DM, the DM sprayed Clorox spray onto a dry rag and wiped the food counter surface, then later sprayed a solution in a bottle labeled QUAT, directly to the counter surface. The Quat was mixed from a built in Quat tubing system/solution at the kitchen sink. The DM stated this is the facility's process she has been using. DM stated staff are trained to use Clorox spray from the original manufacturer's bottle to clean the counter surfaces and all other kitchen surfaces. DM stated, first, staff would spray the Clorox onto the dry rag, wipe the counter after spraying the Clorox, then spray the QUAT spray directly on the kitchen surface counters, leave to air dry, and walk away. DM stated staff will check the strips for chlorine levels only when the QUAT bottle is empty and needs to be refilled. During a review of facility's policy and procedure (P&P), the P&P titled, Tray Line Area Cleaning . Cleaning Procedure. The P&P indicated, 1. Grab clean cart, plastic container. Fill container w/hot water & comet/bleach. Use clean rag . 2. Submerge clean rag into water ring out. Rinse rag . 3. Wipe off self . 11. Dump bleach water . 14. Put dirty rag in bucket. During a review of facility's P&P, the P&P titled, Kitchen Equipment and Maintenance, dated 2001. The P&P indicated, Policy Statement . It is the policy of the facility to ensure that all the kitchen equipment used in the preparation and service of food is maintained in a safe and sanitary condition to provide high-quality meals for residents. This policy outlines the necessary procedures for the regular inspection, cleaning, and maintenance of kitchen equipment to minimize the risk of accidents, foodborne illnesses, and operational disruptions . Purpose . The purpose of this policy is to . maintain kitchen equipment in optional working condition . ensure the safety of kitchen staff, residents, and visitors . comply with regulatory requirements regarding food safety and sanitation . Procedure . 1. Regular inspection and prevention maintenance . All kitchen equipment will be inspected at least monthly by the kitchen manager or designated staff . A maintenance checklist will be used to record the inspection results, including a review of the following . Cleanliness of the equipment, proper functioning of all components (e.g. burners, buttons, doors, thermometers), no visible damage or wear . 3. Cleaning and sanitizing equipment, all kitchen equipment must be cleaned and sanitized daily, following the manufacturer's instruction. This includes cleaning filters, vents, and exhaust fans . 5. Equipment repairs and replacement, when equipment is identified as malfunctioning or requiring repair, it will be evaluated for possible repair or replacement . Priority repairs will be made immediately to avoid disruptions of food service . Review and Evaluation . This policy will be reviewed annually to ensure its effectiveness and compliance with current regulations .Modification will be made as needed based on feedback from kitchen staff, maintenance personnel, or regulatory changes.

Based on observation, interview, and record review, the facility failed to repair and maintain a functional resident call light system (the means of communication between residents and staff) in residents' rooms, bathrooms, and shower rooms for a period of four months. The facility had 14 of 26 sampled residents with identified malfunctioning call lights (Residents 4, 5, 6, 9, 8, 11, 13, 15, 1, 3, 14, 12, 10, and 7), an alternative interim call bell (commonly known as service/reception bell) system/ process was not utilized, and residents had no means of calling for assistance. Additionally, 6 of 18 identified cognitively or physically impaired sampled residents (Residents 16, 17, 18, 19, 20, and 21) who were incapable of using the call system, did not have an alternate communication system in place in order to have their needs met. Two of two shower rooms (Shower rooms [ROOM NUMBERS]) and four resident bathrooms which included Room A (Residents 27 and 28), Room B (Resident 31), Room C (Resident 11), and Room D (Residents 2 and 13) had no working call system. Finally, the facility did not have a signed contract or determined start date for a call light system replacement. These multiple failures resulted in residents not being able to efficiently communicate their needs and placed residents at risk for serious harm, up to and including death, by not being able to call for staff in an emergency. It was determined that this constituted an Immediate Jeopardy (IJ- a situation in which a facility's actions places one or more residents in jeopardy of being significantly harmed up to the point of potential for death to occur if not corrected immediately) situation. The Assistant Director of Nursing (ADON) and Nurse Consultant were verbally notified of the IJ on 4/28/23 at 3:01 p.m., and the Administrator (ADM) was verbally informed of the IJ on 4/28/23 at 3:08 p.m. Through observations, interviews, and record reviews, the facility showed they initiated the plan of action by securing a contract to replace the facility's malfunctioning call system, with installation beginning on 5/8/23. The facility provided call bells to all affected residents, including in their bathrooms, with instructions on the use of. Baby monitors were deployed to residents incapable of using the interim bell system and were added to both shower rooms. Documentation of staff training; and updated resident care plans were done with focus on individualizing for their specific call light communication needs. The IJ was removed onsite on 5/2/23, at 12:40 p.m. Findings: During a concurrent observation and interview on 4/28/23, at 9:11 a.m., with Certified Nurse Assistant 1 (CNA 1), in Resident 7 and 10's shared room, CNA 1 pressed the call buttons and stated, the bulb outside their shared room should light up and it did not. CNA 1 stated, Resident 7 and 10's call lights were not working. CNA 1 stated, she was not aware that Resident 7 and 10's call lights were not working. During a concurrent observation and interview on 4/28/23, at 9:18 a.m., CNA 1 pushed Resident 5, 6, and 9's call light and stated, call lights were not functional and they did not have alternative call bells. CNA 1 stated, she reported to the maintenance department that the call light was not working for Residents 5, 6, and 9, but did not know the exact date it began malfunctioning