Every finding on record at Madera Care Center

Based on interview and record review, the facility failed to report to the state agency two episodes of alleged or suspected abuse violations when;1. An unknown intruder entered the facility without staff knowledge and interacted with Resident 1, Resident 2, Resident 3, and Resident 4. 2. One resident (Resident 6) struck another resident (Resident 5) across the face with a walker, causing a laceration (cut in the skin) on his left eyebrow. These failures resulted in delayed investigations, potential for delayed protection and continued harm for the five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). During a review of the document titled On-Line Health Facility Complaint (OLHFC), dated 3/12/26, at 10:38 a.m., from the [NAME] County Department of Social Services, the OLHFC indicated, On March 12, 2026, the [[NAME] County Department of Social Services] received a written report of suspected elder abuse from [NAME] Police Department (case # 26M-00810). It was reported that the officer was dispatched to the [facility] on 02/06/26 to a report of an unidentified male, [NAME] Doe, bothering elderly females. The following was reported in summary: The original reporting party (ORP), [Administrator], who is an employee of the [facility] was contacted. ORP said on 2/3/26, at approximately [7:30 p.m.], an unknown male entered the facility and was acting strangely with the tenants. During a review of the document titled On-Line Health Facility Complaint (OLHFC), dated 3/13/26, at 11:03 a.m., from the [NAME] County Department of Social Services, the OLHFC indicated, On March 12, 2026, the [[NAME] County Department of Social Services] received a written report (Case #26M-01530) of suspected elder abuse from [NAME] Police Department for an incident on 3/9/26 [that occurred at the facility]. It was reported while the nurse was helping [Resident 6] out of his bed for a therapy walk, [Resident 6 grabbed his walker and struck Resident 5] on the left side of his head causing approximately a one-inch laceration on the left side of [Resident 5's] head, above his left eyebrow. During an interview on 3/18/26, at 10:25 a.m., with the Director of Staff Development (DSD), the DSD stated she was the primary facility educator regarding abuse and abuse prevention policy and procedures. The DSD stated, I cover this information for new hires, about mandated reporting, annual competencies. If abuse occurs, we report the appropriate agencies, which [include the Department]. The incident between Resident 5 and Resident 6 on 3/9/26 was resident-to-resident abuse, with injury, and that should have been reported to the Department. I educate everyone to this. When asked if the incident with the intruder on 2/3/26 should also have been reported to the Department, the DSD stated, I feel nauseous. I need some fresh air. During an interview on 3/18/26, at 11:17 a.m., with Resident 1, Resident 1 stated she recalled the evening of 2/3/26, when an unwanted and unknown visitor entered her room before 8 p.m., while she was in her bed. Resident 1 stated the unknown and unwanted visitor was wearing a sweatshirt hoodie and spoke to her roommate, Resident 2, first, then turned his attention to her and stated if she wanted to 'follow the word of God' and if she wanted to 'follow him'. Resident 1 stated, I told him he'd better get out of here. We called the nurse [Licensed Vocational Nurse, or LVN, 1] but she didn't come right away. We were both scared, we both have had sleepless nights [since then]. Every time I hear the exit doors at the end of the hallway open, I think it could be him again or another intruder. I don't feel safe here. It could happen again. During a review of Resident 1's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool), dated 1/22/26, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment). During an interview on 3/18/26, at 11:30 a.m., with Resident 2, Resident 2 stated she recalled the evening of 2/3/26, when an unwanted and unknown visitor entered her room before 8 p.m., while she was in her bed. Resident 2 stated, I was sleeping and I awoke to see this man inches from my face, he was leaning forward as if he was going to kiss me. I put my hands up to stop him, he put his hands up, and our hands met. I said to him: Listen - what is your name? He answered: A good citizen. I said to him: You need to get out of here. He finally left the room. Looking back on it, I should have stabbed him with my scissors. I was scared, I felt the need to protect myself from him. During a review of Resident 2's MDS, dated 2/23/26, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 2 was cognitively intact. During an interview on 3/18/26, at 11:10 a.m., with Resident 3, Resident 3 stated she recalled the evening of 2/3/26, when an unwanted and unknown visitor entered her room before 8 p.m. Resident 3 stated she was sitting in her bedside chair when the unwanted visitor walked in and went to her roommate's (Resident 4) bed and attempted to lift her roommate out of her bed. Resident 3 stated, He tried to pick her up out of her bed. Like he was on dope or something. I was scared, I didn't know if he had a gun or what. He tried to take [Resident 4] out of this building, that's what it looked like to me he was trying to do. I raised my voice to him, and in that commotion, that's when a nurse came into the room and got him to leave. The nurse was [LVN 1]. During a review of Resident 3's MDS, dated 2/16/26, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 3 was cognitively intact. During an interview on 3/18/26, at 11:15 a.m., with Resident 4, Resident 4 recalled an event where an unwanted and unknown visitor entered her room and tried to lift her up. Resident 4 stated, I was scared. He was so rough with me. He made me mad. During a review of Resident 4's MDS, dated 2/2/26, the MDS indicated at Question C0500 a score of 9 out of a possible 15, which indicated Resident 4's cognition was moderately impaired. During an observation on 3/18/26, at 11:45 a.m., Resident 5 was noted seated in wheelchair in the dining room. Over Resident 5's left eyebrow, a small bandage was noted. During a review of Resident 5's clinical record, the document titled Order Summary Report (OSR), dated 3/9/26, the OSR indicated he had a physician's order for Monitor steri-strips [small adhesive bandages] on skin tear to left eyebrow. During a review of Resident 5's clinical record, the document titled Progress Notes (PN), dated 3/10/26, at 11:19 a.m., the PN indicated, This resident was involved in a resident to resident altercation. This resident was the receiver. [Resident 6] threw his walker at [Resident 5] and made contact with his left eyebrow. Appropriate entities notified of event by sending SOC 341 [Report of Suspected Dependent Adult/Elder Abuse, an official document used by mandated reporters] faxed out to Ombudsman [a trained advocate who investigates complaints, protects rights, and improves the quality of life for residents in nursing homes, assisted living, and similar adult care facilities] . and [NAME] [Police Department]. The Department was not included in the PN as an entity notified. During an interview on 3/18/26, at 3:05 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she recalled the evening of 2/3/26. LVN 1 stated she had just returned from her evening meal break about 7 p.m. LVN 1 stated I noticed a gentleman at the nurses' station. Visiting Hours are from 8 a.m. to 8 p.m., and I lock the front doors at 8 p.m. He was already in the building when I returned from break, I did not see him walk through the front door. At about 7:15 p.m., I began passing my medications. I was at room [ROOM NUMBER], I saw him go into room [ROOM NUMBER]. I did not think anything about it at the time, I thought he was a visitor. Then, later, I heard [Resident 3, who resides in room [ROOM NUMBER]] saying 'I don't know you, get out of my room' or words to that effect. That got my attention. I went to the doorway of room [ROOM NUMBER] and confronted him. He was standing in front of [Resident 3's] bed. I asked him: what are you doing? He responded with a 'hands up' gesture' and said 'I'm spreading happiness and love' or similar words. He said he was visiting [Resident 1, whose name is printed on a sign near her door]. I told him: You need to leave. [Resident 3] then told me he was trying to lift [Resident 4] out of her bed. That's when I told him to get out. He then left via the exit doors by room [ROOM NUMBER], without further incident. Later, [Resident 4] told me this act scared her. Resident 2 told me he had bent over and tried to kiss her. I didn't think this incident needed to be reported to the Department. At the time, nobody was injured, but [Resident 2] had emotional distress. During an interview on 3/19/26, at 10:25 a.m., with the Director of Nursing (DON), the DON stated, these two incidents were reported to the local police department. The DON stated the event involving the intruder on 2/3/26 was reported by LVN 1, and the event between Resident 5 and Resident 6 was reported by myself. The DON stated, These incidents were not reported to the Department. We reviewed our policy and the regulations and all that, and thought it was not reportable. My understanding was since neither event resulted in physical harm, it was not reportable to the Department. I define physical harm as any skin tear, fracture, hematoma [bruise]. During an interview on 3/19/26, at 2:25 p.m., with the Administrator, the Administrator stated she was the facility's Abuse Prevention Coordinator. The Administrator stated that in regard to the facility intrusion event on 2/3/26, No residents were physically harmed, so there was no point in reporting to [the Department]. As for the resident-to-resident event between [Resident 5 and Resident 6], it was back and forth, we didn't think we needed to report that. Yes, an intruder physically lifting [Resident 4] out of her bed can be physical abuse. I guess I would call that physical abuse. [Resident 2] being awakened by [intruder's] face next to hers, and she had to use her hands to keep him away, she was about to be touched non-consensually, that is abuse. We did not do a 5-day abuse investigation after either incident. During a review of the facility's Policy and Procedure (P&P) titled, Compliance with Reporting Allegations of Abuse/Neglect Exploitation, dated 12/19/22, the P&P indicated, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment . are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Alleged violation: A situation or occurrence that is observed or reported by staff, resident . but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements for mistreatment . or abuse . The facility will report all alleged violations . to the state agency and to all other agencies as required. The Administrator or designee will notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery of the incident. During a review of the facility document titled Administrator, undated, the document indicated, in part, Types of Abuse - Mental abuse: Includes, but is not limited to, humiliation, harassment, sexual coercion or assault. Investigation of abuse - State and licensing agencies will be notified, as required . During a review of the facility Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 12/19/22, the P&P indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include . resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.

Based on interview and record review, the facility failed to provide adequate supervision and failed to report an elopement (resident leaving a healthcare facility, hospital, or care setting without authorization, without being discharged , or without notifying staff.) to the State Survey Agency within the required timeframe for one of three residents (Resident 1), when Resident 1 was not reassessed for risk of elopement after repeatedly expressing the desire to leave the facility and return to the river. On 2/8/26, Resident 1 left the facility without staff knowledge or supervision. The State Agency was unaware of the elopement until it was reported by the Ombudsman (a neutral, independent advocate who investigates, and resolves issues between patients/residents and healthcare providers, insurers, and long term care facilities) on 2/26/26. This failure placed Resident 1 at risk for harm including injury from traffic, lack of access to food or medications, and exposure to the environmental elements, as temperatures on 2/8/26 were reported to be as low as 39 degrees. During a review of Resident 1's admission Record (AR- a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/27/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of Wedge compression fracture of the second lumbar vertebra (the front part of that specific lower-back bone collapses due to pressure, taking on a wedge shape while the back part remains intact), Obstructive and reflux uropathy (blockage at any point in the urinary tract [kidneys, ureters, bladder, or urethra] that prevents urine from flowing out of the body), heart disease (condition that damages the heart or blood vessels), Acute kidney failure (the sudden, temporary loss of kidney function), urine retention(the inability to fully empty your bladder, resulting in urine building up and causing discomfort or pain), urinary tract infection (a common infection caused by bacteria entering and multiplying within the urinary system), and homelessness (the state of lacking a fixed, regular, and adequate nighttime residence. This includes living in places not meant for human habitation [cars, parks, streets], emergency shelters, or transitional housing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/17/26, the MDS section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive [involving the process of thinking, learning and understanding] understanding on a scale of 1-15 ) score of 8 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 1 had moderate cognitive impairment.During a review of Resident 1's Nurses Progress Notes, dated 2/8/26, the nurses progress notes indicated, at approximately 3:15 p.m. today Certified Nursing Assistant (CNA) asked if I had seen resident.informed CNA last seen resident at 2:15 p.m. while doing initial rounds. CNA stated that she can't find resident.3:30 p.m., entire building and perimeter checked.patient was not located. Search was extended to the outside and surrounding buildings.again not located.notified Director of Nursing (DON) and Administrator at 3:40 p.m. via phone.contact PD (Police Department) at 3:48 p.m. gave all necessary information.has expressed the desire to go home in the past couple of days.PD arrived at 7:17 p.m. to do report with writer.reported at facility regarding patient elopement.During review of Resident 1's Summary of Care Provided Hospital course -Discharge Summary (DS), dated 1/12/26, the DS indicated, Resident 1 was admitted to the hospital on [DATE] and discharged from the hospital on 1/12/26.reason for hospital stay urinary retention.significant hospital diagnoses urinary retention, hypertension, substance use disorder risk (amphetamine positive), homelessness.During an interview on 2/27/26 at 9:55 a.m. with the Administrator, the Administrator stated after Resident 1 left the facility, staff reviewed his medical record and conducted interviews with staff. It was only following this review-after the resident's departure, the facility determined Resident 1 was alert and oriented times three (A&Ox3 - a medical assessment indicating a patient is awake, responsive, and aware of three key spheres: person [their name], place [where they are], and time [date/day/year]. It signifies normal cognitive function and consciousness), and capable of making his own decisions. The Administrator stated as a result, the incident was processed as an Against Medical Advice (AMA) discharge rather than an elopement.During an interview on 2/27/26 at 10:05 a.m., the Social Services Director (SSD) reported on 2/8/26, nursing staff informed her Resident 1 had left the facility and could not be located. The SSD subsequently contacted Adult Protective Services (APS) and completed the necessary paperwork regarding Resident 1's departure on 2/9/26. When asked if staff saw Resident 1 leave, the SSD stated no one witnessed his departure.During a concurrent interview and record review on 2/27/26 at 10:33 a.m., with the Director of Staff Development (DSD), Resident 1's Electronic Medical Record (EMR), was reviewed. The EMR indicated Resident 1 was admitted on [DATE] with diagnoses including wedge compression fracture of the spine and urinary obstruction. The DSD confirmed a record review indicated Resident 1 had a BIMS score of 8. The DSD confirmed during record review Resident 1 had a history of homelessness. The DSD stated documentation indicated that a Certified Nursing Assistant (CNA) reported Resident 1 was missing and staff conducted a search of the facility and surrounding areas. The DSD stated documentation indicated Resident 1 had last been seen on 2/8/26 at 2:15 p.m. and reported missing at approximately 3:15 p.m. The DSD stated documentation initially identified the event as an elopement however after the elopement, documentation dated 2/9/26 from the Interdisciplinary Team (IDT) indicating Resident 1 had the mental capacity to choose to leave the facility AMA. The DSD stated the IDT came to this conclusion based on the post elopement staff interview and physician's H&P documentation indicating resident 1 was A&Ox3.The DSD stated there was no documentation of intervention or safety precautions for Resident 1 after verbal expression of desire to leave. The DSD stated Resident 1 had made no prior attempts to leave the facility, he would only say he wanted to leave. The DSD stated a care plan and safety plan with interventions such as frequents checks on Resident 1 should have been created for Resident 1.During an interview on 2/27/26 at 11:01 a.m., in the DSD office with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated she did recall reporting Resident 1 missing. LVN 1 stated she observed the resident earlier during medication pass. The LVN stated a Certified Nursing Assistant (CNA) later reported the resident could not be located, and staff conducted a search of the facility and surrounding area but were unable to locate him. The LVN stated the resident had previously expressed a desire to leave the facility but did not inform staff he was leaving at that time. LVN 1 stated she was not instructed to report the incident to the State Survey Agency at that time.During a concurrent interview and record review on 2/27/26, at 1:30 p.m., with the Administrator, the facility's policy and procedure (P&P) titled, Elopements and Wandering Residents, dated 12/19/22 was reviewed. The P&P indicated .Definition:. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.DON or designee shall notify the physician.Appropriate reporting requirements to the State Survey agency shall be conducted. The Administrator confirmed the facility did not report the incident to the State Survey Agency. The Administrator stated after interviewing staff and reviewing the physicians H&P, the incident was determined AMA and was not an elopement. The Administrator acknowledged that the facility did not report the incident to the State Survey Agency. She explained that, after reviewing staff interviews and the physician's H&P, the facility concluded the event was an AMA discharge rather than an elopement. However, the Administrator recognized that Resident 1 left without staff awareness or supervision and had expressed a clear desire to leave. The Administrator stated for resident's safety, the incident should have been reported and confirmed that Resident 1 had still not been located at the time of the interview.During a phone interview on 3/5/26 at 3:00 p.m. with the Director of Nursing (DON), the DON confirmed Resident 1's assessment dated [DATE] documented a BIMS score of 8. The DON confirmed an elopement risk assessment completed on 1/12/26 indicated Resident 1 was not considered an elopement for risk. When asked about Resident 1's BIMS score of eight the DON stated Resident 1 appeared alert and oriented during interactions and a reassessment should have been initiated if there was a change in condition. The DON stated the physician's documentation indicated Resident 1 was alert and oriented however, confirmed no reassessment of BIMS had been completed. The DON confirmed Resident 1 went missing on 2/8/26 and nursing staff documentation initially indicated the incident was an elopement. The DON stated the facility did not report this incident to the State Survey Agency while the facility was conducting its investigation and stated she did not have a reason why the incident was not reported if it had been classified as an elopement.During a review of the facility's P&P titled Elopement and Wandering Residents, dated 12/19/22, the P&P indicated .The facility shall establish and utilize a systematic approach to monitoring residents at risk for elopement.Residents will be assessed for risk of elopement and unsafe wandering, when clinically appropriate.evaluate the unique factors contributing to risk.develop a person-centered care plan.Definition:. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.DON or designee shall notify the physician.Appropriate reporting requirements to the State Survey agency shall be conducted. increase staff awareness of resident's risk,.adequate supervision will be provided to help prevent accidents or elopements. During a review of the facility's P&P titled Resident Assessment-RAI, dated 12/19/22, the P&P indicated, . this facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences.the facility will use the results of the assessment to develop, review and revise the resident's comprehensive care plan.During a review of the facility's P&P titled Accidents and Supervision, dated 12/19/22, the P&P indicated, .each resident will receive adequate supervision and assistive devices to prevent accidents.monitoring for effectiveness and modifying interventions when necessary.During a review of the facility's P&P titled Transfer and Discharge (including AMA), dated 12/19/22, the P&P indicated . transfer and discharge includes movement of a resident to a bed outside of the certified facility whether the bed is in the same physical place or not. Resident -initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment) .Discharge Against Medical Advice (AMA). The physician should be notified of the intended AMA discharge and encouraged to speak with the residents to encourage them to stay at their facility. Documentation of this notification should be entered in the nurses notes by the nursing department. notify adult protection services or other entity, as appropriate if self-neglect is suspected document accordingly.During a review of the facility's P&P titled Compliance with Reporting Allegations, dated 12/19/22, the P&P indicated, .Reporting/Response: The facility will report all alleged violations.to the state agency and to all other agencies as required, and take all necessary corrective actions.

