Every finding on record at Montebello Care Center

Based on interview and record review, the facility failed to ensure a coordination of care between the facility and hospice (care designed to give supportive care to people in the final phase if a terminal illness and focus on comfort and quality of life, rather than cure) staff for two of two sampled residents (Residents 6 and 40) by failing to ensure:Resident 6's hospice medications were reflected on the physician's orders.Resident 40's care plan reflected hospice care and interventions with hospice 1(HSP1).These deficient practices have the potential for Residents 6 and 40 to not receive the hospice care and services necessary to promote comfort and quality of life.Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified dementia (memory loss and impaired daily functioning), unspecified convulsions (sudden, involuntary muscle contractions or shaking when the exact type of seizure [a sudden and uncontrolled surge of electrical activity in the brain]or its underlying cause remains undetermined), and personal history of pneumonia (history of lung infection). During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 4/1/2026, the MDS indicated Resident 6 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 6 was dependent (helper does all of the effort) with eating, toileting/personal hygiene, upper body dressing, rolling left and right, and sit to lying. The MDS also indicated Resident 6 was in hospice care. During a review of Resident 6's Order Summary Report, dated 5/14/2026, the Order Summary Report indicated a physician order, with a start date of 10/1/2025, for the following: Admit to Hospice (HSP) on routine level of care. HSP to manage care related to Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). HSP to provide medications related to comfort, symptom control and management of terminal illness. Follow plan of care and collaborate any changes with HSP. During a review of Resident 6's Hospice Medication List, as of 5/8/2026, the Medication List indicated Resident 6 was ordered the following medications: Lorazepam (medication for anxiety) 0.5 milligrams (mg- unit of measurement) 1 tablet sublingually (sl- under the tongue) every four hours as needed for restless behavior or combativeness, with a start date of 4/20/2026 Milk of Magnesia (medication for constipation) 400 mg/5 milliliters (ml- unit of measurement) 30 ml by mouth (po) every 12 hours as needed if no bowel movement (BM) x 3 days, with a start date of 9/30/2025 Ondansetron HCl (medication to prevent and treat nausea and vomiting) 4 mg 1 tablet by mouth every four hours as needed for nausea and vomiting, with a start date of 9/30/2025 Phenobarbital (medication for seizures) 120 mg per rectum (PR) as needed for seizure activity then call hospice immediately, with a start date of 3/13/2026 Zinc (a supplement used for wound healing) 50 mg 1 tablet by mouth once daily, with a start date of 9/30/2026 During a concurrent interview and record review on 5/13/2026, at 4:11 PM, with the Director of Nursing (DON), Resident 6's Order Summary Report, dated 5/14/2026 and Hospice Medication List were reviewed. The DON stated Resident 6's Order Summary Report did not include the following medications that were in Resident 6's Hospice Medication List: Lorazepam 0.5 mg 1 tablet sl every four hours as needed for restless behavior or combativeness, with a start date of 4/20/2026 Milk of Magnesia 400 mg/5 ml 30 ml by po every 12 hours as needed if no BM x 3 days, with a start date of 9/30/2025 Ondansetron HCl 4 mg 1 tablet by mouth every four hours as needed for nausea and vomiting, with a start date of 9/30/2025 Phenobarbital 120 mg PR as needed for seizure activity then call hospice immediately, with a start date of 3/13/2026 Zinc 50 mg 1 tablet by mouth once daily, with a start date of 9/30/2026 The DON stated the medications of residents in hospice care were discussed with the hospice coordinator upon admission, quarterly and whenever there was a change in the resident's care. The DON stated it was important that all of Resident 6's hospice medications were reviewed and included in Resident 6's ordered medications to prevent complications especially when there was an exacerbation of Resident 6's symptoms. The DON stated Resident 6 has not been taking zinc because it was not included in Order Summary Report. The DON stated Resident 6 had pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and it was important for Resident 6 to take zinc because it was a supplement to promote wound healing. The DON also stated Resident 6's Order Summary Report did not include phenobarbital which was indicated for seizures. During the same concurrent interview and record review on 5/13/2026, at 4:11 PM, with the DON, Resident 6's Hospice Medication List was reviewed. The DON stated Resident 6's Hospice Medication List did not include Naloxone HCl (a life-saving medication that rapidly reverses opioid [strong pain killers that block pain signals in the brain] overdose) 4mg/0.1ml 1 application alternating nostrils as needed for opioid overdose which was included in Resident 6's Order Summary Report. The DON stated it was the responsibility of the hospice staff to ensure that Resident 6's hospice medications matched the medications in the Order Summary Report. The DON stated she was unsure if the hospice staff had access to the list of medications Resident 6 was taking in the facility. The DON stated Resident 6's Hospice Medication List should be reviewed and compared to the list of medications in the Order Summary Report during recap (a routine, usually monthly, administrative review of the Resident's medical chart). The DON stated it was important that the medications in the Hospice Medication List and the Order Summary Report match to ensure that the medications are coordinated and available when needed. During a review of the facility's policy and procedure (P&P), titled, Hospice, revised 3/1/2018, the P&P indicated the hospice and Center (facility) must communicate, establish, and agree upon a coordinated plan of care which reflects the hospice philosophy, and is based on an assessment of the patient's needs. During a review of the Hospice and Nursing Facility Service Agreement, signed 9/26/2016, between the facility and HSP, the Hospice and Nursing Facility Service Agreement indicated the under Facility Responsibilities that, Hospice and Facility will communicate pertinent information with each other either verbally or in the patient's medical record at each hospice patient visit or more frequently, whenever needed to ensure that the needs of each hospice patients are met 24 hours per day. Documentation of such communication shall be included in the patient's medical record. 