and/or when she reported it to maintenance. During an interview on 4/28/23, at 9:20 a.m., with Maintenance Supervisor (MS), MS stated, the facility was in the process of changing the call lights because the current system had issues. MS stated, the call light for Residents 7, 10, 18, 20, 21, and 26 were broken for over a month now. MS stated, he did not know how many resident rooms were affected in total. During a concurrent observation and interview on 4/28/23, at 9:29 a.m., while in Resident 4's room, MS stated, Residents 4, 18, 20, and 35 were without a functioning call light for over a month. MS stated, Resident 4 did not have an alternate call bell at the bedside. During a concurrent interview and record review, on 4/28/23, at 9:33 a.m., at the Nursing Station 1, with MS, the facility's Maintenance Binder was reviewed. The Maintenance Binder had, Maintenance Request Log with columns titled, Date, Room #, Location, Problem/Issue, Requested By, Completion Date, and Initials. The MS stated the facility staff was responsible to log date, room #, location, and problem/issue that needed the maintenance department's attention. The MS stated, he was responsible to fix the issue and log the completion date and initial it. The MS stated, the facility had call light malfunction issues since September 2022; however, he didn't sign the entries for call light malfunction in December 2022 and January 2023 because the call light malfunction could not be fixed. The MS stated, the reported malfunctions were escalated to the ADM. The MS continued by stating, a contractor recently visited the facility to assess the call light system malfunction and a full rewiring or replacement of the call light system was required. During a record review, on 4/28/23, at 10:36 a.m., while the presence of the Social Services Director (SSD), an Email Correspondence from Resident 26's daughter, dated 4/24/23, with responses dated 4/25/23 and 4/26/23, was reviewed. According to the email correspondence Resident 26's daughter indicated that the call light was again not working when she visited on 4/23/23 and wanted to know what it would take to fix the call button issue permanently. During an interview on 4/28/23, at 10:57 a.m., the SSD stated, malfunctioning call lights and/or staff not answering call lights or attending to residents' needs placed residents at risk for anxiety (nervousness) and could impact their psychosocial wellbeing. During a concurrent observation and interview on 4/28/23, at 11:10 a.m., with Resident 2, in Resident 2 and 13's shared room, Resident 13 did not have a call bell. Resident 2 stated, he used his call bell to call staff for his roommate (Resident 13), when Resident 13 called out to staff for assistance. During an interview on 4/28/23, at 11:15 a.m., with the MS, outside of Resident 13's room, the MS stated, he gave a list of residents affected by the call light system malfunction to the ADON and will get a call bell for Resident 13. During a concurrent interview and record review on 4/28/23, at 11:16 a.m., with the ADON, an undated pink sticky note titled Call Lights Not Working, was reviewed. The ADON stated, the facility identified nonfunctioning call lights for Room A (Residents 27 and 28), Room B (Resident 31), Room D (Residents 2 and 13), Room E (Residents 8 and 29), Room F (Residents 30 and 32), Room G (Residents 1, 3, 14, and 33), Room H (Residents 12, 16, 19, and 34), Room I (Residents 7, 10, 21, and 26), and Room J (Residents 4, 18, 20, and 35). During an interview on 4/28/23, at 11:45 a.m., Certified Nursing Assistant 3 (CNA3) stated, Resident 11 has a call bell because the call light was not working. Resident 11's room was not written on the Call Lights Not Working list provided by the ADON. During an observation and interview on 4/28/23, at 11:54 a.m., with Case Manager 1 (CM 1), in the hall outside of Resident 2 and 13's room, CM 1 closed Resident 2 and 13's door without offering assistance after one of the residents rang the call bell. CM 1 stated, she did not hear the call bell. During an observation on 4/28/23, at 1:15 p.m., in Resident 12's room, Resident 12 did not have a functioning call light nor a call bell present at her bedside. During an observation on 4/28/23, at 1:20 p.m., in Residents 2 and 13's room, the bathroom call light was not working. During a concurrent observation and interview on 4/28/23, at 1:21 p.m., with Residents 1 and 3, in Resident 1, 3, and 14's shared room without a functioning call light system, a call bell was missing for all three residents. Resident 1 stated, she got up and walked out to the nursing station when she needed assistance because her call light or bell was not answered. Resident 3 stated, when her call light or bell wasn't answered she called out or waited for staff to come help her. During an observation on 4/28/23, at 1:28 p.m., in Resident 11's room, the bathroom call light was not working. During a concurrent observation and interview on 4/28/23, at 1:28 p.m., with Certified Nursing Assistant 2 (CNA2), while in Residents 1, 3, and 14's shared room, each resident was missing a call bell. CNA 2 stated, she would get call bells for Residents 1, 3, and 14. During a follow up observation on 4/28/23, at 1:29 p.m., while in Resident 13's room, Resident 13 did not have a call bell since 11:10 a.m. During a concurrent observation and interview on 4/28/23, at 1:29 p.m.,while in Residents 8 and 29's room, Resident 29 stated, the bathroom call light was not working. Resident 29 stated, he had to call out for help while in the bathroom. During an observation on 4/28/23, at 1:30 p.m., while in Residents 27 and 28's room, the bathroom call light was not working. During an interview on 4/28/23, at 1:31 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, the facility had been using bells for a month or so. LVN 1 stated, it was hard to know which resident rang the bell and staff had to go room by room to check on residents. LVN 1 stated, a call light or bell was important for residents to communicate their needs or if they had an emergency like a breathing difficulty or heart problem. During an interview on 4/28/23, at 2:51 p.m., CNA 6 stated, a bathroom call light was important for residents to have privacy, prevent falls and get assistance when needed. During a concurrent interview and record review on 4/28/23, at 11:29 a.m., with the ADM, a document titled