Based on observation, interview and record review, the facility failed to ensure there was consistently enough linen (specifically towels and washcloths) available for incontinent residents (those unable to control their bowels and/or bladders) during night shifts. This failure resulted in the facility's incontinent residents, approximately over half of the facility's census of 64, to receive incontinent care with non-linen items such as toilet paper, which has the potential to increase discomfort, decrease cleaning, and increase chance of skin issues. (Linens, such as washcloths, provide better to provide care to incontinent residents with because they can retain moisture better, are gentler on skin, reduce the risk of skin breakdown, clean better, and are more comfortable, especially when pre-moistened with warm water). Findings: During an interview on 4/11/25, at 1:50 p.m., with Laundry Worker (LW) 1, LW 1 stated she normally begins her shift at 5 a.m., and is responsible for washing, drying, folding, sorting, and delivering clean and sanitized linen throughout the facility. LW 1 stated the facility has three clean linen closets in resident care areas to store the clean linens, such as resident gowns, towels, washcloths, bed sheets and pillow cases. LW 1 stated there are times when she arrives to work at 5 a.m., and finds the three linen closets without linens such as washcloths and towels. LW 1 stated she has to order five dozen new washcloths every week, and stated, I don't know where they go. LW 1 stated a low amount of linen could negatively impact resident care by not having enough clean linen to clean residents with. During a concurrent observation and interview on 4/11/25, at 1:55 p.m., with LW 1, the three linen closets in the facility were observed and photographed. LW 1 stated the facility has three hallways, with a locked linen closet on each hall, for a total of three linen closets. LW 1 stated there were no other storage areas for clean linen in the facility for staff to use. The first linen closet, by room [ROOM NUMBER], contained approximately one dozen washcloths and approximately one dozen towels. The second linen closet, by room [ROOM NUMBER], contained approximately one dozen washcloths and towels. The third linen closet, by room [ROOM NUMBER], contained approximately seven washcloths and approximately nine towels. During an interview on 4/11/25, at 2:03 p.m., with Housekeeper (HK) 1, HK 1 stated, she, on occasion, finds dirty washcloths in the resident trash cans. HK 1 says this should not be happening, and when she sees it, she reports it to her supervisor. During an interview on 4/11/25, at 2:03 p.m., with Staff 1, Staff 1 stated, they provide direct care to residents in the facility. Staff 1 stated they work day shifts and night shifts. Staff 1 stated there are no issues with linen shortages during the day, but there are linen shortages during the night while residents sleep. Staff 1 stated, If there are no washcloths for a resident, we have to use toilet paper to clean residents [after an incontinent episode, when a person cannot control their bowels and/or bladder and release these wastes while in bed]. During an interview on 4/11/25, at 2:14 p.m., with the Director of Staff Development (DSD), the DSD stated during the last staff meeting on 3/28/25, the topic of throwing away linen and not hoarding linen in resident rooms was discussed. During a review of the facility document titled, All Staff , dated 3/28/25, the All Staff indicated a meeting took place and among the items discussed was Hoarding of linen in room needs to stop. and Please do not throw away linen, it needs to be placed in proper laundry barrel for laundry. The All Staff was signed by 25 employees. During a concurrent observation and interview, on 4/11/25, at 2:25 p.m., with the Administrator and Director of Nursing (DON), the three photographs of the three linen closets were reviewed. The DON and Administrator stated the facility is licensed for 64 residents. Both the Administrator and DON stated the photographs of the linen closets did not contain enough linen, and appeared to be a low quantity, and were not enough to provide services to the facility residents throughout the evening and night shifts. During an interview on 4/11/25, at 2:35 p.m., with Central Supply Worker (CSW) 1, CSW 1 stated, We order five dozen washcloths every two weeks, but they are being thrown away, so the facility keeps ordering them. My suggestion would be to stock more linen. During an interview on 4/11/25, at 3:15 p.m., with Staff 2, Staff 2 stated they provide direct resident care, and stated, We run low [on linen] sometimes at the end of the shift. During a concurrent observation and interview on 4/16/25, at 3:45 a.m., with Staff 3, the facility's three linen closets were observed. Staff 3 stated they provide direct resident care and their linen inventory was very light. The linen closet located by room [ROOM NUMBER] contained zero washcloths and two towels. The linen closet located by room [ROOM NUMBER] contained zero washcloths and zero towels. The linen closet located by room [ROOM NUMBER] contained eight towels and 4 washcloths. Staff 3 stated, We have not started last rounds yet [a process where facility staff goes to each resident to determine if they have had an incontinent episode, and if so, provides incontinent care]. This is a problem, but only if they have had a bowel movement. We need more washcloths and towels to clean them properly. This is not enough to last us through last rounds. During an interview on 4/16/25, at 3:50 a.m., with Staff 4, Staff 4 stated they provide direct resident care. Staff 4 stated, We are usually short of linens on night shift. This is pretty typical. During an interview on 4/16/25, at 3:52 a.m., with Staff 5, Staff 5 stated they provide direct resident care. Staff 5 stated, the linen closet on their assigned area was empty of washcloths and towels since the beginning of their shift at 10:30 p.m. Staff 5 stated they have been using toilet paper and a cleaning spray to clean residents after an incontinent episode. Staff 5 stated, It gets annoying when you don't have the proper linen to care for residents. Duirng an interview on 4/17/25, at 4:54 p.m., with Staff 6, Staff 6 stated they provide direct resident care, and the facility's lack of washcloths during night shift is a real problem. Night after night I work with no washcloths. I have to buy my own. I arrive to work at 10:30 p.m., and already there are no washcloths. There's not enough at the start of the shift. We need those washcloths for pericare, to wipe the bottoms of the residents after an incontinent episode. There are no showers or baths at night, we only use them for incontinent care. The facility has 64 beds and there are usually over 60 residents there at any time. I'd say over half are incontinent, not everyone, but over half. [Not having enough linen] is not fair to the residents and it's not right.

Based on observation, interview, and record review, the facility failed to treat one of three residents (Resident 1) with dignity and respect when Resident 1 requested assistance from the Certified Nursing Assistant (CNA) to locate the footrest (a stationary hanger and footplate for the user's feet to rest on the wheelchair) to her wheelchair and the CNA told Resident 1 to shut up on 3/31/25. This failure resulted in Resident 1 to experience mental and emotional distress (anger and frustration) on 3/31/25. Findings: During a concurrent observation and interview on 4/3/25 at 9:47 a.m. with Resident 1 in Resident 1's room, Resident 1 was sitting in her wheelchair and Spanish speaking only. The Unit Manager (UM) interpreted. Resident 1 was alert and oriented to person, place, and time. Resident 1 stated on 3/31/25 at 3:30 a.m., the CNA came to assist her to get ready for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys have failed). Resident 1 stated she requested the CNA to assist her with her shoes and the CNA said no. Resident 1 stated she asked the CNA to hurry because the dialysis transportation was waiting outside. Resident 1 stated the CNA replied by saying I don't know. Shut up. Resident 1 stated the CNA was on her phone. Resident 1 stated the CNA should not have treated her that way. Resident 1 stated staff were paid employees and were expected to treat residents with respect. During a review of Resident 1's admission Record (AR), dated 4/3/25, the AR indicated Resident 1 was admitted on [DATE] with a history of right femur fracture (broken upper leg bone) and End Stage Renal Disease (a medical condition where the kidneys have permanently lost the ability to function adequately, requiring dialysis or a kidney transplant to survive) During a review of Resident 1's Minimum Data Set (MDS- a federally mandated process for clinical assessment of all residents of long term care nursing facilities) , dated 3/3/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 12 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 required moderate assistance (Helper does less than half the effort) with transfer (unable to move without help from another person or persons) from bed to chair and required moderate assistance with dressing and personal hygiene (habits to maintain cleanliness). During a review of the facility's Interdisciplinary Team(a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Post Incident Meeting (IDT) , dated 3/31/25, the IDT indicated, . Unit Manager informed [Administrator]/[Director of Nursing] today at [3:00 p.m.] that Resident 1 reported to her that she feels like going home and does not like it here . Resident 1 informed the UM that the [night] shift Registry (an individual licensed or certified by a regulatory agency who receives compensation from a third party to work at a nursing care facility) [name of CNA] was using her phone and told her to shut up when asked to be changed . DON interviewed Registry CNA [name of CNA] via phone who denied the allegation . For safety reasons, this facility has blocked this CNA to defer from situations like this . IDT RECOMMENDATIONS: DON blocked CNA from picking up more shifts on [name of Registry's website] . During an interview on 4/3/25 at 10:10 a.m. with Resident 2, Resident 2 stated on 3/31/25 the CNA came into the room to assist Resident 1 go to dialysis, but their roommate, Resident 3 was soaked and wet with urine. Resident 2 stated the CNA instructed Resident 3 to take her clothes and sheets off. Resident 2 stated Resident 3 was unable to do that, and Resident 2 informed the CNA Resident 3 required assistance. Resident 2 stated Resident 1 asked the CNA for the footrest to her wheelchair and the CNA told Resident 1 to wait and shut up. Resident 2 stated Resident 1 was Spanish speaking only and Resident 2 told the CNA not to talk to Resident 1 like that. Resident 2 stated the CNA no longer provided care at the facility. During an interview on 4/3/25 at 12:35 p.m. with the CNA, the CNA stated on 3/31/25 at 3:30 a.m. she went to Resident 1's room to assist her to go to dialysis. The CNA stated she assisted Resident 1 to the bathroom and Resident 3 complained of being cold. The CNA went to check Resident 3 and Resident 3 was wet with urine, and Resident 3 had soiled her clothes and linen. The CNA stated she changed Resident 3 while Resident 1 was in the bathroom brushing her teeth and hair. The CNA stated Resident 1 requested the footrest for her wheelchair and the CNA was unable to find the footrest. The CNA stated Resident 2 stated the blue footrest was hers, and Resident 1 started saying callate callate callate over and over again (meaning shut up in Spanish). The CNA stated she asked Resident 1 who she was saying callate to and Resident 2 stated Resident 1 wanted to go to the front for dialysis. The CNA denied telling Resident 1 to shut up. The CNA stated it was not acceptable to tell any residents to shut up for any reason. The CNA stated staff were required to treat residents with respect and dignity. During an interview on 4/3/25 at 10:31 a.m. with the Director of Staff Development (DSD), the DSD stated the CNA assisted Resident 1 on 3/31/25 and was not kind to Resident 1. The DSD stated staff and Registry staff were required to treat residents with dignity and respect. The DSD stated staff and Registry staff were required to abide by the residents privacy and residents rights policy and procedure. The DSD stated the CNA's behavior on 3/31/25 was unacceptable and the CNA was no longer allowed to work at the facility. During an interview on 4/3/25 at 10:33 a.m. with the DON, the DON stated Resident 1 alleged that the CNA told her to shut up on 3/31/25. The DON stated the allegation was investigated and was substantiated (confirmed) with Resident 2 as a witness. The DON stated the CNA was no longer allowed to work at the facility and would be reported to the Board (the agency that provides oversight for Certified Nursing Assistants). The DON stated staff and Registry staff were required to treat residents with kindness and respect. The DON stated the facility was the resident's home and should be treated with dignity. During an interview on 4/3/25 at 11:35 a.m. with the Administrator (ADM), the ADM stated Resident 1 asked for assistance on 3/31/25 and was told to shut up. The ADM stated an investigation was conducted and the CNA's behavior was unacceptable. The ADM stated the CNA no longer provided care at the facility and would be reported to the Board. The ADM stated residents should be treated with dignity and respect by all staff. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/2021, the P&P 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 of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #7) of 1 sampled resident reviewed for dialysis. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 08/2024, indicated, Enhanced barrier precautions (EBP's) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. The policy revealed the section titled Policy Interpretation and Implementation, included, 5. EBPs are indicated (when contact precautions do not otherwise apply) for resident with wounds and/or indwelling medical devise regardless of MDRO colonization. Further review revealed, b. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. The policy revealed, 6. EBP's remain in place for the duration of the resident's stay or until the resolution of the wound or discontinuation of the indwelling medical device that places them at risk. Per the policy, 11. Signs are posted in [sic] the door or wall outside the resident room indicating the type of precautions and PPE required. An Admission Record revealed the facility admitted Resident #7 on 09/13/2024. According to the Admission Record, the resident had a medical history that included diagnoses of dependence on renal dialysis and acquired arteriovenous fistula. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #7 received hemodialysis. Resident #7's Care Plan Report included a focus area, revised 03/27/2025, that indicated the resident had an arteriovenous fistula to the left arm. Interventions directed staff to monitor for thrill and bruit every shift and notify the medical doctor of any complications. Resident #7's Order Summary Report, with active orders as of 04/01/2025, contained an order dated 11/08/2024, that instructed staff to monitor dialysis fistula every shift for potential complications and signs and symptoms of infection. The Order Summary Report contained an order dated 11/08/2024, that instructed staff to monitor dialysis fistula every shift for thrill and bruit. Further review of the resident's Order Summary Report did not reveal an order for EBP. On 03/31/2025 at 10:07 AM, Resident #7 stated that upon returning to dialysis, the nurse checked their dialysis access site, removed the dressing, and took vital signs. Resident #7 stated that the nurses did not wear gowns when checking the resident's arteriovenous fistula site. During a concurrent observation there were no EBP postings for Resident #7. Resident #7 stated that they did not think they were on precautions. A document titled Enhanced Barrier Precautions provided by the facility and dated 04/01/2025 revealed a list of residents at the facility on EBP. Further review revealed Resident #7 was not listed as being on EBP. On 04/01/2025 at 1:03 PM, Licensed Vocational Nurse (LVN) #1 stated that Resident #7 received dialysis but was not on EBP. LVN #1 said that nurses performed a post-assessment after dialysis, including checking vital signs, the dialysis access site for bruit and thrill, and disposing of the dialysis access site dressing. LVN #1 could not explain why the resident was not on EBP and recommended asking the Infection Preventionist (IP). LVN #7 stated that residents on dialysis had EBP signs posted on their door, but Resident #7 did not. On 04/01/2025 at 1:56 PM, the Unit Manager (UM) stated the facility posted EBP signage to alert staff when extra precautions were needed for residents with indwelling devices, like a fistula. She said Resident #7 had a fistula that required EBP. The UM stated the IP reviewed orders and the resident's condition to decide if EBP was needed. The UM stated the IP would tell the nurse to get an order from the medical doctor for EBP and that it was missed for Resident #7. On 04/02/2025 at 7:50 AM, the IP stated that the goal of EBP was to prevent the spread of MDROs between residents, especially those with indwelling devices or wounds. The IP said Resident #7 met the EBP requirements, but the precaution was not implemented, and the resident did not have an order for EBP. On 04/02/2025 at 1:14 PM, the Director of Nursing (DON) stated that the facility's expectation was for the IP to recognize when a resident required EBP and implement it immediately. According to the DON, EBP was intended for residents with a point of entry, with the goal of protecting them from infection. The DON stated Resident #7's condition met the criteria for EBP, but it was not implemented. On 04/03/2025 at 7:45 AM, the Executive Director stated residents needing EBP should be placed on the program to ensure safety protocols are followed. The Executive Director stated Resident #7, who was on dialysis, should have been on EBP but was not. The Executive Director stated he expected staff to follow the facility's EBP policy for residents' safety.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of three residents (Resident 1), when Resident 1 required two person assist for transfer but was transferred from wheelchair to bed by Certified Nursing Assistant (CNA) 1 without another person to assist on [DATE]. This failure resulted in Resident 1 falling out of bed and onto the floor on [DATE] and the potential for Resident 1 to be injured. Findings: During a concurrent observation and interview on [DATE] at 9:41 a.m. with Resident 1 in Resident 1's room, Resident 1 was sitting in a wheelchair. Resident 1's left arm and left leg was contracted (a medical condition where muscles, tendons, or other tissues become permanently shortened and tight, resulting in limited range of motion and joint stiffness). Resident 1 stated he fell off the bed a few days ago. Resident 1 was unable to recall the date. Resident 1 stated one staff member was transferring him from his wheelchair to his bed when he fell . Resident 1 stated he required assistance with transfers. During a review of Resident 1's Admission Record (AR), dated [DATE], the AR indicated, Resident 1 was admitted on [DATE] with a history of Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness on one side of the body) affecting left non-dominant side and Contracture of the left knee, left ankle and left upper arm. During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long term care nursing facilities), dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 6 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated, Resident 1 was dependent (relying on others) on toileting hygiene (the ability to maintain cleanliness after voiding or bowel movement) and dependent on transfer to and from bed to chair. During a review of the Resident 1's IDT (Interdisciplinary Team; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Post Incident Meeting (IDT), dated [DATE], the IDT indicated, Resident had an unwitnessed fall (on [DATE]) at 1:30 p.m., resident was found by CNA 1. Per CN (Charge Nurse) resident was found on the floor by the L (left) bedside floor fall mat, lying on his R (right) side. Per CN resident stated he wanted to get up, CN reports resident has discoloration with no drainage on the Right top parietal (side of head), Right posterior (the back or rear part of the body) ribcage, and right knee . During an interview on [DATE] at 9:46 a.m. with CNA 1, CNA 1 stated on [DATE], he transferred Resident 1 from the wheelchair to the bed. CNA 1 stated he sat Resident 1 down on the bed, and with CNA 1's left arm, CNA 1 moved the wheelchair away. CNA 1 stated while he moved the wheelchair, Resident 1 slipped off the bed and fell on to the floor and landed on Resident 1's right shoulder. CNA 1 stated Resident 1 had a bump on the right side of his head. CNA 1 stated he put a pillow under Resident 1's head and notified the Charge Nurse. CNA 1 stated Resident 1 required two staff members for transfer but stated he has been transferring Resident 1 without an assistant and thought it was safe. CNA 1 stated he was provided in-service (education) after the incident to transfer Resident 1 with an assistant to ensure safe transfer and was instructed to refer to Resident 1's Kardex (a communication tool used to provide the type of care and assistance a resident required). During an interview on [DATE] at 1:37 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had left sided weakness and required two staff members to transfer to ensure safe transfer. LVN 1 stated CNA 1 should have had another staff member to assist when transferring Resident 1 from wheelchair to bed on [DATE] to avoid falling. During a review of Resident 1's Morse Fall Scale (MFS; a tool that assesses a patient's risk of falling), dated [DATE], the MFS indicated, Score: 45 (High Risk: Total Score greater than 45, Moderate Risk: Total Score ,d+[DATE] and Low Risk: Total Score less than 25). During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, [Resident 1] has an ADL (Activities of Daily Living; basic self-care tasks that are necessary for maintaining personal hygiene, health, and overall well-being) Self Care Performance Deficit r/t (related to) muscle weakness, hemiplegia left side . Interventions/Tasks: . Transfer: [Resident 1] requires total assistance of (2) staff for transferring . During an interview on [DATE] at 10:40 a.m. with the Director of Staff Development (DSD), the DSD stated CNA 1 was provided in-service on the use of the facility's Kardex to identify Resident 1's care plan. The DSD stated instructing employees with the use of the Kardex was completed during orientation (training) upon hire and as needed. The DSD stated the information on the Kardex was needed to provide safe care to the residents. The DSD stated Resident 1's Kardex indicated two staff members were required for transfer. During an interview on [DATE] at 10:45 a.m. with the Director of Nursing (DON), the DON stated Resident 1 had left sided weakness, had impaired mobility (a disability that limits a person's ability to move freely) and was a high fall risk. The DON stated Resident 1's care plan indicated two staff members were required to assist during transfer on [DATE]. The DON stated two staff members were required to ensure safe transfer and to avoid falling. During an interview on [DATE] at 10:52 a.m. with the Administrator (ADM), the ADM stated Resident 1 had left sided weakness and contracture in his left arm. The ADM stated Resident 1's care plan indicated two staff members were required to assist with transfer due to Resident 1's impaired mobility. The ADM stated two staff members were required to assist Resident 1 with transfer on [DATE] to ensure safe transfer. During a review of the facility's policy and procedure (P&P) titled, Fall Management and Neurological Check, dated ,d+[DATE], the P&P indicated, Policy Statement: The center implements a fall management plan based on medical history review and resident evaluation . Procedure: . 5. The LN (Licensed Nurse) updates care plans reflecting individualized intervention in an attempt to reduce or prevent falls . During a review of the facility's P&P titled, Safety and Supervision of Residents, dated ,d+[DATE], the P&P indicated, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Policy Interpretation and Implementation. Facility-Oriented Approach to Safety. 1. Our facility-oriented approach to safety addresses risks for groups of residents . 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents . Individualized, Resident-Centered Approach to Safety. 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices .

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received supplemental oxygen (from a portable tank which delivers oxygen through a tube inserted into the nostrils), as ordered by her physician, when she left the facility to go to a medical appointment. This failure resulted in Resident 1 going approximately 7 hours without her physician-ordered supplemental oxygen, which has the potential to cause respiratory distress such as shortness of breath, elevated heart rate, anxiety, and confusion. Findings: During a review of Resident 1's Admission Record (AR) dated 7/3/24, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility with diagnoses that included Acute and Chronic Respiratory Failure with Hypercapnia (a condition where there is too much carbon dioxide, a waste product, in the body), and Dependence on Supplemental Oxygen. During a review of Resident 1's Order Summary Report (OSR), dated 7/3/24, the OSR indicated Resident 1 had a physician's order for Oxygen administered continuous [at all times] at 2 Liters, every shift for oxygen, dated as beginning on 4/17/24. During a review of Resident 1's Care Plan (CP), dated 4/18/24, the CP indicated Resident 1 has oxygen therapy. Resident is on oxygen. During a review of Resident 1's Progress Notes (PN), dated 5/28/24, at 3:44 PM, the PN indicated that earlier that day, at 1:45 PM, Resident 1 had returned from a medical appointment outside the facility. A PN dated 5/28/24, at 3:50 PM, indicated Resident 1 was at the appointment for most of AM shift. Both Progress Notes were written by Licensed Vocational Nurse (LVN) 1. During an interview with the Administrator, on 7/3/24, at 10:50 AM, the Administrator stated Resident 1 had gone to this appointment without her ordered supplemental oxygen. The Administrator stated this incident was investigated by the facility, found it to be substantiated , and LVN 1 had been assigned to Resident 1's care when she left for her appointmen.t During an interview on 7/3/24, at 11:45 AM, with LVN 1, LVN 1 stated he recalled Resident 1 going to a medical appointment outside the facility that day. LVN 1 stated he was assigned to Resident 1's care and transportation had arrived early that morning at about 6:30 AM to take her to the appointment. LVN 1 stated he assigned Certified Nursing Assistants to get her up out of bed and ready for her appointment, and he did not notice she was to have oxygen, and subsequently Resident 1 left the facility with no supplemental oxygen. LVN 1 stated Resident 1 returned to the facility later that day about 1 or 1:30 PM in no respiratory distress but was notified by her accompanying family she was to be on supplemental oxygen. During a review of the facility document titled Verification of Investigation Report (VOIR), dated 6/20/24, the VOIR indicated .facility identified that the nurse was [LVN 1] and he admitted to forgetting to send [Resident 1] out with [oxygen] tank. Employee was in-serviced by the Director of Nursing and Director of Staff Development. During a review of the facility document titled Employee Correction Notice (ECR), dated 6/20/24, the ECR indicated that on 5/28/24, LVN 1 Failed to follow MD [Medical Doctor] order for Resident 1 on that date, and failed to ensure [Resident 1] was wearing and receiving oxygen via nasal cannula [flexible tubing that is inserted into the nostrils] prior to leaving for a doctor appointment as per MD order. The ECR was signed by LVN 1. During a review of the facility Policy and Procedure (P&P) titled, Oxygen Administration, dated 10/10, the P&P indicated, in part, Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three residents (Resident 1) when Resident 1 was admitted with a stage 3 pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) to the sacral (tailbone) region on 4/17/24 and Resident 1 ' s stage 3 pressure ulcer assessment was not documented (a process used to learn about a patient's condition) until 5/14/24. This failure was not the standard of practice according to the facility ' s policy and procedure titled, Charting and Documentation, and Prevention of Pressure Injuries. Findings: During a review of Resident 1 ' s Admission Record (AR), dated 6/19/24, the AR indicated Resident 1 had a stage 3 pressure ulcer to the sacral region. During a review of Resident 1 ' s Admission/Readmission Evaluation (ARE), dated 4/17/24, the ARE indicated, 4a. Is a skin issue present? Yes. Site: Sacrum. Description: Stage III (3) pressure ulcer. During a review of Resident 1 ' s IDT Skin Meeting (ISM), dated 4/24/24, the ISM indicated, Reason for Meeting: Open area to coccyx (tailbone). During a review of Resident 1 ' s Progress Report (PR), dated 5/14/24, the PR indicated, Wound Details: Location: Center Midline Coccyx. Classification: Pressure Ulceration. Stage: Stage III. Width: 7.5 cm (centimeters; unit of measurement). Length: 6 cm. Depth: 0.1 cm. Area 4.5 cm2 (centimeter squared; unit of measurement). Volume: 4.5 cm2. During an interview on 6/19/24 at 12:11 p.m. with Registered Nurse (RN), RN stated she was the designated wound nurse on the weekend. RN stated she provided wound treatment and wound assessment weekly for residents with wounds. RN stated she provided wound care and wound assessment for Resident 1. RN stated she was unable to locate the wound assessment record with measurements of the wound she completed for Resident 1 from 4/17/24 through 5/13/24. RN stated wound assessments with measurements of the wounds were required to record the condition and progress of the wound. During an interview on 7/9/24 at 3:42 p.m. with Physician Assistant (PA), PA stated she visited residents with wounds at the facility once a week. PA stated Resident 1 was referred to her on 5/14/24 with an open area to her coccyx. PA stated Resident 1 ' s wound was fully covered in eschar (dead tissue that forms over healthy skin and then, over time) during the first assessment. PA stated weekly assessments of the wound was required as proof of care. PA stated wounds should be measured and photographed to determine the progress of the wound. PA stated medical records should be complete and accurate. During an interview on 7/11/24 3:14 p.m. with Director of Nursing (DON), DON stated the wound nurse was available only on the weekend. DON stated licensed nurses were required to assess and provide care for the wound when the wound nurse was not available. DON stated wound assessments were required to be completed weekly either by the licensed nurses or the wound nurse. DON stated wound assessment were to monitor the change of condition of the wound; if the wound is getting worse or better. DON stated untreated wounds can lead to sepsis (blood poisoning) and death. DON stated wounds should be assessed (including measurements) when providing treatment and should be assessed at minimum of once a week. DON stated documentation of the assessments were required to be kept in the resident ' s medical record to monitor trend. DON stated the medical record must be complete and accurate to reflect the quality of care provided at the facility. During an interview on 7/11/23 at 3:23 p.m. with Administrator (ADM), ADM stated the reason for wound assessment were to see if the wound was getting better or worse. ADM stated wounds should be assessed at minimum weekly and during each treatment to see if the treatment is effective. ADM stated assessments were required to be in medical records to reflect care provided. ADM stated the resident ' s medical record must be complete and accurate in case family request a copy of the resident ' s medical record. ADM stated if wound care was completed and documented and the assessments (with measurements) were not documented it was not completed. During a review of the facility ' s policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record . Policy Interpretation and Implementation: .2. The following information is to be documented in the resident medical record: .c. Treatments or services performed . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . 7. Documentation of procedures and treatments will include care-specific details, including: .c. The assessment data and/or any unusual findings obtained during the procedure/treatment . During a review of the facility ' s P&P titled, Prevention of Pressure Injuries, dated 4/2020, the P&P indicated, Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review of the resident ' s care plan identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition . Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident ' s risk factors, and prior to discharge .

Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety when: 1. There was a build-up of food crumbs and debris under the dishwasher, this had the potential for microorganism growth and to attract pests. 2. The ceiling had a patch that was not smooth and easily cleanable, this had the potential for build-up of dust and microorganism growth. These failures had the potential for microorganism growth that could be inadvertently transferred to food and to attract pests in the kitchen that prepared food for 47 out of 47 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 2/13/24 at 10:47 a.m. with the Dietary Supervisory (DS) in the kitchen, a build-up of food crumbs and debris was seen under the dishwasher area. The DS stated it is hard to clean under the dishwasher area. During a phone interview on 2/15/24 at 4:01 p.m. with the Registered Dietician (RD), the RD stated her expectation was for staff to thoroughly clean the dishwasher area after each use. During a review of the facility's policy and procedure (P&P) titled, Environment, revised 9/2017, the P&P indicated, .POLICY STATEMENT: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted . 2. During a concurrent observation and interview on 2/13/24 at 2:35 p.m. with the DS in the kitchen, a 12 inch by 12 inch portion of the ceiling was covered with a piece of plywood, unpainted. The DS stated, the ceiling should be smooth and easily cleanable. The DS stated, the plywood was not an acceptable surface for the kitchen ceiling. During a phone interview on 2/14/24 at 4:01 p.m. with the RD, the RD stated her expectation was to not have plywood on the ceiling. During a phone interview on 2/16/24 at 3:22 p.m. with the MS, the MS stated the leak in the kitchen ceiling was reported a month and a half ago. The MS stated he had attended to a few small leaks in the kitchen ceiling. The MS stated he had worked on the kitchen ceiling multiple times. The MS stated he screwed a wood patch in the kitchen ceiling. The MS stated he would need help to put in a dry wall for the ceiling. During a review of the facility's policy and procedure (P&P) titled, Environment, revised 9/2017, the P&P indicated, .POLICY STATEMENT: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. PROCEDURES: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation . During a review of the FDA Federal Food Code, dated 2022, 4-101.19 indicated, Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. In addition, Nonfood-contact surfaces of equipment routinely exposed to splash or food debris are required to be constructed of nonabsorbent materials to facilitate cleaning. Equipment that is easily cleaned minimizes the presence of pathogenic organisms, moisture, and debris and deters the attraction of rodents and insects.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered Care Plan (CP-the process by which healthcare professionals and patients discuss, agree, and review an action plan to achieve the goals or behavior change of most importance to the patient) to prevent falls and injuries, for four (4) of fifty-four (54) sampled residents (Resident 4, Resident 28, Resident 250, and Resident 410) when: 1. Resident 4's supervision CP during meals was not implemented. This failure put Resident 4 at an increased risk of choking and aspiration of food. 2. Resident 28's toenail clipping and/or podiatry care was not done and there was no CP to address repeated refusals to bathe or shower. This failure placed Resident 28 at risk for infection and other diabetic (high blood sugar disease) complications. 3. Resident 250 fell out of bed on 9/13/23 and the fall mat (a cushion made of high-density foam and covered with a non-slip material to minimize the risk of injury) was not put in place by staff members based on Resident 250's CP. This failure resulted in avoidable injuries when Resident 1 fell from bed and sustained a displaced nasal bone fracture (broken nose) and left periorbital (area surrounding the socket of the eye) soft tissue contusion (bruise), a laceration (cut) of the left eyebrow and experienced pain and discomfort. 4. Resident 410 was not turned or repositioned every two hours as indicated on her CP. This failure placed resident 410 at risk of developing a pressure injury and had the potential to cause delayed healing to a current pressure injury. Findings: 1. During an observation on 2/13/24 at 12:58 p.m. in Resident 4's room, Resident 4 was observed sitting up in bed eating her meal. Resident observed feeding herself with no staff in the room and the Resident's door was closed. Resident did not respond when spoken to. Observed Resident 4's call light hanging over the side of the bed behind her and no bell on Resident 4's bedside table. During a review of Resident 4's Admission Record (AR), dated 2/15/24, the AR indicated, Resident 4 was admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, dysphagia (difficulty swallowing foods or liquids) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/30/24, the MDS Section C indicated, Resident 4 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) of 0 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 4 was severely cognitively impaired. During an interview on 2/15/24 at 10:35 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 4 did not use the call light. CNA 4 stated Resident 4 was able to feed herself. CNA 4 stated we would just set up her food and check on her. During a concurrent interview and record review on 2/15/24 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 4's CP, dated 2/15/24 was reviewed. The CP indicated, Resident 4 was to eat only with supervision. LVN 1 stated Resident 4 needed a CNA in the room for meals. LVN 1 stated Resident 4 was unable to use her call light. During an interview on 2/16/24 at 4:19 p.m. with the Director of Staff Development (DSD), the DSD stated her expectation was for staff to follow physician's orders and CPs. During an interview on 2/20/24 at 12:24 with the Director of Nursing (DON), the DON stated staff should be following the CP. The DON stated if a resident has a diagnosis of dysphagia and has no supervision during meals, there is the potential for choking. 2. During an observation on 2/14/24 at 8:31 a.m. in Resident 28's room, Resident 28 was observed seated in bed, finishing breakfast. Resident observed to be alert, hair uncombed and a detectible mild sour body odor. Resident 28 agreed to allow LVN 2 to remove the socks to observe his feet. During a review of Resident 28's AR, dated 2/14/23, the AR indicated, Resident 28 was admitted on [DATE] with diagnoses of congestive heart failure (CHF- long-term condition that happens when your heart can't pump blood well enough), chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (high blood sugar), chronic ulcer of right and left lower leg (areas on the legs, ankles or feet where underlying tissue damage, or a trauma, has caused skin loss, leaving a raw wound that takes a long time to heal), retention of urine, chronic kidney disease, pain, use of anticoagulants (blood thinners), use of insulin (an animal-derived or synthetic form of insulin used to treat diabetes)and cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 28's MDS, dated [DATE], the MDS Section C indicated, Resident 28 had a BIMS of 14 out of 15 which suggested Resident 28 was cognitively intact. During an interview on 2/14/24 at 8:35 AM, with LVN 2, LVN 2 stated that Resident 28's toenails were a problem. LVN 2 stated Resident 28 refuses a lot of care he has his favorite staff and sometimes they can get him to participate or cooperate with care. LVN 2 stated that CNA's do nail care for residents that are not diabetic. LVN 2 stated that [licensed] nurses (LNs) can clip/file diabetic resident toenails but if toenails are too thick or difficult to clip/file, the residents are referred to a podiatrist (foot doctor). LVN 2 stated if a resident needs podiatry, the LN reports to the Social Services Director (SSD) for coordination of a podiatry visit, either in-house or out-patient visit. LVN 2 stated, can't remember when they [podiatry] were last here. LVN 2 stated if a resident refuses care, the refusal is documented on either the Medication Administration Record (MAR) or Treatment Administration Record (TAR) depending on what care is refused. During an interview on 2/14/24 at 8:48 a.m., with the Social Services Director (SSD), SSD stated the podiatry group was scheduled to come next week. SSD stated the podiatrist usually does a round (visits residents), and request consent for services, if a resident refuses service she is made aware. SSD stated Resident 28 is his own RP (RP- Responsible Party) and able to give consent to treat. SSD stated that because of COVID (a disease caused by a virus named SARS-CoV-2) [podiatry doesn't come in] they send residents out to the office. SSD stated she does not have a list of residents that have been sent out [for podiatry services]. During a concurrent interview and record review on 2/14/24 at 10:19 a.m., with the facility Administrator (ADM), the facilities Podiatry Services Agreement, dated 2/6/23, was reviewed. ADM validated her signature on the new contract with Podiatry, as 2/9/24. ADM stated prior to this agreement, the facility was with a previous group. During an interview on 2/15/24 at 9:34 a.m., with CNA 6, CNA 6 stated that the resident fingernails and toenails care is done while bathing. CNA 6 stated this includes cleansing the nails on hands with a nail brush disposable or resident assigned. Then toenails and fingernails, if the resident is not diabetic, is done after the shower when the nails are softened a bit. CNA 6 stated nail care is documented in the CNA documentation in the computer under personal care area. CNA 6 stated she would not be able to tell me if Resident 28 was a diabetic. CNA 6 stated that Resident 28 had dressings to both legs, nurses do dressings. CNA 6 stated she has not visualized the resident's legs without dressings. CNA 6 stated she would not be able to tell if Resident 28's toenails have been clipped or filed, because he keeps his socks on. CNA 6 stated that if residents allow, the CNA should be looking at legs/feet to apply lotion and alert nurse to any concerns. During a concurrent interview and record review on 2/15/24 at 09:37 a.m., with CNA 6, Resident 28's Electronic Medical Record (EMR), dated ? CNA 6 stated Resident 28 likes to be independent. CNA 6 stated that Resident 28 is scheduled for a bath or shower each Monday and Thursday evening on the PM (2nd) shift. CNA 6 stated Resident refused a shower on Monday, 2/12/24. CNA 6 stated that if a resident refuses a shower the CNA is to alert LN, offer multiple times, may offer another CNA if preferred. CNA 6 stated once the nurse is notified about a refusal, then one can document refused and create a new alert. CNA 6 stated she would document a summary of what happened and chart that the assigned charge nurse LN was notified. CNA 6 stated according to the EMR, Resident 28 refused a shower/bath on 2/8/24 -Refused, 2/5/24 -Refused, 2/1- Refused 1/29 - Not in room/facility. CNA 6 stated, it does seem he needs a shower; body odor is strong. During a concurrent interview and record review on 2/15/24 at 10:34 a.m., with Unit Manager, Registered Nurse (UM-RN), Resident 28's Electronic Medical Record (EMR), was reviewed, UM-RN stated she was familiar with Resident 28. UM-RN stated Resident 28, was his own RP, able to tell staff what he wants and is independent with care and if he allows it, staff provide some assistance for ADL's (Activities of Daily Living- bathing, dressing, etc.). UM-RN stated she has not observed any podiatry visits for Resident 28. UM-RN stated there has been no attempts to cut Resident 28's toenails. UM-RN stated she has a good rapport with Resident 28, and she can get him to accept care. UM-RN stated that Resident 28 is a diabetic, but stable and would do his nail care herself. UM-RN stated she is not aware of a recent referral to podiatry. UM-RN stated she has not offered toenail care today and doesn't believe it has been offered. UM-RN stated Resident 28's toenails are manageable, they look fine, the nails could have been trimmed. UM-RN indicated Resident 28 has a standing order that is PRN (PRN- As Needed) but has not been referred. UM-RN stated that Resident 28's nails should have been addressed, the refusals are a challenge. UM-RN stated that refused care is documented in the MAR/TAR with a progress note. UM-RN stated that for residents with standing orders for podiatry, she will verbalize to SSD and ask them to start the referral process, if it is a resident/family request a note would be documented UM-RN stated that the LNs are expected to enter a note if the provider of (vision, dental or podiatry) comes to the facility to deliver care under a progress note. UM-RN stated that there is the potential of harm to a diabetic resident, if foot care is not being done , because it takes longer for a wound to heal as a diabetic and can lead to other complications such as risk for infection/amputation., foot care is important. UM-RN stated that if a resident refuses care, repeatedly, she would CP and follow planned interventions. If interventions are not working, they should be change and reassess the effectiveness. UM-RN stated LN's do the CP update revisions. CNA's can do nail care if the resident is non-diabetic, LN's can do the care of a trim and file if nails are tough/thick. UM-RN stated Resident 28 should have been placed on the podiatry list. During a concurrent interview and record review on 2/15/24 at 10:38 a.m., with UM-RN, Resident 28's CP dated 2/14/24 was reviewed. The CP indicated, .Focus Resident 28 has history of resistive to care, refuses finger and toenail care. Refuses to allow staff to clean, trim, cut or file . Goal [Resident 28's] preferences will continue to be met through the next review date with no negative outcomes due to his preference .Interventions Allow [Resident 28] to make decisions about treatment regime, to provide sense of control .Healthcare teaching provided .Notify MD of any complications . Staff to encourage compliance . UM-RN stated she thinks that the interventions could have added to offer a bed bath, or offer other alternatives. UM-RN stated, we should have incorporated a better hygiene plan and emphasized how important it is to his health. UM-RN stated they could have changed the approach to care, offer choices and allow him to be the driver of his care. Resident 28 liked to control everything, so approach is important, he likes to decide. UM-RN stated, There isn't documentation of his preferences or evidence of a meeting to address them. The UM-RN stated, the CNAs seem to think it is ok to not bathe/shower and that isn't OK. UM-RN stated LNs rely on CNA reports of any concerns to the LVN/RN or CN. UM-RN stated her expectation of the nurses is that assessments are done weekly, as assigned to each nurse to do in the A.M./ P.M. and notify the RN of any Change in Condition. UM-RN stated she does not routinely review the weekly assessments or attend Interdisciplinary Team (IDT) meetings. During a concurrent interview and record review on 2/15/24 at 10:34 a.m. with Unit Manager, RN (UM-RN), Resident 28's Electronic Medical Record (EMR), was reviewed. UM-RN stated Resident 28 is regularly refused bathing and showers, in the last 30 days in the computer. UM-RN stated she has not been made aware of this consistent refusing. UM-RN stated if repeatedly refusing as with Resident 28, she would offer a sponge bath, notify MD if he refuses a bed bath. UM-RN stated that as the UM-RN she should have been notified, to come up with another plan. Um-RN stated that the potential harm to the resident no showered/bathed, is infection, not good for skin/care, and poor hygiene which can lead to sickness During an interview on 2/15/24 at 2:37 p.m., with the facility Director of Nurses (DON), DON stated her expectation regarding resident nail care is nursing driven, staff should be performing nail care per the facility policy. DON stated if a resident is identified as needing podiatry care, the facility would coordinate foot care with an outside podiatry office. DON stated that the Social Services department handles referrals, with the Central Supply department coordinating the transportation. DON stated that with the prior podiatry contract, SSD coordinated the podiatrist visit to the facility. DON stated the last podiatry visit to the facility was on 11/2022. DON stated she was not sure what was done for the residents during that visit. DON stated that her care expectation is that the resident in need, if non-diabetic have their nails cleaned, trimmed and/or filed during personal hygiene care done every shift. DON stated that CNAs should provide nail care, and if they are not comfortable the charge nurse should be notified. DON stated that if a resident refuses care, the LN documents the resident refusal. DON stated if the resident refuses repeatedly, the LN is expected to notify the physician and RP/family. DON stated her expectation is that LNs document the refusal-of assessment and reason for the refusal. DON stated with diabetic residents their diagnosis causes slow healing, possible infections, and lesions (open skin) increase risks for infection or losing their toes. During an interview on 2/15/24 at 3:17 p.m., with DON and [NAME] President of Clinical Operations (VPCO), DON stated she expects staff to notify the physician and IDT of resident refusals of care. DON stated the IDT would speak with resident to determine the reason for refusals and recommend any alternative interventions be add to the CP along with resident preferences/wishes. DON stated then staff should follow through with the resident wishes. DON stated CNA's can escalate to DON or other Department Head for intervention if nurse does not respond to reports. DON stated the resident is entitled to a dignified existence and hygiene. DON stated she cannot recall any reports of repeated refusals of care; she would have responded herself to any chronic refusals of care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2022, indicated . each resident's comprehensive person-centered CP is consistent with the resident's right to . receive the services and/or items included in the plan of care . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 3. During a concurrent observation and interview on 9/26/23 at 8:57 a.m. with Resident 250 in Resident 250's room, Resident 250 was sleeping in bed. Resident 250 had a healing wound to the upper left eyebrow, a bruised nose, and bruised right and left cheek. Resident 1 was easily arousable (awake) and did not respond to simple questions. During a review of Resident 250's Admission Record (AR), dated 9/18/23, the AR indicated, Resident 250's diagnosis included contusion (bruise) of other part of head (left eye) and fracture of the nasal bone, Alzheimer (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Muscle Weakness, and Difficulty in Walking. During a review of Resident 250's Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents of long term care nursing facilities) dated 6/14/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status (the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 0 (a score of 0 - 7 indicate severe cognitive impairment, a score of 8 - 12 indicate moderate cognitive impairment, and a score of 13 - 15 indicate the resident is cognitively intact). During a review of Resident 250's MDS for Functional Status (FS), dated 6/14/23, the FS indicated Resident 250 required one-person extensive to total assistance with activities of daily living (eating, dressing, bathing, etc.) and two-person physical assistance with transfers (how residents move between surfaces including to or from: bed, chair, wheelchair, standing position). During a review of Resident 250's Morse Fall Scale (MFS - a simple method of assessing a person's likelihood of falling), dated 9/15/23, the MFS indicated Resident 250 had a fall risk score of 55 (a score 0 - 24 was low risk; a score 25 - 44 was moderate risk and a score 45 or higher was high risk). During a review of Resident 250's Care Plan (CP), dated 5/1/18, the CP indicated, Resident 250 was at risk for falls related to gait (walking) balance problems, muscle weakness, difficulty walking, abnormalities of gait and mobility, history of falls, cognitive impairment, diagnoses of Alzheimer's Disease, and severe Dementia. The CP interventions indicated, Resident may have fall mats on each side of her bed. During a review of Resident 250's ED (Emergency Department) Provider (Physician) Notes (EPN), dated 9/13/23, the EPN indicated, CT Maxillofacial wo (without) Contrast (CT - Computed Tomography; a diagnostic imaging test that uses specialized X-ray equipment to create detailed cross-sectional images of the bones, tissues, and sinuses in the face and skull region. Contrast - a substance used to make specific organs, blood vessels, or types of tissue (such as tumors) more visible on X-rays). Final Result: Age-indeterminate (breaks in the bones where it's challenging to precisely determine the age of the injury) mildly displaced nasal bone fracture. Left periorbital soft tissue contusion. The EPN indicated, Resident 1 had a one cm (centimeter - unit of measurement) laceration to her left eyebrow and required a laceration repair with [brand name; a skin adhesive to close a wound] in the ED. During an interview on 9/26/23 at 9:04 a.m. with Resident 3, Resident 3 stated Resident 250 was lying in bed too close to the edge of the bed and fell on [DATE]. Resident 3 stated the bed was not at its lowest position. Resident 3 stated Resident 250's bed was approximately hip high (the height of the average person's hip). Resident 3 stated staff was still moving Resident 250's personal belongings (clothes, etc.) into room [ROOM NUMBER] when Resident 250 fell . Resident 3 stated she called the nursing station to notify the nurse that Resident 250 fell . During an interview on 9/26/23 at 9:53 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 3 was moved to room [ROOM NUMBER] from room [ROOM NUMBER] since Resident 250's roommate in room [ROOM NUMBER] tested positive for COVID (an infectious disease caused by the SARS-CoV-2 virus) on 9/13/23. LVN 1 stated Resident 250's roommate in room [ROOM NUMBER] telephoned the nursing station and notified LVN 1 that Resident 250 fell out of bed and was on the floor. LVN 1 stated when LVN 1 went to the room [ROOM NUMBER], Resident 250 was on the floor on the right side of the bed. LVN 1 was unable to recall the height of Resident 250's bed but stated the bed was not at its lowest position and there was no fall mats on the floor next to Resident 250's bed. LVN 1 stated Resident 250 was bleeding from the nose. LVN 1 stated she gave Resident 250 [brand name - pain medication] and called the physician. Resident 250 was transferred to the hospital and had a hematoma (a solid swelling of clotted blood within the tissues) above the left eye and a broken nose. LVN 1 stated the fall was unavoidable, but the injuries could have been less severe (serious) had the fall mats been put in place to absorb the impact of the fall. During an interview on 9/26/23 at 10:21 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 9/13/23, CNA 1 moved Resident 250 to room [ROOM NUMBER] from room [ROOM NUMBER] due to Resident 250's roommate in room [ROOM NUMBER] tested positive for COVID. CNA 1 stated she put Resident 250 in bed in room [ROOM NUMBER] and went to retrieve the rest of Resident 250's personal belongings (clothes, etc.) from room [ROOM NUMBER]. CNA 1 stated LVN 1 informed CNA 1 that Resident 250 fell while CNA 1 was gathering Resident 1's belongings from the closet in room [ROOM NUMBER]. CNA 1 stated Resident 250's bed was low but not in its lowest position. CNA 1 was unable to recall the height of Resident 250's bed. CNA 1 stated Resident 250 required total care, was a high fall risk, and required fall mats. CNA 1 stated the fall mats were still in room [ROOM NUMBER] at the time of the fall. CNA 1 stated she should have placed the fall mats on the floor immediately after moving Resident 250 to room [ROOM NUMBER]. CNA 1 stated Resident 250's injuries could have been less severe (serious) if Resident 250 had fallen onto the fall mat. During an interview on 9/26/23 at 11:13 a.m. with Director of Nursing (DON), DON stated staff were required to follow each resident's care plan. DON stated Resident 250 had a history of falls and was high risk for falls. DON stated Resident 250's bed should always be in the lowest position when not providing care and the fall mats should be in place at all times. DON stated Resident 250's injuries could have been minimized if the fall mats were in place to absorb the impact of the fall. During a professional reference review retrieved from https://elderlyfallprevention.com/reducing-fall-injuries-with-fall-mats/titled, Reducing Fall Injuries with Fall Mats, dated 3/16/23, the professional reference indicated, .Falls are common events among nursing home residents with dementia or confusion (may be affected by medication) who forget or are unable to use the call bell. These residents often get out of bed without assistance or roll out of bed and hurt themselves . Fall mats are specially designed floor mats made from different materials. They are placed on the floor at the bed or chair to protect the elderly from serious physical trauma resulting from falls. A fall mat is useful for cushioning a fall and reducing the impact when the elderly accidentally rolls out of bed at night . The fall mat is placed at the side of the bed where the patient exits the bed from. Only place the mat on the floor when the patient rests in bed . During a review of the facility's Policy and Procedure (P&P), titled, Falls - Clinical Protocol, dated 3/2018, the P&P indicated, .Treatment/Management. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . 4. During a review of Resident 410's Admission Record (AR), dated 2/15/24, the AR indicated, resident 410 was admitted on [DATE] with diagnoses of Diabetes Mellitus, Dementia, Psychotic disturbance, Mood disturbance and Anxiety. During a review of Resident 410's MDS, dated [DATE], the MDS indicated Resident 410 had a BIMS of 6, which suggested severe cognitive impairment. During an interview on 2/15/24 at 11:23 a.m. with CNA 5, CNA 5 stated Resident 410 had no pressure ulcers or new wounds. CNA 5 stated Resident 410 was to be turned every 2 hours. CNA 5 stated she checked on Resident 410 every so often. CNA 5 stated Resident 410 could not press her call light button. During a review of Resident 410's CP, dated (undated), the CP indicated . turn and reposition every 2 hours and as needed . for Resident 410's interventions. During a concurrent interview and record review on 2/16/24 at 4:19 p.m. with the DSD, Resident 410's Turn and Reposition Record was reviewed. The Turn and Reposition Record indicated, Resident 410 was not turned every 2 hours as ordered on Resident 410's CP. The DSD stated Resident 410 was not being turned every 2 hours. The DSD stated Resident 410 had orders to be turned every 2 hours or as needed. The DSD stated there were some breaks in time. The DSD stated her expectation was that staff follow the CPs and turned Resident 410 every 2 hours due to Resident 410 being more prone to skin breakdown. During a concurrent interview and record review on 2/20/22 at 12:24 p.m. with the DON, the facility's policy, and procedure (P&P) titled, Repositioning, dated 2013 was reviewed. The P&P indicated, . Residents who are in bed should be on at least an every two hour [q2 hour] repositioning schedule . for residents with a Stage I or above pressure ulcer, an every two hour [q2 hour] repositioning schedule is inadequate . The DON stated her expectation is the resident should be turned every 2 hours or as needed. The DON stated if the CP is not followed, there is the potential for skin breakdown. 48739

