Every finding on record at Monrovia Gardens Healthcare Center

Based on interview and record review, the facility failed to develop an individualized care plan (CP) for one of two sampled residents (Resident 1) that addressed Resident 1's behavior of taking off Resident 1's clothes and lying naked in bed.This deficient practice had the potential to result in unmet individualized needs for Resident 1 and the potential to affect Resident 1's physical and psychosocial well-being.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/24/2024, with diagnoses that included dementia (a progressive state of decline in mental abilities), displaced fracture of the second cervical vertebrae (the second bone in the neck bone is broken and the broken pieces have moved out of their normal place).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 8/29/2025, the MDS indicated Resident 1 had severe deficit in cognition (ability to think and make decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort, the resident does none of the effort to complete the activity) with toileting hygiene and required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort).During a review of Resident 1's Progress Notes (PN) dated 7/11/2026, timed at 4:35 AM, the PN indicated Licensed Vocational Nurse 1 (LVN 1) observed Resident 1 lying in bed with Resident 1's gown removed.During an interview on 7/14/2026 at 12:01 PM, with the Responsible Party (RP, Resident 1's responsible party) stated the RP visited Resident 1 last week at approximately 1:00 AM, the RP stated the RP saw Resident 1 lying naked in bed. The RP stated the RP also saw Resident 1's diaper (adult brief) was on the floor.During a telephone interview on 7/14/2026 at 1:10 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 would report being unable to sleep at night and Resident 1 tossed and turned and would remove Resident 1's clothes. CNA 2 stated Resident 1 removed Resident 1's clothing by tugging at the neck part of Resident 1's gown.During an interview on 7/14/2026 at 2:19 PM with CNA 3, CNA 3 stated when Resident 1 was in bed, Resident 1 liked to remove Resident 1's clothes.During an interview on 7/15/2026 at 6:36 AM with CNA 1, CNA 1 stated Resident 1's usual behavior was to take off Resident 1's clothes.During an interview on 7/15/2026 at 6:56 AM with CNA 4, CNA 4 stated CNA 4 was assigned to Resident 1 March 2026 and during this month, Resident 1 stripped naked at night.During an interview on 7/15/2026 at 12:27 PM with the Minimum Data Set Nurse (MDSN), the MDSN stated a CP should be developed to address a resident's (in general) behavior, preferences, and any change in condition. The MDSN stated all behaviors (in general) were discussed during the interdisciplinary team meeting. The MDSN stated all the charge nurses (in general) initiated and developed CPs or staff (in general) communicated concerns through the communication board. The MDSN stated Resident 1's behavior, of taking off Resident 1's clothes, was not care planned and the behavior needed to be investigated to find the reason for Resident 1's behavior. The MDSN stated a CP [addressing Resident 1's behavior] with appropriate interventions [needed to be developed].During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered revised March 2022, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The P&P indicated when possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. The P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review, the facility staff failed to assist a resident who was unable to carry out activities of daily living (ADLs) for one of three sampled residents (Resident 1) by failing to ensure: 1. Resident 1's hair was washed. 2. Resident 1 received assistance to effectively communicate with staff. 3. Resident 1 received set-up assistance during mealtime. These deficient practices had the potential to result in a negative impact on Residents 1's quality of life and self-esteem. These deficient practices potentially caused a delay in care and miscommunication. During an observation on 7/7/2026 at 11:46 a.m., in Resident 1's room, Resident 1 was in bed, wearing a bonnet (hat worn to sleep to protect textured, curly, or natural hair). Resident 1 did not have a communication board, writing pad or an iPad at bedside. During an observation on 7/8/2026 at 12:50 p.m., in Resident 1's room, Resident 1's lunch was untouched. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included aphonia (the complete loss of voice or the inability to produce vocal sounds) and depression (a common and serious medical illness that negatively affects how a person feels, thinks, and acts. It causes feelings of sadness and/or a loss of interest in activities they once enjoyed). During a review of Resident 1's H&P, dated 9/4/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/4/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 1 required set up or clean-up assistance for eating and oral hygiene. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for shower/bathing and personal hygiene. The MDS indicated Resident 1 was independent toileting hygiene, for lower body dressing and putting on/taking off footwear. During a review of Resident 1's care plan for hair hygiene, dated 10/6/2025, the care pan indicated Resident 1's goal was to shampoo Resident 1's hair weekly. The care plan indicated Resident 1's intervention was to shampoo Resident 1's hair weekly. During a review of Resident 1's care plan for hair hygiene, dated 10/16/2025, the care pan indicated Resident 1's goal was that Resident 1 would not have any new complaints regarding care. Resident 1's intervention was to provide ADLs per Resident 1's request and wash Resident 1's hair every Wednesday. During a review of Resident 1's care plan for communication, dated 10/16/2025, the care plan indicated Resident 1's goal was Resident 1 would comply with the use of white communication board daily. The care plan indicated Resident 1's intervention was to ensure availability and functioning of adaptive communication equipment message board or telephone. The care plan indicated Resident 1's intervention was to use an iPad as a means of communication. During an interview on 7/7/2026 11:46 a.m. with Resident 1, Resident 1 stated staff did not wash Resident 1's hair and staff did not want to fix Resident 1's hair. Resident 1 stated Resident 1's hair had not been washed in a long time. Resident 1 stated Resident 1's head was itchy. Resident 1 stated Resident 1 covered hair with a bonnet because Resident 1 was embarrassed in the way the hair looked. Resident 1 stated the facility did not provide any communication method for Resident 1 to use with staff. Resident 1 stated the facility was to provide a tablet at all times but staff took it away and did not return it to Resident 1. Resident 1 stated Resident 1 had never seen a communication board and staff never used one. During a concurrent observation and interview on 7/7/2026 at 12:02 p.m. with Certified Nursing Attendant (CNA) 1, in Resident 1's room, CNA 1 handed an iPad to Resident 1. CNA 1 stated Resident 1 used an iPad to communicate with staff. CNA 1 stated Resident 1 did not like to use the communication board and only preferred to use the iPad. CNA 1 stated the communication board should be inside Resident 1's room but Resident did not want it inside her room. CNA 1 stated CNA 1 did not use a communication board to communicate with Resident 1. CNA 1 stated CNA 1 used hand gestures to communicate with Resident 1. CNA 1 stated it was hard to communicate with Resident 1 but CNA 1 eventually understood what Resident 1 was trying to say. CNA 1 stated residents would not be able to express themselves if they had no communication method at bedside and residents' needs would not be met. CNA 1 stated Resident 1 could not keep an iPad at bedside and CNA 1 needed to return the iPad to the activity department. During an interview on 7/7/2026 at 12:12 P.M. with Visitor 1, Visitor 1 stated Resident 1 had never had a communication board at bedside and never had an iPad at bedside. Visitor 1 stated Resident 1 had to request an iPad because it was not at bedside. During an interview on 7//8/2026 at 11:40 a.m. with Activity Director (AD), AD stated AD communicated with Resident 1 via communication board, iPad and hand gestures. AD stated other staff informed AD Resident 1 did not like to use the communication board. AD stated AD did not ask Resident 1 if Resident 1 wanted to use a communication board or why Resident 1 did not like to use a communication board. AD stated a communication board must be close to a resident, by bedside, or placed outside of resident room. AD stated the purpose of a communication board was to provide a voice to residents who could not communicate. AD stated it was important to provide a way for residents to communicate because that was the way they expressed their needs. AD stated Resident 1 preferred to use a tablet to communicate with staff. AD stated Resident 1 must have a tablet at bedside at all times because that was Resident 1's preferred method of communication. AD stated Resident 1 did not want to return the iPad to AD and the police department was called to retrieve it. AD stated Resident 1 wanted to keep the iPad to face time (video call, able to see and speak to each other in real-time over internet or cellular) Resident 1's mother and without a tablet Resident 1 could not use facetime. AD stated the facility only had 1 iPad for all residents to use and AD had not thought about getting more iPads for residents. AD stated the police department would be called again if Resident 1 did not want to return the iPad. During an interview on 7/8/2026 at 12:58 p.m. with CNA 2, CNA 2 stated CNA 2 did not know Resident 2 needed set-up assistance during meals. CNA 2 stated Resident 1 had never requested assistance during mealtime. CNA 2 stated Resident 1 was not able to move right hand and was not able to cut food. CNA 2 stated if Resident 1 did not get set-up assistance during mealtime, Resident 1 would not be able to eat. CNA 2 stated CNA 2 was supposed to offer to cut food into smaller pieces for Resident 1 but CNA 2 did not do that. CNA 2 stated CNA 2 communicated with Resident 1 through hand gestures. CNA 2 stated CNA 2 never used a communication board and it was never kept in Resident 1's room. During an interview on 7/8/2026 at 1:35 p.m. with CNA 2, CNA 2 stated CNA 2 assisted Resident 1 to shower today. CNA 2 stated CNA 2 did not wash Resident 1's hair because CNA 2 was not supposed to wash it. CNA 2 stated CNA 2 washed all other residents' hair but not Resident 1's hair. CNA 2 stated CNA 2 would wash Resident 1's hair if Resident 1 wanted it washed but CNA 2 did not ask Resident 1 if Resident 1 wanted Resident 1's hair to be washed. CNA 2 stated all residents should get their hair washed for hygienic purposes. CNA 2 stated Resident 1's hair did not get washed because staff did not have experience caring for textured hair. CNA 2 stated if CNA 2 attempted to brush the hair, CNA 2 would be concerned to rip Resident 1's hair out. During an interview on 7/8/2026 at 2:52 p.m., with AD, in Resident 1's room, AD stated it was AD's job to make sure Resident 1 had a communication tablet at all times. AD stated she was sure that Resident 1 had a tablet at bedside. AD stated AD never saw the tablet at Resident 1's bedside but AD assumed Resident 1 had a tablet. AD stated AD did not ask Resident 1 if Resident 1 had a tablet. AD stated if Resident 1 did not have a tablet there was a risk for Resident 1 not to be able to communicate Resident 1's needs. [NAME] an interview on 7/8/2026 at 4;36 P.M., with Registered Nurse (RN) 1, RN 1 stated set-up assistance during mealtime was removing lids from food/drinks, put utensils close to residents' strong side, and staff must ask all residents if they need assistance. RN 1 stated Resident 1's left arm was stronger than the right arm and Resident 1 required assistance during mealtime. RN 1 stated the staff member that takes a meal tray into a resident's room must offer assistance to that resident. RN1 stated Resident 1 required assistance from staff to cut food. RN 1 stated if food was not cut Resident 1 would not be able to eat. RN 1 stated it was important for Resident 1 to eat to get the nutrition Resident 1 needed. RN 1 stated Resident 1 required to have an iPad at all times to be able to communicate needs to staff. RN 1 stated it was important to provide a communication method to residents to better assist resident's needs. RN 1 stated the risk in not providing a communication method to Resident 1 was potentially a delay of care. RN 1 stated all residents' hair must be washed every time they given a shower. RN 1 stated it was important to wash resident's hair to keep bacteria and dirt low and for hygienic purposes. RN 1 stated RN 1 was not aware Resident 1's hair had not been washed because CNAs did not report it. During a review of facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised on 3/2018, the P&P indicated residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The P&P indicated residents would receive appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), dining (meals and snacks) and communication (speech, language, and any functional communication systems).

Based on observation, interview and record review, the facility failed to provide a diet that met the nutritional needs for one of three sampled residents (Resident 1) by failing to ensure: 1. Resident 1 received meals according to the dietary menu (a structured, planned selection of food items tailored to meet specific nutritional, health, lifestyle, or cultural needs) on 7/7/2026. 2. Resident 1's meal tray had the correct food according to Resident 1's dietary slip. 3. Dietary staff served Resident 1 a meal that offered nutritional value. These deficient practices had the potential to impact Resident 1's nutritional status and placed Resident 1 at risk for undesired weight loss and malnutrition. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included aphonia (the complete loss of voice or the inability to produce vocal sounds) and depression (a common and serious medical illness that negatively affects how a person feels, thinks, and acts. It causes feelings of sadness and/or a loss of interest in activities they once enjoyed). During a review of Resident 1's History and Physical (H&P), dated 9/4/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Mini Nutritional Assessment ([MNA] a validated screening tool used to identify an adult who is malnourished or at risk for malnutrition), dated 3/26/2026, 4/5/2026, and 7/4/2026, the MNA indicated Resident 1 had a score of 9 (12 to 14 points: Normal nutritional status, 8 to 11 points: At risk of malnutrition, and 0 to 7 points: Malnourished). During a review of Resident 1's Mini Nutritional Assessment ([MNA] a validated screening tool used to identify an adult who is malnourished or at risk for malnutrition), dated 3/26/2026, 4/5/2026, and 7/4/2026, the MNA indicated Resident 1 had a score of 9 (12 to 14 points: Normal nutritional status, 8 to 11 points: At risk of malnutrition, and 0 to 7 points: Malnourished). During a review of Resident 1's Dietary Profile and Preferences, dated 4/1/2026 and 6/30/2026, the Dietary Profile and Preferences indicated Resident 1's had an order for a regular diet. The Dietary Profile and Preferences indicated beverage preference for breakfast, lunch, and dinner was a strawberry smoothie with almond milk. The Dietary Profile and Preferences indicated Resident 1 was used to eating three meals a day. The Dietary Profile and Preferences indicated Resident 1's main meal of the day was lunch. During a review of Resident 1's Order Summary Report for the month of July 2026, the Order Summary Report indicated Resident 1 had an order for a regular diet with regular texture start date of 10/4/2023. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/4/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 1 required set up assistance for eating and oral hygiene. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for shower/bathing and personal hygiene. The MDS indicated Resident 1 was independent toileting hygiene, for lower body dressing and putting on/taking off footwear. During an interview on 7/7/2026 at 11:46 a.m. with Resident 1, Resident 1 stated the facility did not provide Resident 1 with any food, only a milkshake during mealtimes. Resident 1 stated Resident wanted food for all meals and did not know why the facility only served Resident 1 a milkshake. Resident 1 stated Resident 1 stayed hungry and would ask Resident 1's mother to order food. During an interview on 7/7/2026 at 12:12 p.m. with Resident 1's Visitor (1), Visitor 1 stated Visitor 1 had been witnessed when Resident 1 received meal tray with only a milkshake. Visitor 1 stated Residents 1's roommates received food and Resident 1 only received a cup with a milkshake. Visitor 1 stated Visitor 1 questioned staff why Resident 1 only received a milkshake and staff stated Resident 1 only wanted a milkshake. During an observation 7/7/2026 at 12:20 p.m. in Resident 1's room, Certified Nursing Attendant (CNA) 1 brought meal tray to Resident 1. CNA 1 placed meal tray on bedside table and left room. Resident 1's meal tray had a milkshake cup. During a review of Resident 1's dietary slip, dated 7/7/2026, the dietary slip indicated noon meal was roast beef/gravy, mashed potatoes, Italian blend vegetables, bread roll with margarine, butterscotch square and water. The dietary slip indicated Resident 1 had a regular diet with regular texture. During a review of facility's menu, dated 7/7/2026, the menu indicated noon meal was roast beef/gravy, mashed potatoes, Italian blend vegetables, bread roll with margarine, butterscotch square and water. The menu indicated the alternative menu for 7/7/2026 was egg drop soup, chicken teriyaki, streamed rice, zucchini/mushrooms, seasonal fresh food, water. During an interview on 7/7/2026 at 1:18 p.m. with the Dietary [NAME] (DC), The DC stated Resident 1 did not receive food today because Resident 1 always received a milkshake. The DC stated the DC did not know why Resident 1 only received a milkshake instead of food for lunch and dinner. The DC stated nursing staff was responsible to check all residents' food trays to make sure the residents received correct food. The DC stated a milkshake instead of a full meal would not provide Resident 1 with sufficient nutritional value that Resident 1 needed. The DC stated a milkshake did not offer the same nutritional value as a full meal. During an interview on 7/7/2026 at 2:20 p.m. with Certified Nursing Attendant (CNA) 1, CNA 1 stated Resident 1 always received only a milkshake for meals. CNA 1 stated Resident 1 received a milkshake for lunch today and CNA 1 did not offer Resident 1 any food. CNA 1 stated she was supposed to check Resident 1's dietary slip to make sure Resident 1 received the correct food based on Resident 1's dietary slip, but CNA 1 did not do that. During an interview on 7/8/2026 at 3:15 p.m. with the Dietary Services Supervisor (DSS), The DSS stated Resident had an order for a regular diet. The DSS stated the food that Resident 1 received must match what was on Resident 1's dietary slip. The DSS stated in the past, Resident 1 had requested a smoothie because Resident 1 did not want to eat what was served. The DSS stated Resident 1 was supposed to receive a meal and Resident 1 could refuse to eat meal if Resident 1 chose to. The DSS stated it was not acceptable for facility's staff to serve only a smoothie to Resident 1 because Resident 1 was supposed to receive a full meal and a smoothie with all meals. During an interview on 7/8/2026 at 4:35 p.m. with Registered Nurse (RN) 1, RN 1 stated kitchen staff must verify if food was correct on meal trays before leaving the kitchen. RN 1 stated licensed nurses were responsible for checking residents' food before delivering the food tray to the residents rooms. RN 1 stated CNAs were responsible to check if food was correct before leaving the residents' rooms. RN 1 stated all staff were responsible to check food and if the food did not look right (match with the dietary slip), staff must notify kitchen staff to get the correct food item. RN 1 stated when staff saw only a milkshake on Resident 1's meal tray, staff should have questioned it (questioned the discrepancy) and asked someone if it was correct (double check with other staff). RN 1 stated Resident 1's dietary slip should match with the food was on Resident 1's food tray. RN 1 stated it was important for all residents to receive food during mealtimes to get the nutrition they need. RN 1 stated all residents must receive food every day to receive adequate calories (amount of potential energy locked inside of food and beverages) and for residents not to lose weight. RN 1 stated it was not acceptable not to serve a resident food during mealtime. During a review of facility's [NAME] Job Description, undated, the job description indicated the purpose for the position was to prepare food in accordance with current applicable federal, state, and local standards that govern the facility and as directed by the Dietary Department Management. The job description indicated the cook would follow menu and recipes. During a review of facility's Policy and Procedure (P&P) titled, Food and Nutrition Services, dated 10/2017, the P&P indicated each resident would be provided a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The P&P indicated food and nutrition services staff would inspect food trays to ensure that the correct meal was provided to each resident, the food appears palatable, and attractive, and it was served at a safe and appetizing temperature.