Contract, dated 4/01/23, was reviewed. The ADM stated the contract indicated it was an estimate for a call light system and was unsigned. ADM stated, he was aware a new call light system was needed for the whole facility and the old system could not be repaired. The ADM stated the contract was not signed yet and only a verbal authorization was given to the company to install a new nurse call light system. The ADM also stated, there was no specific start date to replace the facility-wide call light system. During an interview on 4/28/23, at 1:09 p.m., Licensed Vocational Nurse (LVN 2) stated, residents needed functioning call lights to notify staff of needs or serious medical conditions, such as chest pain. LVN 2 further stated, residents feel isolated or stressed without call lights. During an interview on 4/28/23, at 2:06 p.m., with Central Supply and Maintenance Supervisor (CSM), the CSM stated, the contractor installing the call light system did not show up when scheduled a month ago to check the wiring. The CSM stated, the call light malfunction affected both sides of the building. During a concurrent interview and record review on 4/28/23, at 2:22 p.m., with the CSM in the conference room and MS on the phone, the facility's Quarterly Preventative Maintenance Log was reviewed. The Quarterly Preventative Maintenance Log sheet had a list of inspection items that maintenance department was responsible for. The MS stated, the item titled, Inspect residents' rooms/bathrooms for needed repairs and proper operation of all equipment included inspection of the call light system. The MS also stated the quarterly preventative maintenance inspections had not been completed since 12/30/22. The MS stated, the facility had call light malfunctions dating back to September 2022. The MS further stated, the facility did not complete a quarterly preventative maintenance log after December 2022. During a concurrent interview and record review on 5/01/23, at 1:34 p.m., with the Director of Nursing (DON),the facility's document titled, Cognitively and Physically Impaired Residents Who Are Unable to Utilize The Call System, undated, was reviewed. The DON stated, the facility had 12 residents who were cognitively or physically impaired and unable to use a call bell, including Residents 6, 9, 16, 17, 18, 20, 22, 23, and 24. The DON stated, the facility was doing increased rounds to monitor those 12 residents every 15 minutes, but was unable to provide documentation of increased monitoring in residents' clinical records and/or direct care staff's training records on increased resident monitoring . The DON stated facility purchased five baby monitors (an electronic device used to hear someone in another room) for residents who were unable to use the call bells, but none of them were deployed yet. During a concurrent interview and record review on 5/2/23, at 9:22 a.m., with ADM, facility's untitled document containing a list of cognitively and physically impaired residents, undated, was reviewed. ADM stated, facility identified and added Residents 10, 21, 25, and 26 to the list of cognitively and physically impaired residents the facility identified as incapable of using the call bell, indicating the facility had a total of 16 residents who were not able to use the call bell, which was the facility's alternative for malfunctioning call lights. During an interview on 5/02/23, at 10:14 a.m., Certified Nursing Assistant (CNA 4) stated, the facility had two shower rooms (Shower rooms [ROOM NUMBERS]). CNA 4 stated, Occupational Therapy used Shower 1 for rehabilitation and to train residents with activities of daily living. During a concurrent observation and interview on 5/02/23, at 10:16 a.m., with CNA 4 and Occupational Therapist 1 (OT 1), in Shower 1, OT 1 tested the call light. OT 1 stated it was not working. During an interview on 5/02/23, at 10:43 a.m., in Shower 2, Certified Nursing Assistant (CNA 5) stated, she was the designated shower staff for the day. CNA 5 stated two emergency call lights in Shower 2 were not working. CNA 5 stated, she had to yell out or schedule staff to pick up residents after 15 minutes because she didn't have a pager or other way to contact staff. During an interview on 5/2/23, at 12:14 p.m., with the Director of Rehabilitation (DOR), the DOR stated, she did not know the call light system was malfunctioned in Shower 1. The DOR stated, staff yelled out for help when help was needed. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light, dated October 2010, the P&P indicated, the purpose of this procedure is to respond to the resident's requests and needs . The policy indicated staff are to report all defective call lights to the nurse supervisor promptly.

Based on observation, interview and record review, the facility failed to ensure one (Resident 24) of one sampled residents did not develop a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) and provide the necessary assessment, treatment and services to promote healing of a pressure ulcer when: Resident 24 developed a pressure ulcer over the buttocks and sacrum (large triangular bone in the lower back) on 12/24/20 and was not assessed or treated until 1/1/21, which resulted in Resident 24 developing a pressure ulcer and later development into a stage 4 (a wound with full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed). Resident 24 was sent to the acute hospital for wound debridement (the removal of damaged and/or infected skin tissue to help a wound heal) and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the Admission Record dated 4/14/21, indicated Resident 24 was initially admitted on [DATE] to the facility and then readmitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of quarterly Minimum Data Set (MDS-an assessment tool used to guide care) dated 10/6/20, the MDS indicated Resident 24 was totally dependent and required two plus persons physical assist to position body while in bed, move to and from lying position, and turn side to side. The MDS also indicated Resident 24 was always incontinent of bowel. Further review of the MDS, it indicated Resident 24 had no unhealed pressure ulcers, but was at risk for developing pressure ulcers. During a review of the quarterly Braden Scale Observation/Assessment (BSOA) (a tool for assessing a resident's risk for developing a pressure ulcer) dated 10/16/20, the BSOA indicated a score of 13 