2.During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included dementia (a progressive state of decline in mental abilities), atrial fibrillation (AFib, is the most common type of irregular heartbeat), and atrioventricular block (AV block, a malfunction in the heart's electrical wiring) During a review of Resident 40's Order Summary Report, dated 5/14/2026, the Order Summary Report indicated an order to admit Resident 40 to HSP (Hospice) on routine level of care, ordered on 8/19/2025. During a review of Resident 40's Minimum Data Set (MDS – a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 40's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 40 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing. The MDS indicated Resident 40 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower, lower body dressing, putting on/off footwear and personal hygiene. The MDS indicated Resident 40 was in hospice care while a resident of the facility. During a concurrent record review and interview on 5/15/2026 at 9:45 AM with Registered Nurse 1 (RN 1), Resident 40's medical records were reviewed. RN 1 stated that Resident 40 was discharged from hospice 2 (HSP 2) on 6/27/2025. RN 1 stated that Resident 40 was admitted to HSP 1 on 8/19/2025RN 1 stated Resident 40 did not have care plan that addressed being under the care of HSP 1. RN 1 stated it was important to have a HSP care plan to determine the coordination of Resident 40's care between HSP 1 and the facility to ensure Resident 40's comfort. RN 1 stated that Resident 40's hospice frequency of visits from HSP 1 was not and should have been in the care plan. RN 1 stated that it was important to reflect hospice frequency of visits on the care plan for coordination of care. During a concurrent record review and interview on 5/15/2026 at 2:25 PM with Registered Nurse 2 (RN 2), Resident 40's medical records and HSP binder were reviewed. RN 2 verified that Resident 40 does not have and should have a care plan regarding care under HSP 1. RN 2 stated this can lead to inconsistency of care that may cause harm to Resident 40. RN 2 stated that the hospice care plan should include all the orders that are indicated in Resident 40's POC summary filed in the hospice binder, like the frequency of hospice staff visits. During a review of the Contract Agreement between HSP and facility, dated 8/26/2019, the Contract Agreement indicated Joint Responsibilities/Mutual Promises between HSP and facility with development and implementation of plan of care, Hospice and Facility shall jointly develop and agree upon the Patient's plan of care. The Contract Agreement indicated modification of plan of care/communication protocols, hospice and facility shall jointly coordinate and participate in periodic review and modification of each's patient's plan of care. During a review of facility's Policy and Procedure (P&P) titled, Hospice Program, revised in July 2017, the P&P indicated facility will coordinate with hospice representatives and coordinate facility staff participation in the hospice care planning process for resident receiving these services.

Based on observation, interview, and record review, the facility failed to follow proper food handling procedures and to maintain the food service area in a clean and sanitary manner in accordance with the facility's policy and procedure (P&P) by failing to ensure: The can opener was free of rust, peeling metal, and food residue.Containers of ground white pepper, oregano, ground black pepper, and onion powder were properly closed or sealed.The Brand 1 blender pitcher did not have a crack and did not have a whitish to yellowish color buildup.The Brand 2 food processor cover was not cracked and did not have a yellowish to whitish calcification buildup.The clear container of food thickener was properly closed.The microwave top and bottom interior was not rusted; the lining was peeled off, chipped and had dry food residue.The resident's refrigerator was kept clean and checked daily for cleaning according to the facility's policies and procedures.Three (3) Brand 3 yogurts were labeled with the resident's name and discarded after the best-by date (expiration or use by date) on 5/2/2026.The resident's freezer door did not have a brown color dripping.The mozzarella cheese container, chocolate ice cream, Brand 4 Maple Griddle, Brand 5 Bowls Mexican Casserole, Brand 6 Lasagna with Meat Sauce, and Cheese Ravioli were dated with when it was [NAME] in by the resident's family or representative and labeled with the resident's name and room number.The [NAME] Style Beef [NAME] was discarded after the best-by date on 4/22/2026.All five conventional oven knobs have temperature settings and were not dirty with grease and food residue buildup. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization. Findings: During an observation in the kitchen on 5/12/2026 at 7:48 AM, a can opener was observed to be rusted, with peeling metal and food residue buildup. During an observation in the kitchen on 5/12/2026 at 7:49 AM, containers of ground white pepper, oregano, ground black pepper, and onion powder on the spice rack were not properly closed or sealed. During an observation in the kitchen on 5/12/2026 at 7:50 AM, the Brand 1 blender pitcher was observed to have cracks and whitish to yellowish colored substance buildup During an observation in the kitchen on 5/12/2026 at 7:51 AM, the Brand 2 food processor cover was observed to be cracked and have yellowish to whitish, and brownish substance buildup. During an observation in the kitchen's stock room on 5/12/2026 at 7:57 AM, a clear container of food thickener was not properly closed. During an observation in the kitchen on 5/12/2026 at 7:58 AM, the microwave's interior was rusted, chipped, and had dry food like residue. During a concurrent observation and interview on 5/12/2026 at 8:04 AM at the employee's breakroom with the Dietary Supervisor (DS), the resident's refrigerator was dirty, with dry crusted food debris and accumulation of visible liquid residue. DS stated the resident refrigerator was dirty and the log indicated that resident's refrigerator should have been checked and cleaned every day. During a concurrent