Based on observation and interview, the facility did not provide a working call light to one of three sampled residents (Resident 1). This deficient practice had the potential to cause a delay in care or the inability to obtain necessary care and services for Resident 1. Based on observation and interview, the facility did not provide a working call light (a communication device used by patients in hospital or nursing facilities to request assistance from nursing staff) to one of three sampled residents (Resident 1). This deficient practice had the potential to cause a delay in care or the inability to obtain necessary care and services for Resident 1. During an observation on 7/7/2026 at 11:46 a.m., in Resident 1's room, Resident 1's call light did not work when Resident 1 pushed the call light button. Resident 1's call light did not light up inside room or outside of Resident 1's room and there was no audible sound. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included aphonia (the complete loss of voice or the inability to produce vocal sounds) and depression (a common and serious medical illness that negatively affects how a person feels, thinks, and acts. It causes feelings of sadness and/or a loss of interest in activities they once enjoyed). During a review of Resident 1's H&P, dated 9/4/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/4/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 1 required set-up assistance for eating and oral hygiene. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for shower/bathing and personal hygiene. The MDS indicated Resident 1 was independent toileting hygiene, for lower body dressing and putting on/taking off footwear. During an interview on 7/7/2026 at 11:46 a.m. with Resident 1, Resident 1 stated the call light that was provided to Resident 1 did not work. During an interview on 7/8/2026 at 12:20 p.m., with the Director of Staff Development (DSD), DSD stated all staff must make sure residents call light are working. DSD stated DSD expected staff to push call lights, make sure light inside resident's room (in general) lights up, light outside blinks (in general), and there was a noise heard in the hallway. During an interview on 7/8/2026 at 1:28 p.m., with Certified Nursing Attendant (CNA) 1, CNA 1 stated CNA 1 was not supposed to check if call lights were working. CNA 1 stated maintenance department was responsible for checking if call lights were working. CNA 1 stated CNA 1 worked with Resident 1 yesterday (7/7/2026) and CNA 1 did not check if Resident 1's call light was working. During an interview on 7/8/2026 at 1:35 p.m., with CNA 2, CNA 2 stated CNA 2 did not check if Resident 1's call light was working. CNA 2 stated CNA 2 was supposed to check if it was working but she did not do that. CNA 2 stated CNAs must check on call lights so residents can call for help. During an interview on 7/8/2026 at 4:35 p.m., with Registered Nurse (RN) 1, RN 1 stated a call light was a device used by residents to get assistance from staff. RN 1 stated if residents call light did not work residents would not be able to call for help. RN 1 stated if call lights were not checked it could potentially cause a delay in care. During a review of facility's Policy and Procedure (P&P) titled, Answering the Call Light, undated, the P&P indicated staff must make sure the call light was plugged in and functioning at all times.

Based on interview and record review, the facility failed to monitor for side effects (unpleasant or adverse reactions) for two of three sampled residents (Residents 1 and 3) who were prescribed opioid medications (a class of drugs that act on the nervous system to relieve pain) while at the facility.These failures resulted in necessary medication and had the potential for Residents 1 and 3 to experience side effects from opioid medications while in the care of the facility. (Cross Reference F552)a. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/3/2026 with diagnoses including fracture (broken bone) of sacrum (bone located at the base of the backbone), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and lack of coordination. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) on 5/11/2026. The AR indicated Resident 1's daughter (RR 1) was Resident 1's emergency contact. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene and dressing. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing.During a review of Resident 1's Care Plan Report (CPR), undated, the CPR indicated the facility initiated a care plan on 5/9/2026, indicating The resident is at risk for pain. The CPR indicated an intervention to be, Administer medications as ordered. Monitor/document for side effects and effectiveness.During a review of Resident 1's Order Summary Report (OSR), dated 6/22/2026, the OSR indicated a physician order was started on 5/7/2026 for Resident 1 to receive Percocet oral tablet 10-325 milligram (mg, a unit of measurement) by mouth (PO) every 6 hours for pain management.b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 9/3/2025 with diagnoses including hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), dysphagia (difficulty swallowing foods or liquids), and muscle spasm.During a review of Resident 3's CPR, undated, the CPR indicated the facility initiated a care plan on 1/16/2026, the CPR indicated The resident is at risks for discomfort pain. The CPR indicated interventions including to monitor and document for side effects and effectiveness of the ordered pain medication.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had no impaired in cognitive skills. The MDS indicated Resident 3 was dependent on staff for toileting hygiene, personal hygiene, dressing, and bathing.During a review of Resident 3's Medication Administration Record (MAR), dated June 2026, the MAR indicated Resident 3's as needed (PRN) pain medication order was changed on 6/18/2026. The MAR indicated the physician stopped the order for hydrocodone - acetaminophen oral tablet (an opioid mediation used to treat pain) 5-325 milligram (mg, a unit of measurement) give 1 tablet by mouth (PO) every 6 hours PRN for severe pain on 6/18/2026. The MAR indicated the physician instead ordered oxycodone Hcl oral tablet (an opioid mediation used to treat pain) 5 mg give 1 tablet PO every 6 hours PRN for severe pain. The MAR failed to indicate Resident 3 was being monitored for side effects of the ordered pain medications.During a telephone interview on 6/22/2026 at 12:42 PM with Resident 1's Responsible Party (RR 1), RR 1 stated RR 1 was never informed Resident 1's doctor (in general) had prescribed Percocet to Resident 1. RR 1 stated if RR 1 had been informed of the order for Percocet, RR 1 would have refused for Resident 1 to take Percocet because Resident 1 had a history of hallucinating when taking narcotics in the hospital. RR 1 stated when Resident 1 was admitted to the facility, Resident 1 was not confused. RR 1 stated RR 1 noticed a change in Resident 1 on 5/6/2026 (3 days after admission). RR 1 stated Resident 1 was starting to hallucinate and was mumbling. RR 1 stated that on 5/7/2026, Resident 1 also started wetting herself. During an interview on 6/22/2026 at 1:28 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was sometimes confused. CNA 1 stated CNA 1 remembered a time when Resident 1 hallucinated while CNA 1 was providing care to Resident 1. CNA 1 stated Resident 1 saw another person in the room with CNA 1 but that there was not another person with CNA1. CNA 1 stated CNA 1 did not remember the exact date Resident 1 was hallucinating. During an interview on 6/22/2026 at 2:49 PM with Registered Nurse (RN) 1, RN 1 stated Resident 1 took care of Resident 1 on 5/10 and 5/11/2026. RN 1 stated Resident 1was confused when RN 1 took care of Resident 1 on 5/11/2026 and had received report from the previous night shift that Resident 1 had been hallucinating. During an interview on 6/23/2026 at 10:50 AM with Resident 3, Resident 3 confirmed Resident 3 was taking pain medications. Resident 3 stated the doctor (in general) increased Resident 3's medication the previous week. Resident 3 stated the medication was controlling the pain better for Resident 3, but that Resident 3 was sleepier after the medication was increased.During a telephone interview on 6/23/2026 at 11:52 AM with Resident 1's Primary Physician (MD 1), MD 1 stated Resident 1 was transferred from the facility to General Acute Care Hospital (GACH) 1 on 5/11/2026 for altered mental status (AMS). MD 1 stated Resident 1's ordered Percocet may have contributed to Resident 1's AMS. MD 1 stated the facility nurses (in general) should monitor residents (in general) for side effects of pain medications such as confusion or increased sleepiness. During a concurrent interview and record review on 6/23/2026 at 12:15 PM with the Director of Nursing (DON), Resident 1's MAR, dated May 2026, was reviewed. Resident 1's MAR failed to indicate the monitoring of side effects for Resident 1's Percocet. The DON stated the facility nurses (in general) should monitor residents (in general) who take opioid pain medications for side effects of the medications. The DON stated the monitoring of side effects should be documented in the residents' (in general) MAR. During a review of the facility's Policy and Procedure (P&P) titled, Pain - Clinical Protocol, revised October 2022, the P&P indicated, If the physician determines that opioid medication is an appropriate option for managing acute (or in some cases chronic) pain in the resident, the lowest possible effective dose is prescribed for the shortest time possible with ongoing staff monitoring for effectiveness and adverse effects. The P&P indicated, The staff will reassess the individual's pain and related consequences at regular intervals.Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. The P&P indicated, The staff and physician will monitor for adverse effects of pain medications such as .anorexia, confusion, lethargy, severe constipation related to opioids.The physician will adjust or discontinue medications accordingly, based on effectiveness and side effects.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) or Resident 1's Responsible Party (RR 1) was informed in advance of the risks and benefits of taking Resident 1's Physician ordered Percocet (a prescription medication combining the opioid [a class of drugs that act on the nervous system to relieve pain] pain reliever oxycodone and the non-opioid pain reliever acetaminophen).This failure resulted in the violation of Resident 1's right to be informed of risks and benefits of Resident 1's treatment for pain and had the potential for Resident 1 to experience negative side effects of taking Percocet. (Cross Reference F757)During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/3/2026 with diagnoses including fracture (broken bone) of sacrum (bone located at the base of the backbone), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and lack of coordination. The AR indicated Resident 1 was discharged to General Acute Care Hospital (GACH) 1 on 5/11/2026. The AR indicated Resident 1's daughter (RR 1) was Resident 1's emergency contact. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene and dressing. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for bathing.During a review of Resident 1's Order Summary Report (OSR), dated 6/22/2026, the OSR indicated a physician order was started on 5/7/2026 for Resident 1 to receive Percocet oral tablet 10-325 milligram (mg, a unit of measurement) by mouth (PO) every 6 hours for pain management.During a telephone interview on 6/22/2026 at 12:42 PM with RR 1, RR 1 stated one of Resident 1's doctors (MD 2) called RR 1 on 5/11/2026 around 7:30 AM. RR 1 stated MD 2 informed RR 1 that MD 2 thought Resident 1 was overmedicated with Percocet. RR 1 stated RR was not aware Resident 1 had been prescribed Percocet. RR 1 stated RR 1 was not informed when Resident 1's doctor (in general) had prescribed Percocet to Resident 1. RR 1 stated if RR 1 had been informed of the order for Percocet, RR 1 would have refused Resident 1 to take Percocet because Resident 1 had a history of hallucinating when taking opioids in the hospital.During a telephone interview on 6/23/2026 at 11:52 AM with Resident 1's Primary Physician (MD 1), MD 1 stated MD 1 ordered Percocet for Resident 1 to control Resident 1's pain from Resident 1's sacral fracture. MD 1 stated MD 1 did not get informed consent from RR 1 when MD 1 started Resident 1 on Percocet. MD 1 stated the facility was responsible for getting informed consent for ordered medications. During an interview on 6/23/2026 at 12:15 PM with the Director of Nursing (DON), the DON stated it was not the facility's practice to get informed consent when residents (in general) were prescribed pain medications.During a review of the facility's Policy and Procedure (P&P) titled, Health, Medical Condition and Treatment Options, Informing Residents of, revised February 2021, the P&P indicated, Each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on an on-going basis. If a resident has an appointed representative, the representative is also informed.