which meant moderate risk for pressure ulcer development. During a review of a care plan titled Potential for Pressure Ulcer Development initiated on 4/17/19, the care plan indicated Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's policy and procedure titled, Prevention of Pressure Injuries revised 4/2020, indicated Skin Assessment- 3. Inspect the skin on a daily basis when performing or assisting with personal ADLS. a. Identify any signs of developing pressure injuries (i.e., non-blanchable [CONDITION(S)]). b. Inspect pressure points (sacrum, etc.). Mobility/Repositioning-1. Reposition all residents with or at risk for pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Monitoring-1. Evaluate, report and document potential changes in the skin. During a review of the Progress Notes (PN) for Resident 24, dated 12/24/20, the PN indicated the charge nurse reported an open wound on the buttocks area with eschar (devitalized tissue that can appear as a dry dark scab) and described as an unstageable (UTD, a full thickness tissue loss in which the wound bed is completely obscured by dead tissue). The notes did not include the measurement and description of the wound. The notes further indicated the physician was notified for wound care orders During a review of a facility document titled FAX for Resident 24, dated 12/24/20, the document indicated the facility staff sent a request regarding Resident 24 to the Medical Doctor (MD) on 12/24/20 for a treatment order for an open wound buttocks and sacral area. During a review of the Doctor's Progress Note (DPN), dated 12/31/20, the DPN indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 4/15/21 at 8:26 a.m., Resident 24 was given wound care to sacral area pressure ulcer by LVN 2. Resident 24's pressure ulcer bed had pink tissue with small amount of yellow tissue. The skin surrounding Resident 24's pressure ulcer was discolored. Resident 24's sacral pressure ulcer had light brown drainage. LVN 2 stated Resident 24's pressure ulcer bed had slough (dead tissue that may have a yellow or white appearance) and red tissue. LVN 2 stated the sacral pressure ulcer was a stage 4. LVN 2 measured Resident 24's sacral pressure ulcer and stated the length was 12 centimeters (cm), width was 10.5 cm and had no depth. LVN 2 measured and stated Resident 24's pressure ulcer had 1 cm tunneling (a passageway underneath the skin through soft tissue with potential for abscess formation) at the twelve o'clock position, 1.3 cm tunneling at the three o'clock position, and 1.8 cm tunneling at the seven o'clock position. During a review of the care plan titled Impaired Skin Integrity-Pressure Ulcer of the Sacrum for Resident 24, dated 12/31/20, the care plan indicated it was implemented seven days after Resident 24's pressure ulcer was observed. During a review of Treatment Administration Record (TAR) for Resident 24, dated 1/1/21-1/31/21, the TAR indicated Resident 24 received his first treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview with RN 2 on 4/15/21 at 11:20 a.m., RN 2 stated on 12/24/20, a CNA told her Resident 24 had a black area on his buttocks. RN 2 stated she could not leave the red zone (area for COVID 19 positive residents), so she took a picture of Resident 24's pressure ulcer from her cell phone and sent it to RN 3. RN 2 stated she made a recommendation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 2 stated she did not measure Resident 24's wound. During an interview with RN 3 on 4/15/21 at 7:35 a.m., RN 3 stated RN 2 discovered Resident 24's pressure ulcer on 12/24/20. RN 3 stated RN 2 took a picture of Resident 24's wound and showed it to him. RN 3 stated Resident 24's wound bed had eschar (dark dead skin). RN 3 stated Resident 24's pressure ulcer was one big wound that included both buttocks and sacral areas. RN 3 stated he did not have time to measure the pressure ulcer. RN 3 stated he should have measured the pressure ulcer on 12/24/20 since it was newly discovered. RN 3 stated he did not call MD's office to confirm that the fax was received, and he did not call the facility's Medical Director when did not get a timely response from MD. Review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol revised 4/2018, indicated Assessment and Recognition-2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth and presence of exudates or necrotic tissue. Monitoring-1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. During an interview and concurrent record review with DON on 4/15/21 at 1:20 p.m., DON reviewed Resident 24's record and stated MD documented on 1/12/21 that Resident 24 had a large sacrum stage 4 wound with probable [CONDITION(S)]. During a phone interview with MD on 4/15/21 at 11:10 a.m., MD stated Resident 24 had a bad pressure ulcer during the time of the facility's COVID 19 outbreak. MD stated Resident 24 was a high risk for pressure ulcers because he had malnutrition, diabetes, could not turn himself and could not control his bowel. MD stated Resident 24 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of a Doctor's Progress Notes (DPN) for Resident 24, dated 1/12/21, the DPN indicated Resident 24 had a Sacrum area large stage IV decubitus, 2 inches deep, with probable [CONDITION(S)]. During a review of the Hospital Discharge Summary (HDS) dated 1/18/21, the HDS indicated Resident 24 was admitted to the hospital on 1/13/21 and discharged on [DATE]. The HDS also indicated Resident 24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the HDS indicated that an antibiotic to treat bacterial infections was started on 1/13/20, debridement of the sacral decubitus ulcer was done 1/13/21 and a wound vacuum (a device to treat wounds) was placed on 1/14/21. The HDS indicated on 1/14/21 Resident 24 had a Large open wound of coccyx 14 x 14 cm. wound vac in place. The HDS indicated the Computerized Tomography Scan (CT scan, a medical imaging technique used in radiology to get detailed images of the body noninvasively) showed extensive decubitus ulceration with large pocket of gas and fluid -filled collection within the pelvis to the left of the rectum measuring 9.8x4.9x6.1 cm. There was further indication of extensive tissue swelling. The HDS also indicated Hand size large ulcer, covered with black color mole, pus drainage and inch deep to use finger probe. Minimal [CONDITION(S)] (reddening of the skin) around the wound and, odor smell strong.

