Every finding on record at Meadow Peak Rehabilitation

Based on observation, interview, and record review, it was determined that the facility did not ensure that each resident received and that the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, there were numerous resident complaints about the food served at the facility, there were resident council concerns about the food served at the facility, and the test tray that surveyors sampled was not palatable.Findings included:1. On 5/6/26 at 9:43 AM, an interview was conducted with resident 2, who stated that the food served at the facility was sometimes good, sometimes marginal. 2. On 5/5/26 at 1:23 PM, an interview was conducted with resident 4, who expressed concerns about the taste of the food served at the facility.3. On 5/6/26 at 8:29 AM, an interview was conducted with resident 5, who stated that the flavor of the food served at the facility could be better. Resident 5 stated that dinner tended to be worse than other meals. 4. On 5/6/26 at 9:37 AM, an interview was conducted with resident 9 who stated the food was horrible. Resident 9 stated that she had verbally told them that the food was not good. Resident 9 stated she was on a feeding tube before this and it was better than the actual food served at the facility. 5. On 5/6/26 at 8:18 AM, an interview was conducted with resident 41 who stated the food really was not good and that it lacked flavor, had inconsistent portions, and was often unidentifiable. Resident 41 believed she was not receiving enough protein and relied on outside food that she purchased. Resident 41 reported these concerns to nursing and dietary staff, but felt the dietary department's response was dismissive.6. On 5/6/26 at 8:46 AM, an interview was conducted with resident 53 who stated the presentation of the food was poor and it just did not taste good. Resident 53 stated the facility administration had told them it would be better starting last week but it had not changed and was still awful. 7. On 5/5/26 at 11:13 AM, an interview was conducted with resident 56 who stated the food had no flavor and was cold. The food just did not taste very good. The desserts were not very good and residents only had pie. Resident 56 stated that the other day they only had cut up red beets with onions on top of it, Who wants to eat that?! Resident 56 stated the drinks had black specks in them. 8. On 5/5/26 at 12:09 PM, an interview was conducted with resident 67 who stated that the food was just awful. 9. Resident council notes were reviewed from 2025 and 2026. a. During the January 2025 resident council meeting, residents complained that the portions served at the facility were too large and that their eggs were frequently served cold. b. During the July 2025 resident council meeting, residents complained about food being served cold and juices from vegetables causing the bread served with meals to be soggy.c. During the August 2025 resident council meeting, residents complained about juices from vegetables causing the bread served with meals to be soggy.d. During the October 2025 resident council meeting, residents expressed concerns about wanting fresh fruit rather than canned fruit. e. During the November 2025 resident council meeting, residents expressed concerns about food being served cold and late.f. During the January 2026 resident council meeting, residents expressed concerns about food being served cold and late.g. During the April 2026 resident council meeting, residents expressed concerns about food being served cold and late. 8. On 5/7/26 at 12:09 PM, surveyors sampled a test tray from the lunch time meal service. The meal was chicken alfredo pasta with green beans. The green beans were overcooked, mushy, and were not seasoned. The alfredo sauce did not have any flavor. The chicken was gristly and difficult to chew. On 5/7/26 at 11:27 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that if residents had complaints about food served at the facility they could tell the aides, nurses, or come to her directly with concerns. The DM stated that food concerns were discussed at the resident council and the dining committee meetings. The DM stated that the facility recently switched to a new menu.On 5/11/26 at 1:37 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated that if a resident complained about the food to her during an assessment, she would pass the concern on to the dietary manager.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Specifically, two residents' physicians orders for lidocaine lacked a dosage and did not match the administration record; and the facility staff were taping narcotic medications back into the medication cards. Resident identifiers: 49 and 84.Findings included:1. Resident 49 was admitted to the facility on [DATE] with diagnoses of nondisplaced fracture of shaft of right clavicle; spondylosis without myelopathy or radiculopathy cervical region; and multiple fractures of ribs, left side and left humerus.Resident 49's medical record was reviewed 5/5/26 through 5/11/26.A physician's order dated 4/7/26 at 2:48 PM indicated, Lidocaine External Patch (Lidocaine) Apply to affected area topically two times a day for pain.A Medication Administration Record (MAR) dated April 2026 indicated that a Lidocaine External Patch of an unknown dose was placed on resident 49 on 4/8/26 at 8:00 PM with no indication of when it was removed. It indicated a Lidocaine External Patch of an unknown dose was placed on resident 49 on 4/9/26 at 8:00 PM and removed on 4/10/26 at 8:00 PM. It indicated a Lidocaine External Patch of an unknown dose was placed on resident 49 on 4/11/26 at 8:00 AM and 8:00 PM and no indication of when it was removed for either application. It indicated a Lidocaine External Patch of an unknown dose was placed on resident 49 on 4/12/26 at 8:00 PM with no documentation of when it was removed and a new patch was placed on 4/13/26 at 8:00 AM. It indicated a Lidocaine External Patch of an unknown dose was placed on resident 49 on 4/22/26 with no indication of when it was removed.2. Resident 84 was admitted to the facility on [DATE] with diagnoses which included unstable burst fracture of first lumbar vertebra and thoracic vertebra T11-T12, fusion of spine thoracolumbar region, osteoarthritis, idiopathic peripheral autonomic neuropathy, ankylosing spondylitis lumbar region, and arthrodesis status.Resident 84's medical record was reviewed 5/5/26 through 5/11/26.A Physician Authorized Lidocaine Therapeutic Interchange of Medications document dated 4/28/26 indicated, LIDOCAINE 4% (percent) PATCHES.USE ONE PATCH ONCE DAILY (12 HRS [hours] ON/ 12 HRS OFF).A physician's order dated 4/28/26 at 4:17 PM indicated, Lidocaine External Patch (Lidocaine) Apply to affected area topically two times a day for pain.A MAR dated April 2026 indicated that on 4/28/26 at 8:00 PM, a Lidocaine External Patch of an unknown dose was placed on resident 84, with no indication of when it was removed On 4/29/26 and 4/30/26 at 8:00 AM, the MAR indicated a Lidocaine External Patch of an unknown dose was placed on resident 84 and taken off at 8:00 PM.A MAR dated May 2026 indicated a Lidocaine External Patch of an unknown dose was placed on resident 84 at 8:00 AM and was taken off at 8:00 PM on 5/1/26-5/5/26.On 5/11/26 at 1:15 PM, an interview was conducted with Registered Nurse (RN) 1 while she reviewed resident 84's electronic medical record. RN 1 stated the lidocaine order was incomplete because it lacked a specific dosage, a 12-hour on/off schedule, and a designated application and removal time.On 5/11/26 at 2:37 PM, an interview was conducted with the Director of Nursing (DON) and she stated that a second nurse should have reviewed all new orders for accuracy, noting that the lidocaine orders for residents 49 and 84 were incomplete because they lacked a dosage, a 12-hour on/off schedule, and documentation of the patch placement location.3. On 5/7/26 at 8:50 AM, during morning medication administration an observation was made of the facility North East medication cart with Registered Nurse (RN) 2. The following medications were observed in the medication cart: a. Two multi dose medication cards which held Clonazepam 0.5 mg were observed. The first multi dose medication card had the back of pocket numbers 1, 7 and 11 that were opened with tape now closing the pocket. There were no medications observed in pocket numbers 7 and 11, pocket number 1 had a white tablet taped back into the pocket. The second multi dose medication card of Clonazepam 0.5 mg had pocket number 27 taped with a white tablet taped back into the pocket.On 5/7/26 at 9:15 AM, during morning medication administration an observation was made of the facility SouthEast medication cart with Registered Nurse (RN) 3. The following medications were observed in the medication cart:b. A multi dose medication card which held Oxycodone 10 mg had the back of pocket numbers 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 27, 28 and 29 that was opened with tape now closing the pocket. There was a white tablet observed to be in pockets 9 and 26.On 5/7/26 at 9:30 AM, an observation was made of the facility South [NAME] medication cart with Licensed Practical Nurse (LPN) 2. The following medication was observed in the medication cart:c. A multi dose medication card which held Hydrocodone - Acetaminophen 5/325 mg had the back of pocket numbers 23, 24 and 26 that was opened with tape now closing the pocket. There was a white tablet observed in pocket 24. On 5/7/26 at 9:45 AM, an interview was conducted with RN 2 who stated the nurses were supposed to do a narcotic count with the oncoming shift. RN 2 stated medications were not supposed to be taped back into the medication cards and that they were supposed to be wasted with another nurse. On 5/7/26 at 9:15 AM, an interview was conducted with RN 3 who stated that the staff taped the back of the narcotic cards when the medication was reduced and they only needed half of the pill. RN 2 stated she would have no way of knowing whether the correct medication was placed back into the card or if the medication had been touched by the previous nurse. On 5/7/26 at 9:30 AM, an interview was conducted with LPN 2 who stated they did not tape narcotics back into the medication cards, they wasted them with another nurse. On 5/7/26 at 9:45 AM, an interview was conducted with RN 4 who stated narcotics or any medication should not be taped back into the medication card. RN 4 stated that the medication should be wasted because there was no way of knowing if the medication was clean or if the correct medication had been put back into the card. On 5/7/26 at 10:15 AM, an interview was conducted with the Director of Nursing (DON) who stated it was not appropriate to tape medications back into the medication cards. The DON stated the staff should be wasting them with another nurse.

Based on record review and interview, it was determined that the facility failed to develop and implement policies and procedures to ensure all of the following: When COVID-19 vaccine was available to the facility, each staff member was offered the COVID-19 vaccine unless the immunization was medically contraindicated or the resident or staff member had already been immunized, and before offering COVID-19 vaccine, all staff members were provided with education regarding the benefits and risks and potential side effects associated with the vaccine. The facility also failed to maintain documentation related to staff COVID-19 vaccination that included at a minimum, the following: Staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and the COVID-19 vaccine status of staff and related information was indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Specifically, there was no documentation that four staff members were offered the COVID-19 vaccine and no policy was found to address staff COVID-19 vaccine requirements.Findings included:COVID-19 vaccine documentation was requested for four staff members: Registered Nurse 4, Certified Nurse Assistant 4, Licensed Practical Nurse 2, and the Dietary Manager.On 5/11/26 at 3:29 PM, an interview was conducted with the Director of Nursing (DON) and she stated they held a flu and COVID-19 clinic every year and that it was open to staff. The DON stated every staff member was offered the COVID-19 vaccine but it was not documented. No documentation for any of the four requested staff members was provided that indicated they were offered or had accepted or declined the COVID-19 vaccine.No policy was provided that indicated the required elements for staff regarding the COVID-19 vaccine.