observation of resident's refrigerator and interview on 5/12/2026 at 8:05 AM in the employee's break room with the DS, DS stated the Brand 3 Yogurt in the resident's refrigerator was not labeled with the resident's name and room number. Brand 3 yogurt has a best by date of 5/2/2026 (10 days). During the same concurrent observation of the resident's refrigerator and interview on 5/12/2026 at 8:05 AM in the employee breakroom with the DS, the DS stated that the freezer door had visible brown colored substance or chocolate like drippings. The mozzarella cheese, chocolate ice cream, Brand 4 Maple Griddle, Brand 5 Bowls Mexican Casserole, Brand 6 Lasagna with Meat Sauce, and cheese ravioli were not dated with when it was [NAME] in by the resident's family or representative and labeled with resident's name. The DS also stated that the [NAME] Style Beef [NAME]'s best by date was 4/22/2026. During a concurrent observation and interview on 5/14/2026 at 11:00 PM with Dietary District Manager (DDM) in the kitchen, DDM stated the conventional oven knobs did not have visible numbers and setting for temperature. DDM asked Dietary [NAME] (DK 1) how they determine the correct temperature when cooking and DK 1 responded that they estimate it. DK 1 also stated the conventional oven has been like that for long time. During an interview on 5/14/2026 at 2:26 PM with Dietary Aid (DA) 1, DA 1 stated the can opener was rusted, with the metal covering peeled off and food residue present. DA 1 also stated, the Brand 1 blender and Brand 2 food processor were cracked and had yellowish to whitish buildup. DA 1 also stated the conventional oven knobs do not have visible numbers or settings for temperature. DA 1 added the knobs were dirty with grease and food residue buildup. DA 1 also stated all food and spices containers should be sealed properly and noted that these conditions or practice were not acceptable and could cause food contamination and sickness. During a concurrent interview and record review on 5/14/2026 at 3:13 PM with DS, the facility's P&P titled Food Brought by Family/Visitors, revised on 3/28/2024, was reviewed. DS stated the P&P indicated that when a food item is intended for later consumption, the responsible staff member will label the food with the resident's name, current date, and use-by date and items will be discarded after 48 hours. DS also stated the P&P indicated that the refrigerator/freezer for storage of food brought in by visitors will be properly maintained and cleaned daily. DS added the P&P was not followed since the resident's refrigerator was not cleaned daily, and the food that was stored in the resident's refrigerator were not labeled with the resident's name and labeled with the use- by date. During a concurrent interview and record review on 5/14/2026 at 3:15 PM with the DS, the facility's P&P titled Food Storage: Cold Foods, revised 2/2023, was reviewed. DS stated the P&P indicated all food must be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross-contamination (the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food, and then touch ready-to-eat foods). DS stated the P&P was not followed. During a concurrent interview and record review on 5/14/2026 at 3:17 PM with the DS, the facility's P&P titled Equipment revised 9/2017 was reviewed. The P&P indicated, all equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. DS stated that all food service equipment such as the resident's refrigerator and conventional oven should be kept clean, sanitary, and maintained in proper working order. DS stated that the P&P was not followed. During a concurrent interview and record review on 5/14/2026 at 3:19 PM with the DS, the facility's P&P titled Receiving revised 2/2023 was reviewed. DS stated that the P&P indicated all non- perishable foods and supplies will be stored appropriately. During an interview on 5/15/2026 at 10:28 AM with the Registered Nurse (RN 2), RN 2 stated that all food containers in the kitchen should be labeled, dated, and closed properly. RN 2 also stated all equipment should be in good condition to prevent food contamination and illnesses such as stomach flu and diarrhea.

Based on observation, interview, and record review, the facility failed to accurately measure the shredded Monterey [NAME] Cheese used to prepare Quesadilla served for lunch on 5/14/2026. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, and weight loss for the six (6) of 6 sampled residents who received the Quesadilla on 5/14/2026.Findings: During an observation in the kitchen on 5/14/2026 at 11:59 AM, Dietary [NAME] (DK 2) was observed using a black - colored scoop (scoop size number 30, capacity of one ounce [oz, unit of measurement]) to measure the Monterey [NAME] shredded cheese used for Quesadilla. During an observation in the kitchen on 5/14/2026 at 12 PM, DK 1 was observed using a yellow-colored scoop (scoop size number 20, capacity of one and five-eighths [1 5/8 oz]) to measure the Monterey [NAME] shredded cheese used for Quesadilla. During an interview on 5/14/2026 at 2:42 PM, DK 1 stated that she used the yellow scoop to measure the Monterey [NAME] cheese for preparing the quesadilla. DK 1 stated she used the scoop to make one quesadilla and added that the yellow scoop was the correct tool, while the black scoop was not. During an interview on 5/14/2026 at 2:57 PM, DK 2 stated that she used the black scoop to measure Monterey [NAME] cheese for preparing the quesadillas. DK 2 stated she used the scoop to make five quesadillas. DK 2 stated that the yellow scoop and not the black scoop was the correct tool to use to provide proper nutrition for the residents. During a concurrent interview and record review on 5/15/2026 at 10:26 AM with Registered Nurse (RN 2), the Quesadilla recipe dated 2002 was reviewed. RN 2 stated that the menu for quesadillas indicated, under method 2: Place tortillas on the hot griddle and quickly place two oz of cheese on each tortilla. RN 2 stated that 2 oz corresponded to the blue scoop as indicated on the facility's Portion Control Chart (a visual reference tool that illustrates appropriate food serving sizes). During a concurrent interview and record review on 5/15/2026 at 10:27 AM with RN 2, the facility's Policy and Procedure (P&P) titled, Menus, revised 10/2022, was reviewed. RN 2 stated that the P&P indicated that menus will be served as written, unless a substitution is provided in response to preference, availability of an item, or special meal.