Based on interview, and record review, the facility failed to prevent a fall with fractures for one of three sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 transferred Resident to the wheelchair without assistance. This failure resulted in Resident 1 sustaining severe injuries, including fractures of both thigh bones. Findings: A review of the clinical record on 8/19/16 showed Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS, an assessment tool), dated 5/5/16, showed Resident 1 required extensive assistance of two or more persons to transfer to and from the bed and the wheelchair. Resident 1's care plan, updated on 8/5/16, showed a risk for falls due to a heart condition, arthritis, receiving a medication (Metropol) with risks for side effects, such as dizziness, a history of falls, attempted unsafe self transfers, poor vision and resistance to care at times. The facility's approach to decrease the risk for falls included transfers with extensive assistance. Resident 1's care plan also indicated she had previous falls on 8/27/15 and 12/15/15. A Post Fall Observation (nurse assessment form completed after a fall), dated 8/11/16 at 2:30 p.m., indicated Resident 1 started to fall during a transfer to the wheelchair and was assisted to the floor by CNA 1. Facility progress notes, dated 8/13/16 at 7:00 a.m., almost two days after the fall, indicated Resident 1 had pain in her right leg with swelling of the thigh and knee. Resident 1 was transferred to the hospital on [DATE]. During an interview on 8/19/16 at 11:15 a.m., CNA 1 stated she was assisting Resident 1 to the wheelchair at 2:10 p.m. on 8/11/16. CNA 1 stated she sat Resident 1 up on the side of the bed and lifted her by holding her around the waist. CNA 1 told Resident 1 to hold onto her. Resident 1 reached to grab the arm of the wheelchair. The wheelchair tilted and CNA 1 and Resident 1 went to the floor. CNA 1 further stated most staff do not want to put Resident 1 in the wheelchair because it is not easy. CNA 1 stated, She puts up a fuss. During an interview on 9/7/16 at 11:27 a.m., CNA 2 stated she cared for Resident 1 on 8/11/16. CNA 2 stated she placed Resident 1 back in bed from the wheelchair with the assistance of another CNA 3 at about 3:10 p.m. CNA 2 stated Resident 1 was yelling and holding her right side when she put her back in bed. CNA 2 stated she always used two people to transfer Resident 1 from the wheelchair, because she was not comfortable moving Resident 1 by herself. During an interview on 9/7/16 at 11:35 a.m., Licensed Vocational Nurse 1 (LVN 1) stated she cared for Resident 1 on the night shift on 8/11/16. LVN 1 stated she was told that Resident 1 had almost fallen, but had been caught by the CNA 1. LVN 1 did not document any after-fall assessment, nor observations of Resident 1 that night. A review of the facility's policy and procedure titled, Assessing Falls, Their Causes, Definition, dated 10/2010, indicated, The definition of a fall is an unintentional change in position coming to rest on the ground or floor. Nursing staff will observe for delayed complications of a fall for approximately seventy-two hours after an observed or suspected fall, and will document findings in the medical record. The policy and procedure also indicated, Documentation will include any observed signs of pain, swelling, bruising, deformity and/or decreased mobility; and any change in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. During an interview on 8/19/16 at 9:40 a.m., Registered Nurse 1 (RN 1) stated she provided care for Resident 1 on 8/13/16. RN 1 stated CNA 3 told her Resident 1 had bruising and swelling of her right leg. RN 1 stated she examined Resident 1 and noted a sharp piece of bone just under the skin of her right thigh, her right knee was rotated inwardly, and her right knee and ankle were bruised. RN 1 stated she was not aware of the fall Resident 1 had on 8/11/16. During an interview on 9/22/16 at 3:04 p.m. the facility's Director of Nursing, stated Resident 1 did not get out of bed again after the fall on 8/11/16. A review of the hospital discharge summary dated 8/19/16, showed Resident 1 was treated at the hospital for a right femoral shaft stress fracture (break in the thigh bone caused by a twisting force) and a left femur comminuted fracture (break in the thigh bone when the bone has broken into three or more pieces). Resident 1 had surgery to repair the right femur fracture and a cast was placed on the right leg. Resident 1 was discharged from the hospital to have hospice care (end of life care). During a telephone interview on 9/27/16 at 9:46 a.m., the physician who treated Resident 1 in the emergency room (MD 1), stated he would not expect the types of fractures Resident 1 sustained to occur in an assisted fall. MD 1 stated the fracture to Resident 1's right leg was a high energy fracture, meaning a direct fall onto her right knee. MD 1 reviewed Resident 1's x-rays and stated he did not see any osteoporosis of her bones (condition in which bones become weak and brittle).

Based on observation, interview, and record review the facility failed to prevent an accident with injury for two of three sampled residents (Resident 1 and Resident 2). Resident 1 had an unwitnessed fall on 8/8/15 while in her bathroom without assistance or supervision. This failure resulted in Resident 1 sustaining a fractured hip. Resident 2 had an unwitnessed fall on 8/1/15 while attempting to go to the bathroom without assistance or supervision. This failure resulted in Resident 2 sustaining multiple bruises to the right knee and both arms, and a fractured, deviated nose. Findings: 1. Review of the clinical record showed Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimal Data Set Assessment (MDS-an evaluation tool used to guide care), dated 6/10/15, showed Resident 1's thinking ability was not intact and she needed one person to assist in walking. Resident 1's MDS showed she was frequently incontinent of urine and did not have a scheduled toileting program. Review of the Fall Risk Evaluation, dated 6/17/15 and 3/17/15, showed Resident 1 had a score of 15, which indicated Resident 1 had a High Risk for falls. Resident 1 fell on [DATE] and was sent to the hospital. Review of the Emergency Progress Notes, dated 8/8/15, showed Resident 1 sustained a right hip fracture and a right eyebrow laceration. Resident 1 complained of right hip/groin pain, and had the inability to bear weight. Resident 1 had emergent surgery on 8/8/15. In a telephone interview on 8/13/15 at 11:30 a.m., Responsible Party (RP) 1 stated Resident 1 was a fall risk and needed assistance to go to the bathroom. RP 1 stated Resident 1 was witnessed in the past by family members being in the bathroom unattended. In an interview on 8/21/15 at 11:07 a.m., Restorative Nursing Assistant (RNA) 1 stated Resident 1's gait was not good and would drag her feet when she walked. RNA 1 stated Resident 1 would hold on to staff or onto her cane when she walked. RNA 1 stated Resident 1 would