Based on observation, interview, and record review the facility failed to provide a clean, safe, and sanitary homelike environment for six of 19 sampled residents (Residents 4, 8, 10, 15, 29 and 31) when: 1. There were missing floor tile in Residents 4 and Resident 10's bathroom with darkened areas in the tile grout. 2. There was a missing baseboard from the wall behind Resident 8's bed exposing chipped paint and grime. 3. The floor tile by Resident 15's bed was broken with missing pieces of tile. 4. There were trash and dirt on the floors and dirty (blackened) floor tiles in Resident 29's room. 5. The privacy curtain in Resident 31's room was torn. These failures placed Residents 4, 8, 10, 15, 31 and 29 in an unclean, unsafe, unsanitary and a non-homelike environment which could affect residents' well-being. Findings: 1. During a concurrent observation and interview on 2/13/24 at 11:50 a.m., with Resident 10 in Resident 10's room, Resident 10 was observed sitting up in a wheelchair. Resident 10 stated she needed help to move her wheelchair. Resident 10's bathroom was observed to be missing tile on the bathroom floor, with dark areas on the tile and on the surface of the missing tile areas. During a review of Resident 10's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/20/24, the AR indicated, Resident 10's admitted was 1/28/22 with diagnoses of epilepsy (a seizure a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/11/24, the MDS indicated, Resident 10 had a Brief Interview for Mental Status (BIMS - a screening tool used to assess resident cognitive level) score of 10 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact) which suggested Resident 10 was moderately impaired. During an observation on 2/13/24 at 12:11 p.m. in Resident 4's room, Resident 4 was observed sleeping in bed. Resident 4 did not respond when spoken to. Observed tile missing from the bathroom floor with dark areas observed on the tile and on the surface of the missing tile areas. During a review of Resident 4's AR, dated 2/15/24, the AR indicated, Resident 4 was admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, dysphagia and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had a BIMS of 0, which indicated Resident 4 was severely cognitively impaired. During an interview on 2/15/24 at 11:15 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the broken tile in Resident 4's shower could be a trip hazard. LVN 1 stated housekeeping would not be able to get into the cracks of the tile to properly clean. LVN 1 stated it could be an infection hazard. 2. During a concurrent observation and interview on 2/13/24 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 8's room, the baseboard behind Resident 8's bed was observed missing. The wall with missing baseboard was observed with chipped paint and a brown substance. LVN 2 stated the wall behind Resident 8's bed had peeled off paint that appeared to have been removed with the base board. LVN 2 stated the missing baseboard appearance did not provide a homelike environment for Resident 8. During a review of Resident 8's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated, Resident 8 was admitted to the facility on [DATE] with diagnosis, . Neurocognitive Disorder with Lewy Bodies (disorder that leads to decline in thinking, reasoning and self-function . During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment dated [DATE], the MDS indicated Resident 8's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 5 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) which indicated Resident 8 BIMS indicated severe cognitive impairment. During a concurrent observation and interview on 2/15/24 at 10:59 a.m. with the Regional Maintenance Supervisor (RMS) in Resident 8's room, the area with the missing baseboard behind Resident 8's bed was observed. The RMS stated the baseboard should have been placed back on the wall as is, did not provide a homelike environment for Resident 8. During an interview on 2/16/24 at 5:17 p.m. with the Regional Infection Preventionist (RIP), the RIP stated there were concerns regarding the missing baseboard because of the potential for harm. The RIP stated the facility should have kept up with the issues to prevent residents from infection that could have been caused by growing organisms from not cleaning the surfaces thoroughly. 3. During an observation on 2/13/24 at 2:21 p.m. in Resident 15's room, the floor tile next to Resident 15's bed was observed broken with missing pieces, the area appeared to be the size of a tennis ball with tile pieces broken off that remained inside the open tile. During a review of Resident 15's Admission Record (AR), indicated, Resident 15 was admitted to the facility on [DATE] with diagnosis, . Alzheimer's Disease (destroys memory and other mental functions . During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/11/24, the MDS indicated, Resident 15's Brief Interview for Mental Status score was 6 out of 15 which indicated Resident 15's BIMS was severe cognitive impairment. During a concurrent observation and interview on 2/15/24 at 11:01 a.m. with the Regional Maintenance Supervisor (RMS) in Resident 15's room, the floor tile next to Resident 15's bed was observed broken with missing pieces. The RMS stated the tile needed to be replaced and there was a safety concern due to the potential of falls with the missing and broken tile. During a telephone interview on 2/16/24 at 3:22 p.m. with the Maintenance Supervisor (MS), the MS stated the broken tile in resident 15's room was on the list of maintenance issues to complete in the facility. The MS stated there were other projects in the facility that were currently being worked on, but the facility had not completed the task for the broken tiles. The MS stated the missing baseboard in resident 8's room was approved for replacement. The MS stated although the missing baseboard was not pleasant to look at, it was livable for resident 15. A Work Order List was requested on 2/16/24 from RMS for review, no records were provided. During an interview on 2/16/24 at 5:12 p.m. with the Administrator (ADM,) the ADM stated the expectation was to maintain the facility as homelike as possible. The ADM stated there was not a list of the current projects within the facility. The ADM stated the facility expectation was for resident safety to come first and expected the MS to make the determination of prioritizing the facility projects. During an interview on 2/16/24 at 5:17 p.m. with the Regional Infection Preventionist (RIP), the RIP stated there were concerns regarding the missing tile and base board because of the potential for harm. The RIP stated the facility should have unkempt the issues to prevent residents from infection that could have been caused by growing organisms from not cleaning the surfaces thoroughly. 4. During an observation on 2/13/24 at 2:44 p.m. in Resident 29's room, the floor behind and next to Resident 29's bed was observed to have dirt and crumpled paper next to the wall. The wall behind Resident 29's bed was observed to have missing paint. The floor in front of the bathroom door in Resident 29's room was observed to have black marks on the tile and black grime in the grout. During a review of Resident 29's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/15/24, the AR indicated, Resident 29 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for palliative (comfort) care and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 29's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment), dated 12/18/23, the MDS indicated, a Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level)score of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills] 8-12 indicated moderate cognitive impairment, 13-15 indicated cognitively intact), which suggested Resident 29 was cognitively intact. During a concurrent observation and interview on 2/14/24 at 8:50 a.m. with the Maintenance Supervisor (MS), in the first shower, the transition between the hallway and the shower room was observed to be missing tiles that created an uneven area between the two areas, exposed cement, dirt and yellow dried adhesive. The MS stated the transition on the floor under the door needed to be replaced. The MS stated it was unsanitary and unsafe. During an interview on 2/15/24 at 1:59 p.m. with the House Keeping Manager (HSK MGR), the HSK MGR stated the floor behind and next to Resident 29's bed was dirty. The HSK MGR stated his expectation was the floor would be clean and up to standards. The HSK MGR stated the black grime buildup between the tiles and black marks on the floor tiles by the bathroom in Resident 29's room was from the glue coming up from the tile. The HSK MGR stated dirty floors can be infectious to residents. The HSK MGR stated he was responsible for monitoring the cleaning of residents' rooms. During a review of the facility's policy and procedure (P&P) titled, Job Description . Light Housekeeper, dated (undated), the Job Description indicated . the light housekeeper . cleans floors in residents' rooms: Dry mops, wet mops, sweeps and disinfects; pulls dresser and moves furniture while dust mopping and damp mopping . ensures that established sanitation and safety standards are maintained . follows infection control and universal precautions policies and procedures to ensure that a sanitary environment is maintained at all times. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 12/2009 was reviewed. The P&P indicated, . The maintenance department is responsible for maintaining the buildings . in safe and operable manner . maintaining the building in good repair . the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds . are maintained in safe operable manner .the maintenance director is responsible for maintaining the following records/reports. Inspection of building. Work order requests . records shall be maintained in the maintenance director's office . Review of professional reference titled, Why Is Cleanliness Critical For Nursing Home Resident Safety?, dated, 2024, available at: https://braswellmurphy.com/why-is-cleanliness-critical-for-nursing-home-resident-safety/. The professional reference Indicated, .Nursing residents often suffer from several conditions linked to their age. Their immune systems are often not adequately equipped to handle exposure to germs which may be linked to poor cleanliness in a facility . During a review of profession reference titled, CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South [NAME]: Infection Control [NAME] Network, dated 2019, available at: https://www.cdc.gov/hai/prevent/resource-limited/index.html, and http://www.icanetwork.co.za/icanguideline2019/, indicated, It is well documented that environmental contamination in healthcare settings plays a role in the transmission of HAIs.2,3 Therefore, environmental cleaning is a fundamental intervention for infection prevention and control (IPC) . outbreak investigations have determined that the risk of patient colonization and infection increased significantly if the patient occupied a room that had been previously occupied by an infected or colonized patient. Therefore, the role of immediate patient care environment-particularly, environmental surfaces within the patient zone that are frequently touched by or in direct physical contact with the patient such as bed rails, bedside tables, and chairs-in facilitating survival and subsequent transfer of microorganisms was established . 5. During an observation on 2/13/24 at 11:16 a.m. in Resident 31's room, the privacy curtain was observed to have three rings that hold up the curtain to be torn off and hanging down. During a review of Resident 31's Admission Record (AR), dated 2/15/24, the AR indicated Resident 31 was admitted on [DATE] with diagnoses of heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/9/23, the MDS Section C indicated Resident 31 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 31 was cognitively intact. During an interview on 2/14/24 at 4:00 p.m. with Resident 31, Resident 31 stated his curtain had been torn for a while. Resident 31 stated he did not remember when it happened. Resident 31 stated the cleaning lady knows about it. During an interview on 2/15/24 at 1:59 p.m. with the Housekeeping Manager (HSK MGR), the HSK MGR stated he was aware of Resident 31's torn curtain. The HSK MGR stated they were waiting for the curtain order to come in. During a review of the facility's policy and procedure (P&P) titled, Job Description . Light Housekeeper, dated (undated), the Job Description indicated . the light housekeeper . cleans floors in residents' rooms: Dry mops, wet mops, sweeps and disinfects; pulls dresser and moves furniture while dust mopping and damp mopping . ensures that established sanitation and safety standards are maintained . follows infection control and universal precautions policies and procedures to ensure that a sanitary environment is maintained at all times.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the dysphagia advanced (bite-sized foods that are moist) diet for five of 47 sampled residents (Residents 17, 22, 31, 35, and 36) when Residents 17, 22, 31, 35, and 36 received puree broccoli instead of chopped broccoli for lunch. This failure had the potential to result in Residents 17, 22, 31, 35, and 36 having a decrease in satisfaction with their meal because it was not the correct texture of food as prescribed by the physician. Findings: During an observation on 2/13/24 at 11:54 a.m. in the kitchen, Cook 1 plated the food for residents and served Resident 36 who was on a dysphagia advanced diet pureed broccoli. During a concurrent interview and record review on 2/15/24 at 10:29 a.m. with the Dietary Supervisor (DS), Resident 36's lunch meal tray ticket (document which indicates food items residents received for their meal), dated 2/13/24 was reviewed. The lunch meal tray ticket indicated, Resident 36 should receive half a cup of chopped roasted brussels sprouts (broccoli was substituted). The DS stated, the Cook should have prepared and served chopped broccoli. The DS stated, a dysphagia advanced diet should have a little more texture than a puree texture. During a review of the facility's document titled, Census List , dated 2/13/24, the document indicated five residents (Residents 17, 22, 31, 35 and 36) were on a dysphagia advanced diet. During a review of the facility's document titled, Production Counts, dated 2/13/24, the document indicated five servings of chopped roasted brussels sprouts (broccoli was substituted) should had been prepared and served for lunch. During a phone interview on 2/15/24 at 4:01 p.m. with the Registered Dietician (RD), the RD stated, her expectation for staff was to serve residents on a dysphagia advanced diet chopped vegetables. The RD stated her expectation was for staff to understand there were different versions of the dysphagia diet and should know how each diet should be served. During a review of the facility's Diet and Nutrition Care Manual, dated 2019, the Diet and Nutrition Care Manual indicated a dysphagia advanced diet would receive .cooked, tender, chopped, shredded . vegetables.