Based on interview and record review, it was determined for 1 out of 33 sampled residents, that the facility failed to ensure each resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred. Specifically, one resident's representative was not notified in advance of the risks and benefits or alternatives before starting or when changes were made for psychotropic medications. Resident identifier: 91.Findings included:Resident 91 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, depression, and anxiety disorder.Resident 91's medical record was reviewed 5/5/26 through 5/11/26.A physician's order dated 4/29/26 at 8:05 AM indicated, busPIRone HCl [hydrochloride] Tablet 10 MG [milligrams] .Give 10 mg by mouth three times a day related to ANXIETY DISORDER.On 5/11/26 at 2:37 PM, an interview was conducted with the Director of Nursing and she was unable to provide information that resident 91's representative was notified of the risks and benefits or alternatives before starting buspirone for anxiety.No documentation was provided to indicate resident 91's representative was notified of the risks and benefits or alternatives before starting buspirone for anxiety.

Based on record review and interview, it was determined that the facility failed to conduct an annual review of its IPCP (infection prevention and control program) and update their program, as necessary. Specifically, there was no documentation indicating that the Infection Prevention and Control Policy was reviewed annually.Findings included:The Policy / Procedure - Infection Prevention and Control Section: Subject: Infection Prevention and Control Program Infection Prevention and Control Program Overview adopted 09/2017 indicated, UPDATING THE INFECTION PREVENTION AND CONTROL PLAN The Infection Prevention and Control Plan will be reviewed annually and updated as indicated by changes in services, changes in the population served, or other changes as appropriate.On 5/11/26 at 3:29 PM, an interview was conducted with the Director of Nursing (DON) and she stated that IPCP policy was reviewed annually with corporate. Documentation that indicated when it was reviewed last was requested but was not provided.

Based on observation and interview, the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, two insulin pens were not labeled with an open date and a resident was given an inhaler that was not labeled with a resident identifier or open date. Resident identifiers: 9. Findings included:On [DATE] at 8:10 AM, an observation was made of the North East medication cart during morning medication pass with Registered Nurse (RN) 2, the following medications were located in the medication cart: A prefilled insulin pen containing Novolog 100 unit/ml (milliliter) was open and available for use, no open date was observed on the insulin pen. A prefilled insulin pen containing Glargine 100 unit/ml was open and available for use, no open date was observed on the insulin pen. An immediate interview was conducted with RN 2 who stated the insulin pens were supposed to have the resident's name and an open date written on them so the staff knew when they expired. RN 2 stated the staff should date the insulin when they got it out of the medication room. On [DATE] at 8:42 AM, an observation was made of the North East medication cart during morning medication pass with RN 2. RN 2 was observed to obtain a Umeclidinium Bromide InhalationAerosol Powder 62.5 MCG/ACT (microgram/per actuation) inhaler from the bottom drawer in the medication cart after multiple attempts to locate the needed inhaler. There was no resident identification or open date observed on the inhaler. RN 2 was observed to give the inhaler to resident 9 who took 1 puff orally from the inhaler. An immediate interview was conducted with RN 2 who stated she was not sure if the inhaler belonged to resident 9 but it was with her other medications so she assumed it was resident 9's. RN 2 was then observed to write resident 9's name on the inhaler, no date was written. The inhaler was then returned to the bottom drawer of the medication cart, no box with the resident's prescription or identifier was observed. On [DATE] at 10:15 AM, an interview was conducted with the Director of Nursing (DON) who stated the staff were expected to write the date on the medication when it was pulled out of the storage room, and the medication should already have the prescription label on it. The DON stated a medication should not be given to a resident if there was not a prescription label on it and if the staff did not know who the medication belonged to. The DON stated if the medication was not labeled the staff would not know if the medication belonged to that resident and if the medication was the correct medication for that resident.

Based on interview and record review, it was determined that the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 33 sampled residents, a resident received more seizure medication than was prescribed on eight different occasions. Resident identifier: 9.Findings included:Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder, mood disorder and tremors. During record review on 5/11/26 at 12:38 PM, an incident report was reviewed and revealed that resident 9 had been administered 2000 mg (milligrams) of Depakote three times a day (TID) when only 500 mg of Depakote should have been administered.The initial physician order dated 9/22/25 at 4:33 PM revealed the following order, Depakote Oral Tablet Delayed Release 500 mg (Divalproex Sodium). Give 3 tablet by mouth three times a day related to BIPOLAR DISORDER, UNSPECIFIED. This order was discontinued on 9/22/25 at 7:39 PM.A follow up order dated 9/22/25 at 7:39 PM revealed the order was changed to the following, Depakote Oral Tablet Delayed Release 500 MG (Devalproex Sodium). Give 4 tablet by mouth three times a day related to BIPOLAR DISORDER, UNSPECIFIED.The September 2025 Medication Administration Record (MAR) was reviewed and documented resident 9 had received 2000 mg of Depakote one time on 9/22/25 and 6000 mg of Depakote on 9/23/25 and 9/24/25. It should be noted that resident 9 should have only received 500 mg of Depakote on 9/22/25 and 1500 mg of Depakote on 9/23/25 and 9/24/25. A nursing progress note dated 9/22/25 at 4:38 PM documented, The order you have entered Depakote Oral Tablet Delayed Release 500 MG (Divaloproex Sodium) Give 3 tablet by mouth three times a day related to BIPOLAR DISORDER, UNSPECIFIED - The dosing regimen of 3 tablets 3 times a day exceeds the usual dosing regimen of 0.5 tablet 2 times per day to 2.33 tablets 3 times per day. It should be noted that the medication dosage was not adjusted after this computer generated warning. A nursing progress note dated 9/22/25 at 7:40 PM documented, The order you have entered Depakote Oral Tablet Delayed Release 500 MG (Divaloproex Sodium) Give 3 tablet by mouth three times a day related to BIPOLAR DISORDER, UNSPECIFIED - The dosing regimen of 3 tablets 3 times a day exceeds the usual dosing regimen of 0.5 tablet 2 times per day to 2.33 tablets 3 times per day. - The single dose of 4 tables exceeds the maximum single dose of 3.4096 tablets. The usual dosing regimen is 0.5 tablet 2 times per day to 2.33 tablets 3 times a day.It should be noted that the medication dosage was not adjusted after this computer generated warning. A nursing progress note dated 9/25/25 at 8:00 AM documented, This nurse noted that [resident 9's] previous Depakote order was 500 mg TID (4 sprinkle capsules of 125 mg form) and that it had recently been changed to 2000 mg TID (4 tabs of 500 mg ER [extended release] form). Double checked dosing with provider and he stated that it was input incorrectly and should still be 500 mg TID. Notified resident and family, stated gratitude for update. Notified administration. Corrected order form [sic] 4 tabs of 500 mg Depakote TID to 1 tab 500 mg TID. Provider gave order to hold AM [morning] dose and draw STAT [immediate] valproic acid level. VSS [vital signs stable], cont [continue] O2 [oxygen] via NC [nasal cannula], no noted drowsiness or other ASE [adverse side effect]. Added order to monitor for ASE and VS [vital signs] q [every] shift x [times] 3 days. Valproic acid level returned, 61.2. Notified provider, order to resume Depakote administration.A nursing progress note dated 9/26/25 at 12:50 PM documented, [Resident 9] did sleep this morning and c/o [complained of] drowsiness but currently awake and eating lunch.A nursing progress note dated 9/26/25 at 3:34 PM, Patient reviewed in psychotropic meeting with [provider], pharmacist, DON [Director of Nursing] and ADON [Assistant Director of Nursing]. Next review in 30 days. No changes to medications at this time .On 5/11/26 at 2:36 PM, an interview was conducted with the DON and the Administrator (ADM). The DON stated the provider would give a verbal order to the floor nurse, the DON, or the ADON. The DON stated that whoever was currently working could put the order into the medical records system. The DON stated that herself, and both ADONs reviewed any new orders daily. The DON stated the order then goes to the pharmacy for review. The DON stated that with this incident the nurse put the order in wrong and it wasn't caught until a few days later. The DON stated resident 9 got a few doses because the medication was ordered four times a day. The ADM stated that they added medication error to the facility in-services and to their daily rounding. The DON stated the computer generated warning always comes up when any order is entered, it's a red warning to make them aware that the medication interacted with other medications. The DON and ADM stated they had educated the nurses who were directly affected by the incident but not every nurse in the facility. The DON stated that they wished that it hadn't happened and that they made a mistake.

Based on observation and interview, it was determined that the facility failed to post the nurse staff posting data in a prominent place readily accessible to residents, staff, and visitors and failed to post the resident census on a daily basis. Specifically, the nurse staff posting did not include the resident census and was not in an area that residents and visitors would readily find. Findings included:On 5/7/26 at 3:25 PM, an observation was made from the entrance of the facility throughout all of the main hallways of the resident rooms and nursing stations. No nurse staff posting was observed. The Director of Nursing (DON) was then found and she walked the surveyor down the south east rehabilitation hallway down to a cubby on the left side of the hallway next to staff offices to view the nurse staff posting. There was no resident census included on the posting.On 5/7/26 at 3:25 PM, a concurrent interview was conducted with the DON and she stated that family and residents go to the office next to the nurse staff posting for meetings with staff so they knew where it was found.

Based on record review and interview, it was determined that for 1 of 33 sampled residents, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice. Specifically, one resident did not have vital signs, weights, and assessments of their AV (arteriovenous) fistula documented before and after dialysis treatments and communication of the patient's status with the dialysis center was not complete. Resident identifier: 49.Findings included:Resident 49 was admitted to the facility on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis.Resident 49's medical record was reviewed 5/5/26 through 5/11/26.Renal Dialysis Communication Forms were reviewed and revealed the following: Form dated 4/10/26 was missing vital signs, weight, and assessment of the access site prior to leaving the facility. Form dated 4/13/26 was missing vital signs, weight, and assessment of the access site prior to leaving the facility. Form dated 4/20/26 was missing vital signs and weight prior to leaving the facility and a missing post dialysis weight. Form dated 4/29/26 was missing vital signs, weights, and assessments of the access site prior to leaving the facility and post dialysis. Form dated 5/4/26 was missing vital signs, weight, and assessment of the access site prior to leaving the facility.An APP (Advanced Practice Provider) Admit Visit Note dated 4/12/26 at 5:28 PM indicated, END STAGE RENAL DISEASE Continue scheduled hemodialysis (M/W/F) [Monday/Wednesday/Friday]. Monitor for complications (electrolytes, volume status, access issues) . ARTERIOVENOUS FISTULA, ACQUIRED Monitor for patency, signs of infection or dysfunction.Review of the medical record indicated that there was no documentation of AV fistula assessment prior to leaving the facility for dialysis on 4/10/26.Review of the medical record indicated that there was no documentation of AV fistula assessment when resident the returned from dialysis on 4/8/26, 4/10/26, 4/13/26, 4/15/26, 4/20/26, 4/22/26, 4/24/26, 4/26/26, 4/29/26, 5/1/26, 5/4/26, and 5/6/26.Review of the medical record indicated that there were no vital signs obtained when the resident returned from dialysis on 4/20/26, 4/22/26, 4/24/26, 4/26/26, 4/29/26, 5/1/26, and 5/4/26. The Care Plan Report indicated a Focus initiated on 4/8/26 of The resident needs dialysis (hemo) r/t [related to] renal failure. It indicated the Goal The resident will have no s/sx [signs or symptoms] of complications from dialysis through the review date. It further indicated interventions which included, Coordinate care with Dialysis center using communication form; Monitor VITAL SIGNS as indicated. Notify MD [medical doctor] of significant abnormalities; Monitor/document/report PRN [as needed] any s/sx of infection to access site: Redness, Swelling, warmth or drainage; and Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock.On 5/7/26 at 2:36 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2 and she stated that the dialysis communication form needed to be filled out prior to sending the resident to dialysis and reviewed when they returned from dialysis. LPN 2 stated they reviewed the note to see if there were any notes from the dialysis center and to ensure the vital signs were okay. LPN 2 stated they did not need to do an assessment of the resident when they returned from dialysis as long as that form was okay.On 5/7/26 at 2:59 PM, an interview was conducted with Registered Nurse (RN) 4 and he stated when a resident came back from dialysis, they should assess the access site for bleeding, check the bruit and thrill to ensure proper function, and obtain a blood pressure to monitor for fluid-shift fluctuations.On 5/11/26 at 3:25 PM, an interview was conducted with the Director of Nursing (DON) and she stated that post-dialysis nursing assessments must include monitoring vital signs, skin color, and the fistula site for bleeding, infection, and a positive bruit and thrill.The facility Policy/Procedure Dialysis Services dated 10/2017 indicated, It is the policy of this facility that staff will coordinate with the dialysis center, in individual cares for residents receiving dialysis services and will complete duties and obligations as agreed upon by the facility and the dialysis center. PURPOSE: To establish protocol which will facilitate coordination with the dialysis center to ensure proper care for dialysis residents.11. Nursing staff will monitor port site for signs of bleeding and infection. 12. Nursing staff will monitor for bruits and thrills at port site.