Based on observation, interview, and record review, the facility failed to ensure three (3) of 3 sampled residents (Residents 3, 23 and 71) reviewed for dignity were treated with respect and dignity in accordance with the facility's policy and procedure (P&P) when: Resident 3's indwelling catheter (a hollow tube inserted into the bladder [a hollow, balloon-shaped muscular organ located in your lower pelvis. Its primary job is to collect and store urine made by your kidneys until it is ready to be released from the body] to drain or collect urine) collection bag (ICCB) was not fully covered with a dignity bag. The dignity bag was covering the top half of the ICCB exposing the urine at the bottom of the ICCB. Resident 71's supra pubic catheter (a flexible tube surgically inserted through a small abdominal incision directly into the bladder to drain urine) bag (SPCB)was not fully covered with the dignity bag exposing the urine on top half of the supra pubic catheter bag.Resident 23 had yellow, dry, crusted substances on both eyes while sitting in his wheelchair in the hallway. These deficient practices have the potential to cause Residents 3, 23 and 71 to have diminished feelings of self-worth and self-esteem. Findings: 1. During a review of Resident 3's admission Record, it indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and unstageable (a full-thickness pressure injury [pressure ulcer- localized injuries to the skin and underlying tissue. They are primarily caused by prolonged, unrelieved pressure, friction, or shear on the skin, which restricts blood flow and damages tissues over time] where the base of the ulcer is obscured by dead skin or a dark, dry scab, making it impossible to determine the depth of the tissue damage) pressure ulcer of sacrum (lower end of the spinal area at the base of the spine). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 4/20/2026, the MDS indicated Resident 1 was assessed to have severely impaired cognitive (ability to think and process information) ability. The MDS indicated Resident 3 was dependent (helper does all the effort) for oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear, and rolling left and right. During an observation on 5/14/2026 at 2:48 PM, Resident 3's ICCB was not fully covered with a dignity bag. The dignity bag was covering the top half of the ICCB exposing the urine at the bottom of the ICCB. During a concurrent observation in Resident 3's room and interview on 5/14/2026 at 2:54 PM with Licensed Vocational Nurse (LVN) 2, Resident 3's ICCB was observed with a dignity bag covering the top half of the ICCB leaving the collected urine at the bottom of the ICCB exposed. LVN 2 stated the dignity bag is not covering the bottom half of the ICCB exposing the urine collected on the top half of the ICCB. LVN 2 stated Resident 3's urine is visible to everyone who passes by, and the purpose of the dignity bag is to maintain the dignity of the resident by covering the urine. LVN 2 stated the resident's dignity is compromised if the dignity bag is not fully covering the ICCB. During a concurrent interview and record review on 5/15/2026 at 10:49 AM with Registered Nurse (RN) 1, the facility's policy and procedure (P&P) titled, dignity, dated 2/2021 was reviewed. The P&P indicated: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered. RN 1 stated the policy indicated that a resident's dignity, feelings of self-worth and satisfaction must be maintained and promoted and that ICCB must remain covered with the dignity bag. RN 1 stated a resident is not being treated with dignity if their urine is not covered with the dignity bag because the resident's urine is exposed to everyone to see and it may lessen the resident's sense of worth. 2. During a review of Resident 71's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of urinary tract infection (UTI, an infection of the bladder and urinary system), paraplegia (partial or complete paralysis [loss of voluntary muscle function] of the lower half of the body with involvement of both legs) and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel). During a review of Resident 71's Care Plan Report initiated on 7/21/2025 and revised on 11/17/2026, the care plan indicated that Resident 71 requires suprapubic catheter due to neurogenic bladder for the diagnosis of paraplegia. The Care plan indicated under intervention to provide privacy bag (dignity bag). During a review of Resident 71 's History and Physical Examination (H&P), dated 11/14/2025, the H&P indicated that, under general appearance, Resident 71's abdomen had a suprapubic catheter. During a review of Resident 71'S MDS dated [DATE], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. The MDs also indicated Resident 71 was dependent on toilet hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having bowel movement). During a review of Resident 71's Medication Review Report dated 4/30/2026, it indicated, Suprapubic Catheter French 16 (size) with 10 cubic centimeters (the volume of sterile water, expressed in cubic centimeters [cc] used to inflate the retention balloon of a indwelling catheter to hold it in place inside the bladder) for neurogenic bladder ( a disorder causing difficulty or full inability to pass urine without use of a catheter or other method) related to paraplegia. During a concurrent observation outside Resident 71's room and interview on 5/12/2026 at 12:47 PM with LVN 5, LVN 5 stated Resident 71's clear yellow urine in the SPCB was visibly seen from the hallway. LVN 5 also stated the SPCB was not fully covered with the dignity bag, the bottom part was exposed. During an interview on 5/14/2026 at 4:08 PM with the Infection Preventionist Nurse (IPN), the IPN stated all SPCB and ICCB were supposed to be fully covered with the dignity bag. The IPN explained residents might feel embarrassed, sad, or even angry because they were not treated with respect and dignity by not ensuring the SPCB or ICCB was not properly covered. 