Based on observation, interview, and record review, the facility failed to provide necessary communication care and services for one of two sampled residents (Resident 1) when Mandarin (a major Chinese language) communication cards (picture or word based cards used to help a resident understand what staff are saying and used to express the resident's needs when speaking is difficult or English is limited) were not available for Resident 1 in Resident 1's room.This deficient practice had the potential to result in Resident 1 being unable to communicate needs effectively and the potential to affect Resident 1's psychosocial (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) well-being.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 1/21/26 with diagnoses including sepsis (a life-threatening blood infection [(the invasion and growth of germs in the body), and Parkinson's disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary body movements).During a review of Resident 1's History and Physical (H&P), dated 1/23/26, the H&P indicated Resident 1 did not have the capacity to understand and make decisions but could make basic needs known.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/24/26, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 1 required setup or clean- up assistance with eating and oral hygiene, required partial/moderate assistance with personal hygiene, and was dependent on toileting, showering, and dressing. Additionally, the MDS indicated Resident 1's preferred language was Mandarin and Resident 1 would need/want an interpreter to communicate with a doctor or health care staff.During a concurrent observation and interview on 6/4/26 at 10:23 AM with Certified Nursing Assistant (CNA) 1 in Resident 1's room, Resident 1 was observed attempting to communicate with CNA 1 using hand gestures. CNA 1 stated Resident 1 was only able to speak a little English. CNA 1 stated there were no communication cards available for Resident 1 in Resident 1's room. CNA 1 stated there should be communication cards in Resident 1's room to assist Resident 1 to express Resident 1's needs.During an interview on 6/4/26 at 10:35 AM with Resident 1, Resident 1 stated Resident 1 had difficulty communicating with staff because the staff (in general) did not speak Resident 1's preferred language, Mandarin. Resident 1 stated even though the staff (in general) repeated themselves in English, Resident 1 could not understand them. Resident 1 stated Resident 1 preferred staff to communicate with Resident 1 in Mandarin. Resident 1 stated it made Resident 1 feel anxious when staff could not communicate with Resident 1.During an interview on 6/4/26 at 1:50 PM with the Director of Staffing Development (DSD), the DSD stated residents (in general) who had language barriers should be provided with communication cards upon admission to the facility. The DSD stated the communication cards should be kept at the resident's bedside or within reach of the residents. Additionally, the DSD stated communication cards were placed within reach of the resident so the resident could communicate their needs.During an interview on 6/4/26 at 3:49 PM with the Social Services Director (SSD), the SSD stated Resident 1 had a language barrier and Resident 1 should have been provided with communication cards at the bedside upon admission. The SSD stated it was important to have the communication cards available so Resident 1 could communicate better with staff.During a review of the facility's Policy and Procedure (P&P) titled, Translation and/or Interpretation of Facility Services, revised January 2024, the P&P's policy statement indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. The P&P's policy interpretation and implementation indicated, The coordinator of this facility's language access program is the director of social services, or his/her designee. This facility shall provide written translations of vital information pertaining to health services. Translation of information that is not available in written translations shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): communication devices.

Based on interview and record review, the facility failed to revise the care plan interventions for one of four sampled residents (Resident 1) who had a weight loss of 24 pounds (lbs.) in one month.This deficient practice placed Resident 1 at risk for continued weight loss and had the potential for Resident 1 to receive inappropriate care and treatment.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side (damage to the right hemisphere of the brain, causing left-sided motor impairment) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/8/25, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 was dependent on staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During record review of Resident 1's Weights and Vitals Summary, Resident 1's weights were as follows:9/4/25 - admitted to facility at 225 lbs.9/11/25 at 219 pounds (lbs. - unit of weight measurement) 9/18/25 at 213 lbs. 10/2/25 at 201 lbs. 11/8/25 at 189 lbs. 11/13/25 at 184 lbs. 11/21/25 at 183 lbs. 12/9/25 at 183 lbs. 1/4/26 at 182 lbs. 2/10/26 at 178 lbs. During the 5-month period from 9/4/25 to 2/10/26, Resident 1 lost 47 lbs. (from 225 lbs. to 178 lbs.).During a review of Resident 1's care plan for unplanned/unexpected weight loss of 24 lbs. x 1 month [from 9/4/25 - 10/2/25] related to poor food intake (date initiated 10/14/25 and revised on 10/19/25) the interventions indicated the following: If weight decline persists, contact physician and dietician immediately (date intervention initiated 10/19/25; date revised 2/5/25).Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss (date intervention initiated 10/19/25; date revised 2/5/25).During a review of Resident 1's Weights and Vitals Summary, Resident 1 lost 19 lbs. from 11/8/25 to 1/4/26. No care plan for unplanned/unexpected weight loss was updated for Resident 1 until 1/21/26.During a record review of Resident 1's care plans, there were no care plans to indicate Resident 1 planned to lose -47 lbs. in 5 months.During an interview with Dietary Supervisor (DS) on 2/25/26 at 2:22 p.m., DS stated, Resident 1 is very alert, gets food from outside, most of the time, (Resident 1) orders out.DS stated, Resident 1's had a puree diet initially and now she is on a regular diet.DS stated, In the beginning Resident 1 was eating puree (only eating 24%).During an interview with Resident 1 on 3/26/26 at 11:15 a.m., Resident 1 stated, (Resident 1) orders food from outside of the facility because (Resident 1) doesn't like the facility food. Resident 1 denied losing any weight.During an interview with Registered Dietician 1 (RD 1) on 3/3/26 at 9:35 a.m., RD 1 stated, Resident 1 had a goal of losing weight and (Resident 1's) ideal weight was 170 lbs.RD 1 stated before RD 1worked at the facility, Resident 1 had lost 19 lbs. in 3 months then 1 lb. in a month after RD 1 started working at the facility in December 2025.RD 1 stated Resident 1 was non-compliant with Resident 1's diet and was ordering a lot of food from outside of the facility.

Based on observation, interview and record review, the facility failed to provide podiatry (treatment of the feet and feet disorders) care to one of four sampled residents (Resident 1).This deficient practice resulted in Resident 1 not getting treatment for long and thickened toenails for 112 days (from 11/20/25 to 3/2/26) and placed Resident 1 at risk for ingrown toenails (when the nail grows into the surrounding skin), pain, injury, and infection.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 FFwas initially admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting left non-dominant side (damage to the right hemisphere of the brain, causing left-sided motor impairment) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/8/25, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 was dependent on staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a record review of Resident 1's Oder Summary Report (OSR), dated 3/2/26, the OSR indicated a physician order (PO) for Podiatry (branch of medicine focused on the diagnosis, treatment, and prevention of foot, ankle, and lower leg disorders) consult and treatment as needed. On hold. Order date: 11/2/25. During an interview with Resident 1 on 3/2/26 at 11:15 am in Resident 1's room, Resident 1 stated Resident 1's only concern was about a podiatrist (doctor who practices podiatry care) appointment. Resident 1 stated it was last week when a facility staff (unidentified) was going to make the podiatry appointment for Resident 1 and Resident 1 had not heard back from the facility on the status of the appointment.During concurrent record review and interview with Licensed Vocational Nurse 3 (LVN 3) on 3/3/26 at 10:26 am, LVN 3 stated Resident 1 went to the hospital on [DATE], and all of Resident 1's POs were put on hold. LVN 3 stated when Resident 1 returned to the facility on [DATE], all POs were resumed except for the podiatry consult. LVN 3 stated, It looks like that order (podiatry consult) was missed when Resident 1 returned to the facility and that order (podiatry consult) was not active (order) as a result.During an interview with LVN 2 on 3/3/26 at 1:15 pm, LVN 2 stated LVN 2 was aware of Resident 1's long and thickened toenails on 11/20/25, the day LVN 2 completed a Change of Condition report for Resident 1's left and right heel redness. LVN 2 stated LVN 2 did not complete a change of condition report and did not inform Resident 1's physician regarding Resident 1's long and thickened toenails. LVN 2 stated Resident 1 was diabetic, and staff (in general) would not be able to trim Resident 1's toenails because Resident 1 was at high risk for infection.During a concurrent interview and observation with Resident 1 and Certified Nursing Assistant (CNA) 2 on 3/3/26 at 4:35 pm, Resident 1's feet were uncovered and both feet were observed with toenails that were thickened and long.During a review of the facility policy & procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated, Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence; be notified of his or her medical condition and of any changes in his or her condition; and be informed of, and participate in, his or her care planning and treatment.During a review of the facility P&P titled, Change in a Resident's Condition Status, dated 2/2021, the P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition.A 'significant change' of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 2) had the resident's hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) pressure dressing on the right upper arm removed in accordance with the physician order.This deficient practice placed Resident 2 at risk for forming a blood clot in the right upper arm dialysis fistula (a surgically created connection between an artery and a vein, typically in the arm, designed for long-term hemodialysis [dialysis] access) which could result in Resident 2 missing life-saving hemodialysis treatment.Findings:During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD-irreversible kidney failure) and dependence on renal dialysis.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 2/23/26, the MDS indicated Resident 2 had severely impaired cognition (thinking, knowing, and being aware) for daily decision making. The MDS indicated Resident 2 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's Order Summary Report (OSR), dated 3/2/26, the OSR indicated a physician order (PO), dated 2/22/26, to remove Resident 2's dialysis pressure dressing four (4) hours after return from dialysis treatment.During a review of Resident 2's Nursing Progress Note (NPN), dated 2/24/26 and timed at 2:15 pm, the NPN indicated Resident 2 returned from dialysis to the facility with right upper arm fistula intact, no swelling, and no signs or symptoms of infection.During a review of Resident 2's NPN, dated 2/24/26 and timed at 10:50 pm, the NPN indicated, Pressure dressing removed and new dressing applied for (Resident 2).During a phone interview with Licensed Vocational Nurse (LVN) 5 on 3/12/26 at 1:25 pm, Resident 2's NPN, dated 2/24/26 and timed at 2:15 pm, was reviewed with LVN 5. LVN 5 stated Resident 2 returned from dialysis appointment on 2/24/26 at approximately 2:15 pm and Resident 2's right upper arm fistula site was intact with no swelling and no signs or symptoms of infection. During a phone interview with Licensed Vocational Nurse 6 (LVN 6) on 3/12/26 at 4:50 pm, Resident 2's NPNs and Resident 2's physician order, dated 2/22/26, were reviewed with LVN 6. LVN 6 stated on 2/24/26, LVN 6 documented Resident 2's pressure dressing removal and application of a new dressing on the dialysis fistula site. LVN 6 stated LVN 6 looked at Resident 2's right upper arm at 4 pm on 2/24/26 to assess Resident 2's pressure dressing after the previous shift's nurse informed LVN 6 that Resident 2 had returned from dialysis. LVN 6 stated there was no leaking or signs of infection on the right upper arm at the time LVN 6 checked Resident 2. LVN 6 stated according to Resident 2's physician order, dated 2/22/26, Resident 2's pressure dressing should be removed four (4) hours after Resident 2 returned from dialysis treatment to the facility. LVN 6 stated LVN 6 did not remove Resident 2's pressure dressing on the right upper arm on 2/24/26 until approximately 8 pm and applied a new dressing due to a scant amount of bleeding on the top of the fistula site. LVN 6 stated LVN 6 documented the dressing change on the NPN on 2/24/26 at 10:50 pm. LVN 6 reviewed Resident 2's NPN created by LVN 5 on 2/24/26 and stated the NPN indicated Resident 2 returned from dialysis treatment on 2/24/26 at approximately 2:15 pm. LVN 6 stated the pressure dressing on Resident 2's dialysis fistula should be changed 4 hours after Resident 2's return from dialysis according to the physician order. LVN 6 stated there was an increased risk of clotting the longer the pressure dressing was left on Resident 2's dialysis fistula site.During a review of the facility's policy & procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident with, dated September 2010, the P&P indicated, Policy Statement: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: the care of grafts and fistulas .

Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Resident 10, Resident 1, and Resident 51), had information regarding Advance Directives (AD - legal document indicating resident preference on end-of-life treatment decisions) filed in Resident 10, Resident 1, and Resident 51's medical records as indicated in the facility's policy and procedure (P&P) titled, Advance Directives.This deficient practice had the potential to cause confusion among the healthcare providers in the event Resident 10, Resident 1 and Resident 51 required immediate medical care and/treatment and had the potential for the residents to receive inadequate or medically unnecessary care and/or treatment/services regarding life-sustaining treatment. Findings:During a review of Resident 10's admission Record (AR), the AR indicated, Resident 10 was originally admitted to the facility on [DATE] and readmitted the resident on 11/4/2025 with multiple diagnoses including acute (sudden) respiratory failure (when the lungs can't release enough oxygen into your blood), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified, and essential (primary) hypertension (HTN - high blood pressure).During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool), dated 10/12/2025, the MDS indicated Resident 10's cognitive skills (ability to think and process information) for daily decision making were moderately impaired. The MDS indicated Resident 10 was dependent (helper does all of the effort) to required set up or clean-up assistance (helper sets up or cleans up; resident completes activity) with activities of daily living (ADLs).During a review of Resident 10's History and Physical Examination (H&P), dated 11/9/2025, the H&P indicated, Resident 10 had the capacity to understand and make decisions. During a review of Resident 1's AR, the AR indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM II - adult onset disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), essential (primary) hypertension, and unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbance, psychotic disturbance (losing touch with reality), mood disturbance, and anxiety (a feeling of fear, worry, and uneasiness).During a review of Resident 1's H&P, dated 11/10/2025, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 1 was dependent to required partial/moderate assistance (helper does less than half the effort) with ADLs.During a review of Resident 51's AR, the AR indicated, Resident 51 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, alcohol abuse, uncomplicated, and essential (primary) hypertension.During a review of Resident 51's H&P, dated 12/10/2025, the H&P indicated, Resident 51 had the capacity to understand and make decisions.During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51's cognitive skills for daily decision making were intact. The MDS indicated Resident 51 required substantial/maximal assistance (helper does more than half the effort) to requiring set up or clean-up assistance with ADLs.During an interview on 12/17/2025 at 1:24 PM with Resident 51, Resident 51 stated, Resident 51 had an AD and Resident 51's brother had Resident 51's AD.During a concurrent interview and record review on 12/17/2025 at 1:39 PM with the Social Services Director (SSD), Resident 10, Resident 1, and Resident 51's medical records were reviewed. The SSD stated, an AD was when a resident assigned somebody to make medical decisions when the resident could not make the decision. The SSD stated, residents were screened for information regarding the AD upon admission by the Registered Nurse Supervisor (RN, unnamed) and the SSD would normally ask the resident [if there was an existing AD]. The SSD stated an Advanced Healthcare Directive Acknowledgement Form (AHDAF) was filled out and completed upon admission. The SSD stated Resident 10 had two AHDAF on file [in the medical record]. An AHDAF dated 10/7/2025 signed by Resident 10 and RN 2 indicated, Resident 10 did not have an AD. An AHDAF dated 11/5/2025, signed by Resident 10 and RN 1 was incomplete and did not indicate whether Resident 10 had or did not have an AD. The SSD stated the facility ideally went by the latest AHDAF. The SSD stated, Resident 10's AHDAF, dated 11/5/2025 should have been filled out and completed by whoever screened Resident 10 since filling out and completing Resident 10's latest AHDAF, was important because the information might have changed, maybe she [Resident 10] has an AD. The SSD stated Resident 1 was admitted on [DATE] and Resident 1 did not have an AHDAF on file. The SSD stated Resident 51 was admitted on [DATE] and did not have an AHDAF on file. The SSD stated, there should have been an AHDAF for Residents 1 and 51 and it was important to have AHDAFs on file for the facility to have a record of who was responsible to make medical decisions in the event something happens to Resident 1 and Resident 51. During an interview on 12/18/2025 at 9:12 AM with Resident 10, Resident 10 stated, Resident 10's daughter took care of AHDAF [matters]. Resident 10 stated, Resident 10 did not have an AD.During a review of the facility's P&P titled, Advance Directives, date revised 9/2022, the P&P indicated, prior to or upon admission of a resident, the social services director or designee inquires with the resident, his/her family members, and/or his or legal representative, about the existence of any written advance directives. The P&P indicated, information about whether or not the resident had executed an advance directive was displayed prominently in the medical record in a section of the record that was retrievable by any staff.