Based on record review and interview, it was determined that for 1 out of 33 sampled residents, the facility failed to ensure that each resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible and who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possible. Specifically, one resident who was incontinent of bowel and bladder did not receive services to restore function to the extent possible. Resident identifier: 47.Findings included:Resident 47 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side.Resident 47's medical record was reviewed 5/5/26 through 5/11/26.A Minimum Data Set assessment dated [DATE] indicated resident 47 was always incontinent of bowel and bladder continence and had not had an attempted trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) on admission/entry or reentry or since urinary incontinence was noted in this facility and was not currently on a toileting program to manage the resident's bowel continence.A Care Plan Report indicated a Focus initiated on 9/6/24 of [Resident 47] has bladder/bowel incontinence r/t [related to] Impaired Mobility. It indicated a Goal of [Resident 47] will remain free from skin breakdown due to incontinence and brief use through the review date. It further indicated Interventions of, INCONTINENT: Check Q2 [every 2] hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN [as needed] after incontinence episodes.A Care Plan Report indicated a Focus initiated on 6/2/24 of [Resident 47] has an ADL [activities of daily living] self-care performance deficit r/t/ hx [history] of CVA [cerebrovascular accident] with hemiplegia, weakness. She has functional limitation in ROM [range of motion] to both RUE [right upper extremity] and RLE [right lower extremity] on the right side. It indicated a Goal of [Resident 47] will maintain current level of function in [sic] through the review date. It further indicated interventions that included, TOILET USE: [Resident 47] is usually dependent with toileting; and, TRANSFER: [Resident 47] is usually dependent to transfer. Requires a 2 person assist.On 5/11/26 at 1:25 PM, an interview was conducted with Licensed Professional Nurse (LPN) 1. LPN 1 stated that resident 47 used to be able to get up to the wheelchair to use the bathroom but was now incontinent and dependent on 2 people to help her stand. LPN 1 stated resident 47 had no medical reason to be incontinent and that she was alert and oriented to person, place, time, and situation and could convey her needs.On 5/11/26 at 1:47 PM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that resident 47 was incontinent but was able to communicate her needs. CNA 3 stated resident 47 could alert staff both before needing to use the restroom and when she required a brief change.On 5/11/26 at 3:21 PM, an interview was conducted with the Director of Nursing (DON) and she stated that she was not sure if resident 47 had been on a bowel and bladder retraining program and that she would have to look into it.No documentation was provided that indicated that resident 47 received bowel and bladder retraining.

Based on observation, interview, and record review, it was determined for 1 of 33 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a dependent resident was transferred using a Hoyer lift by only one staff member on two separate occasions. Resident identifier: 30.Findings included:Resident 30 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of parietal lobe, major depressive disorder, repeated falls, dependence on supplemental oxygen, age related osteoporosis, altered mental status and encephalopathy. Resident 30 was admitted to hospice services on 11/13/25. On 5/4/26 at 8:23 AM, resident 30 was observed to be lying in bed. A staff member was observed to take a Hoyer lift into resident 30's room and close the door. There was no other staff observed to be in resident 30's room prior to the door closing. Approximately 10 minutes later the staff member opened the door and exited the room with the Hoyer lift. No other staff members were observed to enter the room while the door was closed. Resident 30 was then observed to be sitting in her wheelchair and the bed was made. An immediate interview was conducted with the staff member who identified herself as a hospice aide. The hospice aide (HA) stated that she saw resident 30 in the mornings to get her ready for the day. HA stated that she was the only hospice aide that comes in to see resident 30, so she would usually get her out of bed on her own. On 5/7/26 at 8:32 AM, an observation was made of the HA taking the Hoyer lift into resident 30's room, there were no other staff present. Resident 30 was observed to be in bed. The HA closed the door and reopened the door 10 minutes later and resident 30 was sitting in her wheelchair. The HA stated she had gotten resident 30 into her wheelchair and ready for the day. A Minimum Data Set (MDS) dated [DATE] documented resident 30 was dependent for toileting hygiene and required substantial/maximum assistance with bathing and dressing. Resident 30's medical record dashboard documented, Hospice aide for ADLs (Activities of Daily Living) every morning, including weekends . MUST BE A HOYER LIFT FOR TRANSFERS.A care plan entry dated 10/18/25 had a goal of ADL self-care performance deficit r/t (related to) brain tumor and impaired mobility. With interventions dated 11/24/25 that included resident 30 was usually dependent with transfers and required dependent assistance with personal hygiene.On 5/7/26 at 2:04 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1 who stated that resident 30 used a Hoyer for transfers. CNA 1 stated that there should always be two people to assist with a Hoyer lift. CNA 1 stated that they should always have 2 people to assist so the resident was safe no matter if it was regular staff, agency or home health/hospice. On 5/11/26 at 10:00 AM, an interview was conducted with CNA 2 who stated resident 30 was a 2-person assist and that a Hoyer lift was needed to transfer her. CNA 2 stated there should always be 2 people when using a Hoyer lift and the hospice aides could ask the regular staff for help if needed.On 5/11/26 at 2:34 PM, an interview was conducted with the Director of Nursing (DON) and the Administrator (ADM). The DON stated that resident 30 was a 2-person assist with transfers and the Hoyer was used with those transfers. The ADM stated it was best practice to have 2 people when using a Hoyer lift. The DON stated that all staff should have a second staff member with them if they were using the Hoyer lift, this included contracted staff or those who work for outside agencies which included hospice services. The DON stated the hospice aides were expected to ask another staff member for assistance if they had a resident who required a Hoyer lift for transfers.

Based on interview and record review, it was determined that, for 1 of 33 sampled residents, that the facility did not ensure that a transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. Specifically, the facility did not document what documentation was sent with a resident that was discharged to a hospital after a change in condition. Resident identifier: 80.Findings included:Resident 80 was admitted on [DATE], and discharged on 4/5/26, with diagnoses including, but not limited to parkinson's disease without dyskinesia without mention of fluctuations and personal history of transient ischemic attack and cerebral infarction without residual deficits.Resident 80's medical record was reviewed from 5/5/26 through 5/11/26.On 4/5/26 at 6:26 AM, a nursing progress note stated, Approx [approximately] 5:25am resident vomited coffee ground colored emesis, Obtained [sic] VS [vital signs] BP [blood pressure] 102/69, P [pulse] 92, R [respirations] 18, Sats [oxygen saturation] 75% RA [room air], temp [temperature] 97.9. Verbally responded to name and touch. O2 [oxygen] applied and sats 92% on 5 liters with no active vomiting observed. [Name of provider company] on call provider notified and received verbal order to send to hospital for further evaluation of condition. Patient agreed to be sent to hospital. [Ambulance service] called and transported to [Name of hospital]. Nurse management and family also notified.On 4/6/26 at 2:42 PM, a nursing progress note stated, Admissions coordinator verified that [Resident 80] was admitted to [Name of hospital].There was not a progress note, assessment, discharge summary, or uploaded document that stated what documentation was sent with the resident when they were transferred to the hospital. On 5/11/26 at 12:11 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when a resident was discharged to the hospital she sent their profile page, order summary, medication list, and a copy of the resident's provider order for life sustaining treatment (POLST). RN 1 stated that she also entered a progress note that documented what happened.On 5/11/26 at 12:22 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that when a resident was discharged to the hospital, they sent the resident's face sheet, the resident's medication list, a list of treatments that the resident received, a copy of the resident's POLST form, and a copy of the resident's face sheet. LPN 1 stated that they made two copies, one for the hospital and one for the ambulance. LPN 1 stated that they usually documented the discharge in a progress note.On 5/11/26 at 3:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident is discharged to the hospital, facility staff should send a face sheet, a POLST, a medication list, and send all of this information with the patient. The DON stated that this should be documented in the medical record.