go to the bathroom by herself without assistance. RNA 1 stated she found Resident 1 in the bathroom by herself without staff assistance in the past. RNA 1 stated staff needed to be with Resident 1 if she needed to use the bathroom. RNA 1 confirmed Resident 1's bed was located next to the bathroom. In an interview on 8/21/15 at 11:30 a.m., CNA 1 stated Resident 1 was confused and would go to the bathroom without assistance. CNA 1 stated Resident 1 did not use her call light all the time. In an interview on 8/21/15 at 2:55 p.m., CNA 2 confirmed Resident 1 did not use non-skid socks. CNA 2 confirmed Resident 1 usually locked herself in the bathroom alone. In an observation and concurrent interview on 8/21/15 at 11:45 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 did not use the call light when she needed to use the bathroom because she was forgetful. LVN 1 stated he did not know Resident 1 was at high risk for falls. LVN 1 stated a CNA (did not know who) informed him Resident 1 was locked in the bathroom. LVN 1 stated he unlocked Resident 1's bathroom and found Resident 1 sitting on the floor with an open area over the eyebrow with blood. LVN 1 stated Resident 1 complained of pain when placed back in bed by himself and two other CNAs. LVN 1 showed where Resident 1 was found and confirmed Resident 1's bed was located next to the bathroom. In an interview on 8/27/15 at 2:00 p.m., the Director of Staff Development (DSD) stated the facility did not implement their policy and procedure for a toileting schedule for any residents. In a telephone interview on 12/1/15 at 11:00 a.m., the Director of Nursing (DON) confirmed Resident 1 was forgetful and known to use the bathroom without assistance. Record review of Resident 1's care plan titled, At risk for fall and injury related to: on psychiatric medication, risks for adverse side effects, unsteady gait, joint/other pain, impaired vision related to forgetful/confused, no date noted, with interventions to, Monitor for environmental hazards. Bedside commode as needed. There were no fall prevention methods used, such as an alarm that would sound when the resident got up. Record review of Resident 1's Physical Therapy Evaluation and Plan of Treatment, dated 6/5/15 showed, Patient goals: I want to get stronger, I can barely walk to the bathroom. 2. The facility reported that Resident 2 fell on [DATE] and sustained a fractured nose. Review of the clinical record showed Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] showed Resident 2 had both short and long term memory problems, needed extensive assistance for toileting, and her balance was not steady without staff assistance. Review of the Interdisciplinary Progress Note, dated 6/2/15, showed Resident 2 had a fall on 5/29/15, and Resident 2 attempts to stand by self. CNA reports seeing Resident 2 get out of bed without assistance to turn off roommates TV. Review of the Fall Risk Evaluation dated 11/13/14 showed Resident 2 was considered at high risk for falls. In an interview on 8/21/15 at 11:00 a.m., RNA 1 confirmed Resident 2 always tried to get out of bed without assistance. RNA 1 confirmed Resident 2 did not use her call light for assistance. RNA 1 confirmed Resident 2 did not have a fall mat. In an interview on 8/21/15 at 11:17 a.m., CNA 3 confirmed Resident 2 was a high fall risk and Resident 2 did not know how to use the call light for assistance. In an interview on 8/21/15 at 12:38 p.m., Resident 3 confirmed Resident 2 tried to get out of bed on 8/1/15 and fell . Resident 3 stated she did not hear a bed alarm sound off. In an interview on 8/26/15 at 12:55 p.m., RP 2 confirmed Resident 2 was known by the facility to crawl out of bed. RP 2 stated Resident 2's falls happened too often at the facility and he was concerned not enough was done to prevent them. Review of the clinical record titled Resident Chronology, dated 8/1/15, showed, About 3:30 a.m. when CNA responded to the call light seen Resident 2 on floor was half lying position on back. When asked to the patient how it happened .she stated, I was trying to go bathroom. Asked the roommate. She stated she did not see fall because curtain was closed but heard Resident 2 saying her nose was hurting so she pressed the call light. There was no documentation to show if the bed alarm went off when Resident 2 got out of bed. Resident 2 was sent to the emergency room at 3:45 a.m. Review of the Narrative Note-Nursing for 8/1/15 4:45 a.m. showed Resident 2 returned to the facility at 8:55 a.m. with bruises of the arms and nasal fracture.

Based on interview and record review, for one of three residents (Resident 1), the facility failed to provide adequate supervision with ambulation (to walk from place to place) to prevent accidents. This failure had led to Resident 1's avoidable unwitnessed fall, sustained a baseball-sized bump on the back of her head along with nausea and dizziness after the fall that required transfer to the acute hospital via 911. Resident 1 was seen in the Emergency Department and was diagnosed with [REDACTED]. Findings: Review of the clinical record showed that Resident 1, an elderly female resident who spoke a language that was not common at the facility, was admitted on [DATE] with multiple medical [DIAGNOSES REDACTED]. It also showed that Resident 1 was referred to PT due to decrease in strength, decrease in functional mobility (refers to activities that include walking, how one moves between surfaces), ability to safely ambulate, balance and increased need for assistance from others. The evaluation indicated the need for PT to increase independence with walking, promote safety awareness, increase lower extremity strength and minimize falls. The same PT evaluation included an assessment that showed Resident 1 was on fall risk precaution, and that Resident 1 needed staff assistance when walking with a front-wheeled walker. In an interview on 5/20/14 at 2:55 p.m., Certified Nursing Assistant (CNA) 1 stated that on 5/8/14 at around 2 a.m., Resident 1's room had the call light on so she went into the room to answer the call button. She said that when she went into the room, she saw Resident 1 standing by Resident 2's bed. CNA 1 further said that she helped Resident 1 go to the bathroom as she had told her that she wanted to go to the bathroom and that she helped Resident 1 back to bed afterwards. CNA 1 stated that while Resident 1 was sitting on her bed, she noted Resident 1 rubbing the back of her head. CNA 1 quickly examined Resident 1's head and saw a baseball-sized bump on the back of her head. CNA 1 stated that as she checked Resident 1's head, Resident 2 had told her that Resident 1 fell . CNA 1 then went out of the room to call Registered Nurse (RN) 1 to report the fall and CNA 2, who spoke Resident 1's language, to help translate what Resident 1 said. CNA 1 stated that she had reminded Resident 1 in the past to use the call button if she needed help but sometimes Resident 1 "just does it by herself". During an interview on 5/20/14 at 3:15 p.m., RN 