Based on interview and record review the facility failed to ensure necessary care and services were provided for two of two sampled residents (Residents 48 and 51) by failing to:a. Ensure Resident 48's neurology (the branch of medicine that deals with the brain, spinal cord, and nerves) consult (getting expert opinion or advice about a patient's condition) was ordered in a timely manner.b. Ensure Resident 51 did not self-administer Pepto Bismol Ultra (a double-strength medication used to relieve nausea, heartburn, indigestion, upset stomach and diarrhea) brought from home and kept at Resident 51's bedside without a physician's order. This deficient practice resulted in the delay of care for Resident 48 and had the potential to result in unmet physical needs to Resident 48. The deficient practice could have potentially resulted in Resident 51 taking the incorrect Pepto Bismol Ultra dose and result in drug interactions leading to serious physical harm to Resident 51. Findings: a. During a review of Resident 48's admission Record (AR), the AR indicated the facility originally admitted Resident 48 on 8/24/2024 and readmitted the resident on 11/10/2025 with diagnoses including unspecified disorientation (a condition referring to confusion or lack of awareness without a clearly identified reason) and lack of coordination (difficulty in moving smoothly or controlling body movements). During a review of Resident 48's History and Physical (H&P), dated 8/25/2025, the H&P indicated Resident 48 had the capacity to understand and make decisions. During a review of Resident 48's Minimum Data Set (MDS- a resident assessment tool), dated 11/28/2025, the MDS indicated Resident 48's cognitive (the ability to think and process information) skills for daily decision making were severely impaired. During a review of Resident 48's Office Visit Note (OVN), date of encounter 11/19/2025, the OVN's plan indicated Resident 48 was to follow up with neurology to rule out an acute (sudden) cardiovascular accident (CVA-a medical condition where blood flow to the brain is disrupted, causing brain and tissue damage). During a review of Resident 48's OVN Physician Order (PO), dated 11/19/2025, the PO indicated a follow up with the Neurologist was ordered for Resident 48. During a review of Resident 48's Progress Note (PN) titled Physician's Order Note, dated 12/16/2025, timed at 2:30 PM, the PN indicated, New order Neurology consult [regarding]: [rule out] acute CVA per Cardiologist [a doctor who specializes in treating heart and blood vessel problems]. During an interview on 12/17/2025 at 2:44 PM with Registered Nurse Supervisor (RN) 1, RN 1 stated Resident 48 had returned from a Cardiologist appointment on 11/19/2025 with an order from the Cardiologist's office that indicated Resident 48 was to have a neurology appointment. RN 1 stated the neurology consultation was not ordered [by the facility] until 12/16/2025. RN 1 stated it was the policy of the facility to place orders in the resident's (in general) medical record right away to ensure continuity of care (sharing accurate information between all caregivers so the patient gets safe, coordinated treatment without gaps) and to maintain the resident's health. During an interview on 12/19/2025 at 9:10 AM with the Director of Nursing (DON), the DON stated Resident 48's neurology consult order should have been ordered on 11/19/2025. The DON stated the importance of placing the order in a timely manner was to ensure Resident 48's safety and to prevent delayed treatment. During a review of the facility's policy and procedure (P&P) titled, Request for Diagnostic Services, dated 4/2007, the P&P indicated orders for diagnostic services will be promptly carried out as [indicated] by the physician's order. During a review of the facility's undated P&P titled, Referrals, Social Services, the P&P indicated social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. b. During a review of Resident 51's AR, the AR indicated Resident 51 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM II - adult onset disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), alcohol abuse, uncomplicated, and essential (primary) hypertension (HTN - high blood pressure). During a review of Resident 51's H&P, dated 12/10/2025, the H&P indicated Resident 51 had the capacity to understand and make decisions. During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51's cognitive skills for daily decision making were intact. The MDS indicated, Resident 51 required from substantial/maximal assistance (helper does more than half the effort) to set up or clean-up assistance (helper sets up or cleans up; resident completes activity). During a review of Resident 51's Change in Condition Evaluation (COC), dated 12/12/2025, timed at 10:39 PM, the COC indicated, Resident 51 had nausea/vomiting and Nurse Practitioner (NP) 2 ordered Zofran (Ondansetron – a medication used to prevent nausea and vomiting) four (4) mg (milligrams – unit of measurement) prn (as needed) every six (6) hours. During a review of Resident 51's Order Summary Report (OSR), active orders as of 12/16/2025, the OSR did not indicate a physician's order for Pepto Bismol Ultra and for Resident 51 to take own medication from home. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3 on 12/16/2025 at 11:32 AM, Resident 51 was not in Resident 51's room. There was a 4 fluid ounce (Fl. Oz. – a unit of liquid volume) bottle of Pepto Bismol Ultra Liquid with three quarters of remaining medication contents on top of Resident 51's bedside table. The medicine measuring cup was over the bottle's cap and there were multiple drinks on the table. LVN 3 stated the Pepto Bismol Ultra Liquid medication should not have been at Resident 51's bedside table due to [self-administration of medications] needed assessments and physician orders and Resident 51 could be taking the Pepto Bismol Ultra Liquid. During an interview on 12/17/2025 at 7:48 AM with Resident 51, Resident 51 stated Resident 51 took one shot of the Pepto Bismol Ultra Liquid medication that was brought [to the facility] by Resident 51's son on 12/13/2025. Resident 51 stated, Resident 51 had reported to the staff (unnamed) that Resident 51 had heartburns and nausea, and the Ondansetron medication was effective. Resident 51 stated, Resident 51 took the Pepto Bismol Ultra Liquid medication because Resident 51 still had residual from my heartburn. During an interview on 12/18/2025 at 2:35 PM with RN 1, RN 1 stated, it was important not to leave Resident 51's Pepto Bismol Ultra Liquid medication (or any medications), brought from home, at Resident 51's bedside so staff could control how often Resident 51 took the medication. RN 1 stated, residents are forgetful, and Resident 51's roommate could potentially take the medication not knowing what the medication was for, for safety. RN 1 stated, Resident 51 needed to have an order for [self-administration of] Pepto Bismol liquid medication and [the medication] had to be consented (to take own medication). During a review of the facility's undated P&P, titled, Medications Brought to the Facility by the Resident/Family, the P&P indicated, the facility should ordinarily not permit residents and families to bring medications into the facility. The P&P indicated, if a medication was not otherwise available and/or it was determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the director of nursing services and nursing staff, with support of the attending physician and consultant pharmacist, should check to ensure that the medications have been ordered by the resident's attending physician, and documented on the physician's order sheet. During a review of the P&P, titled, Medication and Treatment Orders, date revised 7/2016, the P&P indicated, medications should be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.

Based on interview and record review, the facility failed to properly store discontinued controlled medications (DCM, drugs strictly regulated by government law due to their high potential for abuse, addiction or dependence) for two of two sampled residents (Resident 87 and Resident 89) as indicated in the facility's policy and procedures (P&P) titled, Controlled Substance, and Controlled Medication Storage. This deficient practice had the potential to result in diversion (illegally taking prescription drugs from their intended use, taking the drug from the healthcare setting for personal abuse) or medication errors involving Resident 87 and 89's DCMs.Findings: a. During a review of Resident 87's admission Record (AR), the AR indicated Resident 87 was admitted to the facility on [DATE] with diagnosis that included insomnia (inability to sleep) and hypertension (high blood pressure). During a review of Resident 87's Physician Orders (PO), the PO indicated hydrocodone - acetaminophen (a controlled medication used to treat pain) 10-325 milligram (mg, unit of measurement) given every three hours, as needed (PRN), this PO was discontinued on 12/5/2025. The PO, dated 11/29/2025, indicated to transfer Resident 87 to the general acute care hospital (GACH). b. During a review of Resident 89's AR, the AR indicated Resident 89 was admitted to the facility on [DATE] with diagnosis that included Type 2 Diabetes Mellitus (DM, a condition that results in elevated blood sugar) and Atrial fibrillation (AF, irregular heartbeats). During a review of Resident 89's PO, dated 10/21/2025, it indicated Hydrocodone-Acetaminophen 10-325 mg to be given every four hours for moderate to severe pain as needed was ordered for the resident. This PO was discontinued 12/11/2025 due to Resident 89's transfer to the GACH. During a review of Resident 89's PO, dated 11/14/2025, the PO indicated alprazolam (a controlled medication, used to treat anxiety and panic disorders) 0.25 mg given every six hours PRN for Resident 89's anxiety. During a review of Resident 89's Order Listing Report (OLR), dated 11/18/2025, the OLS indicated alprazolam 0.25 mg was completed (discontinued). During a review of Resident 89's PO, dated 12/7/2025, the PO indicated for Resident 89 to be transferred the GACH for desaturation (low oxygen). During an observation and concurrent interview with the Director of Nursing (DON) on 12/16/2025 at 2:10 PM, the DON stated the facility process was, when there were DCMs, the licensed nurse (LN) delivered the un-used DCMs (along with the narcotic count sheet [a rigorous process in healthcare facilities where a physical inventory of all controlled drugs are taken and documented on a specific log sheet]) to the DON. Followed by the DON and the LN confirming accuracy, and the DON storing the DCMs inside a double locked cabinet located inside the DON's office for safekeeping. The DON stated the cabinet designated to hold DCMs was empty. The DON stated there were no DCMs in the facility since 11/26/2025. During an interview and concurrent record review, on 12/17/2025 at 9:56 AM, with the DON, a list of discharged residents since 11/26/2025 were reviewed with the DON. The DON stated Resident 84 and Resident 89's DCMs were found inside medication carts, along with other active medications. The DON stated nursing staff should have given Resident 84 and 89's DCMs within 72 hours [of resident discharge]. The DON stated if a resident was discharged , DCMs should be given to the DON right away. The DON stated it was important to dispose of DCMs to avoid possible medication errors (given to another resident) or diversion of DCMs. The DON stated based on nursing best practice the DON taught the nursing team to hand over DCMs to the DON within 72 hours. During an interview with Licensed Vocational Nurse (LVN) 1, on 12/17/2025 at 2:21 PM, LVN 1 stated DCMs were only given to the DON usually on the same day or within 48 hours [after discontinuation of the medication or resident discharge]. LVN 1 stated it [this method] was safer because DCMs can be administered to other residents or used incorrectly. During a review of the facility's P&P titled Controlled Medication Storage, dated 8/2014, the P&P indicated controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely double locked area with restricted access until destroyed by the facility's director of nursing . and a pharmacist. During a review of the facility's P&P titled, Controlled Substance, dated 11/2022, the P&P indicated controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The P&P indicated disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances. The P&P indicated controlled substances remaining in the facility after the order has been discontinued or the residents have been discharged are securely locked in an area with restricted access until destroyed. The P&P indicated accountability record for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. During a review of the facility's Inservice Meeting Minutes, Disposal of Narcotics [controlled medications], dated 10/22/2025 - 10/29/2025, co-presented by the DON, the minutes' s summary of discussion indicated after discontinuation, all narcotics must be counted and turned into the DON or Assistant DON.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1) when the following was observed: 1. A large bag of round brown frozen meat was observed unlabeled and undated in the facility's walk-in freezer. 2. A brown green build up was observed on two of the four corners of the dishwasher.3. The water collection area of the dishwasher had brown, tan gunk buildup in the water and the gunk rimmed the waterline.4. The stove top was observed with an accumulation of layered sticky to touch grease spots and food particles.5. The area behind the stove was dusty, sticky to touch, and colored layer of buildup. These deficient practices had the potential to result in foodborne illnesses (sickness from eating or drinking contaminated food or beverages) to the residents consuming the food prepared in Kitchen 1.Findings:During an initial tour of Kitchen 1 on 12/16/2025 at 8:58 AM, with the Dietary Supervisor (DS), a bag of round brown in color meat was unlabeled and undated with no expiration date.During an interview, on 12/16/2025 at 9:10 AM, with the DS, the DS stated the bag of meat balls did not have a label or a date to indicate the type of food in the bag or the expiration of the food. The DS stated it was important for food to be labeled to know when it was opened and to know when the food had to be used by to prevent the residents (in general) from getting sick. During a follow-up tour of Kitchen 1, on 12/19/2025 at 11:20 AM, with the DS, the following was observed:-The water collection area of the dishwasher had brown, tan gunk buildup in the water and the gunk rimmed the waterline.-The stove top was observed with an accumulation of layered sticky to touch grease spots and food particles.-The area behind the stove was dusty, sticky to touch, and colored layer of buildup. During an interview with the DS on 12/19/2025 at 11:29 AM, the DS stated the kitchen staff cleaned daily, but I don't know, I told them [kitchen staff] to clean everything, they will clean it now. The DS stated Kitchen 1's equipment should be cleaned all the time because it is bad for the food and the food could get the patients sick.During an interview with the Director of Nursing (DON), on 12/19/2025 at 11:38 AM, the DON stated Kitchen 1 had to remain clean. The DON stated Kitchen 1's equipment should be cleaned after each use and cleaned where there was buildup. The DON stated the stove should be cleaned after every use and as needed. The DON stated there should be no buildup of grease on or behind the stove. The DON stated it was important to have a clean and sanitary kitchen so the food was prepared clean to prevent residents from getting sick. During a review of the facility's policy and procedures (P&P) titled, Food Receiving and Storage, revised 11/2022, the P&P indicated food shall received and stored in a manner that complies with safe food handling practices. The P&P indicated refrigerated food is labeled, dated, and monitored so they are used by their use-by-date, frozen or discarded.During a review of the facility's P&P titled, Sanitization, revised 11/2022, the P&P indicated the food service area is maintained in a clean and sanity manner. The P&P all kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. The P&P all utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions . that may affect their use or proper cleaning.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 31), was treated with dignity when on 12/16/2025, Licensed Vocational Nurse 3 (LVN 3) failed to knock on Resident 31's door prior to entering Resident 31's room.This deficient practice resulted in Resident 31 feeling bothered and had the potential to result in Resident 31 feeling invaded to Resident 31's privacy and feeling humiliated, embarrassed, and ashamed.Findings:During a review of Resident 31's admission Record (AR), the AR indicated, Resident 31 was admitted to the facility on [DATE] with multiple diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), unspecified, major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), single episode, unspecified, and colostomy (a surgery to create an opening for the large intestine that lets stools pass through the belly) status.During a review of Resident 31's History and Physical Examination (H&P), dated 12/14/2025, the H&P indicated Resident 31 had the capacity to understand and make decisions.During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool) dated 12/14/2025, the MDS indicated Resident 31's cognitive skills (ability to think and process information) for daily decision making were intact. The MDS indicated Resident 31 was dependent (helper does all the effort) and/or required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living.During a concurrent observation and interview with LVN 3 on 12/16/2025 at 10:03 AM, Resident 31 was lying in bed. LVN 3 entered Resident 31's room without knocking (or announcing self) on the door. LVN 3 stated, LVN 3 knocked earlier but LVN 3 left the room to get Resident 31's Morphine (medication used to treat severe pain). LVN 3 stated, knocking on the door before entering a resident's (in general) room was important for resident's privacy and dignity.During an interview on 12/18/2025 at 8:40 AM with Resident 31, Resident 31 was lying in bed and using his cellphone while having breakfast. Resident 31 stated, some staff knocked on Resident 31's door prior to entering Resident 31's room and some of them [staff] don't. Resident 31 stated, Resident 31 did not want staff to get in trouble but staff not knocking on the door prior to entering Resident 31's room bothered Resident 31 a little bit, and it would be nice if they knock[ed] first.During an interview 12/18/2025 at 2:35 PM with Registered Nurse Supervisor (RN) 1, RN 1 stated, knocking on a resident's door and announcing yourself, prior to entering the resident's room was important for courtesy and politeness [purposes].During a review of the facility's policy and procedure (P&P), titled, Dignity, date revised 2/2021, the P&P indicated residents were treated with dignity and respect at all times. The P&P indicated the residents' private space and property were respected at all times. The P&P indicated, staff were expected to knock and request permission before entering residents' rooms.During a review of the facility's P&P, titled, Resident Rights, date revised 2/2021, the P&P indicated, employees should treat all residents with kindness, respect, and dignity.