An abbreviated complaint survey was conducted on July 9, 2025. Based on interview, observation, and record review, it was determined that for 1 of 5 sampled residents, that the facility failed to provide the services consistent with the resident's needs and choices. Specifically, a resident was not offered a shower for 15 days. Resident identifier: 1. An abbreviated complaint survey was conducted on July 9, 2025. Based on interview, observation, and record review, it was determined that for 1 of 5 sampled residents, that the facility failed to provide the services consistent with the resident's needs and choices. Specifically, a resident was not offered a shower for 15 days. Resident identifier: 1. Findings IncludeThe surveyor reviewed Resident 1's medical records, and the following entries were observed: Resident 1's care plan, initiated May 30, 2025, indicated that Resident 1 had an Activities of Daily Living self-care performance deficit related to her diagnoses. The intervention listed that Resident 1 was able to bathe with a one-person staff assist. Resident 1's Minimum Data Set assessment, dated June 11, 2025, indicated that Resident 1 required substantial/maximal assistance for showering or bathing. Resident 1's shower log revealed that Resident 1 was given a shower on June 13, 2025. It should be noted that this was the first shower given to Resident 1 in 15 days. On July 15, 2025, the survey interviewed the Director of Nursing (DON). The DON stated that all residents are offered showers twice a week. The DON stated that residents can refuse showers or request more showers, and the facility staff would accommodate the residents' needs. The DON stated that staff were instructed to document shower refusals. The DON stated that Resident 1 had refused showers and staff failed to document the refusals. The DON stated that Resident 1 had been given showers that were not documented.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 25 sampled residents, a resident that was dependent on cares was left unattended in the shower, sustained a head laceration that required eight staples and six stitches, and the resident sustained a pelvic fracture. Resident identifier: 118. Findings included: Resident 118 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, fracture of pubis, subluxation of right shoulder joint, localized edema, dysphagia, history of falling, moderate protein-calorie malnutrition, and essential hypertension. Resident 118's medical record was reviewed on 5/20/24. A state optional Minimum Data Set (MDS) assessment dated [DATE], documented that resident 118 required extensive assistance of two plus persons for bed mobility, transfers, and toilet use. A quarterly MDS assessment dated [DATE], documented that resident 118 had a Brief Interview for Mental Status (BIMS) score of 6. A BIMS score of 0 to 7 would indicate severe cognitive impairment. On 1/29/24 at 10:08 AM, a Skilled Nursing Note documented Resident is A&Ox2 [alert and oriented to person and place] and speaks Cantonese only. Staff to anticipate her needs. Resident had no negative behaviors observed or reported this morning. Resident took her morning medications with applesauce with no difficulty swallowing. Resident is an extensive assist x [by] 2 person for ADL's [activities of daily living], bed mobility, and transfers. Resident users her wheelchair for mobility with extensive assist x 1 person. Resident is very limited with ROM [range of motion] r/t [related to] disease process. Resident is turned and repositioned q2h [every two hours] and prn [as needed] to prevent skin breakdown. Call light within reach. On 3/2/24 at 6:45 AM, a Nursing Progress Note documented Note Text: FALL EVENT: CNA [Certified Nursing Assistant] reported to RN [Registered Nurse] that resident has fallen on the floor while attempting her morning shower. RN approached and noted blood on residents face. CNA was applying pressure on the right side of her head to stop the active bleeding. RN observed her head and noted a laceration on the right side of her forehead. Resident was unresponsive to stimuli for a minute. She came back and became agitated and calling out words in her primary language. Vitals [vital signs] immediately taken BP [blood pressure] 169/83 HR [heart rate] 86 O2 [oxygen] 90% @RA [at room air], temp [temperature] 97.4F [Fahrenheit] by CNA and nursing student. RN meanwhile called provider to report and called 911. Report was given 911 representative. Patient family or daughter was notified over the phone. First responders arrived, report given with patient info and they told RN that she will be taken to the nearest hospital which is [name of hospital redacted]. On 3/2/24, an Emergency Department (ED) physician note documented . Alzheimer's dementia who presents to the emergency department from her care facility with concern of fall resulting in head trauma with a laceration. Unclear how the patient fell , as reported she fell while showering but patient is nonambulatory and has chronic contractures of her arms and legs. She was offered admission but family has decided they would like to put her back on hospice and send her back to her care facility. They do not want any further interventions and understands she could get worsening [sic] even die from these injuries and her electrolyte abnormalities, . ASSESSMENT AND PLAN: #Pelvic fractures . Nonoperative, Weight-bear as tolerated though nonambulatory at baseline, Unable to provide benefit with PT [physical therapy] #Age Indeterminate nondisplaced rib fractures . #Chronic right shoulder subluxation . #Forehead laceration Laceration was stapled by the ED attending . On 3/3/24 at 4:46 PM, a Nursing Progress Note documented Late Entry: Note Text: Late entry for 3/3/24: [name of hospice company redacted] nurse informed this nurse that resident had a fractured pelvis. Stated that is what was on the hospital discharge papers. Nurse assessed and no s/s [signs or symptoms] of pain while turning was observed. Resident has head laceration to the left side of her head. Resident has 8 staples and 6 stitches to head laceration. Wound shows no s/s of infection. Resident was more lethargic than her baseline. Resident would respond to verbal stimulation but would go right back to sleep. Resident requires O2 to maintain sats [saturations] > [greater than] 90%. O2 running at 2 L/min [liters per minute]. Resident lungs auscultated upper and lower lobes bilaterally with decreased sounds in the bases and crackles heard in the upper lobes with expiratory wheezing. Resident is sat up in bed to 30 degrees or more to help with her breathing. Resident is resting at this time with no s/s of distress. Staff to continue to monitor resident status throughout this shift. On 3/4/24 at 5:01 PM, a Nursing Progress Note documented Note Text: Resident had a recent fall with injuries. Resident has a head laceration to the left side of her head with 8 staples and 6 stitches. Wound shows no s/s of infection. Wound was cleansed with NS [normal saline] and pat dried with gauze. This nurse spoke with [name redacted], [name of hospice company redacted], and he verified that resident does have a pelvic fracture and fractures to her 4th and 5th rib on the left side. Resident shows no grimacing or guarding during cares. Today, resident asked, through translation through her daughter, [name redacted], that she wanted to use the restroom. Staff got resident up into her wheelchair and was able to use the restroom. Resident had a medium BM [bowel movement]. V/S [vital signs] taken BP: 122/58 P [pulse]: 76 R [respirations]: 16 T [temperature]: 97.7 O2: 87% on 2 L [liters] O2 via NC [nasal cannula]. O2 was titrated up to 3 L O2. While resident was on the toilet, resident had clear, yellowish emesis. Staff got resident into bed and raised the HOB [head of bed] to >30 degrees. Resident did eventually stopped vomiting. New order received from [name of hospice company redacted] on 3/4/24: 1. Albuterol 0.63 mg [milligrams]/3 ml [milliliters] 1 vial nebulize vial q4h [every four hours] PRN for SOB [shortness of breath]; 2. suction machine use yaunker suction PRN for secretions; 3. Keep HOB up 30 degrees at all times, do not lay flat; 4. 2 person assist for any moving/transferring of patient; 5. Please premedicate before any moves or brief changes. A care plan Focus dated 3/5/24, documented [Resident 118] is risk for falls r/t hx [history] of frequent falls. The interventions initiated on 3/5/24, included: a. Anticipate and meet resident 118's needs. Encourage to wait for assistance. b. Be sure bed was in low position and locked in place. c. Be sure resident 118's call light was within reach and encourage the resident to use it for assistance as needed. Resident 118 needs prompt response to all requests for assistance. d. Educate the resident, family, and caregivers about safety reminders and what to do if a fall occurs. e. Encourage to wear well-fitting, non-skid footwear when transferring and ambulating. f. Ensure adequate lighting in room. Check night lights and call lights at bedside, bathrooms and shower rooms, ensure call light was within reach. On 3/5/24 at 7:49 AM, a Nursing Progress Note documented Note Text: Resident had a recent [fall] with injuries. Resident has a laceration to the right side of her head with 8 staples and 6 stitches. Wound shows no s/s of infection. Resident also sustained fractured pelvis and the 4th and 5th ribs on her left side. Nurse educated staff on careful turning and repositioning during cares. Resident is premedicated before all cares for Pain. Resident had no s/s of pain with no facial grimacing or guarding during cares. V/S taken this morning BP: 105/56 P: 67 R: 16 T: 97.6 O2: 90% on 3L O2 via NC. Resident has expiratory wheezes and crackles. Nurse suctioned her this morning per MD [Medical Director] order. Lungs auscultated upper and lower lobes bilaterally with decreased sounds in the bases and crackles heard in the upper lobes. Resident is sat up to 30 degrees or more per MD order. Nurse observed right sided weakness. She is having a hard time getting her right arm up to her walker when she's using the restroom to help balance herself. Staff to stay with her while she's on the toilet. Resident is alert to self and is unable to appropriately communicate her needs r/t language barrier. Staff to anticipate needs and use her picture board to help convey her needs. Resident is more lethargic and did not wake during V/S this morning. Resident is turned and repositioned q2h and PRN to prevent skin breakdown. Staff to continue to monitor resident throughout this shift to ensure comfort and safety. Push pad call light is within reach. On 3/5/24 at 4:57 PM, a Nursing Progress Note documented Note Text : CNA informed nurse that resident wasn't responding to verbal or physical stimuli. Nurse went in and found resident not breathing and pale. Nurse auscultated heart for five minutes and heard no sounds. Time of death 1625 [4:25 PM] on 3/5/24. Family was present while nurse was listening to her heart. [Name redacted] from [name of hospice company redacted] was notified. On 5/21/24 at 12:15 PM, an interview was conducted with CNA 2. CNA 2 stated on the day in question it was resident 118's shower day. CNA 2 stated he put resident 118 in the shower chair and pushed resident 118 into the shower room. CNA 2 stated the shower room was in the resident's bathroom. CNA 2 stated the towels and gloves were in the chair in resident 118's room. CNA 2 state he grabbed the towels and gloves that were in the chair and when he came back to the shower room resident 118 was on the floor. CNA 2 stated there should have been two people for the transfer of resident 118 to the shower Chair. CNA 2 stated when he put resident 118 in bed he could do that by himself even though resident 118 was heavy. CNA 2 stated that CNA 3 had helped him transfer resident 118 to the shower chair and then CNA 3 left to go back to her section. CNA 3 stated that resident 118 only needed one person for the shower. On 5/21/24 at 2:51 PM, an interview was conducted with CNA 3. CNA 3 stated that she had helped CNA 2 transfer resident 118 from the bed to the chair but she did not help CNA 2 transfer resident 118 to the shower chair the night of the incident. CNA 3 stated that CNA 2 was tall and a big guy and he probably transferred resident 118 himself. CNA 3 stated that she had heard resident 118 scream but resident 118 was already on the floor when she had arrived at resident 118's room. CNA 3 stated that resident 118 was not able to sit in a chair by herself and that resident 118 would lean over. CNA 3 stated that the shower chair was a bench with holes and it did not have sides. CNA 3 stated resident 118 was a two person assist for transfers, resident 118 could not walk, and resident 118 was total dependent with cares. CNA 3 stated that resident 118 was a one person assist for showers. On 5/21/24 at 3:01 PM, an interview was conducted with the PT Director. The PT Director stated that resident 118 was never able to ambulate while resident 118 was a resident at the facility. The PT Director stated that resident 118's right ankle had limited ROM and the left ankle was more so limited. The PT Director stated that resident 118's right hand had limited ROM. The PT Director stated that resident 118 was able to sit in a chair unassisted. The PT Director stated if the shower chair had a back rest he would think that resident 118 would have been able to sit up. The PT Director stated that resident 118 would sit in the bedside chair for extended periods. On 5/21/24 at 3:13 PM, an interview was conducted with Medication Technician (MT) 3. MT 3 stated she was not working the night that resident 118 fell . MT 3 stated the day that resident 118 was getting her shower the staff were not using the shower chair that should have been used. An observation was conducted with MT 3 of a similar shower chair that was used when resident 118 fell . The shower chair was observed to be a bench with holes and the bench had a back rest attached. An observation was conducted with MT 3 of a similar shower chair that resident 118 should of been using. The shower chair was observed to look like a bedside commode with arm rest but according to MT 3 the one resident 118 used was smaller. MT 3 stated that resident 118 did not lean when sitting in a chair and was more ridged. MT 3 stated that resident 118 was dependent on all cares. MT 3 stated that resident 118 was not able to hold onto the arm rests of the shower chair and the arm rests were more for security. MT 3 stated that resident 118 had limited ROM in her hands but would hold onto a walker from a sitting position in the wheelchair. MT 3 stated resident 118 would not be able to grasp the walker to get up and walk. On 5/21/24 at 3:30 PM, an interview was conducted with RN 2. RN 2 stated it was early morning and she had just started her shift. RN 2 stated that she liked to do rounds to look in on the residents to see how they were doing and resident 118 was sleeping. RN 2 stated the CNA went to shower resident 118 and it happened so fast. RN 2 stated that resident 118 was bleeding from the head and she had applied pressure to the area. RN 2 stated that resident 118 usually required one person for showers. RN 2 stated that resident 118 was very low maintenance. RN 2 stated that resident 118 spoke Cantonese and the family was very involved. RN 2 stated that during the day resident 118 would sit in her chair and would have a walker in front of her. RN 2 stated that having the walker in front of resident 118 was a mental thing and resident 118 had her bags on the walker. RN 2 stated that resident 118 could not pull herself up or walk. RN 2 stated it was an unfortunate event. On 5/22/24 at 12:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they had continued education with the staff regarding gathering supplies before going into the shower and using the call light to ask for assistance. The DON stated that she would have not thought that resident 118 could not be left alone. The DON stated that resident 118 would sit on the edge of the bed. The DON stated that resident 118 did not have to have the walker to sit on the edge of the bed.