3. During a review of Resident 23 's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of type 2 diabetes mellitus, hypertension (high blood pressure), and adult failure to thrive (refers to a state where the resident experiences a substantial decline in overall health and functional abilities) . During a review of Resident 23's Care Plan Report initiated on 12/17/2025 and revised on 4/13/2026, the care plan indicated that Resident 23 requires assistance with the Activities of Daily Living (ADLs – activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) related to disease process, limited mobility , impaired balance. During a review of Resident 23 's MDS, dated [DATE], the MDS indicated the resident had severe impairment; cognitive skills for daily decision making were severely impaired. Resident 23 needed supervision and touching assistance (helper provides cues and/or touching assistance as residents complete the activity) for showering/bathing self (the ability to bathe oneself). During a concurrent observation and interview on 5/12/2026 at 12:18 PM in the hallway with the Certified Nursing Assistant (CNA 2), CNA 2 stated Resident 23 was sitting on his wheelchair in the hallway, and Resident 23's had yellow, dry, crusted substance under the resident's eyes. During a concurrent interview and record review on 5/15/2026 at 10:01 AM with the Registered Nurse (RN 2), the facility's Policy and Procedures (P&P) titled Care Plan Baseline, dated 8/25/2021, was reviewed. RN 2 stated the P&P indicated a baseline care plan for each resident, which includes instructions needed to provide effective and person-centered care that meets professional standards of quality care, which should be developed and implemented for each resident. During a concurrent interview and record review on 5/15/2026 at 10:05 AM with RN 2, the facility's Policy and Procedures (P&P) titled Dignity, revised 2/2021, was reviewed. RN 2 stated the P&P indicated residents need to be groomed as they wish to be groomed. RN 2 stated residents need to be checked for their hygiene even if they are independent; they are supposed to be presentable at all times. RN 2 stated, That is why we are here; they need to be taken care of. RN 2 stated that the P&P was not followed.

Based on observation, interview, and record review, the facility failed to revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one (1) of 23 sampled resident (Resident 40) when Resident was discharged from Hospice 2 (hospice, care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) on 6/27/2025. This deficient practice had the potential to prevent Resident 40 from receiving care that addressed the resident's specific needs, which could negatively affect the residents' overall wellbeing.Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE]. It also indicated Resident 40's diagnosis included dementia (a progressive state of decline in mental abilities), atrial fibrillation (often called AFib, is the most common type of irregular heartbeat), and atrioventricular block (AV block, a malfunction in the heart's electrical wiring)During a review of Resident 40's Care Plan (CP) focusing on hospice care due to medical condition and diagnosis of Afib, initiated on 3/13/2024, the CP indicated Resident 40 is under Hospice 2. During a review of Resident 40's Order Summary Report, dated 5/14/2026, the Order Summary Report indicated an order to admit Resident 40 to HSP (Hospice 1) on routine level of care, ordered on 8/19/2025. During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool), dated 2/16/2026, the MDS indicated Resident 40's cognitive skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 40 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing. The MDS indicated Resident 40 was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower, lower body dressing, putting on/off footwear and personal hygiene. The MDS indicated Resident 40 was in hospice care while a resident of the facility. During a concurrent record review and interview on 5/15/2026 at 9:41 AM with Registered Nurse 1 (RN 1), Resident 40's medical records dated from 6/27/2025 to 5/15/2026 were reviewed. RN 1 stated all licensed nurses can initiate and revise care plans. RN 1 stated Resident 40 was discharged from Hospice 2 on 6/27/2025 and Resident 40 was admitted to HSP on 8/19/2025. RN 1 verified Resident 40's care plan focusing on hospice care due to medical condition and diagnosis of Afib, initiated on 3/13/2024 indicated Resident 40 was under the care of Hospice 2 and it did not indicate a discontinue date nor the date Resident 40 was discharged from Hospice 2. RN 1 stated the care plan was not updated to reflect that Resident 40 was under the hospice care of HSP since 8/19/2025. RN 1 stated she does not know the HSP's frequency of visit to Resident 40, which is usually indicated in the hospice care plan. RN 1 stated Resident 40's care plan regarding Hospice 2 was not and should have been completed and discontinued when Resident 40 was discharged to Hospice 2 on 6/27/2025. During a concurrent record review and interview on 5/15/2026 at 2:23 PM with Registered Nurse 2 (RN 2), Resident 40's medical records dated from 6/27/2025 to 5/15/2026 were reviewed. RN 2 verified Resident 40 still has an active care plan initiated on 3/13/2024 regarding Hospice 2 and it was not revised to reflect that Resident 40 was no longer under the care of Hospice 2 since 6/27/2025. RN 2 also stated Resident 40 is under the care of HSP 1 on 8/19/2025. RN 2 stated the care plan regarding Hospice 2 should have been resolved or completed on 6/27/2025. RN 2 emphasized, updating or revising care plans is important to ensure staff members caring for Resident 40 have the necessary knowledge to provide appropriate and resident centered care to the residents. RN 2 added according to Resident 40's order history, Resident 40 was discharged from Hospice 2 on 6/27/2025 and that the resident is not under hospice care until 8/18/2025. RN 2 stated Reisdent 40's care plan should have been removed, discontinued, completed or resolved for staff to know that Resident 40 is not on hospice care. During a record review of Facility's Policy and Procedure (P&P) titled Care Plan Comprehensive, dated 8/25/2021, the P&P indicated assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change.