Based on interview and record review, the facility failed to do a background check for one of three sampled certified nursing assistant (CNA 2).This failure had the potential to risk the residents' personal safety, mistreatment and misappropriation of personal funds.Findings:During a review of Certified Nursing Assistant (CNA) 2's employee file, it indicated CNA 2 was hired on 2/18/2025. CNA 2's employee file did indicate a background check was completed.During an interview on 12/19/2025 at 9:19 am with Director of Staff Development (DSD), DSD stated there was no background check done on CNA 2. DSD stated background checks should always be done to make sure the patients are safe and that they are qualified to work for the facility.During an interview on 12/19/2025 at 11:30 am with the DSD, DSD stated she was unable to find paperwork for CNA 2's background check that included criminal conviction investigation and sex offender checks. DSD stated CNA 2 was hired when there was no Director of Staff Development in the facility.During a review of the facility's policy and procedure (P&P) titled, Background Screening Investigations, undated, the P&P indicated the facility is to conduct background screening checks, reference checks and criminal conviction investigations on all applicants who will have direct access to residents.

Based on interview and record review the facility failed to develop a comprehensive care plan (CP), for one of one sampled residents (Resident 4), that addressed diabetes mellitus (a chronic [persistent or long-lasting] disease characterized by high blood sugar levels due to insufficient insulin [a hormone which regulates the amount of sugar in the blood] production) and anticoagulant (a medication that helps prevent blood clots) use.This failure had the potential to result in unmet individualized medical needs for Resident 4 and the potential to affect the resident's physical and psychosocial well-being.Findings:During a review of Resident 4's admission Record (AR), the AR indicated the facility originally admitted Resident 4 on 9/3/2025 with diagnoses including hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue damage) affecting the left non-dominant side (the side of the body that is used less) and type 2 diabetes mellitus with hyperglycemia (high blood sugar levels).During a review of Resident 4's History and Physical (H&P), dated 11/2/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 12/8/2025, the MDS indicated Resident 4's cognitive (the ability to think and process information) skills for daily decision making were intact.During a review of Resident 4's Order Summary Report (OSR), dated active as of 12/18/2025, the OSR indicated heparin sodium (an anticoagulant) 5000 units (a unit of measurement) was ordered for Resident 4, start date of 11/3/2025.During a concurrent interview and record review on 12/18/2025 at 1:20 PM with Registered Nurse Supervisor (RN) 1, Resident 4's CPs were reviewed. RN 1 stated CPs addressing diabetes mellitus and anticoagulant therapy were not developed for Resident 4. RN 1 stated it was important to develop comprehensive CPs to ensure appropriate monitoring of Resident 4's medical conditions and to maintain Resident 4's safety and continuity of care (sharing accurate information between all caregivers so the patient gets safe, coordinated treatment without gaps). During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P's policy statement indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial (relates to how a person's mental health and social environment [relationships, community] affect each other) and functional needs was developed and implemented for each resident. The P&P's policy interpretation and implementation indicated the comprehensive, person-centered care plan should be developed no more than 21 days after admission.

Based on interview and record review, the facility failed to revise one of one sampled resident's (Resident 8's) fall risk care plan after Resident 8 had a fall on 11/26/2025. This failure placed Resident 8 at risk for future and recurrent falls.Findings: During a review of Resident 8's admission Record (AR), the AR indicated Resident 8 was admitted on [DATE] with diagnoses that included end-stage renal disease (ESRD-irreversible kidney failure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and blindness in the left eye. During a review of Resident 8's History & Physical (H&P), dated 7/27/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 8 had moderately impaired cognition (ability to think) and was dependent (helper does all the effort and the resident does none of the effort to complete the activity) on facility staff (in general) to complete most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated Resident 8 was dependent on facility staff (in general) to move around in bed and for transfers. During a review of Resident 8's Fall Risk Care Plan (CP), initiated on 4/2/2022, the CP indicated Resident 8 was at risk for falling out of bed with a goal to remain free from injury and or falls. The CP Interventions initiated on 4/2/2022 indicated to check Resident 8 frequently and reposition Resident 8 in bed, to encourage Resident 8 to use the call light and to keep the call light within Resident 8's reach, to apply bilateral grab bars in bed to prevent sliding and rolling off the bed. The CP also indicated Resident 8 slipped through the lift sling and slid down the shower chair on 11/26/2025 but there were no new interventions added, or revisions made on the CP on 11/26/2025. During a review of Resident 8's Change in Condition Evaluation (CIC/SBAR - situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 11/26/2025, the CIC indicated Resident 8 fell the morning of 11/26/2025 while being transferred by a nursing assistant in a Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place). During a concurrent interview and record review on 12/18/2025 at 12:19 PM with Registered Nurse Supervisor 1 (RN 1), Resident 8's Fall Risk Care Plan (CP), initiated on 4/2/2022, was reviewed. RN 1 stated Resident 8's CP for falls indicated there was no revision to the CP. RN 1 stated the CP's purpose was to guide the licensed nurses and nursing assistants in providing care to the resident and allowed them to know what monitoring was needed for the resident. RN 1 stated, the CP should have been updated after Resident 8's fall on 11/26/2025. During an interview on 12/19/2025 at 9:20 AM with the Director of Nursing (DON), the DON stated CPs were updated when a resident had any change of condition and must be updated after a fall by the nurse who documented the resident's change in condition. The DON stated revising the CP was important to ensure fall interventions were in place, to prevent further falls, to minimize injuries, and to guarantee residents were receiving the best care from staff. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last revised 7/2017, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P indicated, events, incidents or accidents involving the resident and progress toward or changes in the care plan goals and objectives should be documented in the medical record. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised February 2021, the P&P indicated, a significant change of condition was a major decline or improvement in the resident's status that required interdisciplinary review and/or revision to the care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated, a comprehensive, person-centered CP that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The P&P indicated, assessments of residents were ongoing and CPs were revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review, the facility failed to provide one of one sampled resident (Resident 60) with their chosen individual activity when their television was not working.This failure had the potential to affect the resident's psychosocial well-being, mental health and self-satisfaction.Findings:During a review of Resident 60's admission Record, it indicated Resident 60 was admitted on [DATE] with diagnoses that included but not limited to: fracture (crack or break) of right femur, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (a mental health condition marked by persistent, excessive, and hard to control worry about everyday things), and abnormalities of gait and mobility.During a review of Resident 60's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 11/16/2025, the MDS indicated Resident 60 has normal thinking and memory. Resident 60 requires a helper for less than half the effort for dressing, hygiene, bed mobility, sit to stand, and walking ten feet.During a review of Resident 60's History and Physical (H&P) dated 11/18/2025, the H&P indicated Resident 60 has the capacity to understand and make decisions.During a review of Resident 60's Activity Participation Review (APR) dated 11/20/2025, the APR indicated Resident 60 is independent with her activity involvement and enjoys watching television.During a review of the facility's Maintenance Request Log (MRL), the MRL indicated Resident 60 requested for her television to be repaired on 11/18/2025, 11/20/2025, and 11/21/2025. Each request was signed off as corrected on the same date.During a concurrent observation and interview on 12/16/2025 at 9:40 am with Resident 60, in Resident 60's room, Resident 60 showed that many of the basic television channels did not have a picture. Resident 60 stated the channels that work do not interest her, and she has been asking the facility staff to repair the television. Resident 60 stated the Maintenance Supervisor (MS) had told her he would replace the television but has not.During an interview on 12/18/2025 at 11:30 am with Certified Nursing Assistant (CNA) 1, CNA 1 stated that residents often complain of the televisions not working. CNA 1 stated Resident 60 complained this morning about her television needing to be changed. CNA 1 placed a request in the MRL.During an interview on 12/18/2025 at 2:15 pm with MS in Resident 60's room, MS stated that Resident 60's television is missing channels and needs repair. MS stated he received multiple complaints from Resident 60, he could not provide a work order for the cable company. MS stated the repair will be completed promptly, emphasizing the importance of functioning televisions for residents' happiness and engagement.During a review of the facility's policy and procedure (P&P) titled, Activity Evaluation, the P&P indicated individual activities promote physical, mental and psychosocial well-being of residents.

Based on observation, interview and record review, the facility failed to ensure pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) measures for one of two sampled residents (Resident 9) were provided as ordered by the physician when Resident 9's low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries) was set to static (not moving, changing, or active) and Resident 9's heel protectors were not on. These failures had the potential to worsen and prevent the healing for Resident 9's pressure ulcer/injury and had the potential for Resident 9 to develop further skin injury.Findings: During a review of Resident 9's admission Record (AR), the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included encounter for a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), pressure ulcer/injury (PU) stage 3 (full-thickness loss of skin. Dead and black tissue may be visible), dementia (a progressive state of decline in mental abilities), and a right-hand contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 9's History & Physical (H&P), dated 9/21/2025, the H&P indicated the resident had contracted legs and did not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set assessment (MDS - a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 9 had severely impaired cognition (ability to think) and was dependent (helper does all the effort and the resident does none of the effort to complete the activity or the assistance of two or more helpers was required for the resident to complete the activity) on staff (in general) to roll left and right in bed or move from sitting to lying or vice versa in bed. The MDS indicated Resident 9 was at risk of developing PUs and a skin and ulcer/injury treatment used was a pressure reducing device for the bed. During a review of Resident 9's Order Summary Report (OS), the OS indicated Resident 9 had an active physician order for a Low Air Loss Mattress, every shift for skin management, ordered on 5/25/2025 and may have foot boots, every shift, ordered on 6/22/2025. During a review of Resident 9's Care Plan (CP), revised 6/23/2025, the CP indicated Resident 9 was at risk for PU development related to history of wounds/ulcers and had a right plantar foot deep tissue injury with interventions to float the resident's heels and a LALM. During a review of Resident 9's IDT Wound Management Update (IDT), dated 12/9/2025, the IDT indicated Resident 9 had an open wound to the right plantar foot, classified by the wound specialist as a pressure ulcer, stage 3. The IDT indicated strict pressure offloading (pressure removal), strict offloading of the right foot, and a Prevalon boot (medical boot used for bed-bound or limited mobility patients to prevent/relieve heel pressure injuries by elevating the heel off the bed) was placed to the right foot while Resident 9 was in bed. During a review of Resident 9's Surgical Consult, dated 12/11/2025, the consult indicated Resident 9 had a PU on the right plantar foot that was not healed and measured 1.2 centimeters (cm - unit of measure) in length by 0.6 cm in width by 0.3 cm in depth. The consult further recommended continuing offloading, turning, and continuing the pressure reducing mattress for Resident 9. During an observation on 12/16/2025 at 9:10 AM in Resident 9's room, Resident 9 was in bed with the LALM on the static mode (a setting that creates a firm surface). During a concurrent observation and interview on 12/16/2025 at 9:48 AM with Licensed Vocational Nurse 1 (LVN 1) in Resident 9's room, Resident 9 was in bed and his LALM setting was on static and foot boots were off. LVN 1 stated, Resident 9 needed a LALM setting instead of LALM being in static mode because of a wound on his foot and should have been wearing a foot boot. During a concurrent observation and interview on 12/16/2025 at 9:52 AM with Treatment Nurse 1 (TN 1) in Resident 9's room, Resident 9 was in bed with the LALM without foot boots and the LALM static setting was on. TN 1 confirmed the bed was set to static and the foot boots were not applied to Resident 9. TN 1 stated, Resident 9 currently had a stage three PU on his right plantar foot and should always be wearing a foot boot for pressure relief. TN 1 stated the LALM was needed due to Resident 9's contractures, immobility, history of recurrent wounds, and was used as a method to counteract the pressure Resident 9 placed on Resident 9's foot. TN 1 further stated, the LALM should not remain on static, as it made the mattress harder, leading to further skin breakdown. During a review of Resident 9's Braden Scale for Predicting Pressure Sore Risk (assessment tool used to assess a resident's risk of developing a pressure ulcer), dated 12/17/2025, the Braden Scale indicated Resident 9 was bedfast (confined to bed) with a very limited ability to change and control body position (made occasional slight changes in body or extremity position but unable to make a frequent or significant changes independently) and was classified at high risk for developing PUs. During an interview on 12/19/2025 at 9:23 AM with the Director of Nursing (DON), DON stated, a LALM was typically used for residents with stage 3 or 4 PUs used to aid in wound healing and prevention. DON stated, Resident 9 was bedbound, had a history of wounds, and was at high-risk for skin breakdown. DON stated, Resident 9's LALM on static may have delayed wound healing or caused wound regression (returned to previous condition). DON stated, Resident 9's foot boots were used to offload the pressure on Resident 9's heels, to aid in Resident 9's wound healing, and eliminate pressure on the wound. DON stated, Resident 9's foot boots should be worn when the resident was in bed to prevent further skin breakdown. During a review of Virgo Medical & Rehab Supply: How to Use the LALM, undated, the guide indicated under operation, the static setting was used to inflate all the mattress cells and when firm enough, the static button should be turned off to allow the mattress to begin the alternating pressure cycle (cycled every six to eight minutes). During a review of Drive: Med-Aire Alternating Pressure Mattress Replacement System with Low Air Loss User Manual Item #14027, dated 2012, the LAL mattress manual indicated the Med-Aire 8, 14027 System was specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort and should be operated as instructed. The manual indicated, the static control button was used to shift between alternating and static mode and when in static mode, the static indicator would turn on and the mattress would become a firm surface. During a review of the facility's policy and procedure (P&P) titled, Support Surface Guidelines, revised 2/2024, the P&P indicated, the purpose of the procedure was to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The P&P indicated, redistributing support surfaces were to promote comfort for all bed- or chairbound residents, promote circulation and provide pressure relief or reduction. The P&P indicated, individuals at risk for developing pressure ulcers should be placed on redistribution support surface, such as foam, static air, alternating air, gel, or air-loss device, when lying in bed.