Based on interview and record review, the facility did not ensure each resident's drug regime was free from unnecessary drugs. Specifically, for 1 out of 25 sampled residents, staff were not monitoring a resident's blood pressure as instructed in a physician's order. Resident identifier: 33. Findings Included: Resident 33 was admitted to the facility on [DATE] with diagnoses which included end state heart failure, depression, hypertensive heart and chronic kidney disease, encounter for palliative care, chronic combined systolic and diastolic heart failure, anxiety disorder, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, hyperlipidemia, essential hypertension, and gastro-esophageal reflux disease. Resident 33's medical record was reviewed on 5/23/24. Resident 33 had a physician's order that stated, amLODIPine Besylate Oral Tablet 10 MG [milligrams] (Amlodipine Besylate). The order stated, Give 10 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION. The order instructed to Hold if SBP [systolic blood pressure] < [less than] 110 or DBP [diastolic blood pressure] <60. Call physician if SBP > [greater than] 180. The Start Date was 12/2/23 at 8:00 AM. Resident 33's Medication Administration Record (MAR) was reviewed. a. The March 2024 MAR documented that resident 33 received Amlodipine from 3/1/24 to 3/12/24, and 3/14/24 to 3/31/24. Resident 33 did not receive Amlodipine on 3/13/24, due to the resident not being at the facility that day. b. The April 2024 MAR documented that resident 33 received Amlodipine from 4/1/24 to 4/29/24, and Amlodipine was refused by resident 33 on 4/30/24. c. The May 2024 MAR documented that resident 33 received Amlodipine each day from 5/1/23 to 5/23/23. Resident 33's blood pressure (BP) values were reviewed and the following were documented. The BP values were recorded in millimeters of mercury. a. On 3/22/24, 100/52 b. On 3/23/24, 110/57 c. On 3/24/24, 102/66 d. On 3/24/24, 99/69 e. On 3/26/24, 112/69 f. On 4/13/24, 102/58 g. On 5/19/24, 109/59 h. On 5/23/24, 130/70 On 5/22/24 at 8:08 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that if he were to documented a resident's vital signs prior to administering a blood pressure medication he would document the vital signs in the medical record under the vital signs tab. LPN 1 further stated that he may document the vital signs on the MAR also. LPN 1 stated he was not sure where the Certified Nursing Assistant's (CNA's) documented the vitals signs that they had collected. On 5/22/24 at 8:25 AM, an interview with Medication Technician (MT) 2 was conducted. MT 2 stated that if the nurse needed vital signs for a resident assessment then the nurse would document the vital signs. MT 2 stated that the other vital signs collected by the CNA's would have been documented by the CNA under the vital signs section of the resident's medical record. On 5/23/24 at 8:36 AM, an interview with MT 1 was conducted. MT 1 stated that typically when a resident had an order with specific parameters, the vital signs could be directly added to the MAR when medications were administered. MT 1 stated that resident 33's current vital signs were typically documented in resident 33's medical record, and she would refer to the most recent vital signs prior to administering the Amlodipine. MT 1 stated that resident 33's most recent blood pressure was documented on 5/19/24. MT 1 stated that she would take resident 33's blood pressure today prior to administering the Amlodipine because resident 33 did not have a more current blood pressure reading. MT 1 stated that resident 33's blood pressure would get documented in the vitals section of the medical record because there was not a place to add the blood pressure values to the MAR. On 5/23/24 at 9:00 AM, an interview with CNA 1 was conducted. CNA 1 stated that a nurse would instruct the CNA's as to which resident's needed vital signs taken. CNA 1 stated that sometimes the CNA's would chart the vital signs, and sometimes the CNA's would write down the vital signs and give the information to the nurse. CNA 1 stated that she had not yet taken resident 33's blood pressure today. On 5/23/24 at 9:06 AM, an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated that nurses would normally create a sheet that included which residents needed their vital signs taken. RN 1 stated that if a resident had a medication that had specific parameters, the nurse or MT administering the medication was responsible for ensuring that the vital signs were recently done or checking the vital signs themselves prior to administering the medication. RN 1 stated that resident 33 had her blood pressure checked every morning. RN 1 stated that whomever checked resident 33's blood pressure would document the vital signs into resident 33's medical record. On 5/23/24 at 10:25 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that checking a resident's blood pressure was not always required for long term residents who were on a stable blood pressure medication. The DON stated that resident 33's order was changed in December of 2023 and the requirement to check the resident's blood pressure was supposed to be removed. The DON stated that the verbiage that instructed staff to check resident 33's blood pressure was left on the order, and that it was a mistake and should have been taken off.

Based on interview and record review, the facility did not ensure that residents did not receive psychotropic drugs pursuant to an as needed (PRN) order unless the PRN order for psychotropic drugs were limited to 14 days. If the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order. In addition, residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, for 2 out of 25 sampled residents, residents had PRN orders for Trazodone that were not limited to 14 days, and the physician or prescribing practitioner had not evaluated the residents for the appropriateness of the medication. In addition, a resident with an order for an antipsychotic medication did not have an appropriate indication for use. Resident identifiers: 28 and 44. Findings included: 1. Resident 44 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of right foot, acute osteomyelitis right ankle and foot, dehiscence of amputation stump, type 2 diabetes mellitus, traumatic subdural hemorrhage with loss of consciousness, abrasion left great toe, dementia severe with agitation, essential hypertension, and normal pressure hydrocephalus. Resident 44's medical record was reviewed on 5/21/24. On 4/18/24, a physician's order documented traZODone HCl [hydrochloride] Oral Tablet 50 MG [milligrams] (Trazodone HCl) Give 25 mg by mouth every 4 hours as needed for agitation. The physician's order had an indefinite end date and was discontinued on 5/21/24. [Note: The physician's order was not limited to 14 days and the physician did not document their rationale in the resident's medical record for extending the Trazodone.] On 5/21/24, a physician's order documented traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 25 mg by mouth every 4 hours as needed for sleep pattern disturbance with depressive symptoms. The April and May 2024 Medication Administration Record (MAR) were reviewed. Resident 44 did not have any requested administrations of Trazodone in April 2024. Resident 44 had requested Trazodone on one occasion in May 2024 on 5/7/24. On 5/21/24 at 8:18 AM, a Nursing Progress Note documented Note Text: Resident is on psychotropic medications without appropriate diagnoses: Aripiprazole, Trazodone. Notified provider to address for appropriateness/continuation of medications. Resident does have sleep pattern disturbance, Dementia with occasional behaviors, and Moca [Montreal Cognitive Assessment] of 3. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affection right dominant side, functional quadriplegia, type 2 diabetes mellitus with foot ulcer and autonomic neuropathy, chronic kidney disease stage 3, esophageal varices without bleeding, atrial fibrillation, and chronic pain. Resident 28's medical record was reviewed on 5/22/24. The hospital discharge orders dated 5/2/24, included a prescription details for quetiapine fumarate. The prescription included to dispense five tablets with no refills. On 5/2/24, a physician's order documented QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 6.25 mg by mouth at bedtime for delusions. Resident 28 had no documented behaviors of delusions and resident 28 did not have an appropriate indication for use. On 5/2/24, a physician's order documented traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 50 mg by mouth every 24 hours as needed for sleep. The physician's order had an indefinite end date and was discontinued on 5/21/24. [Note: The physician's order was not limited to 14 days and the physician did not document their rationale in the resident's medical record for extending the Trazodone.] On 5/21/24, a physician's order documented traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 50 mg by mouth every 24 hours as needed for sleep pattern disturbance related to INSOMNIA, . The May 2024 MAR was reviewed. Resident 28 did not have any requested administrations of Trazodone in May 2024. On 5/22/24 at 12:52 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON stated that psychotropics were reviewed on admission and the goal was to have a 14 day stop on PRN psychotropics and a review of the medications. The DON stated the psychotropic meeting was held once a month and the Medical Director attended. The DON stated that gradual dose reductions were in place for residents. The DON stated that she preferred not to use many psychotropics but some residents required them. The DON stated the psychotropic meeting would have been held today and the residents in question would have been reviewed. The ADON stated if the resident was not using the PRN medication then it would have been discontinued.