Based on observation, interview, and record review, the facility failed to provide grooming services, in accordance with the care plan and facility policy, for one (1) of three sampled residents (Resident 83) when Resident 83 was observed to have long, jagged fingernails and with a yellowish to light brown substance observed on the resident's right palm, left wrist, and fingernails.This deficient practice had the potential for Resident 83 to have injuries and harbor infection.Findings: During a review of Resident 83's admission Record, the admission Record indicated the resident was initially admitted to the facility on (10/14/2025) with diagnoses of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the body) and hemiparesis (weakness on one side of the body), muscle weakness and dementia (progressive brain disorder that slowly destroys memory and thinking skills). During a review of Resident 83's History and Physical Examination (H&P), dated 10/15/2025, the H&P indicated Resident 83 had poor vision. During a review of Resident 83 's Minimum Data Set (MDS-a resident assessment tool), dated 4/10/2026, the MDS indicated that the resident's cognitive skills (ability to think and understand) for daily decision making were moderately impaired. Resident 83 needed setup and clean-up assistance with personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, and washing/drying face and hands). During a review of Resident 83's Care Plan, initiated on 10/15/2025 and revised on 4/13/2026, the care plan indicated Resident 83 requires assistance with ADL care, including bathing, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The care plan intervention indicated Resident 83 requires setup assistance from one staff member for personal hygiene care. During a concurrent observation and interview on 5/12/2026 at 12:35 PM with Certified Nursing Assistant (CNA 2), Resident 83 was sitting in a wheelchair in the hallway with a dry whitish substance on the resident's left arm. CNA 2 stated Resident 83 had a cream to white colored puree food on the resident's left arm. During an observation on 5/13/2026 at 10:45 AM, Resident 83 was observed sitting in his wheelchair in the hallway. Resident 83 had a dry brownish to yellowish substance on the resident's right palm and left wrist. Resident 83's fingernails were long and jagged, with a yellowish to brownish-black substance under the resident's fingernails. During a concurrent observation and interview on 5/13/2026 at 10:49 AM with CNA 3, Resident 83 was sitting in a wheelchair in the hallway, and the resident had a dry brownish to yellowish substance on the resident's right palm and left wrist. CNA 3 stated that the brownish substance on the resident right palm left wrist and under his long-jagged nails is dry poop. During an interview on 5/14/2026 at 4:11 PM with the Infection Preventionist Nurse (IPN), the IPN stated, residents can put their dirty hands in their mouths and on their eyes, which can cause illness in both residents and staff. IPN stated this was an issue of infection control (a practice used to prevent the spread of germs and infections in healthcare settings, schools, and the community) and cross-contamination (unintentional transfer of harmful bacteria, viruses, or allergens from one surface, object, or food to another). During a concurrent interview and record review on 5/15/2026 at 10:08 AM with the Registered Nurse (RN 2), the facility's Policy and Procedures (P&P) titled Activities of Daily Living, Supporting, dated 3/2018, was reviewed. RN 2 stated, the P&P indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve the resident's ability to carry out ADLs. The P&P also indicated, appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, bathing, dressing, grooming, and oral care. RN 2 stated the P&P was not followed. RN 2 also stated Resident 83 should be clean at all times and properly groomed, especially since Resident 83 was blind and personal hygiene needs to be provided. During an interview on 5/15/2026 at 12:16PM with Resident 83, Resident 83 stated, he wants to be clean all the time and needs somebody to help him.

Based on observation, interview, and record review, the facility failed to provide a clean and homelike environment for one (1) of 23 sampled residents (Resident 102) by failing to ensure that the trashcan used for disposal of soiled (used) personal protective equipment (PPE-including protective clothing, helmets, gloves, face shields, goggles, face masks, respirators, or other equipment designed to protect the wearer from injury or the spread of infection or illness) in the resident's room(Room A) was not overflowing. This deficient practice created an unsanitary and unsafe environment and had the potential to place residents at risk of infection and injury.Findings: During a review of Resident 102's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage), end stage renal disease (advanced stage kidney failure) and muscle weakness. During a review of Resident 102's History and Physical Examination (H&P), dated 5/13/2026, the H&P indicated the resident does not have the capacity to make decisions. During a review of Resident 102's Order Summary Report for the month 5/2026, it indicated on 5/12/2026 an order to place the resident on infection precautions enhanced barrier (EBP, infection control measures used mainly in nursing homes and long term care facilities to help prevent the spread of certain germs, especially multi drug resistant organisms [MDRO, germs usually bacteria that are resistant to multiple antibiotics, making infection harder to treat]) every shift for a gastrostomy tube (G-tube-a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), and a right upper chest permacath (a soft tube placed into a large vein, usually in the chest, used for dialysis [a lifesaving treatment for residents with kidney failure or end-stage renal disease] or other long-term intravenous treatment [treatment means giving fluids, medicine, blood, or nutrients directly into a vein using a needle or catheter]). During an observation on 5/14/2026 at 10:33 AM, Room A's trashcan was overflowing with PPE. During an interview on 5/14/2026 at 4:13 PM with the IPN, IPN was shown a photo of Room A's trashcan taken on 514/2026 at 10:33 AM, IPN verified that the trashcan in Room A was overflowing with soiled PPE. IPN also stated that Room A was on EBP. During an interview on 5/15/2026 at 2:56 PM with the Registered Nurse (RN 1), RN 1 stated that all trashcans are supposed to be closed all the time to prevent contamination or spread of bacteria, especially the trashcans for soiled PPE. During a review of the facility's Policy and Procedures (P&P) titled Homelike Environment dated 2/2021 was reviewed. The P&P indicated the Residents are provided with safe, clean and comfortable and homelike environment.