Based on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 12) as indicated in the facility's policies and procedures (P&P) titled, Falls and Fall Risk, Managing, Safety and Supervision of Residents, and Care Plans, Comprehensive Person-Centered, by failing to: 1. Ensure Certified Nursing Assistant (CNA) 4 and/or Licensed Vocational Nurse (LVN) 6 provided supervision/monitoring (the act of watching a person) to Resident 12, who was assessed as being high risk for falls and had a history of multiple falls when CNA 4 and LVN 6 failed to prevent Resident 1 from being inside the facility's conference room with the door closed, unsupervised, on 12/28/2024. 2. Ensure CNA 4, LVN 6, and all nurses (any CNAs, LVNs, and Registered Nurses [RNs]) in the nursing station implemented Resident 1's untitled care plans for falls when CNA 4, LVN 6, and any nurses who were in the nursing station failed to provide frequent (often, many times) visual checks and keep Resident 12 at the nursing station for monitoring. As a result, on 12/28/2024 at 12 p.m., Resident 12 fell to the floor inside the facility's conference room. Resident 12 sustained a fracture (a break or crack in a bone) of the dens (bony projection of the spine [line of bones down the center of the back that provides support for the body] that allows the head to rotate) of cervical spine 2 (C2 - the upper portion of the spine located in the neck). Resident 1 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 12/28/2024 at 4:10 p.m. for further evaluation. Cross Reference F656 Findings: During a review of Resident 12's Admission Record (AR), the AR indicated the facility admitted Resident 12 to the facility on [DATE], with diagnoses that included congested heart failure (CHF - a heart condition that develops when the heart does not pump enough blood for the body's needs), type 2 diabetes (DM2 - a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and end stage renal disease (ESRD - a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products from the blood) with hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 12's first untitled care plan (CP), initiated on 7/14/2023, and revised on 8/2/2024, the CP indicated Resident 12 was at risk for falls related to limited mobility, balance problems, confusion, poor safety awareness, history of multiple falls, and use of psychotropics (medications that affect the mind, emotions, and behavior) and diuretic (medication that causes the kidneys to make more urine). The CP interventions included to anticipate and meet Resident 12's needs, follow facility's fall protocol, and provide a safe environment. During a review of Resident 12's Fall Risk Assessment (FRA), dated 4/15/2024, the FRA indicated Resident 12 was at high risk for falls due to history of falls, use of psychotropics, antihypertensive (medication to treat high blood pressure), and hypoglycemic agents (medications to treat high blood sugar), urinary incontinence (inability to control the flow of urine from the bladder), agitated (irritable/unpleasant) behavior and predisposing conditions (conditions that give way to the development of disease). During a review of Resident 12's History and Physical Examination (H&P), dated 4/16/2024, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Residents 12's Physical Therapy (PT- therapy used to preserve, enhance, or restore movement and physical function impaired or threatened by disease, injury, or disability) Encounter Notes (PTEN), dated 6/7/2024, the PTEN indicated Resident 12 required maximal assistance (assisting person performed 75 percent (%) of the task) for bed mobility and transfers. During a review of Resident 12's second untitled CP, initiated on 6/14/2024, and revised on 8/7/2024, the CP indicated Resident 12 had an unwitnessed fall (a fall that occurs when no one is present to see it happen) on 6/14/2024. The CP interventions included to provide frequent visual checks and keep Resident 12 at the nursing station so staff (all nursing staff) can monitor and help Resident 12 immediately if Resident 12 tries to stand up without assistance. During a review of Resident 12's third untitled CP, initiated on 9/21/2024, the CP indicated Resident 12 had a witnessed fall (when someone sees another person fall) on 9/21/2024. The CP interventions included to provide frequent visual checks. During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool), dated 10/26/2024, the MDS indicated Resident 12 had severely impaired cognition (ability to think and process information). The MDS indicated Resident 12 normally used a wheelchair for mobility and was dependent (helper does all the effort) on staff for toileting, and personal hygiene, and chair/bed-to-chair transfer. During a review of Resident 12's Change in Condition Evaluation (CICE), dated 12/28/2024, timed at 12:15 p.m., the CICE indicated on 12/28/2024, untimed, Resident 12 had an unwitnessed fall in the facility's conference room located in front of the nursing station. The CICE indicated Resident 12 suffered a bump to Resident 12's left side of the head. The CICE indicated Resident 12 was awake, alert, verbally responsive, able to follow commands, and answer questions. The CICE indicated Resident 12's vital signs (measurements of the body's most basic functions) were stable and Resident 12 had no neurological deficit (impairment or loss of function affecting the brain, spinal cord [a tube of tissues/nerve fibers that runs from the brain to the lower back. The spinal cord carries nerve signals from the brain to the rest of the body and back], nerves, or muscles). The CICE indicated Registered Nurse (RN) 2 notified Resident 12's physician/medical doctor (MD 1) and MD 1 ordered to transfer Resident 12 to GACH 1 for further evaluation and treatment. During a review of Resident 12's GACH 1 Emergency Note (EN), dated 12/28/2024, timed at 4:10 p.m., the EN indicated Resident 12 was brought in by ambulance from the skilled nursing facility (SNF) where Resident 12 had a mechanical fall (a type of fall caused by an external force or object) out of a wheelchair, and hitting Resident 12's left side of the head and face. During a review of Resident 12's GACH 1 Computed Tomography Scan (CT scan, medical imaging technique used to obtain detailed internal images of the body) Report of Resident 12's cervical spine, dated 12/28/2024, timed at 6 pm, the CT Scan Report indicated Resident 1 had a fracture through the dens (a break in the peg-like [a bolt or pin that holds something in place or marks a location] bone at the top of the C2 in the neck). During a review of Resident 12's GACH 1 Magnetic Resonance Imaging (MRI- medical imaging technique used to obtain images of the body) Report of Resident 12's cervical spine, dated 12/28/2024, timed at 9:05 pm, the MRI Report indicated Resident 12 had a fracture of the dens of C2. The MRI Report indicated findings were concerning for nerve compression (occurs when a nerve is under too much pressure from surrounding tissues). The MRI Report indicated neurosurgical (relating to or involving surgery performed on the nervous system, especially the brain and spinal cord) consultation was recommended for further evaluation and management guidance. During a review of Resident 12's Neurosurgery Consultation Notes (NCN), dated 12/29/2024, untimed, the NCN indicated Resident 12 presented for evaluation of dens fracture and found to have severe stenosis (narrowing of any channel or passageway in the body) in the lower cervical spine sustained after a fall at the SNF. The NCN indicated Resident 12 was a high risk for postoperative (after surgery) complications due largely to age and comorbidities (the condition of having two or more diseases at the same time). The NCN indicated Resident 12's family would like to manage Resident 12 conservatively with a brace (a device fitted to a weak or injured part of the body, to give support). During a review of Resident 12's GACH 1 Discharge Summary Notes (DS), dated 12/30/2024, untimed, the DS indicated Resident 12 was a high risk for postoperative complications, quality of life, and there was an unclear benefit if Resident 12 were to have surgery. The DS indicated Resident 12 was to continue with cervical collar (C-collar - an instrument used to support the neck and spine and limit head movement after an injury) and follow-up with spine surgery for a repeat CT scan of the spine in four weeks. During an interview on 1/21/2025 at 8:30 a.m. with CNA 4, CNA 4 stated on 12/28/2024, at around 8:30 a.m., CNA 4 got Resident 12 ready for the day, transferred Resident 12 in Resident 12's wheelchair after breakfast, wheeled Resident 12 in the hallway, and left Resident 12 next to the nursing station. CNA 4 stated residents (in general) who needed to be monitored were taken to the nursing station at around 8:30 a.m. (daily) so nurses (any CNAs, LVNs, and RNs) in the nursing station could monitor the residents who were left there (at the nursing station). CNA 4 stated CNA 4 returned to the nursing station at 12 p.m. but CNA 4 did not find Resident 12 in the hallway next to the nursing station where CNA 4 left Resident 12. CNA 4 stated when CNA 4 went to the conference room, the conference room door was closed. CNA 4 stated CNA 4 opened the conference room door and found Resident 12 on the floor next to Resident 12's wheelchair by herself (alone). CNA 4 stated Resident 12 had a large bump on Resident 12's head. CNA 4 stated there was no staff supervising Resident 12 in the conference room and staff were unable to see Resident 12 in the conference room from the nursing station because the conference room door was closed. During an interview on 1/21/2025 at 12 p.m. with RN 2, RN 2 stated on 12/28/2024, after 12 pm, LVN 6 called RN 2 into the conference room and when RN 2 entered the conference room, Resident 12 was on the floor. RN 2 stated Resident 12 should not be left in the conference room unsupervised since Resident 12 was confused and at high risk for falls. RN 2 stated Resident 12 was able to wheel herself (Resident 12) around the facility. RN 2 stated Resident 12 needed frequent monitoring per Resident 12's care plans and staff did not follow Resident 12's care plans. During an interview on 1/22/2025 at 2:30 p.m. with the Administrator (ADM), the ADM stated Resident 12 had history of multiple falls and needed frequent visual checks. The ADM stated Resident 12 was supposed to be at the nursing station for monitoring. The ADM stated all nurses (any CNAs, LVNs, and RNs) at the nursing station were responsible for supervising/monitoring the residents who were around the nursing station. The ADM stated fall risk and confused residents needed to be monitored every one to two hours. The ADM stated the facility did not know how long Resident 12 was inside the conference room alone and unsupervised. The ADM stated no one witnessed Resident 12 going or being taken into the conference room (on 12/28/2024). During a telephone interview on 1/23/2025 at 3:53 p.m. with LVN 6, LVN 6 stated on 12/28/2024, before lunch time, (unable to recall exact time), LVN 6 checked on Resident 12 and Resident 12 was sitting (in Resident 12's wheelchair) in front of the nursing station . LVN 6 stated Resident 12 was able to wheel herself (Resident 12) to the nursing station. LVN 6 stated (on 12/28/2024) after 12 p.m., CNA 4 notified LVN 6 that Resident 12 had fallen in the conference room. LVN 6 stated when LVN 6 arrived in the conference room, Resident 12 was on the floor next to the door. LVN 6 stated Resident 12 had a bump on Resident 12's left side of the head. LVN 6 stated LVN 6 could not remember if there were any nurses at the nursing station monitoring the residents (all residents including Resident 12) at that time (12/28/2024, before lunch time). LVN 6 stated Resident 12 should not be left alone and unsupervised in the conference room. LVN 6 stated Resident 12 needed to be monitored every hour and frequently because Resident 12 was confused and at high risk for falls. LVN 6 stated since Resident 12's fall was unwitnessed in the conference room, Resident 12 was not being supervised. LVN 6 stated LVN 6 did not see Resident 12 going or being taken to the conference room. LVN 6 stated We, (staff including LVN 6) did not follow Resident 12's care plans to monitor Resident 12 frequently. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017 (most updated), the P&P indicated, Resident safety supervision and assistance to prevent accidents were facility-wide priorities. The P&P indicated, The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate (sufficient for a specific need or requirement) supervision. The P&P indicated, Implementing interventions to reduce accident risks and hazards included the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented . The P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of supervision may vary among residents and over time for the same residents. During a review of the facility's P&P titled, Fall and Fall Risk, Managing, revised 3/2018 (most updated), the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated, The staff will implement a resident-centered fall prevention plan to reduce the risk factor(s) of falls for each resident at risk or with a history of falls. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022 (most updated), the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated, The comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including . which professional services are responsible for each element of care . builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure ulcer development (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/ friction) and to prevent worsening of existing pressure ulcers for four of four residents (Residents 1, 2, 4, and 8) observed for pressure ulcers in a total of 16 sampled residents. 1. For Resident 2, the facility failed to: (a) Implement the plan of care to turn and reposition the resident in bed every two hours. (b) Revise the plan of care to address the frequency in which the resident should be turned and positioned while in bed. (c) Accurately assess the condition of the skin on the resident's left hip. (d) Monitor the resident's skin on her right upper back. These failures resulted in Resident 2 developing an avoidable, unstageable pressure ulcer (full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscure by slough (yellow, tan, gray green or brown) and /or eschar (tan, brown or black) in the wound bed) to her left hip. Resident 2 also developed an avoidable Stage II pressure ulcer (shallow open crater without slough, may also present as an intact or open ruptured serum filled blister) to her right upper back. 2. For Resident 1, the facility failed to: (a) Ensure the resident did not lie on her back directly on the pressure ulcer. (b) Implement the plan of care to turn and reposition the resident in bed every two hours. (c) Revise the plan of care to address the frequency in which the resident should be turned as well as positioned while in bed. (d) Follow the physician's treatment orders to apply Santyl ([MEDICATION NAME] ointment) to Stage III pressure ulcer (full thickness tissue loss). Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) to her Sacrococcyx (sacral (a triangular shaped bone at the bottom of the spine) coccyx (tailbone)) and Duoderm patch (absorbs excretions from the wound) to the Stage II pressure ulcer to her left buttock. (e) Notify the physician of Resident 1's Stage III pressure ulcer to her right buttock. (e) Offload the resident's heels (take off pressure from the heels, to suspend) when in bed. These failures resulted in Resident 1 developing an avoidable Stage III pressure ulcer to her right buttock and Stage II pressure ulcer to her left buttock. 3. For Resident 4, the facility failed to: (a) Implement the care plan to elevate both heels with Stage 1 pressure ulcer on pillow when in bed. (b) Ensure Resident 4's both heels with Stage 1 pressure ulcer were not directly in contact with the pillow or mattress. (c) Coordinate with [MEDICAL TREATMENT] (procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances) center the plan of care to elevate both heels to promote healing and prevent further skin breakdown. These failures resulted to Resident 4's Stage 1 pressure ulcer on the left heel to progress into deep tissue injury (DTI pressure ulcer (deep tissue injury intact or non-intact skin with localized area of persistent non-blanchable deep red maroon, purple discoloration described as purplish red in color) to the middle part of the left heel. 4. For Resident 8 the facility failed to: (a) Ensure Resident 8's pressure ulcers did not worsen. Nor that previous pressure ulcers reopen. (b) Ensure that Resident 8 was not positioned on her back due to a Stage 3 pressure ulcer on the Sacrococcyx. (c) Ensure Resident 8 was positioned correctly when lying side to side and not positioned directly on the pressure ulcers of the left and right buttocks. (d) Monitor and implement the plans of care for the treatment of [REDACTED]. Findings: A review of the Nursing Admission/Readmission Data Tool indicated Resident 2 was readmitted on [DATE], without a pressure ulcer. Resident 2's [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 1/18/17, indicated Resident 2 was assessed with [REDACTED]. A review of the Braden Scale for Predicting Pressure Ulcer Risk-V 1 (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure ulcer) indicated Resident 2 scored 12 on 11/16/15 and 10 on 10/7/16. A total score of 10-12 indicated Resident 12 was high risk for developing pressure ulcer. A review of the Change of Condition SBAR (SBAR-situation background assessment recommendation) indicated Resident 2 was assessed on 11/13/16, with 2 centimeter (cm) in length (L) x 0.5 cm in width (W) oval shape MASD (moisture associated skin damage) to her left hip. On 1/7/17, the left hip MASD had progressed to DTI pressure ulcer (deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red maroon, purple discoloration) described as purplish red in color. The DTI measured 2.5 cm (L) x 1.5 cm (W). On 1/15/17, the left hip DTI had progressed to 2.6 cm (L) x 2 cm (W) unstageable pressure ulcer with brownish (90 %) and yellow (10 %) slough (dead tissue) in the wound bed. On 1/28/17, Resident 2 was assessed with [REDACTED]. The pressure ulcer to the right upper back was not measured. During multiple observations on 2/1/17 at 2:30 p.m., 3:45 p.m., 4:50 p.m.; 2/2/17 at 8:20 a.m., 9:15 a.m., 10:21 a.m., 11:30 a.m., 12:10 p.m., 1:35 p.m.; 2/3/17 at 8 a.m., 9:05 a.m., 10 a.m., 10:35 a.m., Resident 2 was observed lying on her back in bed. During the treatment observation on 2/2/17 at 3:50 p.m., TN 1 (Treatment Nurse) measured the pressure ulcers. Resident 2 was observed with 2.6 cm (L) x 2.3 cm (W) and 1 cm in depth unstageable pressure ulcer to her left hip. The wound bed had large amount of yellow green slough and the periwound (tissue surrounding the wound itself) was brownish red in color. The resident's right upper back had 2.7 cm (L) x 0.8 cm (W) Stage II pressure ulcer described by TN 1 as an opened blister. TN 1 cleansed the left hip pressure ulcer with Normal Saline (sterile mixture of salt and water), applied Santyl ointment and covered the pressure ulcer with bordered gauze dressing. The right upper back Stage II pressure ulcer was cleansed with Normal Saline, applied triple antibiotic and covered with dry dressing. Resident 2 was observed unable to turn and reposition herself in bed due to left sided weakness and contractures to her left upper and lower extremities. On 2/3/17 at 10:35 a.m., CNA 3 (Certified Nursing Assistant) was interviewed in the presence of the Director of Nursing (DON).The Occupational therapist staff acted as the interpreter for CNA 3 a Spanish speaking staff. CNA 3 stated she was aware Resident 2 had pressure ulcers to her left hip and right upper back. CNA 3 stated Resident 2 will have a skin breakdown and the wound will get worse when not turned and repositioned every two hours while in bed. CNA 3 was also aware Resident 2 should be turned and repositioned every two hours but failed to do so. On 2/3/17 at 10:45 a.m., the medical record of Resident 2 was reviewed with DON (Director of Nursing) and TN 1. The initial Care Plan for pressure ulcer prevention dated 11/18/15 indicated Resident 2 had potential/actual impairment to skin integrity related to cardiovascular accident with generalized weakness. The Care Plan interventions included turning and repositioning Resident 2 every two hours and as needed while in bed. The Care Plan interventions for left MASD (11/13/16), left hip DTI pressure ulcer (1/7/17), left hip unstageable pressure ulcer (1/15/17) and right upper back open blister (1/28/17) were not revised to indicate which specific side the resident's body should be turned and repositioned every two hours while in bed to prevent further skin breakdown and to promote healing of the pressure ulcer. The DON was unable to provide documentation as to what caused the left hip to be assessed as MASD on 11/13/16, when the location of the hip was not over the incontinence area. Also, the Care Plan interventions did not indicate monitoring of Resident 2's skin