Based on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner (NP) or clinical nurse specialist. Specifically, for 1 out of 25 sampled residents, a resident had additional labs completed without a physician's order after the resident had completed their antibiotic therapy. Resident identifier: 44. Findings included: Resident 44 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of right foot, acute osteomyelitis right ankle and foot, dehiscence of amputation stump, type 2 diabetes mellitus, traumatic subdural hemorrhage with loss of consciousness, abrasion left great toe, dementia severe with agitation, essential hypertension, and normal pressure hydrocephalus. Resident 44's medical record was reviewed on 5/21/24. On 4/5/24, the hospital Discharge Orders documented . Discharge Antimicrobial Recommendation: Patient will need: Cefuroxime 500 mg [milligrams] PO [by mouth] twice daily for 2 weeks. Second antibiotic: Doxycycline 100 mg PO twice daily for 2 weeks. Stop Date: 4/26/24 While receiving antibiotics recommend the following labs near planned stop date of therapy (SNF [Skilled Nursing Facility], please draw) CBC [complete blood count] w/diff [with differential] CMP [comprehensive metabolic panel] ESR [erythrocyte sedimentation rate] CRP [c-reactive protein] . A physician's order dated 4/18/24, documented Cefuroxime Axetil Oral Tablet 500 MG (Cefuroxime Axetil) Give 500 mg by mouth two times a day for infection until 04/26/2024 23:59 [11:59 PM]. A physician's order dated 4/18/24, documented Doxycycline Hyclate Oral Tablet 100 MG (Doxycycline Hyclate) Give 100 mg by mouth two times a day for infection until 04/26/2024 23:59. A physician's order dated 4/19/24, documented CBC with Diff, CMP, ESR, CRP fax to [doctors name redacted] when results received on 4/24/2024 one time only for 4 Days. The physician's order had a start date of 4/23/24. On 4/29/24 at 9:06 AM, a Nursing Progress Note documented Late Entry: Note Text: NP reviewed recent lab work from 04.29.2024, NNO [no new orders]. CBC W/ [with] Auto Diff [differential], CMP, ESR, [NAME], Sed [sedimentation] Rate, CRP. A lab result dated 5/8/24, documented that a CBC, CMP, and a CRP test were collected. On 5/10/24 at 9:26 AM, a Nursing Progress Note documented Note Text: NP reviewed recent CMP CRP CBC results from 05.08.2024, NNO. A lab result dated 5/16/24, documented that a CBC, CMP, CRP, and an ESR were collected. No documentation could be located or provided to indicate a physician's order was written for the labs collected on 5/8/24 and 5/16/24. On 5/22/24 at 12:47 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON stated that the order from the hospital was to complete the labs weekly. The ADON stated that the antibiotic was stopped on 4/26/24. The ADON stated that resident 44 saw the infectious disease doctor on 5/14/24. The DON stated that they continued the lab orders until resident 44 saw the infectious disease doctor.