1 stated that she noted a baseball-sized bump on Resident 1's right side of the back of her head. RN 1 said that even though Resident 1 had remained alert after the fall, she was particularly concerned about the unusual size of the bump. Resident 1 was sent to the hospital after RN 1 called 911. Review of the ED (Emergency Department) Provider Notes signed by the emergency department physician on 5/8/14 showed that Resident 1 had a large hematoma (a localized collection of blood outside the blood vessel)on the back right side of her head and complained of constant, throbbing posterior head pain. The ED notes also showed that Resident 1 was later on diagnosed with [REDACTED]. The same ED notes showed that Resident 1 was provided critical care time "necessary to treat or prevent further deterioration of the following condition (s): central nervous system failure or compromise. Patient required multiple interventions and frequent assessments ..." Resident 1 was subsequently transferred to a trauma hospital for higher level of care. In another interview on 5/20/14 at 3:20 p.m., Resident 3 stated that she was awakened that night by "what sounded like a crash", heard some moaning, so she turned on her call button to ask for help. Resident 3 further stated that she had seen Resident 1 walk around in the room in the past few days and that "she was definitely handicapped, you can tell". During an interview on 5/20/14 at 3:50 p.m., Resident 2 said that she also was asleep when she heard a sound; she woke up and saw Resident 1 standing by the foot of her bed. Resident 2 added that it was Resident 3 who had turned her call light on so staff could come and help Resident 1. During an interview on 5/21/14 at 4:13 p.m., CNA 2 stated that Resident 1 had told her in her native language that Resident 1 walked to the bathroom by herself and in the process fell and hit her head on the floor. CNA 2 said that Resident 1 was the kind of resident who would follow reminders to use the call light to ask for help but would forget it after some time. The following responses were obtained from interviews with two staff members with regards to Resident 1's ability and level of assistance needed for ambulation: - On 5/20/14 at 3:15 p.m., RN 1 stated that Resident 1 was allowed to go to the bathroom independently with her walker. - On 5/20/14 at 2:55 p.m., CNA 1 stated that Resident 1 used walker and needed staff supervision when going to the bathroom. - On 5/21/14 at 4:13 p.m., CNA 2 confirmed that in the past nights that she helped answer call lights, she had seen Resident 1 walk around in her room by herself. - On 5/23/14 at 1:46 p.m., during a follow-up interview, CNA 1 stated that the afternoon shift had told her that Resident 1 needed staff assistance in walking but added that for her shift (night shift), resident would sometimes go to the bathroom without telling the staff so she just helped Resident 1 walk to the bathroom whenever she saw her up and walking to the bathroom during her rounds, otherwise, Resident 1 was independent with ambulation. Review of Resident 1's Assessment Report by Nursing Department dated 5/8/14 showed under "Functional" that prior to fall, Resident was able to ambulate to bathroom with walker independently. In an interview and concurrent record review on 5/27/14 at 10:30 a.m., Physical Therapist (PT) 1 stated that Resident 1 could not walk on her own because she crisscrossed her legs and that she had vertigo (a type of dizziness where one experiences the perception of motion causing difficulties with standing or walking) when she walked, making her unsteady and may lose her balance. PT 1 further added that from his conversation with Resident 1's family member, Resident 1 has had multiple falls at home prior to her admission to the facility. PT 1 stated that while Resident 1 was able to stand up with her front-wheeled walker independently, the problem was when she starts walking because she would always get dizzy. This information, PT 1 said, was clearly communicated to the nursing staff because there was a white board at Resident 1's bedside where functional ability of Resident 1 was written for direct care staff to know what level of assistance they needed to provide for Resident 1. PT 1 confirmed that for walking, contact guard assist was written on the board which meant that a staff was needed to hold Resident 1 on her back while she walked. PT 1 confirmed that Resident 1 had been considered a fall risk from the time of her admission to the facility until the actual fall on 5/8/14. Review of the Physical Therapy notes titled "Therapy Daily Treatment Note" dated 5/7/14 showed that Resident 1 ambulated using front-wheeled walker with SBA(stand by assist ) but CGA (contact guard assist) during turns and occasionally when she gets dizzy. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/1/14 showed that for activities of daily living assistance, Resident 1 needed limited assistance with one person providing physical assist when walking in her room. The MDS showed that by definition, limited assistance meant that resident is highly involved in the activity but staff needs to provide guided maneuvering of limbs or other non-weight bearing assistance. The same MDS also showed that Resident 1 was a fall risk. Review of Resident 1's care plan titled "Fall Risk Care Plan" dated 4/24/14 showed that Resident 1 was at risk for fall and injury related to abnormal heart rhythm, dizziness/vertigo, use of diuretics (sometimes called water pills, substance that promotes urination), and being forgetful at times. The same care plan showed that one of the approaches to minimize Resident 1's risk for injury as a result of a fall was to provide "resident reminder/staff alert" that included wheelchair and bed alarm. In a follow up interview on 5/23/14 at 1:46 p.m., CNA 1 stated that she did not hear an alarm go off when she went into the room and that what prompted her to go into Resident 1's room was because the call light was on. CNA 1 further said that she could not remember Resident 1 having a bed alarm. When asked if Resident 1 was able to follow directions of using the call button to call for assistance, CNA 1 stated "sometimes she does, sometimes she doesn't". During an interview and record review on 5/27/14 at 11:15 a.m., Registered Nurse Supervisor (RNS) stated that for residents who were newly admitted to the facility, and those who are at risk for falls because they do not call for assistance even if they needed to, bed alarms are really important because nurses have to be alerted if they needed to go and provide help for the residents. RNS added that residents would sometimes press the call light but would not have the patience to wait for the staff to come and help them, thus, would just go to the bathroom unassisted. RNS confirmed that the care plan for falls included an approach to provide bed alarm for Resident 1 but further confirmed that she could not find any documentation in the progress notes that would tell if bed