condition to prevent blister formation to her right upper back. TN 1 stated the Care Plan for pressure ulcers were not revised because she Over looked them. DON and TN 1 both stated staff did not have a written or visual monitoring system to ensure residents who required assistance with bed mobility were appropriately turned and repositioned every two hours and/or not lying directly on the pressure ulcer. According to Medical Surgical Nursing Ninth Edition pages 186-187, Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure sore. 2. A review of the Nursing Admission/Readmission Data Tool indicated Resident 1 was readmitted on [DATE], with the following pressure ulcers: a. Sacrococcyx stage III pressure ulcer measured 4 cm (L) x 2.5 cm (W). b. Left heel stage I pressure ulcer (non-blanchable redness of intact skin) measured 4 cm (L) x 4 cm (W). The resident's right heel also had an arterial ulcer (inadequate blood supply to an area of the skin) measured 3 cm (L) x 2.5 cm (W) when readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of the Minimum (MDS) data set [DATE], indicated Resident 1 was assessed with [REDACTED]. A review of the Braden Scale for Predicting Pressure Ulcer Risk-V 2 (V-2 (Braden scale version 2)) dated 1/25/17, indicated Resident 1 was at risk for developing pressure ulcer due to her very limited sensory perception, very moist skin, bedfast, very limited mobility, inadequate nutrition and maximum assistance in moving. A review of Resident 1's Care Plan intervention for Sacrococcyx stage III pressure ulcer dated 1/24/17 indicated the resident was to be turned and repositioned to her right side and back every two hours while in bed. The Care Plan intervention for Resident 1's left heel Stage I pressure ulcer and right heel pressure ulcer dated 1/25/17, indicated to elevate both heels when in bed. On 2/2/17 at 8:30 a.m., 9:10 a.m., 10:24 a.m., 1120 a.m., 11:50 a.m., 12:05 p.m., 1:37 p.m., 2 p.m.; 2/3/17 at 8:02 a.m., 9:07 a.m., 10:02 a.m., Resident 1 was observed lying in the same position on her back and was not turned and repositioned every two hours while in bed. On 2/2/17 at 11:50 a.m., the resident's feet with heel protectors were observed resting on the foot elevator (blue colored foam cushion). On 2/2/17 at 2:45 p.m., treatment observation was conducted in the presence of DON (Director of Nursing) and CNA 5. TN 1 measured Resident 1's pressure ulcers. The resident was observed with 1.5 cm (L) x 0.5 cm (W) stage 2 pressure ulcer to her coccyx. The resident's right buttock had a stage III pressure ulcer which measured 2 cm (L) x 2 cm (W) with moderate amount of yellow slough in the wound bed. The resident's left buttock was observed with 1.6 cm (L) x 0.8 cm (W) Stage II pressure ulcer. Resident 1's right heel pressure ulcer measured 1.6 cm (L) x 2.1 cm (W) 0.7 cm in depth with moderate amount of yellow slough in the wound bed. The resident's skin on the sacrum and left heel was clear and intact. TN 1 cleansed the coccyx pressure ulcer with Normal Saline and applied Duoderm patch. The right buttock pressure ulcer was cleansed with Normal Saline; Santyl ointment was applied and covered with a bordered wound dressing. The right heel arterial ulcer was cleansed with Normal Saline, Santyl ointment and [MEDICATION NAME] petroleum dressing (non adherent gauze dressing) were applied and the ulcer was covered with a dry dressing. TN 1 stated that the stage II pressure ulcer to the left buttock had no treatment order because it was not observed until 2/2/17, during treatment of [REDACTED]. During an interview on 2/8/17 at 2:35 p.m., CNA 4 (Certified Nursing Assistant) stated she turned and repositioned Resident 1 on her back, left side and right side while in bed. CNA 4 was aware Resident 1 had pressure ulcers to her buttocks and coccyx. CNA 4 stated she was not informed by any staff member not to turn and reposition Resident 1 on her back until 2/7/17. CNA 4 stated pressure ulcers will not heal when the resident is lying directly on the pressure ulcer. CNA 4 stated she got busy taking care of another resident and was unable to turn and reposition Resident 1 every two hours while in bed. CNA 4 stated she incorrectly applied the foot elevator to Resident 1 by not floating her heels. During an interview on 2/8/17 at 3:01 p.m., LVN 2 (Licensed Vocational Nurse) stated she was aware Resident 1 had pressure ulcers to her buttocks and lying directly on the pressure ulcer will make the wound worse. LVN 2 stated she did not realize Resident 1 was lying on her back and the resident's heels were resting on the foot elevator when she went to the resident's room on 2/2/17. On 2/8/17 at 3:26 p.m., the medical record of Resident 1 was reviewed with DON and TN 1. The physician treatment orders for the pressure ulcers indicated the following: a. On 1/25/17, Sacrococcyx stage III pressure ulcer was to be cleansed with Normal Saline, apply Santyl ointment, and cover with bordered gauze dressing daily for 30 days. b. On 2/1/17, left buttock stage II pressure ulcer was to be cleansed with Normal Saline, apply Duoderm patch change every Monday, Wednesday, and Friday for 14 days. The Change of Condition SBAR dated 2/2/17, indicated Resident 1 developed a stage II pressure ulcer to her left buttock measured 1.6 cm (L) x 0.8 cm (W). (Resident 1 was not assessed as having a pressure ulcer to her right buttock nor was the physician notified until 2/2/17, when the resident was observed with a stage III pressure ulcer to her right buttocks, during the treatment observation with the DON). During a concurrent record review and interview with TN 1 stated she was confused for not following the physician's pressure ulcer treatment orders to Resident 1's Sacrococcyx and left buttock. TN 1 stated she applied Santyl ointment to Resident 1's stage III right buttock pressure ulcer on 2/2/17, without notifying the physician for a treatment order. During a concurrent record review and interview with DON stated Care Plan intervention for Sacrococcyx stage III pressure ulcer dated 1/24/17, was incorrect because Resident 1 should not be repositioned on her back because the pressure ulcer will not heal and the resident will have further skin breakdown. The DON stated Care Plan for pressure ulcers to Sacrococcyx and left buttock were not revised to specify Resident 1 should be turned to her right side and left side only while in bed to promote healing of the pressure ulcers. The DON and TN 1 both stated the facility had turning and repositioning schedules every two hours for bedfast residents (confined to bed due to illness) but no monitoring system was in place to make sure it was followed by the staff. 3. A review of the clinical record indicated Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS a standardized assessment and care screening tool, dated 1/31/17 indicated Resident 4's cognitive(mental) skills for daily decision making was severely impaired (never/rarely made decisions). Resident 4 required extensive assistance to total dependence with one to two person physical assist in performing activities of daily living. A review of the facility's Admission/Readmission Nursing Data Tool, dated 1/25/17, completed by registered nurse (RN 1) indicated Resident 4 had Stage 1 pressure injury right heel, measuring 4 x 4 cm (centimeters) and left heel 4 x 4 cm. A review of the facility's Braden Scale for Predicting Pressure Ulcer Risk, dated 1/26/17, completed by TN 1 indicated Resident 4 has very limited sensory perception, the skin was occasionally moist, resident was bedfast, mobility was very limited, resident was on tube feeding and required moderate to maximum assistance in moving. Risk determination indicated Resident 4 was at risk for developing skin/pressure injury. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of Resident 4's care plan initiated on 1/24/17 indicated impaired skin integrity related to stage 1 pressure injury on the right heel on admission and stage 1 pressure injury on the left heel on admission. The care plan goal indicated resident will be free from skin tear/breakdown and show healing with no deterioration. Identified interventions included elevate both heels on pillow when in bed. Resident 4's care plan was revised on 2/2/17 and indicated stage 1 pressure injury on the left heel progressed to deep tissue injury. On 2/2/17 at 11:40 a.m., Resident 4 was observed lying in bed with bilateral heel protectors on with one pillow on resident's upper thighs, not elevating resident's feet. Bilateral heels were observed with heel protectors on but were directly in contact with the mattress, failing to elevate bilateral feet. On 2/2/17 at 11:42 a.m., an interview was conducted with TN 1. TN 1 stated Resident 4 came from the acute care hospital with heel protectors but there was no order for its use while in the facility. TN 1 stated the heel protectors should not have been worn by the resident since there was no order for its use. TN 1 further stated that Resident 4's bilateral feet should have been elevated even with heel protectors on to prevent causing pressure on both heels with stage 1 pressure ulcer already. On 2/2/17 at 11:45 a.m., an interview was conducted with certified nursing assistant (CNA 1) who was with the resident at the time of the observation. CNA 1 stated she was the one who placed the heel protectors to Resident 4. CNA1 stated Resident 4's feet should have been elevated and both feet should not be directly in contact with the mattress. CNA 1 stated the pillow should have been placed in a way to elevate the feet completely and not on resident's upper thighs. On 2/2/17 at 12:05 p.m., during treatment observation, Resident 4's left heel was observed with dark red/maroon colored ulcer on the middle part of the left heel, measuring 3.5 cm x 2.6 cm, surrounding area was pink in color and there were no discharges noted. On 2/2/17 at 12:10 p.m., an interview was conducted with TN 1. TN 1 stated the dark colored area was not there yesterday (2/1/17). TN 1 classified the injury as DTI. TN 1 stated she will document a change of condition assessment and will notify physician and family. TN 1 confirmed the deep tissue injury on the middle part of the resident's heel was acquired in the facility. A review of Resident 4's Change of Condition (SBAR) dated 2/2/17 indicated resident's left heel stage 1 pressure injury noted pinkish/reddish/purplish color, skin intact, no pen area noted; classified as deep tissue injury size 3.5 cm x 2.6 cm. On 2/7/17 at 2:25 p.m., an interview was conducted with CNA 1. CNA1 confirmed there was only one pillow with Resident 4 on 2/2/17 and the resident needed more than just one pillow to elevate both feet. CNA1 stated to prevent blister and rubbing the sheet, the resident's feet needed to be elevated. CNA1 stated when she gave the resident a bed bath on 2/7/17 at 10:30 am, there was only one pillow available to elevate the feet. CNA 1 stated Resident 4 kept on sliding down the bed and there was only one pillow available to elevate both feet. CNA1 stated there were not enough pillows in the room to elevate the resident's feet. On 2/7/17, Resident 4 was observed from 2:45 p.m. to 3 pm, while in bed. Resident was alert and restless with both feet rubbing the mattress. Resident 4 was observed continuously rubbing her feet on the mattress but the resident only had one pillow under her feet. The pillow did not elevate both feet. No staff came to check if both feet were elevated for the entire 15 minutes of observation. On 2/7/17 at 3:05 p.m., CNA 2 confirmed Resident 4's feet were not elevated and both heels were directly rubbing against the mattress. On 2/7/17 at 3:15 p.m., an interview was conducted with licensed vocational nurse (LVN 2) charge nurse. LVN 2 stated Resident 4's feet were not elevated. LVN 2 stated the resident's feet should not be directly in contact with the mattress. LVN 2 stated the resident's feet should be elevated because the resident already had a skin breakdown. LVN 2 stated she will notify the physician and get a device to elevate the resident's feet. On 2/7/17 at 3:45 p.m., an interview was conducted with rehabilitation nurse assistant (RNA 1). RNA 1 stated she was assigned by the director of staff development (DSD) to check that the residents with pressure ulcer were in the right position. RNA 1 stated her role was to make sure the CNAs were correctly turning and repositioning residents with pressure ulcer. RNA 1 stated the facility just started this system on 2/6/17. RNA 1 stated she made sure Resident 4's feet were elevated at 2 p.m RNA 1 stated she elevated the resident's left heel using one folded pillow. RNA 1 acknowledged that the Resident 4 was restless while in bed. RNA 1 stated she should have used more than one folded pillows to elevate the resident's feet. RNA 1 stated the facility had enough pillows in storage and she should have used folded pillows to elevate the resident's feet. On 2/7/17 at 4:10 p.m., a second treatment observation on Resident 4 was observed with director of nursing (DON). Resident 4's left heel was observed with deep tissue injury on the middle part of the left heel, measuring 3.6 cm x 2 cm. During close observation revealed two new dark red/blue colored ulcers on the left lateral malleolus (bony prominence on each side of the ankle) but the skin was intact. Site 1(lower ulcer) measured 0.9 cm x 0.5 cm., and Site 2 (upper ulcer) measured 0.6 cm x 0.5 cm. DON and TN 1 confirmed the ulcers on the left lateral malleolus were acquired in the facility. On 2/8/17 a review of Resident 4's clinical record did not indicate a care plan to communicate with the [MEDICAL TREATMENT] center the plan to elevate both feet to prevent further skin breakdown. Resident 4's plan of care for [MEDICAL TREATMENT] was not individualized for the facility to coordinate with the [MEDICAL TREATMENT] center to elevate bilateral heels. Resident 4's plan of care for stage 1 pressure ulcer was not individualized for the facility to coordinate with the [MEDICAL TREATMENT] center to elevate bilateral heels. Resident 4's nursing progress notes from 1/25/17-2/8/17 were reviewed with DON. Nursing progress notes did not indicate any communication between the facility and the [MEDICAL TREATMENT] center to coordinate plan of care to elevate Resident 4's bilateral feet. A review of the facility's [MEDICAL TREATMENT] Communication Record indicated the following: On 1/25/17 the [MEDICAL TREATMENT] Communication Record indicated left heel stage 1 and right heel stage 1. The communication record did not specifically indicate to elevate Resident 4's both feet. There was no progress note that the facility coordinated with the [MEDICAL TREATMENT] center to elevate Resident 4's bilateral feet. On 1/27/17, there was no [MEDICAL TREATMENT] Communication Record but DON confirmed resident went to the [MEDICAL TREATMENT] center and completed the procedure. On 1/30/17, the [MEDICAL TREATMENT] Communication Record did not indicate any pressure injury for Resident 4. On 2/1/17 and 2/3/17, there were no [MEDICAL TREATMENT] Communication Record but DON confirmed Resident 4 went to the [MEDICAL TREATMENT] center on both days and completed the procedure. DON acknowledged that Resident 4's stage 1 pressure ulcer on the left heel progressed to deep tissue injury on 2/2/17 and should have been communicated with the [MEDICAL TREATMENT] center. On 2/8/17 at 10:30 a.m., an interview was conducted with registered nurse (RN 1). RN 1 stated the facility should have been more specific in communicating with the [MEDICAL TREATMENT] center in coordinating the plan of care for Resident 4 to elevate bilateral feet to prevent further skin breakdown. On 2/8/17 at 3:40 p.m., an interview was conducted with LVN 3. LVN 3 stated she did not know Resident 4 had pressure ulcers on both heels. LVN 3 stated if she had known about the stage 1 pressure ulcers, she should have coordinated the information to the [MEDICAL TREATMENT] center by writing it on the [MEDICAL TREATMENT] Communication Record. A review of the facility's Policy and procedure titled Pressure Ulcers/Skin Breakdown-Clinical Protocol revised March 2014 indicated the following: (a) Pressure Ulcer Treatment: Stage 1 Protocol, redistribute pressure and interventions to off-load, if indicated, implement pressure relieving device(s) in accordance with resident's assessed needs. (b)Prevention of Pressure Ulcers: Risk-Factor (Bed-fast)-consider off-loading pressure hourly if the head of the bed is greater than 30 degrees (example for residents with tube feeding or respiratory issues). A review of the facility's Policy and procedure titled Pressure Ulcers/Skin Breakdown-Clinical Protocol revised March 2014 indicated the following: (a) Pressure Ulcer Treatment: Stage 1 Protocol, redistribute pressure and interventions to off-load, if indicated, implement pressure relieving device(s) in accordance with resident's assessed needs. (b)Prevention of Pressure Ulcers: Risk-Factor (Bed-fast)-consider off-loading pressure hourly if the head of the bed is greater than 30 degrees (example for residents with tube feeding or respiratory issues). A review of the facility's Long Term Care Facility Outpatient [MEDICAL TREATMENT] Services Agreement dated 12/1/14 indicated the facility retains primary responsibility for the development and implementation of the resident's plan of care. The center will cooperate with the facility in coordinating and developing this plan of care. 4. An admission face sheet indicated Resident 8 was admitted to the facility on [DATE] and November 21, 2014. The resident's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), a standardized comprehensive assessment and care screening tool, dated January 7, 2017, indicated Resident 8 was totally dependent on staff with one person assist for transfers, and activities of daily living. Review of the Nursing Admission/Readmission Data Tool Kit, dated October 26, 2016, indicated Resident 8 was admitted to the facility with the following: A Stage II pressure sore (shallow open ulcer with a red pink wound bed) to the coccyx (the tail bone) and a Stage 1 pressure ulcer (intact skin, non blanchable usually over a bony prominence) to the left trochanter (hip). A Braden Scale (tool used for predicting the risk for pressure ulcers) dated January 14, 2017, indicated Resident 8 was at risk for developing pressure sores. Review of a Interdisciplinary Team (IDT) Wound Management Update, dated January 5, 2017, indicated Resident 8 had a Stage III pressure ulcer (full thickness tissue loss, slough may be present, no bone or tendon exposed) to the Sacrococcyx (the fused sacrum (a bone at the bottom of the spine) and coccyx (tailbone)). Recommendations included to turn form side to side. Review of an untitled care plan dated January 18, 2017, indicated an open blister on the right mid buttock classified as a Stage II pressure ulcer. The care plan indicated the Stage II pressure ulcer was a previous wound that had healed on October 18, 2016, prior to readmission to the facility on [DATE]. Nursing interventions included repositioning from side to side when in bed for circulation and prevent pressure. On January 19, 2017 , an IDT Wound Management Update, indicated the Stage III pressure ulcer on the Sacrococcyx had extended to the right buttock and was classified as a Stage II pressure ulcer. In addition the left buttock sites #1 and 2 were Stage II pressure ulcers. Wound specialist recommendation was to cleanse with normal saline (NSS) and start [MEDICATION NAME] 1% cream (applied to the surface of the skin used to treat and prevent infections to wounds) to the right buttock Stage II of the right buttock and Santyl ointment (used to clean wound and remove dead tissue so that healthy tissue can replace it) to the Stage III Sacrococcyx. An untitled care plan dated January 25, 2017, indicated healed left buttock site #1 and #2 at risk for reopening. Nursing interventions indicated resident needed monitoring/reminding/assistance) to turn/reposition at least every two hours, more often as needed or requested. Review of the IDT Weekly Wound Evaluation, dated January 26, 2017, indicated debridment (removal of dead tissue) was done to the Stage III Sacrococcyx. The wound bed was described as having 100% granulation (new tissue that forms on the surfaces of wounds during the healing process). During multiple observations on February 2, 2017 at 9:30 a.m. and 1:27 p.m. Resident 8 was observed lying directly on her back. On February 2, 2017 at 7:10 a.m. and 9:50 a.m Resident 8 was observed lying on her right side directly on her wound at 1:30 p.m., on the same day Resident 8 was observed lying on her back. On February 7, 2017 at 2:45 p.m., Resident 8 was again observed asleep lying on her back. During an interview on February 7, 2017, with CNA 4 stated she had been informed by the director of staff development (DSD) that morning to follow a turning schedule that was placed on the wall above the residents bed. The turning schedule indicated to turn the resident onto her back and onto the left side. CNA 4 stated she was unsure why the resident was not being turned on to her right side. When asked if residents with wounds should be positioned onto the wound, CNA 4 sta