Based on observation, interview, and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 23 sampled residents, residents did not receive preventative interventions and/or adequate supervision to prevent falls and accidents from occurring. Resident identifiers: 2 and 35. Findings included: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, chronic osteomyelitis of left thigh, non-pressure chronic ulcer of left thigh with necrosis of muscle, severe protein-calorie malnutrition, acute respiratory failure with hypoxia, staphlococcus, proteus, essential hypertension, postpolio syndrome, paraplegia, chronic pain syndrome, and retention of urine. On 10/24/22 at 12:38 PM, an interview was conducted with resident 2. Resident 2 stated that he had fallen at the facility. Resident 2 stated that he had broken his leg during one of the falls. Resident 2 stated that he was dumped out of the shower chair by accident by a Certified Nursing Assistant (CNA). Resident 2 stated the staff thought his leg was sprained but resident 2 stated his leg hurt too bad to be a [NAME]. Resident 2 stated the CNA turned the shower chair around with him in it and the CNA was not paying attention when he fell out of the shower chair. Resident 2's medical record was reviewed on 10/25/22. A Care Plan Focus initiated on 4/8/22 documented FALLS [name of resident 2 removed] is at risk for falls r/t [related to] postpolio syndrome, long term use of opioid medications, fall hx [history]. Interventions included, but not limited to, Staff educated regarding shower chairs and safe transfers. Initiated on 2/2/22. On 2/4/22 at 4:25 PM, a Fall incident report documented Nursing Description: Aide [CNA] had just finished showering resident and was trying to wheel him back towards his bed in the shower chair when it tipped over. That specific shower chair needs to be pulled backwards instead of pushed forward so it doesn't tip, aide said she forgot about that. Resident Description: Resident stated that he didn't his [sic] his head when he fell , just landed on shoulder. Injuries Observed at Time of Incident bruise, right inner ankle, bruise, right outer ankle. Level of pain 4/10. On 2/5/22 at 4:58 PM, a Nursing Progress Note documented Resident c/o [complains of] pain continuing in right foot. Area that is bruised has increased from 1x1 cm [centimeter] in two spots to three 3x3 cm spots on foot. Swelling has also increased. Notified on-call doctor and received order for ankle and foot x-ray to rule out fracture. [Name of x-ray company removed] x-ray tech [technician] arrived at 1700 [5:00 PM] and is getting x-ray. Will update physician and PCC [Point Click Care] with results. Resident is his own responsible party. On 2/5/22 at 5:05 PM, a Lab/XRAY documented Type of Lab/XRAY Completed: 3-view ankle and 3-view foot Abnormal Results?: Fx [Fracture] of tibia and fibula New Orders or Redraws?: Order for rigid walking boot to keep foot in correct position. Order to set up ortho [orthopedic] consult next week. Changing oxycodone 10 mg [milligrams] from tid [three times daily] to q6h [every 6 hours], adding new order for ibuprofen 800 mg q8h [every 8 hours] PRN [as needed] x 14 days for breakthrough pain. On 2/5/22 at 8:07 PM, a Nursing Progress Note documented Received order from [Name of physician removed] to send resident to ER [emergency room ] to assess fx. [Name of Ambulance company removed] EMTs [Emergency Medical Technicians] picked him up at 1800 [6:00 PM]. They weren't sure which hospital would take him but said that it would probably either be [name of hospital removed] or [name of hospital removed]. Administered scheduled oxycodone and methadone to resident before he left in an attempt to manage pain before leaving. On 2/5/22 at 9:13 PM, a Lab/XRAY documented Type of Lab/XRAY Completed: Right ankle and right foot 3-view x-ray Abnormal Results?: Right ankle: There are acute osteoporotic fractures involving distal tibial metaphysis and distal fibular metastasis without significant displacement. Ankle joint is still maintained. There is significant soft tissue swelling. IMPRESSION: Acute distal tibia and fibula fractures. New Orders or Redraws?: Sent to ER to have fx assessed and fitted with boot. On 2/6/22 at 12:29 AM, a Nursing Progress Note documented Resident was brought from the [name of hospital removed] at 23.30 [11:30 PM] pm by [name of Ambulance company removed] [NAME] [sic] having diagnosed Closed rt [right] ankle fracture & F/U [follow up] orthopedic Surgeon. Resident is alert & oriented, asked for HS [at bedtime] meds [medications] & went to sleep v/s [vital signs] BP [blood pressure] 116/55, pulse 87, Resp [respirations] 18, Temp [temperature] 98.6 & O2 [oxygen] sat [saturations] 93 . Will cont [continue] to monitor. On 2/7/22 at 5:23 PM, a Skilled Progress Note documented Alert and oriented. Uses electric w/c [wheelchiar] for mobility. Feeds himself. Verbalizes needs. Currently NWB [non-weight bearing] to his right leg d/t [due to] closed ankle fx. To f/u with orthopedic. Not yet scheduled. Resp even and unlabored. On 2/8/22 at 5:01 PM, a Skilled Progress Note documented Resident is alert and oriented x 3-4 [oriented to person, place, time, and situation]. resident co [complains] generalized increased pain andesp [sic] d/t right ankle fx. Resident has breakdown on his gluteal area. Right ankle splinted. Resident is able to make needs known. Resident oob [out of bed] in electric chair this morning. New orders for scheduled tylenol 650 mg q 6 hrs. On 2/9/22 at 11:13 AM, a Skilled Progress Note documented Resident is alert and oriented x4. Resident c/o generalized increased pain d/t right ankle fx. Resident has breakdown on his gluteal area. Right ankle splinted. Resident is able to make needs known. F/u ortho appt [appointment] scheduled today at 1300 [1:00 PM]. New orders for scheduled Tylenol 650 mg q6h. Resident stable today. Will update with any new orders from appt. On 2/9/22 at 8:24 PM, a Nursing Progress Note documented [Name of physician removed] ordered to increase Oxycodone to q4h [every 4 hours] prn x 10 days then back to original order. On 2/10/22 at 12:54 PM, a Skilled Progress Note documented [Name of resident 2 removed] is AXOx4 [alert and oriented to person, place, time, and situation]. He is able to make his wants and needs known. He has been pleasant and cooperative with all aspects of care. He continues to c/o generalized increased pain d/t right ankle fx. Continues to have breakdown on his gluteal area with treatments being followed per MD [Medical Director] order. Right ankle is casted. A care plan intervention initiated on 2/18/22, documented CNAs educated on transfers and proper use of shower chair. [Note: No new interventions were implemented. The same intervention was initiated on 2/2/22, Staff educated regarding shower chairs and safe transfers.] On 3/9/22 at 12:01 PM, a COMMUNICATION - with Physician documented Situation: Ortho follow-up appt with [name of physician removed] at [name of hospital removed] Background: Orders to continue vitamin D3, continue cast x 4 weeks, follow-up appt in 4 weeks (left copy of order for appt coordinator), continue NWB. Notified house physician, no other orders. Resident stable. On 10/25/22 at 1:11 PM, an interview was conducted with Restorative Nurse Assistant (RNA) 1. RNA 1 stated when she showered a resident she would ask the resident if it was there shower day, if the resident would like a shower, and what clothes would the resident like to pick out. RNA 1 stated if the resident could walk or use a walker RNA 1 would assist the resident to walk to the shower room. RNA 1 stated if the resident used a wheelchair RNA 1 would take the resident to the shower room in a wheelchair. RNA 1 stated the shower chair was located in the shower room. RNA 1 stated she would use the shower chair to move the resident if the resident required the hoyer lift to transfer. RNA 1 stated that she would transfer the resident from the bed with the hoyer lift to the shower chair with two CNAs. RNA 1 stated that she pushed the shower chair forward with the resident facing the direction she was moving. RNA 1 stated that she had never had a shower chair tip over. RNA 1 stated that resident 2 should be transferred with the hoyer lift but resident 2 did not like the hoyer lift. RNA 1 stated that two CNAs' would transfer resident 2 to the shower chair by lifting him. RNA 1 stated that resident 2 had an accident in the shower chair one time. RNA 1 stated that she heard that the CNA had pushed the shower chair with resident 2 in the shower chair and RNA 1 thought the wheel was not working very well and the CNA pushed the shower chair harder and the wheel got stuck. RNA 1 stated that the CNA that was pushing resident 2 did not work at the facility anymore. On 10/25/22 at 2:22 PM, an interview was conducted with CNA 4. CNA 4 stated that she was a shower CNA. CNA 4 stated that she transported the residents to the shower room in the shower chair. CNA 4 stated there were two shower chairs, a small shower chair and a big shower chair. CNA 4 stated that she had no issues with the shower chairs. CNA 4 stated that resident 2 used the small shower chair. CNA 4 stated that resident 2 required a two person transfer to the shower chair and CNA 4 would put a towel under his legs. CNA 4 stated that resident 2 did not have any accidents with her. CNA 4 stated that resident 2 told her that he had an accident when the CNA transferred the resident from his motorized wheelchair to the bed. CNA 4 stated that resident 2 required two persons for a transfer. On 10/26/22 at 10:52 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated the CNA was helping resident 2 and the shower chair only worked if pushed backwards. RN 2 stated that the CNA was pushing resident 2 forward in the shower chair and resident 2's foot got stuck somehow and the shower chair may have tipped. RN 2 stated that the CNA forgot that she needed to push the shower chair backwards. RN 2 stated that she had understood that if resident 2's feet were not stuck under the chair it would not have been an issue. RN 2 stated that the weight of resident 2 falling caused the break. RN 2 stated that she helped resident 2 back to bed and resident 2 had no pain until the next day and his ankle swelled more. RN 2 stated that was the first time she had heard of the shower chair having problems. RN 2 stated that she had not seen that shower chair in the facility since the incident. RN 2 stated that the CNA involved in the accident stopped working at the facility a few months ago. On 10/26/22 at 1:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident had a fall the nursing staff would do an assessment of the resident if the resident was on the floor. The DON stated if the resident hit their head the staff would start neurological checks for 72 hours after the fall. The DON stated that staff were to Notify the MD, family, and case manager. The DON stated after everything was completed the staff were to watch the resident. The DON stated if the resident had an injury the staff were to get clarification from the MD. The DON stated if the resident had broken bones the staff were to get an x-ray or send the resident to the hospital with guidance from the MD. The DON stated that the staff were to do as much diagnostics in house as they could. The DON stated the facility had a funky shower chair that was a newer shower chair and resident 2 was getting a shower from one of his favorite CNAs. The DON stated that the shower chair was designed to be pulled backwards. The DON stated that the CNA was pushing resident 2 forward in the shower chair at resident 2's request and the shower chair abruptly stopped and resident 2 fell out of the shower chair. The DON stated that resident 2 had no bruising at the time of fall. The DON stated that the MD was notified and resident 2 was his own representative. The DON stated that the next day bruising was noticed on resident 2 and a X-ray was obtained. The DON stated that resident 2 had lack of feeling in his lower extremities. The DON stated the shower chair and all similar shower chairs were thrown out and new shower chairs were purchased. The DON stated that the CNAs and nurses had to pass competencies with the new shower chairs. The DON stated the incident was a singular incident and interventions were implemented immediately. 2. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, depression, restless leg syndrome, type 2 diabetes mellitus with diabetic chronic kidney disease and diabetic neuropathy, severe protein-calorie malnutrition, opioid dependence, essential hypertension, pulmonary hypertension, chronic atrial fibrillation, chronic diastolic congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, stage 3 chronic kidney disease, and repeated falls. On 10/24/22 at 11:05 AM, an interview was conducted with resident 35. Resident 35 stated she had a fall three to four weeks ago. Resident 35 stated the bed pushed her out and it flipped over. Resident 35 stated that she had a new bed now. Resident 35 stated that she had cut her knee when she fell and had to have 15 stitches in her right knee. Resident 35 stated that her knee was healing very well, and staff were quick to help when she fell . Resident 35's medical record was reviewed on 10/27/22. On 9/7/21, an Alert Charting documented that resident 35 was a High Risk for falls. On 11/19/21 at 4:09 PM, a Fall incident report documented an Incident Description Nurses were called over radio to assist a patient at the front entrance parking lot. Pt [Patient] was found supin [sic] on parking lot floor next to open car door. Patient was A&Ox3 [alert and oriented to person, place, and time], Asked if pt was in pain and pt responded no. Assessed for any lacerations, bruises, bumps or any bleeding and all negative. PERRLA [pupil, equal, round, reactive to light and accommodation] intact. Denied any headaches, neck pain, or lingering pain. Resident Description Pt stated she just fell . Husband [name removed] stated he thought he had her and was not able to tolerate all the weight. Immediate Action Taken Patient was pulled up and transferred to wheel chair with the help of another nurse and therapy director. Pt was brought back into bldg. [building] and assessed for 30 mins [minutes] Vital signs WNL [within normal limits]. Asked by DON if she felt comfortable of [sic] going home and if she was going to have some help getting [sic] out of the care. Pt stated she would ask neighbors for help with trasnferring [sic] out of car when arriving at home. No injuries observed at time of incident. On 11/19/21, an Alert Charting was Incomplete and a fall risk score was not documented. On 11/19/21 at 5:16 PM, a Skilled Progress Note documented Resident is alert and oriented x3 with some forgetfulness. Resident is pleasant and cooperative. PRN Medications given whole with water, no issue noted. Resident uses call light to use toilet instead of brief. Pt happy to go home today. On 11/20/21 at 5:18 PM, a Skilled Progress Note documented Resident is alert and oriented x3 with some forgetfulness. Generalized weakness. Resident is pleasant and cooperative. PRN Medications given whole with water, no issue noted. Resident uses call light to use toilet instead of brief. Pt readmitted today around 1800. On 11/23/21, an Alert Charting was Incomplete and a fall risk score was not documented. A care plan Focus initiated on 11/28/21, documented RESOLVED: ACTUAL FALL The resident has an actual [fall] on 11/19/21. The Goal initiated on 11/22/21, documented RESOLVED: The infection will resolve without complication by the next review. The Interventions initiated included the following: a. RESOLVED: Call light within reach.Date initiated 11/23/21 and date resolved 1/4/22. b. RESOLVED: Educate family, significant other, & visitors of importance of quarantine/transmission based precautions in room on admission & for out of facility absences, LOA [leave of absence], appointments, etc. per facility policy. Date initiated 11/22/21 and date resolved 1/4/22. c. RESOLVED: PT [physical therapy]/OT [occupational therapy] to treat as ordered. Date initiated 11/23/21 and date resolved 1/4/22. On 12/15/21, an Alert Charting documented that resident 35 was a High Risk for falls. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 35 had a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 indicated the resident was cognitively intact. In addition, resident 35 required extensive assistance of one person for transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. On 2/2/22 at 9:10 PM, a Fall incident report documented an Incident Description Aides called me into resident's room and stated that they found her on the ground. Aides had been rounding on all residents regularly all evening and her door was open. They had changed her brief 1-2 hours before her fall. Resident Description Resident stated that she had to go to the bathroom and got out of bed by herself. She made it to the wall by her bed by herself and lost her balance and fell to the floor. She fell on to her right hand and back but stated that she lifted her head up so she wouldn't hit it. She stated that she forgot that she should have used her call light. An order was received from physician to send resident to emergency room for x-ray. No signs or symptoms of injury but acute pain from right shoulder all the way down the arm. [Note: Resident 35 did not have a care plan in place to prevent falls. The previous care plan was resolved on 1/4/22.] On 2/2/22, an Alert Charting documented that resident 35 was a High Risk for falls. On 2/2/22 at 11:22 PM, a Diagnostic Radiology report from the Medical Center documented that an x-ray of the right shoulder with three views was obtained. Resident 35 had a mildly displaced and angulated fracture at the surgical neck of the humerus. On 2/3/22 at 1:38 PM, a Nursing Progress Note documented Resident was seen at [name of Medical Center removed] after an unwitnessed fall. Discharge Dx [diagnoses]: Fall, right Shoulder fracture and UTI [urinary tract infection] symptoms. Follow up appt to be made with [name of physician removed]. Order state to leave shoulder immobilizer or sling in place (adjust so that hand is level with elbow). Apply ice pack to sight for 20 min [minutes] q [every] 1-2 hrs [hours] day one then 3-4 times a day for 2-3 days then as needed. Sling is to remain in place until appt. New order for Norco 5/325 for prn pain po [by mouth] q4h prn x 2 days. On 2/15/22 at 5:24 PM, a Nursing Progress Note documented Resident returned from [Name of Orthopedic physician removed] F/U for shoulder fracture. Orders are for PT to RUE [right upper extremity], hand/wrist and elbow - ROM [range of motion] as tolerated. Forward hang of right shoulder. Follow up in 3 weeks. On 2/17/22 at 10:37 AM, an Orders-Administration Note documented Hand/Wrist and Elbow: ROM as tolerated. Passive only flexion to right shoulder. Every shift Notified Therapy to see if they will follow up. [Note: There were no therapy notes located within resident 35's medical record for the timeframe indicated.] On 3/11/22 at 2:44 PM, a Nursing Progress Note documented Resident returned from appt with new orders: Wean out of sling. Okay to progress range of motion and strengthening at the shoulder but limit to less than 5 lbs [pounds]. Return in 6 weeks with repeat XR [xray]. Resident is own rp [representative] and aware. On 3/31/22, an Alert Charting was Incomplete and a fall risk score was not documented. On 4/16/22 at 12:54 PM, a Lab/XRAY documented a 2-view right shoulder x-ray for follow up orthopedic appointment. Impression documented a surgical neck fracture with impaction present of the right shoulder. Resident stable. On 6/14/22, an Alert Charting was In Progress and a fall risk score was not documented. A quarterly MDS assessment dated [DATE], documented that resident 35 had a BIMS score of 99. A BIMS score of 99 indicated the resident was unable to complete the interview. In addition, resident 35 required extensive assistance of one person for transfers, walk in room, locomotion on and off unit, dressing, toilet use, and personal hygiene. On 8/2/22 at 4:19 AM, a Nursing Progress Note documented Resident had a unwitnessed fall off the bed. Resident found sitting on the floor leaning against the side of the bed. She states she had a dream and rolled off the bed, right knee scraping the side of the bed and having a laceration up to her bone. Left hand also got a small laceration. Resident fully conscious, states that did not hit her head. Vitals stable. Resident helped back into bed with keeping leg stable. Leg raised on pillows and iced. Called 911 and resident is taken to the hospital. On 8/2/22 at 4:54 AM, a Fall incident report documented an Incident Description Resident found sitting on floor leaning against the left hand side of the bed yelling for help. Resident visibly has a big deep laceration on right knee the size of the the [sic] length of the knee and a smaller one on left hand the size of 1 inch x 1 inch. Resident is conscious and responsive and does not appear to have hit her head. Resident Description Resident states she had a bad dream and rolled off the left side of the bed. She states she did not hit her head, does not feel any dizziness or feel any discomfort or pain in chest. On 8/2/22, an Alert Charting documented that resident 35 was a High Risk for falls. On 8/2/22 at 10:39 AM, a Nursing Progress Note documented Resident returned from hospital. With her knee laceration sutured. Left forearm laceration bandaged. She was also treated for atrial fibrillation and given a dose of metoprolol IV [intravenous]. House NP [Nurse Practitioner] and notified. On 8/2/22, the Medical Center Discharge Handout documented that resident 35 had a fall from bed, knee laceration, and rapid atrial fibrillation. Resident 35's right knee required 15 sutures. On 8/2/22 at 10:45 AM, a Nursing Progress Note documented Resident also stated that her righ [sic] knee hit the bottom of the sink cabinet when she fell . That's where she believes she cut her knee open. On 8/26/22, an Alert Charting documented that resident 35 was a Low Risk for falls. A care plan Focus initiated on 8/26/22, documented [Name of resident 35 removed] is high risk for falls r/t generalized weakness, repeated falls in facility, confusion/poor safety awareness. The Goal initiated on 8/26/22, documented [Name of resident 35 removed] will not sustain serious injury through the review date. The Interventions initiated included the following: a. RESOLVED: Anticipate and meet the resident's needs. Encourage to wait for assistance. Date initiated 11/23/21 and date resolved. 11/28/21. b. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Date initiated 11/22/21. c. Call don't fall sign added to room. Date initiated 2/18/22. d. Continually educate the resident regarding safety issues. Date initiated 11/23/21. e. RESOLVED: Educate family, significant other, & visitors of importance of quarantine/transmission based precautions in room on admission & for out of facility absences, LOA, appointments, etc. per facility policy. Date initiated 1/4/22 and date resolved 4/17/22. f. Encourage Resident to wait for assistance. Date initiated 10/25/22. g. Encourage to wear well-fitting, non-skid footwear when transferring/ambulating. Date initiated 2/18/22. h. Ensure proper body positioning. Date initiated 10/25/22. i. Keep room free of clutter and ensure objects the resident may need are within reach. Date initiated 10/25/22. j. Make sure eyeglasses are clean & properly fitting. Date initiated 11/23/21. k. Monitor for signs and symptoms of discomfort, i.e., pain, anxiety, thirst or hunger and the need to toilet. Date initiated 10/25/22. l. Pt/ot evaluate and treat as ordered or PRN. Date initiated 1/4/22. m. RESOLVED: UA [urinalysis] to be done. 2/4/22. Date initiated 8/26/22 and date resolved 10/25/22. n. Visual Cue to use call light (Call don't fall). Date initiated 2/4/22. [Note: The care plan was initiated on 8/26/22, after resident 35 had a fall that resulted in a right shoulder fracture and a fall that resulted in a laceration of the knee to the bone that required sutures.] On 10/25/22 at 11:20 AM, an interview was conducted with CNA 1. CNA 1 stated if a resident was found on the floor, she would use the radio to call for help, tell the nurse, ask the resident if he or she was okay, ask what happened, stay with the resident and assist the nurse, and explain what happened. CNA 1 stated the fall prevention measures for resident 35 included to put bed in low position, check on resident frequently, put table close so resident 35 could reach water and personal items, and make sure the call light was within reach. On 10/25/22 at 12:12 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 35 had not had any recent falls. CNA 2 stated interventions used to prevent falls were to put bed in low position and answer call lights quickly. On 10/25/22 at 2:42 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 35 had not had any recent falls. On 10/26/22 at 1:25 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that resident 35 had not had any recent falls. The CNA Coordinator stated interventions in place to prevent falls were to keep resident 35's door open, help resident 35 to the bathroom or change her in bed, round every two hours or more frequently, put personal items and call light close to resident 35, put bed in lowest position, make sure resident 35 wore shoes or grippy socks with transfers. On 10/26/22 at 2:20 PM, an observed was conducted of resident 35 in bed watching TV, the door was open, bed in lowest position, call light in reach, and a Call, don't fall sign was observed on the bathroom door. On 10/27/22 at 1:20 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 35 had not had any recent fall. CNA 3 stated that she ensured that resident 35's bed was down, the call light was answered, the door was kept open, and CNA 3 would check resident 35 every time she went by the room. CNA 3 stated that resident 35 stayed in the bed most of the time. On 10/27/22 at 2:13 PM, an interview was conducted with the DON. The DON stated pre-fall interventions included call don't fall signs posted in the resident room, education and talking to the resident, and reminding the resident to use the call light. The DON stated an initial fall assessment would be completed and frequent rounding was done. The DON stated that after a fall the resident was assessed for injuries. If the resident hit their head the staff would initiate neurological checks. If the fall was unwitnessed and the resident was not able to state what happened, the nurse would assess and initiate neurological checks. The DON stated the nurses would notify the MD and family after the assessment and ensure the resident was safe. The DON stated the staff were to send the resident to the hospital or conduct diagnostics if needed. The DON stated that staff were to treat the resident as ordered. The DON stated that the care plan should be updated after each fall or injury. The DON stated the care plan to Kardex or point of care should be updated for the CNAs and nurses would have access to the care plan. The DON stated she would expect to see new interventions identified after each fall. The DON stated that resident 35's fall on 11/19/21, happened at resident 35's house. The DON stated that she did not know the full details, resident 35 was discharged from the facility at the time and came back the same day. The DON stated that resident 35 had no injuries identified after the fall. The DON stated that resident 35's husband stated that resident 35 fell . The DON stated that upon readmission resident 35 had no injuries noted. The DON stated the fall resident 35 had on 2/2/22, was an unwitnessed fall and resident 35 was on her way to the bathroom. The DON stated that resident 35 should have used the call light and she did not. The resident was A&Ox3. The interventions were to use call light, and to send resident 35 for an x-ray due to her complaints of shoulder pain. The DON stated that the intervention was to use the call light as resident 35 stated she had not done. The DON stated that the fall on 8/2/22, the resident reported she had a bad dream and fell out of bed. The DON stated that resident 35 refused to have the bed in a low position. It should be noted that no documentation could be found for the refusal of this intervention. The DON stated that resident 35 had fall mats in place prior to the fall and they helped to break the fall. The DON stated the laceration was because resident 35 twisted and fell and she caught her knee under the sink. The DON stated that they placed foam on the area under the sink where she lacerated her leg after the fall occurred. The DON stated that the bed was placed next to the sink. The DON stated that she asked resident 35 if they could move her bed and the resident said no. The DON stated they did not identify this as an intervention and they did not document it anywhere.