Based on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Resident 4 and 55) were free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to ensure:Resident 4 had the correct indication for the use of buspirone (a prescription medication primarily used to treat generalized anxiety disorder [GAD, a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday issues]) as indicated on the facility's policy and procedures (P&P).Resident 55's Ativan (lorazepam, medication used to treat anxiety [persistent and excessive worry that interferes with daily activities) as needed (PRN) order had a documented rationale for extended use, beyond 14 days, in accordance with the facility's P&P.Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. It also indicated Resident 4's diagnoses included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and history of falling. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 3/19/2026, the MDS indicated Resident 4 had severely impaired (never/rarely made decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 4 had symptoms of little interest or pleasure in doing things, feeling down, depressed, hopeless, feeling tired or having little energy and poor appetite or overeating. The MDS also indicated Resident 4 was dependent (helper does all of the effort) with eating, oral and toileting hygiene, shower, upper and lower body dressing, putting on/off footwear and personal hygiene. It indicated Resident 4 was taking antianxiety (medications that can treat anxiety symptoms) and antidepressant medications (medications primarily used to treat major depressive disorder, anxiety disorders, and chronic pain). During a review of Resident 4's Order Summary Report, dated 5/13/2026, the Order Summary Report indicated buspirone hydrochloride five (5) milligram (mg, unit of measurement), give 1 tablet by mouth, every eight (8) hours for dementia with behavioral disturbance manifested by irritability and striking out to staff during activities of daily living care, ordered on 4/9/2026. During a concurrent record review and interview on 5/15/2026 at 12:36 PM with Registered Nurse 1 (RN 1), Resident 4's buspirone order dated 5/13/2026 was reviewed. RN 1 verified Resident 4 has an order for buspirone for dementia, ordered on 4/9/2026. RN 1 stated the diagnosis of dementia as an indication for the use of buspirone was incorrect because buspirone had previously been given (admission to the facility prior to 3/16/2026) for Resident 4's anxiety. RN 1 stated Resident 4 has another order of Aricept (medication used to treat symptoms of dementia). RN 1 stated it was important to indicate the right diagnosis or use of the medication to know that you are giving the right medication to the right purpose. During a concurrent record review and interview on 5/15/2026 at 2:41 PM with Registered Nurse 2 (RN 2), Resident 4's buspirone order dated 5/13/2026 was reviewed. RN 2 verified Resident 4 has an order for buspirone for dementia, ordered on 4/9/2026. RN 2 stated it was important to have an accurate diagnosis as an indication for use of any medication to ensure the resident receives the correct medication for the correct indication. RN 2 stated psychotropic medication orders should have a resident's diagnosis and the behavior that resident is manifesting, to ensure the medication is necessary for the resident. During a review of Facility's undated P&P titled, Medication Utilization and Prescribing-Clinical Protocol,, the P&P indicated when a medication is prescribed for any reason, the physician and staff will identify the indications, considering the resident's age, medical and psychiatric (mental) conditions, risks, health status and existing medication regimen. 2. During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 55's diagnoses included anxiety disorder (a natural human emotion characterized by feelings of worry, nervousness, or unease), claustrophobia (an intense, irrational fear of confined or enclosed spaces) and major depressive disorder. During a review of Resident 55's MDS, dated [DATE], the MDS indicated Resident 55 had modified independence (some difficulty in new situations only) cognitive skills for daily decision making. The MDS indicated Resident 55 has symptoms of feeling down, depressed and hopeless. The MDS indicated Resident 55 required supervision (helper provides verbal cues and/or touching assistance) with eating, oral and personal hygiene. The MDS indicated Resident 55 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing. The MDS indicated Resident 55 was dependent on toileting hygiene, shower, lower body dressing and putting on/off footwear. The MDS indicated Resident 55 was taking antianxiety medication. During a review of Resident 55's Medication Administration Record (MAR) for May 2026, the MAR indicated lorazepam oral tablet 1 mg, give 1 tablet by mouth, every 8 hours as needed for anxiety for 30 days manifested by crying and screaming, with start date of 4/10/2026. During a concurrent record review and interview on 5/15/2026 at 12:21 PM with RN 1, Resident 55's medical records were reviewed. RN 1 verified Resident 55 has an order of lorazepam as needed for anxiety ordered on 4/10/2026, for 30 days. RN 1 stated as needed lorazepam order can be ordered for 30 days if there is documentation from Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) as to why lorazepam needs to be extended for more than 14 days. RN 1 stated there was no Psychiatrist documentation prior to Resident 55's lorazepam as needed order for 30 days on 4/10/2026. RN 1 stated Resident 55's lorazepam as needed order should have been limited to 14 days and 30 days. RN 1 added that a reevaluation to include a rationale will be needed to continue for Resident 55 to receive lorazepam beyond 14 days as indicated on the facility policy. During an interview on 5/15/2026 at 2:37 PM with RN 2, RN 2 stated PRN lorazepam order should be limited to 14 days to minimize the unnecessary use of psychotropic medication. RN 2 stated when it comes to psychotropic orders, licensed nurses need to inform the resident's physician or Psychiatrist of the resident's status and behavior. RN 2 added when Psychiatrist decides for PRN psychotropic medication to extend to 30 days, resident evaluation and rationale documentation should be done prior to placing the order. RN 2 stated Resident 2 was not and should have been evaluated prior to PRN lorazepam order on 4/10/2026 for 30 days. RN 2 stated Psychiatrist reevaluation for the use of PRN lorazepam every 14 days was important to check the effectiveness of the medication, and documentation for the need for order adjustment. RN 2 stated there was no documented reason in Resident 55's medical records why Resident 55 can be on as needed lorazepam order for 30 days instead of 14 days. During a review of Facility's undated P&P titled, Medication Utilization and Prescribing-Clinical Protocol,, the P&P indicated as part of the overall review, the physician and staff will evaluate the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN basis. The P&P also indicated the physician will provide and/or document a rationale when the indication, dose, or frequency of a prescribed medication is greater than commonly practice.