Based on observation, interview and record review the facility failed to ensure drug records to account for the receipt and accurate reconciliation (comparing medication received is being delivered) for controlled medications (medications that may be abused or cause addiction) for one of three sampled residents (Resident 13) when the pharmacy manifest (form that contains information about the type and quantity of medication delivered) was not signed upon delivery of a controlled medication. This failure had the potential for drug diversion (distribution or abuse of a prescription drug or it's use for purpose) of Resident 13's controlled medication. Findings: During a concurrent observation and record review on 2/14/24 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident 13's medication Acetaminophen-codeine (APAP/COD) #3 (controlled medication) tablet 300-30 mg (unit of measure) was observed during Medication cart 2's review of medications. During a review of Resident 13's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 13 was admitted to the facility on [DATE] with diagnosis, .Pain . polyneuropathy (A condition where many peripheral nerves are damages and is characterized by weakness, numbness and burning pain) . During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 13's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 13 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 13 was cognitively intact. During a review of the facility's manifest titled, Consolidated delivery sheets for controlled substances, dated 2/7/24, indicated, . 90-tab APAP/COD 300/30 mg delivered . The manifest was not signed with signature of recipient, dated and time medication was received from the pharmacy. During a review of Resident 13's, Physician Order, dated 7/27/23, indicated, . Acetaminophen-codeine #3 tablet 300-30 mg-controlled drug give one tablet by mouth three times a day for pain . During a concurrent interview and record review on 2/14/24 at 11:48 a.m. with LVN 1, the manifest titled, Consolidated delivery sheets for controlled substances, dated 2/7/24, indicated, . 90-tab APAP/COD 300/30 mg delivered ., was reviewed. LVN 1 stated the manifest was not signed and dated with time of receipt by the charge nurse. LVN 1 stated it was the expectation for the nurse receiving the medication to sign the pharmacy manifest and confirm with another nurse the amount of medication being delivered. LVN 1 stated the manifest for Resident 13's medication should have been signed by the receiving nurse to ensure the medication being delivered was correct. During a concurrent interview and record review on 2/15/24 at 3:33 p.m. with the director of nurses (DON), the manifest titled, Consolidated delivery sheets for controlled substances, dated 2/7/24, indicated, . 90-tab APAP/COD 300/30 mg delivered ., was reviewed. The DON stated the manifest was not signed and dated with time of receipt by the charge nurse. The DON stated upon review of the manifest, the charge nurse did not reconcile the medication for Resident 13 upon delivery. The DON stated it was the facility expectation for the charge nurse receiving medications from the pharmacy, to reconcile, sign and date the manifest before receiving. The DON stated it was important to have an accurate account of medications being received in the facility to avoid medication diversion. During a telephone interview on 2/15/24 at 4:02 p.m. with the pharmacy manager (PM), the PM stated it was the expectation for the facility to sign the manifest of all medications being received in the facility to ensure reconciliation of medications. During a review of the facility's P&P titled, Accepting Delivery of Medications, dated 2/2021 was reviewed. The P&P indicated, . any errors noted in receiving medications shall be brought to the attention of the pharmacist and the director of nursing services . before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/order receipt . if an error is identified when receiving medications from the pharmacy, the nurse verifying the order shall inform the delivery agent of any discrepancies and note them on the delivery ticket return correct medications to the dispensing pharmacy and reorder the correct medication . a nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors .

Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infections when: 1. Unit Manager-Registered Nurse (UM- RN) did not perform hand hygiene during a dressing change to Resident 28; 2. Three hand sanitizer dispensers in the hallway outside resident rooms did not work; These failures placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. During an observation on 2/14/24 at 3:35 p.m. in Resident 28's room, Unit Manager, RN (UM-RN) was observed performing a dressing change to Resident 28's right lower leg. UM-RN was observed removing soiled gloves after removing a soiled bandage and donning (putting on) new clean gloves without performing hand hygiene. During a review of Resident 28's Admission Record (AR), dated 2/15/24, the AR indicated, Resident 28 was admitted to the facility on [DATE] with diagnoses of chronic combined systolic (congestive) and diastolic (congestive) hear failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/5/23, the MDS Section C indicated, Resident 28 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) of 14 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 28 was cognitively intact. During an interview on 2/15/24 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated if staff providing residents wound care, gloves should be worn and once the gloves were taken off the hands should be washed. g. LVN 1 stated if staff is not washing hands after removing and before placing a clean pair of gloves it can cause cross-contamination to the resident. During an interview on 2/15/24 at 3:37 p.m. with the Infection Preventionist (IP), the IP stated staff need to wash hands before putting on gloves and in-between removing and putting on new gloves when doing wound care. The IP stated her expectation is that staff needs to wash hands before putting on the next pair of gloves. The IP stated there is a risk of cross-contamination and the resident's wound could get infected if proper hand hygiene is not performed. During an interview on 2/16/24 at 4:19 p.m. with the Director of Staff Development (DSD), the DSD stated her expectation is for staff to wash hands prior to providing wound care and after providing wound care. The DSD stated her expectation is for staff to wash their hands anytime their gloves become soiled and after taking off gloves. During an interview on 2/20/24 at 12:24 p.m. with the Director of Nursing (DON), the DON stated prior to performing a dressing change staff should perform hand hygiene: before applying clean gloves, after the removal of a soiled dressing, and perform hand hygiene again before applying a clean dressing. After performing the dressing change, remove gloves and perform hand hygiene. The DON stated staff should perform hand washing each time after removing gloves. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 2019, the P&P indicated, . all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . wash hands with soap . when hands are visibly soiled . before handling clean or soiled dressings . after contact with blood or bodily fluids . after handling used dressings . after removing gloves . hand hygiene is the final step after removing and disposing of personal protective equipment (PPE). During a review of the training and in-service logs titled, Enhanced Precaution Introduction . Washing Hands ., dated 3/29/23, indicated, UM-RN was not listed on the training log. During a review of the training and in-service logs titled, Hand hygiene/Peri hygiene, dated 4/28/23, indicated, UM-RN was not listed on the training log. 2. During an observation on 12/13/24 at 12:00 p.m. in the Unit B Hall, two sanitizer dispensers were observed to not dispense sanitizer solution. During an observation on 12/13/24 at 3:05 p.m. in the Unit C Hall, one sanitizer dispenser was observed to not dispense sanitizer solution. During a concurrent observation and interview on 2/15/24 at 9:55 a.m. with Housekeeper (HSK) 1 in the Unit B Hall, HSK checked the 2 sanitizer dispensers and was unable to get sanitizer solution to dispense. HSK stated if dispensers are not working, you could get germs, and everyone could get sick. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 2019, the P&P indicated, . Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff to use .

Based on interview and record review the facility failed to provide needed care according to professional standards of practice for one of four sampled residents (Resident 59) when facility did not notify physician of Resident 59's change of condition (COC) of hyperglycemia (high blood sugar). This failure had the potential to result in Resident 59's development of diabetic ketoacidosis (DKA- complication of diabetes, when the body can't make enough insulin to allow blood sugar into the cells for energy and the body breaks down fat). Findings: During a review of Resident 59's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 59 was admitted to the facility on [DATE] with diagnosis, . Influenza A with Pneumonia (lung inflammation caused by virus or bacteria) . Type 2 Diabetes Mellitus (DM-long term condition in which the body has trouble controlling blood sugar) . Muscle weakness . Dysphagia (difficulty swallowing) . cerebral infarction (disrupted blood flow in the brain) . hemiplegia (loss of ability to move one side of the body) . depression (constant feeling of sadness and loss of interest) . chronic kidney disease (progressive damage and loss of function to the kidneys) . pain . dependence of supplemental oxygen . hyperlipidemia (high fats or lipids in the blood). deficiency (lack of) of other specified B group vitamins (essential for normal growth and nutrition) . During a review of Resident 59's, Discharge Summary for expired residents, dated [DATE], indicated, . date and time of expiration: [DATE] at 12:24 p.m. final diagnosis/cause of death . cardiopulmonary arrest (sudden unexpected loss of heart function, breathing, and consciousness) . During a review of Resident 59's Physician Orders for Life Sustaining Treatment (POLST- a portable form with instructions for emergency medical care that travels with a resident), dated [DATE], indicated, . Do not attempt resuscitation (DNR) . Comfort-focused treatment . request transfer to hospital only if comfort needs cannot be met in current location . During a review of Resident 59's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 59's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 00 out of 15 (,d+[DATE] indicated severe cognitive impairment - [memory loss, poor decision making-skills] ,d+[DATE] moderate cognitive impairment, (,d+[DATE]) cognitively intact) which indicated Resident 59 BIMS could not be completed. During a review of Resident 59's, Nursing Note, dated [DATE] at 9:53 p.m., indicated, . sent Dr . a fax to notify of blood sugar (BS), was 425 and 450 was documented for night (NOC) shift . During a record review of Resident 59's, Blood Sugar Summary, dated [DATE]-[DATE], the summary indicated Resident 59 had a blood sugar documented on:[DATE] at 5:38 a.m. of 440 milligram/deciliter (mg/dL- unit of measure) and a blood sugar documented at 3:34 p.m. of 425 mg/dL. The Summary also indicated blood sugar documented on [DATE] at 7:16 a.m. of 500 mg/dL, 7:21 a.m. of 500 mg/dL, 1:45 p.m. of 411 mg/dL, 3:55 p.m. of 496 mg/dL and 7:02 p.m. of 430 mg/dL. During a review of Resident 59's Order Summary, dated [DATE], indicated, . Check Blood glucose twice a day, notify medical doctor (MD) if BS is more than 400 or less than 60. Two times a day for DM . Linagliptin (medication used to treat DM) oral tablet 5 mg give 1 tablet by mouth in the morning for DM . metformin hydrochloride (medication used to treat DM) give 1 tablet by mouth two times a day for DM . During a review of Resident 59's, Situation, background, assessment and Recommendation (SBAR), dated [DATE] at 5:28 a.m., indicated, . hyperglycemia fasting blood glucose at 500 . recommendation new orders from physician/provider: pending answer. Report given to AM to follow up resident appears in no s/s of pain or discomfort at this time . During a review of Resident 59's, Nursing note, dated [DATE] at 5:28 a.m., indicated, Resident has episode of hyperglycemia, called MD but unable to be reached at this time, faxed home fax, report given to AM shift to follow up with MD, resident appears comfortable at this time, no distress noted, no s/s of pain or discomfort, no facial grimacing or body guarding, no change from level of consciousness(LOC), resident is DNR comfort care, Resident representative (RR) has been made aware . During a review of Resident 59's, Nursing note, dated [DATE] at 11:18 a.m., indicated, . rechecked BS and is 370. Resident only taking 10% of breakfast and refusing to eat more. No distress continue to monitor & assess . During a review of Resident 59's, Nursing note, dated [DATE] at 1:37 p.m., indicated, . insulin (medication used to lower blood sugar) given to right lower quadrant (RLQ) for one time order for blood sugar (BS) 411. Continue to monitor & assess . During a review of Resident 59's, Order Summary, dated [DATE], indicated, . Insulin Lispro subcutaneous solution cartridge 100 unit/mL inject as per sliding scale: if ,d+[DATE] = 12 units; 451+ greater than 450 call MD . one time only for DM for 1 day . order status completed . order date [DATE] . order end date [DATE] . During a review of Resident 59's, Nursing Note, dated [DATE] at 12:45 p.m., indicated, . Resident is on alert charting for s/p hyperglycemia episode, resident had a blood sugar of 496, notified MD who gave order to give an additional 14 units of Humalog, rechecked blood sugar was 430, MD notified with no new orders, residents last blood sugar reading at 197 with insulin given, resident has not had any intake of nutrition, resident refused medications x 3 unable to open mouth properly to take medicine, resident on alert charting for unlabored breathing and high respiration rate, resident's current oxygen (O2) level at 89% on 3 liters via nasal cannula . RP notified, RP wishes to not send resident to hospital, resident is DNR, notified MD. MD gave order to keep resident comfortable, increase oxygen level as needed, resident at this time is laying in bed, when asked if comfortable resident nodded his head, respirations continue to fluctuate between 38 to 42 breaths per minute (BPM) . During a review of Resident 59's, Nursing Note, dated [DATE] at 12:45 p.m., indicated, . resident passed. No respirations and no pulse. Notified Dr . and paperwork started. Notified RP but no response . During a review of Resident 59's, Diabetes Mellitus (DM) Care Plan, dated [DATE], indicated, . the resident has DM at risk for complications . resident will be free from any signs and symptoms (s/sx) of hyperglycemia through the review date . Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness . Dietary consult for nutritional regimen and ongoing monitoring . monitor/document/report PRN compliance with diet and document any problems . During an interview on [DATE] at 11:37 a.m. with Licensed vocational nurse (LVN 4), LVN 4 stated the facility process for a change in condition (COC), was for the charge nurse to complete an assessment, call the residents physician, Resident 59's physician could have been contacted by pager, cell phone, main office line, or fax. LVN 4 stated if there was another physician assigned to the facility, the nurses call them if Residents physician could not be reached. LVN 4 stated it was the expectation for the oncoming nurse to continue to monitor the resident, attempt to contact the physician and document in Resident #'s medical record. LVN 4 stated it was not an acceptable practice to wait two days to notify Resident # physician of the COC and it was the expectation for the charge nurse to continue to follow up with the RP and physician while documenting all interventions completed for the resident. During a concurrent interview and record review on [DATE] at 3:51 p.m. with the director of nurses (DON), Resident 59's, Nurses Note, dated [DATE] at 9:53 p.m., indicated, . sent Dr . a fax to notify of blood sugar glucose (BSG), was 425 and 450 was documented for night (NOC) shift . The DON stated the facility process for a identifying a change of condition (COC) included the assessment of resident symptoms of hyperglycemia including sweating, altered mental status and Resident 59's level of consciousness. The DON stated the nurse should have checked Resident 59's vital signs which include respirations, heart rate, blood pressure, temperature, oxygen levels, blood sugar level and then notify the physician. The DON stated the physician should have been notified first by pager, then by cell phone, physician's office number, lastly by fax and when there was no response from the physician, it was the expectation that the nurse would have called the DON and the resident representative (RR) to update on Resident 59's condition and inability to contact the physician. The DON stated there was a delay in care for Resident 59. The DON stated the nurses note indicated there was not an appropriate assessment completed and the expectation was for the nurse identifying the COC to document the assessment, attempts to notify the physician, RP notification and response understanding the potential outcomes. On [DATE] at 11:34 a.m. a record review of the fax sent to physician to notify of Resident 59's COC was requested. The DON stated the fax was not available in Resident 59's medical chart. During an interview on [DATE] at 11:23 a.m. with LVN 1, LVN 1 stated the facility process for a COC included completion of an SBAR, physician notification, alert charting, and RR notification. LVN 1 stated it was expected to call the physician and allow time to follow up, typically within 30 minutes, if the physician could not be reached, it was expected the charge nurse call the medical director. LVN 1 stated Resident 59's high blood sugar was not a notification that should have been faxed to the physician because it could have taken ,d+[DATE] hours for a response. LVN 1 stated it was the expectation for the charge nurse to call the physician when there was an abnormal result, document the COC and call for emergency services if the physician could not be contacted. LVN 1 stated it was the expectation to educate the RR of the potential of outcomes or death and document in the medical record. During a concurrent interview and record review on [DATE] at 11:24 a.m. with LVN 1, Resident 59's Order Summary, dated [DATE] was reviewed. The order summary indicated, . Insulin Lispro subcutaneous solution cartridge 100 unit/mL inject as per sliding scale: if ,d+[DATE] = 12 units; 451+ greater than 450 call MD . one time only for DM for 1 day . LVN 1 stated that on [DATE] at 3:57 p.m., Resident 59's was administered 12 units of insulin Humalog. LVN 1 stated it was expected to document a follow up completed of resident 59's condition. During a concurrent interview and record review on [DATE] at 11:46 a.m. with the DON, Resident 59's Order Summary, dated [DATE] was reviewed, the order summary indicated, . Check blood glucose twice a day, notify MD if BS is more than 400 or less than 60 . The DON stated it was expected that the charge nurse notify the physician by any means necessary but preferably by phone. During a concurrent interview and record review on [DATE] at 11:46 with the DON, the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated ,d+[DATE]. The P&P indicated, . significant change in condition is a major decline or improvement in the resident's status . except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status . The DON stated Resident 59's elevated blood sugar was considered an emergency and it was expected the charge nurses would have identified the COC as a medical emergency. During a telephone interview on [DATE] at 12:05 p.m. with Resident 59's physician, the physician stated it was the expectation for the facility to have called and notified the physician immediately of Resident 59's significant COC. The physician stated there were protocols that are followed with a COC of high blood sugars and could not recall a fax received regarding Resident 59 from the facility. The physician stated the facility should have treated Resident 59's hyperglycemia even when the POLST stated DNR with comfort measures. The physician stated it was expected the facility explained and encouraged the RR to transfer Resident 59 to the hospital following the COC of elevated blood sugars if the physician was not available. The physician stated it was the expectation for the facility to identify a blood sugar reading of 400 or above as an emergency and should have notified the physician if the blood sugar readings were between ,d+[DATE] as it was expected to identify these readings as a warning sign, the physician further stated the order to notify physician should have read, call the physician. The physician stated the facility was familiar with the physician practices and should have transferred Resident 59 to the hospital when the COC occurred, as the weight loss and high blood sugars could have been a probable contributing factor in Resident 59's death. During a telephone interview on [DATE] at 12:32 p.m. with the resident representative (RR), the RR stated there were two phone calls received from the facility leading up to Resident 59 death. The phone calls were to notify of resident 59's oxygen levels with labored breathing and to inform of high blood sugars with unsuccessful outcome from the insulin administration to lower the blood sugar. The RR stated the facility communicated Resident # condition and upon Resident #'s wishes, resident was not transferred to the hospital. The RR stated Resident 59's death happened so fast following admission to During a telephone interview on [DATE] at 1:24 p.m. with the LVN 3, LVN 3 stated the facility process when a COC was identified was for the charge nurse to complete a resident assessment and notify the physician. The LVN 3 stated the physician was called for Resident 59 and when there was no response, the physician was then faxed. The LVN 3 stated Resident 59's high blood sugar would have been a significant change in condition. The LVN 3 stated there was a lack of documentation following the identified COC for Resident 59 and it was important to have documented the assessment as it would have provided more detail in Resident 59 condition. The LVN 3 stated there should have been more documentation and the COC should have been identified as an emergency requiring transfer to the hospital. During an interview on [DATE] at 1:31 p.m. with LVN 2, LVN 2 stated the facility process for identifying a COC was to notify the physician, RR, and complete an SBAR. LVN 2 stated it was the facility expectation to document an identified COC and resident assessment. LVN 2 stated a high blood sugar would be considered a COC and considered a medical emergency. LVN 2 stated when the physician was not reached by fax, it was the expectation to call the medical director and the DON. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated ,d+[DATE], indicated, . our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .the nurse will notify the resident's attending physician or physician on call when there has been a (an) . significant change in the resident's physical/emotional/mental condition . 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 . impacts more than one area of the resident's heath status . prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR . the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . During a review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated ,d+[DATE], indicated, . purpose to provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring . Diabetic ketoacidosis occurs when hyperglycemia is untreated . symptoms include . high blood sugar . weakness and fatigue . shortness of breath . confusion .establish provider notification protocols, for example . call as soon as possible when . blood glucose values are greater than 250 mg/dL more than once within a 24 hour period . blood glucose values are greater than 300 mg/dL more than once over two consecutive days . support optimal nutrition and protein intake for diabetic residents . monitor the resident for nutritional problems and unintended weight loss and notify the health care provider . During a professional reference review titled, [NAME] Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly . During a review of a professional reference titled, American Nurses Association: Principles of Nursing Documentation, dated 2010, page 8 indicated, .Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation .

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two of four sampled residents (Resident 361 and Resident 17) when 1. Resident 361's toenails were not cut or trimmed for a year and 3 months. 2. Resident 17's toenails were not cut or trimmed. These failures resulted in Resident 361's and Resident 17's toenails to become long and curled which had the potential to result in Resident 361's and Resident 17's toenails to become painful, ingrown or to break off the nail bed causing infection and limit resident's mobility during activities of daily living (ADL). Findings: 1. During an observation on 2/13/24 at 3:20 p.m. in Resident 361's room, Resident 361 was observed lying in bed with both feet exposed, observed to have long, yellow, hard thick toenails (all ten toes). During a review of Resident 361's Admission Record (AR), the AR indicated, Resident 361 was admitted to the facility on [DATE]. The AR indicated Resident 361 had a diagnosis of Unspecified Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Muscle Weakness (Generalized) (a condition when the muscle becomes weak due to aging or disease such as diabetics), Unspecified Abnormalities of the Gait and mobility (an abnormal walking condition), Unspecified Symbolic Dysfunctions (language deficits related to an organic or medical condition), Unspecified hearing loss bilateral (medical condition when both hearing have lost the ability to hear normally), Dysphagia oropharyngeal phase (a term that describes difficulty in swallowing), Major Depressive Disorder Unspecified (medical condition for feeling of sadness), Hypertension (medical condition when the pressure in your blood vessels is too high (140/90 mmHg or higher). During a review of Resident 361's Minimum Data Set (MDS-a resident assessment tool used to identify cognitive (mental processes) and physical function level assessment dated [DATE], the MDS indicated, Resident 361's Brief interview for Mental Status (BIMS-screening tool used to assess resident cognitive level) the score was 3 out of 15 (0-7 indicated severe cognitive impairment-[memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). Review of Resident 361's functional ability and Goals section GG under section I for personal hygiene the score was indicated at 2 (a score of 6 indicated resident is independent -no assistance needed, a of 5 indicated resident need help with setup or clean-up-assistance, a score of 3 indicated partial/moderate assistance [ helper does less than half the effort], a score of 2 indicated substantial/maximal assistance-[helper does more than half the effort], a score of 1 indicated resident is dependent where helper does all of the effect. During a review of Resident 361's Nursing Care Plan (CP), dated 3/11/2022 the CP indicated, Resident 361 has an ADL self-care performance deficit Activity Intolerance .muscle impairment. The CP goals indicate Resident 361 will improve with current level of function with target date of 2/29/2024. Resident 361's intervention included bathing and showering staff to provide personal hygiene routinely, CNAs to assist with dressing and grooming every shift as tolerated. During an interview on 2/13/24 at 3:22 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 361 had a diagnosis of diabetes (a medical condition in which the sugar level is high in the bloodstream). LVN 5 stated the podiatrist (foot doctor) was responsible for trimming Resident 361's toenails due to his diagnosis of diabetes. LVN 5 stated it was the facility process to refer resident's who had a diagnosis of diabetes to the podiatrist for further care. During a review of Resident 361's Order Summary, dated 1/11/24, the Order Summary indicated, .Ordered Date: 1/11/2024 at 4:44 p.m. Description: Podiatry as Needed for Mycotic/hypertrophic [an infection that affects your toenails and separates your nail from your nail bed, making it thick and fragile] and/or keratotic lesion [A bump or patch of thickened skin] . During a concurrent interview and record review on 2/14/24 at 9:26 a.m., with the Unit Manager Registered Nurse (UM-RN), Resident 361's Order Summary dated 1/11/24 was reviewed. The Order Summary indicated, .Ordered Date: 1/11/2024 at 4:44 p.m. Description: Podiatry as Needed for Mycotic/hypertrophic and/or keratotic lesion . The UM-RN stated on 2/14/24 Resident 361's toenail were observed long and proceeded to trim them. The UM-RN stated Resident 361 needed full assistance with ADL's including nail care. The UM-RN stated the Certified Nurse Assistants (CNA) were responsible for notifying the nurses when Resident 361 needed the toenails trimmed because the CNAs were not trained to cut or trim toenails for residents with a diagnosis of diabetes. The UM-RN stated she could not recall the last time Resident 361's toenails were trimmed/cut prior to 2/14/24. During an interview on 2/14/24 at 4:44 p.m. with the Social Services Director (SSD), the SSD stated it was the facility process expectation was to follow up after a grievance was received and obtain a physician order to refer Resident 361 to a podiatrist. The SSD stated after receiving the physician order for referral it was then communicated to the scheduler for transportation and scheduling of podiatry services per insurance. During an interview on 2/15/24 at 9:42 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to care for Resident 361 and was familiar with the resident's care needs. CNA 1 stated it was the facility process to allow CNAs to trim/cut fingernails, but they were not allowed to trim/cut toenails because they were not trained and could potentially cause skin breakdown with residents who were diagnosed with diabetes. CNA 1 stated it was the facility expectation for all scheduled CNAs to observe residents' toenails during ADL care and notify the charge nurse when the toenails needed to be trimmed or cut. During an interview on 2/15/24 at 10:02 a.m. with the SSD, the SSD stated Resident 361 did not have an appointment scheduled with the podiatrist. The SSD stated she was not aware Resident 361's toenails were long and needed to be trimmed. SSD stated it was the facility process to identify needed services such as a referral to a podiatrist and schedule appointments as needed. The SSD stated it was the expectation to follow a grievance from the resident or resident representative (RP) immediately to identify the issue and correct it. During an interview on 2/15/24 at 10:02 a.m., with the Business office Manager (BOM), the BOM stated Resident 361 did not have a referral to be seen by podiatry. The BOM stated there were no notification from facility staff reporting Resident 361's toenails being long and needing to be trimmed or cut. The BOM stated it was the facility process for the BOM to receive a referral from the SSD and provide transportation to the podiatry services. During a concurrent interview and record review on 2/25/24 at 10:14 a.m. with the infection preventionist (IP), a photograph taken on of Resident 361's toenails , was reviewed. The IP stated Resident 361's toenail appearance was a dignity issue and appeared to not have been trimmed or cut for a long period of time. The IP stated it was the facility process that the CNAs provided toenail care on Resident 361's assigned shower days and during ADL care. The IP stated, it was the facility process for the CNAs to notify the charge nurse when Resident 361 needed to have the toenails trimmed or cut, as the CNAs were not allowed to cut any resident's toenails when there was a diagnosis of diabetes. The IP stated it was the expectation for the charge nurse to notify the SSD to schedule an appointment with the podiatrist. The IP stated long toenails could have harmed Resident 361 because of the potential for infection or dislodgment (force out of a secure or settled position) of the toenails. During a concurrent interview and record review on 2/15/24 at 2:37 p.m., with the Director of Nursing (DON), a photograph taken of Resident 361's toenails, was reviewed. The DON stated based on the photograph it appeared the resident had not had nail care provided. The DON stated it was the facility process for the CNAs to provide toenail care during ADL's to resident's who did not have a diagnosis of diabetes and were responsible for notifying the charge nurse when a resident needed toenail care. The DON stated she expected the nurses to obtain a physician order for a referral to schedule an appointment with the podiatrist. The DON stated the SSD was responsible for making an appointment with the podiatrist and schedule the transportation for Resident 361. The DON stated personal hygiene was important due to the potential risk for infection and for a dignified existence. 2. During a concurrent observation and interview on 2/13/24 at 4:56 p.m., with Resident 17, in Resident 17's room, Resident 17 was observed lying in bed, slightly ungroomed in appearance and responsive to voice. Resident 17 stated he has been at the facility for three weeks and no one has asked him about his preferences. Resident 17 stated it is his preference to have his toenails clipped but doesn't bother telling staff because as an example he asked for a washcloth to wash his face about 1 o'clock and nothing, it's been 4 hours. During a review of Resident 17's Admission Record (AR), the AR indicated, Resident 17 was admitted to the facility on [DATE]. The AR indicated Resident 17 had a diagnosis of dementia, muscle weakness, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems) morbid obesity, difficulty in walking, meniscus derangement (describes disorders affecting the knee joint) right knee. During a review of Resident 17's MDS dated [DATE], the MDS indicated Resident 17's BIMS score was 12 out of 15 (moderate cognitive impairment). During a concurrent observation and interview on 2/13/24 at 5:00 p.m., with CNA 7, in Resident 17's room. CNA 7 responded to Resident 17's request for help by using the call light. CNA 7 came in and took Resident 17's vital signs (blood pressure, heart rate, etc.). CNA 7 stated her practice is to, normally, introduces self and tell them [residents] she will be their CNA for the shift. CNA 7 assisted resident to apply non-skid large size socks. CNA 7 stated Resident 17's toenails look like they could be trimmed. Resident 17 stated he would like his toenails clipped and had not been asked this before and they don't listen to me about my preferences. During a review of Resident 17's Order Summary Report dated 2/14/24, the report indicated, .May have dental, vision & eye health, hearing, and podiatry consults as needed .Order Date 12/8/23 . During a Review of Resident 17's Care Plan (CP), dated 2/16/23, CP indicated Focus Resident 17 .has an ADL self-care performance deficit r/t (related to) muscle weakness, torn right knee meniscus .Goal Resident 17 will improve current level of function through the review date .Interventions During Shower Days check fingernails and toenails if need to be trimmed. Notify Charge Nurse . During a concurrent interview and record review on 2/15/24 at 2:37 p.m., with the DON, a photograph taken of Resident 17's toenails, was reviewed. The DON stated based on the photograph it appeared resident had not had nail care provided. The DON stated it was the facility process for the CNAs to provide toenail care during ADL's to resident's who did not have a diagnosis of diabetes and were responsible for notifying the charge nurse when a resident needed toenail care. The DON stated she expected the nurses to obtain a physician order for a referral to schedule an appointment with the podiatrist. The DON stated personal hygiene was important due to the potential risk for infection and for a dignified existence. During a concurrent interview and record review on 2/16/24 at 10:19 a.m., with LVN 4, Resident 17's CP was reviewed. LVN 4 stated one of the goals is .improve current ADL's function . LVN 5 stated he would do toenail care for diabetics, if the nails were too thick the resident would be send out to podiatry. LVN 4 stated CNAs can do nail care for non-diabetics. LVN 5 stated it is hard to know when podiatry was here last due to days off and there are different vendors, the optometrist comes often. LVN 5 stated Resident 17's CP was not updated to reflect resident's current status, he is no longer max assist. LVN 5 stated the CP should be updated when it doesn't match his current level of ability. LVN 5 stated he does not know what the policy states about how often the CP should be updated. During a review of the facility's job description titled, Certified Nursing Assistant, dated 10/2020. The job description indicated, . the primary purpose of this position is to provide residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . assist residents in accordance with their needs ranging from minimal assistance to total dependent care on activities of daily living ADL's . assist residents with bathing functions . assist residents with personal grooming . assist non-diabetic residents with nail care . check each resident routinely to ensure that his/her personal care needs are being met . During a review of the facility's job description titled, Registered Nurse (RN), dated 10/2020. The job description indicated, . the primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents attending physician . provide support and assistance with residents' personal care and activities of daily living as needed . During a review of the facility's policy and procedure (P&P) titled Foot Care, dated 3/2018, the P&P indicated, . residents will receive appropriate care and treatment in order to maintain mobility and foot health . residents will be provided with foot care and treatment in accordance with professional standards of practice . resident will be assisted in making transportation appointments to and from specialists podiatrist . as needed . trained staff may provide routine foot care . During a review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated 11/2020, the P&P indicated, . skin and foot care .toenails should only be trimmed be personnel qualified to do so this can be regular associates, and does not have to be a podiatrist . During a review of the facility's P&P titled, Resident rights, dated 2/2021, the P&P indicated, . employees shall treat all residents with kindness, respect and dignity . the rights include the residents right to a dignified existence . exercise his or her rights . During a review of the Nursing Times article titled, Foot Assessment and Care for Older People dated 12/9/14, the article indicated, .Foot care can prevent mobility problems and social isolation; it is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet . Toenail disorders including hardened or ingrown nails . Toenails can thicken and become hard and brittle with age, which makes it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .Fungal infection of skin, such as athlete's foot - which causes peeling, redness, itching, burning .Fungal nail infections occur when microscopic fungi enter the nail through a break; they result in thick, discolored and brittle nails .Foot assessment .When older people can no longer manage their own foot care, an initial assessment is required to identify what help they need .Podiatrists assess all new nursing home residents . After an individual has been assessed, care may be provided by Podiatrists . Referrals should be made to podiatrists, GPs, or pharmacists (for medication review) if patients have .Medical complications that put feet at risk, such as diabetes .Painful foot lesions, including severe deformities and toenails that are excessively thickened and cause pain, prevent mobility or are a risk to surrounding skin .Loss of sensation .Patients with diabetes who have an increased risk must have an expert assessment carried out by health professionals with specialist experience in the management of the foot in diabetes. Registered nurses should know who to refer and should ensure a timely referral is made and response given .

Based on observation, interview, and record review the facility failed to ensure medications were properly stored and labeled in accordance with professional standards when: 1. The facility's medication emergency kit (ekit) containing controlled medications (medications that may be abused or cause addiction) was observed missing a zip tie. 2. Medication for one of three sampled residents (Resident 14) was observed with expired date in Medication Cart two. These failures had the potential for medication diversion (distribution or abuse of a prescription drug or it's use for purpose) from the ekit and the potential for adverse effects (undesired harmful effect) and medication error for Resident 14 when the expired medication was left in the medication cart. Findings: 1. During a concurrent observation and interview on 2/14/24 at 10:48 a.m. with licensed vocational nurse (LVN) 1 in the medication room, the ekit for medications taken by mouth, was observed inside a file cabinet with one red zip tie on the right-side lock, the left side lock did not have a zip tie. LVN 1 stated once the e-kit was open it was easier to open and retrieve medications. LVN 1 stated the ekit was not properly secured because the zip tie on the left side was missing. LVN 1 stated there was a potential for medications to go missing and the ekit should not have been received by the charge nurse if there was a missing zip tie. During a review of the facility's, Oral Emergency Kit inventory, dated August 2022, indicated, . medication name and strength . Acetaminophen-codeine (controlled pain medication) 30 mg (unit of measure)/300 mg 4 tablets (tabs) . alprazolam (controlled medication used to treat anxiety) 0.5 mg 8 tabs . clonazepam (controlled medication used to treat anxiety) 0.5 mg 8 tabs . lorazepam (controlled medication used to treat anxiety) 0.5 mg 8 tabs . quetiapine(medication used to treat mental disorders) 25 mg 4 tabs . tramadol (controlled pain medication) 50 mg 8 tabs . zolpidem (controlled medication used to treat sleeping disorder) 5 mg 4 tabs . During a review of the facility's, Manifest, dated 2/13/24, the manifest indicated, . emergency PO e-kit new . quantity one delivered . The manifest indicated the facility received the delivery of the e-kit with confirmation of receiving nurse signature, date and time. During an interview on 2/15/24 at 3:28 p.m. with the director of nurses (DON), the DON stated the expectation was for the ekit's to be fully sealed with two zip ties when it arrives from the pharmacy. The DON stated if the ekit was missing a zip tie, it was the expectation for the receiving nurse to refuse acceptance of the ekit and call the pharmacy for a delivery of a sealed ekit. The DON stated there was a potential for drug diversion (illegal distribution or abuse of medications) when the ekit was not properly secure with two zip ties. During a telephone interview on 2/15/24 at 3:55 p.m. with the pharmacy manager (PC), the PC stated it was the expectation for the facility nurse receiving the ekit to sign the acceptance on the pharmacy delivery slip. The PC stated the ekit's delivered to the facility have two red zip ties for quality assurance. The PC stated it was expected that the facility used yellow zip ties to identify when the e-kit was opened and replacement was needed. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated 8/2014 was reviewed. The P&P indicated, . when an emergency or stat dose of a medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply . before reporting off duty, the charge nurse indicates the opened status of the emergency kit at the shift change report . if exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening . During a review of the facility's P&P titled, Accepting Delivery of Medications, dated 2/2021 was reviewed. The P&P indicated, . any errors noted in receiving medications shall be brought to the attention of the pharmacist and the director of nursing services . before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/order receipt . if an error is identified when receiving medications from the pharmacy, the nurse verifying the order shall inform the delivery agent of any discrepancies and note them on the delivery ticket return correct medications to the dispensing pharmacy and reorder the correct medication . a nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors . 2. During a concurrent observation and interview on 2/14/24 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident 14 medication container for nitroglycerin (used to treat chest pain) 0.4 mg (unit of measure) expiration date 10/20/23 was observed in medication cart two. LVN 1 stated the medication for Resident 14 was expired and should not have been left in the medication cart. LVN 1 stated there was a potential for adverse reactions and medication ineffectiveness if the medication was administered. During a review of Resident 14's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 14 was admitted to the facility on [DATE] with diagnosis, .myocardial infarction (heart attack) . congestive heart failure (heart does not pump blood the way it should) . During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 14's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 11 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 14 was moderately cognitively intact. During a review of Resident 14's, Physician order, dated 3/15/2022, indicated, . Nitroglycerin tablet sublingual 0.4 mg give one tablet sublingually (under the tongue) every 5 minutes as needed for chest pain x 3 doses. If no relief call MD . During an interview on 2/15/24 at 3:37 p.m. with the director of nurses (DON), the DON stated the facility expectation was for the expired medications to have been removed from the medication cart. The DON stated there was a potential for Resident 14 to experience adverse effects or medication ineffectiveness if medication was administered. The DON stated it was the expectation for the nurses to check the medication carts daily for expired medications. The DON stated it was the expectation to have an expiration date on all medications to avoid potentially administering expired medications to Resident 14. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 4/2008, indicated, . medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . outdated, contaminated or deteriorated medications and those in containers that are . immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if current order exists . medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified . During a review of the facility's P&P titled, Labeling of Medication Containers, dated 2/2019 indicated, . all medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations . labels for individual resident medications include all necessary information, such as . the expiration date when applicable .

Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when a drawer holding clean utensils used for meal service was no longer on the drawer track (the mechanisms that allow drawers to open and close smoothly) and was difficult to open and close. This failure had the potential to result in contamination of the clean utensils because the drawer could not be completely closed and potential in bodily injury to dietary staff. Findings: During an initial kitchen tour on 2/13/24 at 10:58 a.m., an observation of a drawer holding clean utensils used for meal service was found to be difficult to open and close and it was kept ajar. The drawer was not on the track on one side and it make it difficult to open and close. During a concurrent observation and interview on 2/14/24 at 8:34 a.m. with the District Dietary Manager (DDM) in the kitchen, a drawer was difficult to open and close. The DDM stated, the DDM was not sure if the drawer could be fixed. During an interview on 2/15/24 at 10:41 a.m. with the Regional Maintenance Supervisor (RMS), the RMS stated he was unaware of a drawer in the kitchen that needed to be repaired. During a phone interview on 2/15/24 at 4:01 p.m. with the Registered Dietician (RD), the RD stated, the drawer was difficult to open and close and her expectation was for the drawer to be fixed. During a phone interview on 2/16/24 at 3:22 p.m. with the Maintenance Supervisor (MS), the MS stated, he was notified of the drawer in the kitchen that was difficult to open and close two weeks ago. The MS stated, he was not sure if there was a TELS (facility's electronic work order system) work order created. The MS stated, he had planned to fix the broken drawer but was focused on other projects. During a review of the professional reference titled, FDA Food Code, dated 2022, 4-501.11 indicated, .(B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications . In addition, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed.

Based on interview and record review the facility failed to provide a copy of the resident's medical record for one of one resident (Resident 1) when Resident 1 requested her medical records on 9/21/23. This failure was not the standard of practice according to the facility's policy and procedure (P&P) titled, Release of Information. Findings: During an interview on 10/6/23 at 12:23 p.m., with Resident 1, Resident 1 stated she requested her medical records on 9/21/23 and received her requested documents on 10/2/23. During a review of Resident 1's Medical Record Request form (MRR), dated 9/21/23, the MRR from indicated, Resident 1 and the Medical Records Director signed the MRR on 9/21/23. During a concurrent interview and record review on 10/6/23 at 11:55 a.m., with Medical Records Director (MRD), Resident 1's MMR and the facility's P&P titled, Release of Information, were reviewed. The MMR indicated Resident 1 requested the release of her medical records on 9/21/23. MRD stated Resident 1's medical records were delivered to Resident 1 a week later after the request. MRD stated he did not document when the medical records were delivered. MRD stated the facility did not require documentation of when requested documents were delivered. MRD stated, Resident 1's medical records should have been delivered within 72 hours as indicated in the facility's P&P titled, Medical Record Request. During an interview 10/6/23 12:00 p.m. with the Administrator (ADM), ADM stated receiving the requested documents 6 days after the requested date was not acceptable. ADM stated the standard of practice for delivering the requested documents was to follow the facility's P&P which indicated requested medical records were to be delivered to the resident within 72 hours. ADM stated it was unacceptable for the MDR to not document when requested documents were delivered to the residents upon request. During a review of the facility's P&P titled, Release of Information, dated 11/2009, the P&P indicated, Policy Interpretation and Implementation . 9. A resident may have access to his or her records within 72 hours (excluding weekends or holidays) of the resident's written or oral request .

Based on observation, interview, and record review, the facility failed to ensure resident's food preference were honored for one of 50 sampled residents (Resident 49) when Resident 49 and her family told staff that Resident 49 disliked chopped foods. No food upgrade options were provided for Resident 49, despite informing the staff that she did not want tomatoes soup, yet she still received it on 4/12/23 during dinner. This failure resulted in Resident 49 decreased food intake with an unplanned 1.6-pound weight loss from 1/31/23 until 4/9/23 which further compromised Resident 49's nutritional and medical status. Findings: During a concurrent interview and meal tray ticket reviewed on 4/10/23, at 11:34 a.m., with Resident 49, Resident 49 stated, I told staff a lot of times, I do not like chopped foods, but they still give me chopped foods. Resident 49 stated, I do not know what kind of diet I am on. I got teeth, I can chew. Resident 49 stated, My son has told staff that I do not like chopped foods and requested change the diet texture. Resident 49 stated she was tired of being provided tomatoes soup; even though she requested not to receive it. She asked for a sandwich, but she never got the requested sandwich. Observed Resident's meal tray ticket (which list out all food items served to resident), indicated, Resident on Dysphagia advanced texture (a diet with food texture need to chop up or ground into small piece for resident who have limited chewing and swallowing ability). During a review of Resident 49's Minimum Data Set (MDS- a standardized assessment and care-planning tool), dated 2/1/23, the MDS indicated, Resident 49 had a BIMS (Brief Interview for Mental Status) score of 12 which (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 41 had no cognitive impairment. During a concurrent dining observation and meal tray ticket review on 4/11/23, at 12:39 p.m., Resident 49 was observed being served chopped Swedish meatballs on her Entree. Resident 49 stated, she was not going to touch the served chopped meatballs. Reviewed Resident 49's meal tray ticket, indicated Dysphagia Advanced texture, . Ground Swedish meatballs. During an interview on 4/11/23, at 3:40 p.m., with the Registered Dietitian (RD), the RD stated, honored food preferences was very important for residents. The RD explained that if food preference were not being honored to residents, it could cause decrease amount of foods intake and weight loss. During an interview on 4/12/23, at 10:40 a.m., with Speech and Language Pathologist (SLP), SLP stated, she was unaware that Resident 49 was unhappy with chopped foods and no staff in the facility informed her that Resident 49 dislike chopped foods. Otherwise, she could have reevaluate Resident 49 for potential food texture upgrade. During an interview on 4/12/23, at 11:42 p.m., with Resident 49, Resident 49 stated, she told staff including the Registered Dietitian that she did not want and did not like the chopped foods and she would not eat the chopped foods. Resident 49 stated, she had no issues swallowing and her family brought her regular texture foods weekly and she eat them without problem. Resident 49 stated, My son brings me hamburger. I eat the whole hamburger without problem. Resident 49 stated, she had a history of unplanned weight loss because she would not eat the served chopped foods. Resident 49 stated, It makes my mouth watery when I see my roommate eat bacon, toast. I want a piece of tortilla and ham. But the staff told me I could not have them because I am on chopped foods. During an interview on 4/12/23, at 12:22 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, he was not sure why Resident 49 was required to be on a dysphagia advanced diet. During an interview on 4/12/23, at 3:38 p.m., with RD, the RD stated, she didn't ask Resident 49 why she had been eating less. The RD stated, she had not observed Resident 49's full meal intake, so she had no idea that Resident 49 disliked chopped foods and refused to eat chopped foods. During a concurrent observation and interview on 4/12/23 at 6:08 p.m., with Resident 49, in Resident 49's room, observed a bowl of tomatoes soup being served. Resident 49 stated, she did not want the tomatoes soup anymore and she informed staff about it. Resident 49 also stated, since she did not touch the Swedish chopped meatballs lunch yesterday, she requested sandwich 2 times from staff, but she did not get the sandwich. During an interview on 4/13/23, at 9:03 a.m., with the Dietary Manager (DM), the DM stated, he interviewed Resident 49 on 3/29/23 and the resident told him she did not want tomato soup. During an interview on 4/13/23, at 9:28 a.m., with Resident 49's family member (RF 1), RF 1 stated, His mom told him she doesn't like chopped food and won't eat it. RF 1 stated, he complained to staff about the chopped foods. RF 1 stated, he had asked to speak to the RD all the time regarding his mother's weight loss and why she was not given sandwiches as meal replacements. RF 1 stated, the staff replied to him with the answer that either the RD was gone or busy. RF 1 stated, staff told him if his mom did not care for the provided foods then he could bring foods from home. RF 1 stated, he brought hamburgers, Carne [NAME] (marinated and grilled beef) Tacos, Residents 49 finished foods he brought without any swallowing and chewing issue. RF 1 stated, No one has ever told him why his mom is on this specific diet because she can eat everything with no issues of swallowing or chewing. RF 1 stated, His mom has told him that she has told people that she would like sandwich instead of some of the meals and no one ever brings it to her. He told staff she likes sandwiches and knows they still haven't given her any. During an interview on 4/13/23, at 1:16 p.m., with Director of Nursing (DON), DON stated, Chopped diet needs to be adjusted than speech therapy would have to evaluate that. DON stated, The goal for resident is to advance diet texture to a regular texture if safe. Resident should not be staying on a different diet texture other than regular if the resident can tolerate regular texture, especially if the residents do not prefer the diet texture they are on and of course, as long as they could tolerate it. DON stated, a diet texture concern went to the SLP. DON stated, nursing staff should fill out a communication slip or speak to the SLP directly if diet texture concerns arise. DON stated, nursing staff needed to explain to the residents what the special diet or diet texture the doctor ordered to the residents and the RD needs to be involved in Residents' nutrition care preferences. During a review of Resident 49's Physician ordered, dated on 4/12/23, Physician ordered indicated, Diet: Dysphagia Advance diet, Order date:1/30/23 During a review of Resident 49's weight history: 1/31/23: 100.8 pounds (lbs.), 4/9/23: 99.2. lbs. Resident 49 loss 1.6 lbs. from 1/31/23 (which started Dysphagia Advance diet) until recent. During a review of the facility's policy and procedure (P&P) titled, Dining and Food Preferences, revised 9/2017, the P&P indicated, POLICY: Individual dining, food, and beverage preferences are identified for all residents/patients. PROCEDURE: .The Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups .The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences .Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutritional value.

Based on family/staff interview and record review, the facility failed to meet residents healthcare needs and ensure residents were free from neglect for one of 20 sampled residents Resident (116), when Resident 116 developed a change in condition (fever and vomiting spells) and was not promptly assessed for a change of condition which delayed Resident 116's transfer to the hospital for sixteen hours. This failure resulted in a delay of medical evaluation and treatment at a higher level of care when Resident 116 was admitted to the acute care hospital [MEDICAL CONDITION] and Multi-Organ failure. Findings: Resident 116's Admission Record indicated, she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].), Hx (history) of [MEDICAL CONDITION] (a tube inserted through the trachea (windpipe) to provide an airway), Dysphagia (difficulty of swallowing), Chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] (a deprivation of oxygen to the brain) [MEDICAL CONDITION] (lack of oxygen in the brain) brain damage, [MEDICAL CONDITION] (paralysis of all four limbs . Resident 116's progress notes dated 5/14/18, indicated, ( . resident (116) . does not (speak) but uses gestures to answer or blinks eyes to reply yes or no . Resident 116's progress notes dated 5/23/18 at 11:05 p.m., indicated, V/S (Vital Signs - clinical measurements, pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) (Temperature) 102; (Heart Rate) 110, (Respiration) 22, (Blood Pressure) 89/54, Resident noted to have elevated temperature, and elevated heart rate, resident appeared more lethargic than normal and had emesis (vomiting) X (times) 2, once on my shift and other on the AM shift, resident is nonverbal unable to verbalize (speak) any symptoms, notified the physician and received a new order to send to an acute hospital for treatment and evaluation . (Resident 116) left the facility at around (4:30 p.m., on 5/23/18) by . ambulance. According to the professional reference Vital signs: MedlinePlus Medical Encyclopedia dated 1/26/17, indicated, Normal vital sign ranges for the average healthy adult while resting are: Blood pressure: 90/60 mm Hg to 120/80 mm Hg. Breathing: 12 to 18 breaths per minute. Pulse: 60 to 100 beats per minute. Temperature: 97.8°F (degrees - Fahrenheit) to 99.1°F (36.5°C to 37.3°C)/average 98.6°F (37°C). Resident 116's Medication Administration Record [REDACTED]°. Resident 116's hospital record titled Discharge Referral dated 5/30/18, indicated, Resident 116 was transferred to a local acute hospital on [DATE] [MEDICAL CONDITION] (the presence in tissues of harmful bacteria and their toxins through infection) and bacteremia (presence of bacteria in the blood) . She was transferred from a local acute hospital on [DATE] with altered mental status for unknown duration. She was found to be septic and dehydrated (a harmful reduction in the amount of water in the body) . She was transferred over to an out of town acute hospital for a higher level of care . prognosis remains extremely poor given multiorgan failure and organ damage . the patient in on IV (intravenous) abx (Antibiotics) (Ertapenem 1 gm Q (every) 24 hours for 14 days starting 5/29/18. Ready for DC (discharge) today (5/30/18). On 5/29/18 at 5:45 PM, during a telephone interview, Resident 116's husband stated the resident was sent out to a local acute hospital on [DATE] in the afternoon and was transferred to another acute hospital because of the seriousness of the resident's condition. On 5/30/18 at 2:45 PM, during an interview, Registered Nurse (LN 2) stated on 5/23/18 at 3:30 PM., during an afternoon medication pass while administering medication to Resident 20, he observed Resident 116 vomiting large amount of vomitus (material ejected from vomiting) from her mouth and trachea opening. LN 2 noted the resident's skin felt hot and appeared more lethargic (sluggish or lacking energy). LN 2 stated the resident was non-verbal and would not be able to verbalize any symptoms. The resident's physician was notified 16 hours after resident 20's change of condition developed. LN 2 stated an order was received to send the resident to an acute hospital for evaluation and treatment. LN 2 stated he received report Resident 116 had been vomiting during the morning hours of night shift on 5/23/18. On 5/30/18 at 3:09 PM, during an interview, the Certified Nurse Assistant (CNA 7) stated during the change of shift report, CNA 8 (morning shift) informed her that Resident 116 had fever and had been vomiting during the night shift. CNA 8 reported Resident 116 was unable to urinate during the morning shift. Resident 116's Bladder Elimination record dated 5/23/18, morning shift indicated Resident 116 was incontinent and had not urinate for the eight hour during the day shift. On 5/30/18 at 3:25 PM., during a telephone interview, CNA 8 stated Resident 116 had vomited two times during his night shift at around midnight. When Resident 116 vomited the first time, the amount was not so much but when the resident vomited the second time, it was of large amount which resulted in Resident 116 needing to be cleaned up and her clothes changed. CNA 8 stated the vomitus was the same color and consistency of Resident 116's feeding formula. CNA 8 stated he took Resident 116's temperature by axilla and it was 99.1 F. CNA 8 stated LN 1 asked him to apply cold wash cloth (cooling measures) on Resident 116's forehead. The resident's temperature was rechecked after 1 hour and the fever went down to 98 F. CNA 8 stated she informed CNA 7 (morning CNA) about the Resident 116's fever and vomited two times during the night shift. On 5/30/18 at 3:45 PM, during a telephone interview, LN 1 stated during a midnight medication pass Resident 20 had vomited large amount of feedings that it soiled the resident's clothes. She had requested CNA 8 to clean up the resident and change Resident 116's clothes. LN 1 stated the resident had a fever of 99.1° F and she administered Tylenol (medication used to reduce fever). LN 1 stated she called Resident' 116's physician and informed the physician of Resident 116's vomiting and receiving an order for [REDACTED]. On 5/31/18 at 3:37 p.m., during an interview, the physician stated he had ordered Resident 116 to be sent out to the hospital. The physician stated he did not remember receiving a call during the night shift from the LN regarding Resident 116's change of condition (vomiting and fever). The physician stated, If it was not documented, it was not done. On 5/30/18 at 2:30 p.m., during an interview, LN 4 (Registered Nurse/ Unit Manager) stated he was not informed of Resident 116's fever and vomiting, but stated the resident did not have fever and vomiting during the morning. Resident 116's facility's document titled Progress Notes dated 5/23/18 had no documented evidence of the Resident 116's change of condition during the night and morning shifts. Resident 116's facility's document titled Temperature Summary dated 5/23/18 at 5:22 a.m., indicated Resident 116's body temperature was 99.1 (Axilla), on 5/23/18 at 4 p.m., temperature was 102.2 F. Resident 116's facility's document titled SBAR (Situation-Background- Assessment-Recommendation} Communication Form and Progress Notes for RNs/ LN (Licensed Nurse) dated 5/23/18, indicated Resident 20 was observed with a change of condition, symptoms, or signs observed and evaluated is/are: Abnormal vital signs . nausea and vomiting . Resident 116's facility's document titled Nursing Home to Hospital Transfer Form, indicated the resident was sent out to an acute hospital on [DATE] at 4:05 p.m. On 5/31/18 at 3:15 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated Resident 116 show symptoms of change in condition leading to the transfer of Resident 116 to the hospital on [DATE] at 4 p.m. The DON reviewed Resident 116's clinical record and was unable to provide documented evidence of Resident 116's change of condition (vomiting and fever) from the night and morning shift. The DON was unable to find documented evidence Resident 116's condition was monitored on the morning shifts. The DON stated the expectation would for the LN to document the notification of changes in residents' condition to the attending physician and that did not occur promptly with Resident 116. The facility's policy and procedure titled, Freedom from Abuse, Neglect and Exploitation dated 11/20/17, indicated, Neglect a. Neglect may be occurring, if the facility is aware of, or should have been aware of goods or services that the resident requires but the facility fails to provide them to the resident; b. Neglect maybe the result of failures or the result of one or more failures involving one resident and one staff person. c. the facility will conduct initial and on-going assessment of the resident to identify the goods and services needed by the resident. The facility's policy and procedure titled, Charting and Documentation dated 4/08, indicated, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical records. The facility's policy and procedure titled Acute Condition Changes -Clinical Protocol dated 12/15 indicated, .3. Direct care staff, including nurse assistants will be trained in recognizing subtle but significant changes in the resident . and how to communicate these changes to the Nurse . 6. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician . including the resident's current symptoms and status. b. Nurses are encouraged to use the SBAR Communication Form and Progress Notes as a tool to help gather and organize information before notifying the doctor.