Based on observation and interview, it was determined, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the grill in the food preparation area was dirty, the oil in the deep fryer was cloudy, food items in the walk-in freezer were open to air, food items in the walk-in refrigerator were open to air, food items in the dry storage area were open to air, and a dented can was not removed from the area where usable canned goods were stored. Findings included: On 10/24/22 at 8:28 AM, an initial walk-through was conducted in the kitchen. In the dry storage area, a can of jellied cranberry sauce was observed to be dented and with the usable cans of cranberry sauce. A box of raisins was open to air and a box of fried oriental noodles was open to air. In the walk-in freezer, a box of cinnamon rolls was open to air, a box of cookie dough was open to air, a box of beef patties was open to air and a box of Krabbycakes was open to air. Additionally, the oil in the deep fryer was cloudy and the griddle in the food preparation area had dried grease drippings on the grates. On 10/24/22 at 8:38 AM, an interview was conducted with the morning cook. The morning cook stated the oil in the deep fryer was changed every week. On 10/27/22 at 9:06 AM, a second walk-through was conducted in the kitchen. In the dry storage area, a box of raisins was open to air, a box of dried cranberries was open to air, a box of fried oriental noodles was open to air, and a can of jellied cranberry sauce was dented and with the cans of usable cranberry sauce. In the walk-in refrigerator a box of sausage patties was open to air and a package of luncheon meat was open to air. In the walk-in freezer, a box of beef patties was open to air, a box with lasagna sheets was open to air and had ice crystals on the lasagna sheets, a box of pita chips was open to air, a box of Krabbycakes was open to air, a box of oatmeal raisin cookie dough was open to air, a box of chocolate cookie dough was open to air. [Note: While surveyors were in the walk-in freezer, the Dietary Manager (DM) came to the walk-in freezer and removed the box of chocolate chip cookie dough. The morning cook was making cookies and the DM stated she needed more chocolate chip cookie dough.] On 10/27/22 at 9:23 AM, an interview was conducted with the DM. The DM stated he received the shipments of food items weekly. The DM stated he inspected and dated the food items before putting them away. The DM stated he liked to check the quality of the food items coming to the kitchen. The DM stated the Corporate Dietitian (CD) was at the facility every Tuesday for meetings and would walk through the kitchen to inspect for sanitation and food safety. The DM stated the CD completed a form that would be sent to himself and the Administrator. The DM stated the inspection included sanitation, temperature logs, labeling and dating of food items, and open containers. The DM stated the oil in the deep fryer was changed after every use. The DM stated he did not keep a bunch of oil in the kitchen and did not have any oil for the deep fryer at the time. The DM stated there were no fried foods on the menu for the week, however, chicken strips were always available on the alternate menu. The DM stated chicken strips were served yesterday. The DM stated he told staff to put dented cans in a specific area in the dry food storage room so they could be returned. The DM stated he was aware that there was a can of hominy in the dry food storage room that was not put in the designated spot. The DM stated he had explained to staff about concern for botulism with dented cans and they could not be used. The DM stated staff were aware of where to place dented cans. The DM stated he tried to do weekly education with staff and then stated, but to be honest, it ends up being monthly. The DM stated there was a language barrier with some of the staff so staff had to be educated and shown how to do things correctly in the kitchen. The DM stated he had tried to educate staff about sealing food when they put it back in the refrigerator and freezer, but the language barrier is a thing. The DM stated his assistant or the Certified Nursing Assistant Coordinator were willing to help with communication. The DM stated the in-services he had provided to staff included proper food temperatures, food presentation, hand washing, and sanitation.

Based on interview and record review, it was determined, the facility did not ensure that the interdisciplinary team had determined that the right to self-administer medications was clinically appropriate. Specifically, for 1 out of 23 sampled residents, a resident was self administering a medication without an evaluation to determine if the practice was safe. Resident identifier: 6. Findings included: Resident 6 was admitted on [DATE] with diagnoses which included multiple sclerosis (MS), polyneuropathy, osteoarthritis, scoliosis, methicillin resistant staphylococcus aureus infection, urogential implants, sinusitis, history of urinary tract infections, chronic pain, hypothyroidism, insomnia, mood disorder, psoriasis, rosacea, and intervertebral disc degeneration. On 10/26/22, resident 6's medical record was reviewed. Review of resident 6's physician orders revealed Tecfidera Capsule Delayed Release 240 milligrams, give 1 capsule by mouth in the evening every other day for MS, takes with dinner. The order stated, medication may be left in residents room for self administration. The order was initiated on 4/20/21. No documentation could be found for a self administration evaluation for the Tecfidera medication. On 10/27/22 at 8:35 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 6 was knowledgeable about her medication. LPN 1 stated that the Tecfidera was kept in the medication cart and resident 6 could self administer. LPN 1 stated that resident 6 took all her medication on her own. LPN 1 stated that the Tecfidera was left at resident 6's bedside because she preferred to take the medication after she had eaten dinner. On 10/27/22 at 11:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she would locate the self administration evaluation for the Tecfidera medication. The DON stated that was something that was implemented prior to her arrival at the facility. The DON stated that there were a few medications that were evaluated. On 10/27/22 at 12:23 PM, an interview was conducted with Corporate Resource Nurse (CRN) 1. CRN 1 stated that resident 6 did not self administer the Tecfidera medication. CRN 1 stated that the order had been there a long time. CRN 1 stated that they did not perform a self administration evaluation for the Tecfidera medication. CRN 1 stated that if the medication was left in resident 6's room for self administration, then they would need to conduct a self administration evaluation.