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being of one of three sampled residents (Resident 1) who had the [DIAGNOSES REDACTED].). The facility staff failed to: 1. Adequately assess Resident 1's complaint of chest pain as a potential symptom of a [MEDICAL CONDITION], which occurs when the blood flow to the heart suddenly becomes blocked and the heart can't get oxygen. This would lead to the heart muscle to die and the heart to stop beating. 2. Notify Resident 1's physician of the resident's complaints of chest pain for further evaluation. These failures resulted in delayed medical treatment for [REDACTED]. Findings: A review of the complainant allegations indicated while in the general acute care hospital (GACH) Resident 1 informed GACH staff 1 that on 10/9/16 at 9:30 p.m., he started having chest pains and informed the charge nurse. Resident 1 stated I begged them to call 911, begged them to call paramedics. Resident 1 stated the nurse told him I'm sorry we don't have the authorization to make that call. Resident 1 stated he felt chest pains all night and kept asking the evening nurse to call. Resident 1 stated I think the evening nurse got upset with me and stopped coming. A review of Resident 1's Admission Record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical dated 10/06/2016 included [DIAGNOSES REDACTED]. A review of Resident 1 ' s physician orders [REDACTED]. Aspirin chewable tablets 81 milligrams (mg) one tablet daily to prevent blood clots. [MEDICATION NAME] extended release tablets (prevents chest pain) 30 mg one tablet daily. An interview was conducted with Resident 1 on 10/26/2016 at 11:10 a.m. Resident 1 did not want to talk about the incident of having chest pain which resulted in him going to the hospital. Resident 1 stated he was fearful the facility might retaliate against him. An interview was conducted with Certified Nurse Assistant (CNA 1) on 10/26/16, at 3:00 p.m. CNA 1 stated on 10/9/16, Resident 1 told her around time that he has chest pain and does not feel good. CNA 1 stated she reported Resident 1's complaint right away to registered nurse (RN) 1. CNA 1 stated she did not check Resident 1's vital signs. A review of Resident 1's Daily Skilled Documentation dated 10/9/2016 at 9:36 p.m. indicated the following: Blood pressure 112/64, Temperature 97.6 degrees, pulse 72 beats per minute regular rate, and respiration 22 breaths per minute. Denies pain or discomfort. Lung sounds clear, no congestion and no wheezing and no cough. Respiration even and unlabored, with shortness of breath and no acute distress noted. RN 1 did not document that CNA 1 had informed him of Resident 1's complaint of chest pain. RN 1 did not document that Resident 1 had any complaints of chest pain during that shift. A telephone interview was conducted with RN 1 at 9:40 a.m. on 10/27/2016. RN 1 stated he was at the facility to document Resident 1's episode of chest pain on 10/09/2016. RN 1 stated he assessed Resident 1 at 8 p.m. on 10/09/2016 and forgot to document his assessment. RN 1 also stated he did not inform the doctor because Resident 1 looks normal, vital signs was normal and pulse oximetry (a test to measure the amount of oxygen in the blood) was 98%. A review of RN 1's late entry note for 10/9/2016 at 9:30 p.m., dated 10/27/2016 indicated the following: Resident 1's family member visited around 8 p.m. After 15 minutes the family member told him Resident 1 wanted to go to the hospital because of discomfort. Resident 1 told him, breathing not well and need oxygen. RN 1 took Resident 1's vital signs and performed a top to toe body assessment with good condition. The family member told him to give him oxygen let him feel well. RN 1 set up oxygen for Resident 1 as ordered and Resident 1 and the family member were satisfied. Resident 1 had no further complaints of pain or discomfort. RN 1 failed to document that CNA 1 had informed him of Resident 1's complaint of chest pain and that Resident 1 had continued to complain of chest pain during the night. A review of Resident 1's Health Status Note dated 10/10/2016 at 8:27 a.m. indicated the [MEDICAL TREATMENT] center staff informed the facility that Resident 1 came into the [MEDICAL TREATMENT] center complaining of body aches and pains, not feeling good at all. Resident 1 requested to go to the hospital instead of going back to the nursing home. A review of Resident 1's GACH Internal Medicine Hospital History and Physical record dated 10/10/2016 indicated Resident 1 was sent from the [MEDICAL TREATMENT] center because of cough and chest pain. Resident 1 was admitted due to elevation of Troponin (laboratory test which measures a protein released due to damaged heart muscle) level. Resident 1's GACH Troponin level was 0.490 nanograms (ng) /milliliter (ml) (normal range was 0.000-0.05 ng/ml per GACH standard) which indicated very abnormally high. A review of Resident 1's cardiac angiogram (a procedure performed to diagnose [MEDICAL CONDITION]) report dated 10/12/2016, indicated Resident 1 had a lesion (a region in an organ or tissue that had suffered damage) due to a Non-ST Elevation [MEDICAL CONDITION] Infarction (NSTEMI - a type of [MEDICAL CONDITION] caused by a partially block artery of the heart). Resident 1 sustained damage to his heart due to a decrease in blood flow to a portion of his heart. A review of Resident 1's GACH Discharge Summary dated 10/16/2016 indicated Resident 1 was treated medically and was discharged back to facility. The GACH discharge [DIAGNOSES REDACTED]. National Institutes of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI): What is a [MEDICAL CONDITION]? (Updated January 27, 2015) included the following: Acting fast at the first sign of [MEDICAL CONDITION] symptoms can save your life and limit damage to your heart. Treatment works best when it's given right after symptoms occur. Many people aren't sure what's wrong when they are having symptoms of a [MEDICAL CONDITION]. Some of the most common warning symptoms of a [MEDICAL CONDITION] for both men and women are: -Chest pain or discomfort. Most [MEDICAL CONDITION] involve discomfort in the center or left side of the chest. The discomfort usually lasts more than a few minutes or goes away and comes back. It can feel like pressure, squeezing, fullness, or pain. It also can feel like heartburn or indigestion. -Upper body discomfort. You may feel pain or discomfort in one or both arms, the back, shoulders, neck, jaw, or upper part of the stomach (above the belly button). -Shortness of breath. This may be your only symptom, or it may occur before or along with chest pain or discomfort. It can occur when you are resting or doing a little bit of physical activity. If you think you or someone else may be having [MEDICAL CONDITION] symptoms or a [MEDICAL CONDITION], don't ignore it or feel embarrassed to call for help. Call 9-1-1 for emergency medical care. Acting fast can save your life.