alarm was provided as stated in the care plan. RNS added "the alarm would have helped" and went on to say "we're even running out of alarms, I keep ordering". __________________________________________________________ Class "B" Citation #02-2687- 13-F The facility must ensure that:1. The resident environment remains as free from accident hazards as is possible; and 2. Each resident receives adequate supervision and assistance devices to prevent accidents.The facility is in violation of the above regulation by its failure to:1. Ensure the necessary staff assistance to prevent a fall.2. Implement the patient's care plan for prevention of injury due to fall.The facility admitted Resident 1 on 4/24/14 with multiple medical [DIAGNOSES REDACTED]. Muscle weakness.2. Difficulty in walking.3. Decrease in strength and functional mobility.4. Decrease in ability to safely walk.5. Increased need for assistance from others.The same PT notes reflected that Resident 1 needed PT to increase independence with walking, promote safety awareness, increase lower extremity strength and minimize falls. According to the PT evaluation, Resident 1 was at risk for falls and needed staff assistance when walking with a front-wheeled walker.In an interview on 5/20/14 at 2:55 p.m., Certified Nursing Assistant (CNA) 1 said that on 5/8/14 at around 2 a.m., Resident 1's room had the call light on so she went to answer the call light. She said that when she went into the room, she saw Resident 1 standing by Resident 2's (roommate's) bed. CNA 1 further stated Resident 1 had told her that she wanted to go to the bathroom so she helped Resident 1 go to the bathroom and back to bed afterwards. CNA 1 said that while Resident 1 was sitting on her bed, she noted Resident 1 rubbing the back of her head. CNA 1 quickly examined Resident 1's head and saw a baseball-sized bump on the back of her head. CNA 1 said that as she checked Resident 1's head, Resident 2 told her that Resident 1 had fallen. CNA 1 then went to call Registered Nurse (RN) 1 to report the fall and get CNA 2. CNA 1 said she had reminded Resident 1 in the past to use the call button if she needed help like going to the bathroom, but sometimes Resident 1, "Just does it by herself".During an interview on 5/20/14 at 3:15 p.m., RN 1 said that she noted a baseball-sized bump on Resident 1's right side of the back of her head. She said that even though Resident 1 had remained alert after the fall, she was particularly concerned about the unusual size of the bump. In an interview on 5/20/14 at 3:20 p.m., Resident 3 stated that she was awakened that night by, "What sounded like a crash", heard some moaning, so she turned on her call button to ask for help. Resident 3 further stated she had seen Resident 1 walk around in the room in the past few days and that "she was definitely handicapped, you can tell."During an interview on 5/20/14 at 3:50 p.m., Resident 2 said that she also was asleep when she heard a sound; she woke up and saw Resident 1 standing by the foot of her bed. Resident 2 added that it was Resident 3 who had turned her call light on so staff could come and help Resident 1.In an interview on 5/21/14 at 4:13 p.m., CNA 2 stated that Resident 1 had told her she walked to the bathroom by herself and in the process fell and hit her head on the floor. CNA 2 said that Resident 1 was the kind of resident who would follow reminders to use the call light to ask for help, but would forget it after some time.In an interview on 5/27/14 at 10:30 a.m., Physical Therapist (PT) 1 stated that Resident 1 could no longer walk on her own because she crisscrossed her legs and that she had dizziness when she walked, which made her unsteady and prone to lose her balance. PT 1 further added that Resident 1 had multiple falls at home before admission to the facility. PT 1 also said that this information was clearly communicated to the nursing staff because there was a white board at Resident 1's bedside where Resident 1's ability to walk and the level of assistance needed were written for the nursing staff to know. PT 1 confirmed that a staff had to be at Resident 1's back to assist while she walked. PT 1 added that Resident 1 had been considered a fall risk from the time she was admitted to the facility until the actual fall on 5/8/14.Review of the facility's assessment dated [DATE] showed that Resident 1 needed one person providing physical assistance while walking in her room. The same assessment also showed that Resident 1 had a risk of falling.The facility's plan of care titled "Fall Risk Care Plan," dated 4/24/14, showed that Resident 1 was at risk for fall and injury because of dizziness and being forgetful at times. Resident 1 was also receiving a medication that would make her go to the bathroom for frequent urination. One of the approaches to minimize Resident 1's risk for injury as a result of a fall was for the facility to provide a bed alarm.In an interview on 5/23/14 at 1:46 p.m., CNA 1 stated that she did not hear an alarm go off when she went into Resident 1's room and what prompted her to go into that room was the call light being on. CNA 1 said that she could not remember Resident 1 having a bed alarm while she was in the facility. She also said that Resident 1 sometimes did not follow directions of using the call light when she needed assistance.Review of the facility's nurses' notes dated 5/5/14, 5/6/14 and 5/7/14 showed that for safety, Resident 1 had the "Call Light in Reach" listed as the only intervention to keep her safe. The nurses' notes did not show that sensors/alarms were provided.In an interview on 5/27/14 at 11:15 a.m., Registered Nurse Supervisor stated that for residents who were newly admitted to the facility especially those who were at risk to fall and those who did not wait for assistance, bed alarms were very important because nurses have to be alerted if they needed to provide help for the residents. She confirmed that the care plan for Resident 1 included providing a bed alarm, but said that she could not find any documentation in Resident 1's clinical record that a bed alarm was provided for Resident 1. She added, "Alarm would have helped"..."We're even running out of alarms, I keep ordering."Resident 1 was sent to the hospital immediately on 5/8/14 at 2:27 a.m.Review of the emergency department notes dated 5/8/14 showed that Resident 1 had a large hematoma (a localized collection of blood outside the blood vessel) on the back right side of her head and complained of constant, throbbing posterior head pain. The ED notes also showed that Resident 1 was diagnosed with [REDACTED]. "Patient required multiple interventions and frequent reassessments..." and was treated to prevent further deterioration of central nervous system failure or compromise. Resident 1 was transferred to another hospital for a higher level of care.Therefore the facility failed to: 1. Ensure the necessary staff assistance to prevent a fall.2. Implement the patient's care plan for prevention of injury due to fall.