Based on observation, facility and hospice staff interview, clinical record, administrative document, and professional reference review, the facility failed to ensure residents were free of significant medication errors when one of 16 sampled residents (Resident 1's) Physician order [REDACTED]. These failures resulted in Resident 1's increased physical distress and pain when the [MEDICATION NAME] was withdrawn abruptly, and harm from opioid neurotoxicity (adverse reaction affecting the central nervous system due to long term use, high amount or recent escalation of opioids) contributed to a rapid decline in Resident 1's health status; followed by expiration within 2 days after the [MEDICATION NAME] overdose was discovered and the medication was withdrawn. Findings: Resident 1's clinical record face sheet (resident profile information), indicated Resident 1 was a [AGE] year old diagnosed with [REDACTED]. Resident 1 was transferred from the acute care hospital to the facility for hospice (end of life care) services on [DATE]. Resident 1's clinical record titled, Progress Notes dated [DATE] at 2:09 p.m., indicated Received resident at 10:45 a.m., via (by) ambulance .Resident is alert and oriented x 3 (coherent awareness of person, place and time) . Resident 1's progress note indicated vital signs (clinical measurements of pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were temperature (T) 98.4, heart rate .82, respiratory rate .15, blood pressure (B/P) ,[DATE] . Review of Professional Reference, Fundamental Nursing Skills and Concepts, Ninth Edition; Barbara K. Timby; c. 2009; indicated normal range for vital signs include; Temperature 99.6 to 99.3 degrees Fahrenheit (F), heart rate (pulse) 60 to 100 beats per minute, respiratory rate 14 to 20 breaths per minute, blood pressure ,[DATE]. Resident 1's clinical record titled, Progress Notes dated [DATE], at 5:34 p.m., indicated, .Resident currently resting in bed .is adjusting well to facility and routine. Resident continued on hospice care. No indications of pain or discomfort . Resident 1's clinical record titled, Minimum Data Set (MDS) (a resident assessment tool which directs care planning decisions) assessment, dated [DATE], indicated Resident 1 had no cognitive (pertaining to short and long term memory) impairment. Resident 1's MDS assessment indicated he was able to make himself understood and could understand others. Resident 1's MDS assessment indicated he had no behaviors of agitation, aggression or anxiety. The MDS assessment indicated he was able to feed himself with supervision. Resident 1's MDS assessment revealed he experienced frequent pain, requiring the use of PRN (as necessary) pain medication. Resident 1's clinical record titled, Weekly Assessment dated [DATE], at 3:21 a.m., indicated Resident 1 was alert and oriented to person, place, time and situation and had no noted mood or behavior changes. The document indicated Resident 1 verbalized complaints of pain but the document had not indicated the intensity or location of Resident 1's pain. Review of Resident 1's clinical record titled, (name) Hospice physician's orders [REDACTED].= 4 ml .q (every) 4 hours routine for pain management . A second (name) Hospice physician's order [REDACTED].=0.2 ml .q 4 hours routine for pain .[MEDICATION NAME] 2 mg/0.1 ml give 2 mg= 0.1 ml every 4 hours as needed for breakthrough pain. The time the orders were written were not recorded on the physician orders. On [DATE] at 2 p.m., during an observation at the facility medication cart with the Director of Nursing (DON), a bottle of liquid [MEDICATION NAME] labeled for Resident 1 was dated [DATE], and indicated [MEDICATION NAME] 2 mg/0.1 ml solution. The dosage directions on the bottle matched the second physician order [REDACTED]. On [DATE] at 2:01 p.m., during an interview, the DON stated Resident 1 had been administered incorrect doses of [MEDICATION NAME] beginning [DATE]. The DON stated Resident 1 had an order dated [DATE] for [MEDICATION NAME] 4 mg in a concentration of 1 mg/ml (4 mg = 4 ml). The DON stated there had been a second order for [MEDICATION NAME] 4 mg at a higher concentration of 2 mg/0.1 ml (4 mg = 0.2 ml) also ordered on [DATE]. The DON stated the bottle of the less concentrated [MEDICATION NAME] ran out on [DATE] and the nurses began to use the concentrated solution of 2 mg /0.1 ml but continued to administer 4 ml rather than 0.2 ml (4 ml of concentrated solution equals 80 mg or 20 times the ordered dose) in error. The DON stated Hospice Licensed Nurse (HLN) 2 reviewed Resident 1's clinical record on [DATE] and informed the DON medication errors had been made. The DON stated LN 1 entered the first order for [MEDICATION NAME] into the electronic record system but did not enter the second order. The DON stated the second order should have been entered. The DON stated the practice was for the LN to input the physician order [REDACTED]. The DON stated LN 1 should have followed facility protocol for entering the order into the electronic clinical record. The DON stated the licensed nurses who administered the concentrated solution of [MEDICATION NAME] had not checked the label of the bottle for the concentration before they administered the medication. The DON stated protocol for medication administration had not been followed. On [DATE] at 2:52 p.m., during an interview, LN 1 stated the hospice nurse handed her a physician order [REDACTED]. The second order wasn't entered (in the clinical record). It didn't get done the correct way. LN 1 stated another nurse called HLN 1 on [DATE] and left a voice message to let him know they were running low on Resident 1's [MEDICATION NAME]. LN 1 stated HLN 1 came to the facility on [DATE] and told her they should not be running low on the [MEDICATION NAME] ordered for Resident 1. LN 1 stated she checked on the [MEDICATION NAME] doses administered and realized the nurses gave the wrong amount of [MEDICATION NAME] to Resident 1. LN 1 stated she informed HLN 1 on [DATE] of the medication error. Resident 1's clinical record titled, Progress Notes dated [DATE] at 1:52 p.m., indicated, Hospice nurse in to see resident, new orders written, [MEDICATION NAME] increased from 1 ml q 4 hours to 4 mls every 4 hrs PRN (as needed) [MEDICATION NAME] increased from 1 ml to 2 mls . The progress notes were electronically signed by LN 1. On [DATE] at 3:52 p.m., during an interview, LN 2 stated on [DATE] she administered 80 mg of [MEDICATION NAME] to Resident 1 during the night shift instead of the ordered 4 mg. LN 2 stated she looked at the physician order [REDACTED]. LN 2 stated she located the bottle of [MEDICATION NAME] with Resident 1's name and administered 4 ml of [MEDICATION NAME] without reading the concentration of the medication. LN 2 stated, I'll be honest with you I did not see the dose amount .It's a mistake that I made .the DON told me there was a med error. On [DATE] at 4:15 p.m., during an interview, LN 3 stated she administered 80 mg of [MEDICATION NAME] to Resident 1 instead of the 4 mg that had been ordered by the physician. LN 3 stated she looked at the computerized physician order [REDACTED]. LN 3 stated she looked at the bottle of medication ([MEDICATION NAME]) and Resident 1's name was on the bottle. LN 3 stated she did not read the medication label for the dosage written on the bottle. LN 3 stated she did not compare the label on the bottle with the physician order [REDACTED]. I didn't realize it was a different concentration. LN 3 stated the [MEDICATION NAME] bottle had a 1 ml syringe attached to the bottle and she filled the syringe full four times to administer one dose of [MEDICATION NAME] to Resident 1 without comparing the label on the bottle to the physician's orders [REDACTED]. Review of Resident 1's Controlled Drug Medication Record (CDR) indicated, (Resident 1), [MEDICATION NAME] 2 mg/0.1 ml solution, date ,[DATE], Time 1600 (4 p.m.), Dose 4 ml, Amount Given 4 ml, Nurse Signature (LN 3). LN 3's signature was repeated on the CDR record for ,[DATE] at 8 p.m. to signify LN 3 had administered the same amount of medication to Resident 1 as she had at 4 p.m. On [DATE] at 5:10 p.m., during an observation, Resident 1 was lying in bed, the head of the bed was elevated, his eyes and mouth were open. Resident 1 wore a nasal cannula (tube placed into the nose to supply oxygen). Resident 1 was breathing heavily through his open mouth. Resident 1 stared at the ceiling and had not responded to the presence of visitors in his room. On [DATE] at 3:30 p.m., during an interview, HLN 1 stated she made a visit to Resident 1 at the facility on [DATE]. HLN 1 stated Resident 1 was having significant pain on [DATE]. HLN 1 stated she handed two physician orders [REDACTED]. HLN 1 stated the first concentration was based on the [MEDICATION NAME] bottle the facility had on hand in which the concentration was [MEDICATION NAME] 1 mg/1 ml. HLN 1 stated the second physician order [REDACTED]. HLN 1 stated the second bottle of [MEDICATION NAME] with the higher concentration was supplied with a 1 ml syringe and there was a dark black line on the syringe to indicate the correct (dosing) amount. HLN 1 stated there were directions on the bottle which indicated the correct dose as well. HLN 1 stated, They (nurses) kept going above the line. HLN 1 stated when she visited Resident 1 on [DATE] he was awake and feeding himself. HLN 1 stated when she visited Resident 1 on [DATE] he was agitated, combative and twitching all over. HLN 1 stated the hospice doctor's note indicated Resident 1 had been given an overdose of [MEDICATION NAME] and had symptoms of the overdose exhibited by nonstop jerking movements of his body. HLN 1 stated Resident 1 expired on [DATE]. On [DATE] at 4:25 p.m., during an interview, HLN 2 stated the facility staff had left two messages for him over the weekend of [DATE] indicating a refill was needed for Resident 1's [MEDICATION NAME]. HLN 2 stated on [DATE] he reviewed Resident 1's clinical record with LN 1 and found Resident 1 had been receiving the incorrect dose of [MEDICATION NAME] for eight or ten doses. HLN 2 stated he informed the DON on [DATE] of Resident 1's [MEDICATION NAME] medication errors. HLN 2 stated the DON told him there was only one physician order [REDACTED]. HLN 2 stated he and the DON went into the back room of the nursing station and found the second physician order [REDACTED]. administration. HLN 2 stated the HMD gave an order not to administer [MEDICATION NAME] for 24 hours. Resident 1's hospice clinical record titled, Hospice routine visit on [DATE], indicated Resident 1's vital signs were recorded at 12:02 p.m. The vital signs included an axillary (armpit) temperature of 98.8 Fahrenheit, pulse of 120 beats per minute (high), respiratory rate was 24 breaths per minute and shallow. Resident 1's blood pressure was ,[DATE]. The hospice clinical record indicated, Symptoms: unresponsive, noisy and moist breathing, dyspnea (difficulty breathing), pain, jerking, twitching . The entry was electronically signed by HLN 2. On [DATE] at 4:06 p.m., during an interview and concurrent record review, the DON reviewed Resident 1's CDR. The physician order [REDACTED]. and 0.1 ml (2 mg) .every 4 hours as needed (additionally) for breakthrough pain (Pain unrelieved by the first dose). The DON verified Resident 1 had been administered 80 mg (20 times the ordered dose) instead of 4 mg by four different licensed nurses on eight separate occasions as follows: [DATE] at 8 a.m. [DATE] (time not recorded) [DATE] at 8 a.m. [DATE] at 12 noon [DATE] at 4 p.m. [DATE] at 8 p.m. [DATE] at 12 a.m. [DATE] at 4 a.m. On [DATE] at 8:35 a.m., during a telephone interview, the DON confirmed the overdoses of [MEDICATION NAME] recorded on Resident 1's CDR were administered by LN 1, LN 2, LN 3, and LN 8. The DON stated LN 8 was not currently employed by the facility. On [DATE] at 8:40 a.m., during a telephone interview, LN 7 stated Resident 1's goal in hospice care was to maintain an adequate level of comfort for the end of life care. LN 7 stated prior to [DATE] Resident 1 was alert and oriented to self, time and situation, engaged in conversation and had the physical ability to grip a cup of water from the bedside table and drink independently. LN 7 stated on [DATE] Resident 1 was confused and no longer spoke coherently. On [DATE] at 9:25 a.m., during a telephone interview and concurrent clinical record review, HLN 1 stated she initially saw Resident 1 on [DATE]. HLN 1 stated Resident 1's primary goal while under hospice was for pain management and the promotion of his comfort. HLN 1 stated on [DATE] Resident 1 had been able to feed himself, was awake, alert and able to make his needs known. HLN 1 stated at that time Resident 1 had the ability to engage in a meaningful conversation. On [DATE] at 10:15 a.m., during a telephone interview and concurrent clinical record review, HLN 1 stated she made a 24 hour follow up visit to Resident 1 on [DATE] after the adjustment in the physician orders [REDACTED]. HLN 1 stated Resident 1 appeared to be in good spirits, was talking, feeding himself and requested to speak with his wife. HLN 1 stated the correct dosage of [MEDICATION NAME] had been given and was effective as Resident 1 was no longer in pain. HLN 1 stated the facility called the hospice agency to request a refill for Resident 1's [MEDICATION NAME] on [DATE]. HLN 1 stated the request made to refill the bottle of medication by the facility concerned her and she requested HLN 2 visit the facility the same day the request was made. HLN 1 stated she visited Resident 1 on [DATE] at 9:20 a.m., and saw Resident 1 was very agitated and in a lot of pain. HLN 1 stated Resident 1 was screaming, dry heaving (experiencing the reflex of vomiting), and twitching throughout his entire body. HLN 1 stated on [DATE] she called the HMD to notify him of Resident 1's condition. HLN 1 stated the HMD gave an order for [REDACTED]. HLN 1 stated Resident 1 had still exhibited signs of anxiety not relieved after he received the [MEDICATION NAME]. HLN 1 stated the HMD was called again regarding the severe symptoms of anxiety. The HLN gave an order to discontinue the [MEDICATION NAME] and start [MEDICATION NAME] (medication used for extreme agitation) 5 mg once, then to repeat the dose one time if the initial dose was ineffective. HLN 1 stated [MEDICATION NAME] 2.5 mg was given and taken by Resident 1 at 12:20 p.m. HLN 1 stated Resident 1 was unable to take the [MEDICATION NAME] by mouth and required the HMD order a Macy rectal catheter (tube inserted into the rectum for the purpose of giving medications) for the administration of [MEDICATION NAME]. HLN 1 stated she administered Resident 1's ordered dose of [MEDICATION NAME] through the rectal catheter. HLN 1 stated the HMD arrived to the facility on [DATE] around 1:45 p.m., and assessed Resident 1. HLN 1 stated the HMD spoke with Resident 1's spouse initiating palliative sedation (practice that provides a relief from pain and suffering in terminally ill patients). HLN 1 stated Resident 1 was no longer able to communicate or feed himself on [DATE] and passed away on [DATE] at 11 p.m. Resident 1's hospice clinical record titled, Charts/Clinical Notes, dated [DATE], indicated, (HMD and HNL 1) with family at bedside .(rectal) cath inserted for med (medication) administration Patient dosed at 2 p.m., with 5 mg of [MEDICATION NAME] . Staff gave [MEDICATION NAME] 2.5 mg also at that time via (by way of) (rectal) cath .2:30 p.m .patient remains with extreme anxiety, yelling and striking out if touched Vitals B/P ,[DATE], P (pulse)108, R(respirations) 22 shallow .3 p.m., patient remains with high anxiety yelling out and screaming patient was dosed with another 1 time dose of 5 mg [MEDICATION NAME] via rectal tube at this time patient does not allow anyone to touch him-strikes out not able to do vitals due to extreme anxiety .4 p.m., patient seems a little more calm .Vitals B/P ,[DATE] P 128 R 30 will push away and strike out at times .4:30 p.m., Facility staff nurse gave 2 mg [MEDICATION NAME] routine order via (rectal) cath patient anxiety remains the same yelling, striking out . pulse rate 112 at this time, hit (by the resident) when B/P attempted. Respiratory rate 30 .5:15 p.m., RN .arrived with Versed (medication used in terminally ill patients to relieve pain and suffering ) dose and pump to be started .Vitals B/P ,[DATE], P 134 R 30, still thrashing in the bed striking out .7 p.m., Vitals B/P ,[DATE] P126 R 30 patient comfortable. Patient not striking out or yelling . Resident 1's clinical record titled, Hospice Physician Exam dated [DATE], indicated Opioid Neurotoxicity .The patient's wife and I had an extensive conversation .Versed pump discussed in detail .[MEDICATION NAME] has not helped . On [DATE] at 11:15 a.m., during a telephone interview, the HMD stated Resident 1's neurotoxicity is essentially irreversible. You could potentially dialyze (procedure to remove drugs and waste products from the blood stream using an artificial kidney) a patient but this resident (Resident 1) was severely agitated and restless. The [MEDICAL TREATMENT] would not have been an option for him; he may have not even survived the [MEDICAL TREATMENT]. The HMD stated during his visit on [DATE], Resident 1 was severely agitated, restless, and with increased confusion. The HMD stated the nurses were unable to touch the resident without Resident 1 becoming more agitated. The HMD stated Resident 1 was going through a state called hyperalgesia (an abnormal sensitivity to pain) the HMD stated pain was experienced even by the touch of clothing. The HMD stated [MEDICATION NAME] (medication used to reverse the effects of opioids) was not considered for Resident 1 because the medication could have made Resident 1's situation worse by causing a pain crisis (pain that is severe and causing increased distress). The HMD stated, I didn't want him to experience anymore distress . The HMD stated the use of [MEDICATION NAME] was a practice used to treat residents with decreased respiratory rate from the use of opioids but Resident 1's respiratory rate was not low. The HMD stated there were limited options to treat Resident 1's pain and anxiety given Resident 1's medical condition. The HMD stated Resident 1's final days were agonizing with severe distress. The HMD stated this distress led him to speak to Resident 1's spouse about starting the Versed pump for palliative sedation. The HMD stated the overdose of [MEDICATION NAME] precipitated the neurotoxicity that increased Resident 1's level of distress and caused Resident 1 to suffer. The HMD stated Resident 1 signed up for hospice care to be comfortable. On [DATE] at 11:15 a.m., during a telephone interview, HNL 2 stated he saw Resident 1 on the morning of [DATE] after he had received the overdoses of [MEDICATION NAME]. HNL 2 stated Resident 1 was not coherent and was experiencing symptoms resulting from the [MEDICATION NAME] overdose. HNL 2 stated, (Resident 1) was completely different, he was screaming, yelling out and thrashing in his bed. HLN 2 stated Resident 2 required use of a rectal catheter for the administration of the [MEDICATION NAME] because he was spitting out everything from his mouth. Review of professional reference, 10 Strategies for Preventing Medication Errors 2008 http://minoritynurse.com/10 strategies-for-preventing-medication-errors/ <http://minoritynurse.com/10%20 strategies-for-preventing-medication-errors/> indicated, 1. Ensure the five rights of medication administration. Nurses must ensure that institutional policies related to medication transcription are followed. It isn't adequate to transcribe the medication as prescribed, but to ensure the correct medication is prescribed for the correct patient, in the correct dosage, via the correct route, and timed correctly (also known as the five rights) .3. Double check or even triple check procedures. This is a process whereby another nurse on the same shift or an incoming shift reviews all new orders to ensure each patient's order is noted and transcribed correctly on the physician's orders [REDACTED]. The facility policy and procedure titled, Medication Administration General Guidelines dated ,[DATE], indicated under Procedures, 2. Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive .the nurse calls the physician for clarification prior to the administration of the medication .16. Read medication label and compare with Medication Administration Record [REDACTED] The facility policy and procedure titled, Preparation for Medication Administration dated ,[DATE], indicated, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices .Procedures .5. Prior to administration, the medication and dosage schedule on the resident's MAR indicated [REDACTED]. 10. When administering potent medications in liquid form or those requiring precise measurements .devices provided by the manufacturer or obtained from the provider pharmacy are used to allow accurate measurement of doses. Review of facility policy titled, Orders, Receiving and Transcribing Revised February 2014, indicated, 1 .Orders must be reduced to writing by the person receiving the order, and recorded in the resident's medical record.