Based on interview and record review, the facility failed to ensure accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) to only reflect the resident's active diagnosis for one (1) of 23 sampled residents (Resident 32) in accordance with the facility policy.This deficient practice had the potential for the facility not to develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental psychosocial needs).Findings:During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), depressive disorder (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), and muscle weakness. During a review of Resident 32's Quarterly MDS, dated [DATE], the MDS indicated Resident 32 had moderately impaired (decisions poor, sues/supervision required) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 32 was independent (Resident completes the activity by themselves with no assistance from a helper) with eating. The MDS indicated Resident 32 required setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with oral and personal hygiene and required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and upper body dressing. The MDS also indicated Resident 32 required substantial/maximal assistance (helper does more than half the effort) with shower, lower body dressing and putting on/taking off footwear. In addition, the MDS indicated Resident 32 has a diagnosis psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a concurrent record review and interview on 5/15/2026 at 8:34 AM with Registered Nurse 1 (RN 1), Resident 32's medical records dated from 3/31/2026 to 5/15/2026 were reviewed. RN 1 stated Resident 32's MDS dated [DATE] indicated a diagnosis of psychosis. RN 1 verified Resident 1 has no diagnosis of psychosis, since it is not part of the medical diagnosis listed in the Resident 32s' admission record. RN 1 also stated there were no other documentation that indicated Resident 32 has psychosis. RN 1 stated Resident 32's recent psychiatric consult notes dated 5/6/2026 did not indicate diagnosis of psychosis. RN 1 stated she does not know why Resident 32's MDS dated [DATE] has a diagnosis of psychosis. During a concurrent record review and interview on 5/15/2026 at 1:55 PM with MDS Assistant (MDSA), Resident 32's medical records dated from 3/31/2026 to 5/15/2026 were reviewed. MDSA verified MDS dated [DATE] has a diagnosis of psychosis. MDSA stated psychosis diagnosis should not have been coded in the MDS since Resident 32 has no active diagnosis of psychosis. MDSA verified Resident 32 is not receiving any medication for psychosis. MDSA stated Resident 32 has no care plan regarding psychosis. MDSA stated that accurate MDS is important for the facility to develop a resident centered care plan. During a review of the facility's Policy and Procedure (P&P) titled, MDS Completion and Submission Timeframes, revised on July 2017, the P&P indicated the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. During a review of the facility's P&P titled, Certifying Accuracy of the Resident Assessment, revised on November 2019, the P&P indicated any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The P&P also indicated the information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) for one (1) of three (3) sampled residents (Resident 3) reviewed for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was at the correct settings in accordance with the facility's policy and procedure (P&P) and the resident's care plan (CP). Resident 3 weighed 152 pounds (lbs, unit of measurement for weight) but the LALM was set to 180 lbs. This deficient practice has placed Resident 3 at risk for deterioration of the resident's current pressure ulcer.Findings: During a review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) and unstageable (a full-thickness pressure injury where the base of the ulcer is obscured by dead skin or a dark, dry scab, making it impossible to determine the depth of the tissue damage) pressure ulcer of sacrum (lower end of the spinal area at the base of the spine). During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 4/20/2026, the MDS indicated Resident 1 was assessed to have severely impaired cognitive (ability to think and process information) ability. The MDS indicated Resident 3 was dependent (helper does all the effort) for oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear, and rolling left and right. The MDS indicated Resident 3 was at risk of developing new pressure ulcers and has two (2) unstageable pressure ulcers. The MDS indicated Resident 3's pressure ulcer treatments included a pressure- reducing device for bed. During a review of Resident 3's Order Summary Report dated 4/17/2026, the order summary report indicated that Resident 3 may use a LALM for wound management. During an observation on 5/12/2026 at 9:27 AM, Resident 3's LALM was set to 180 lbs. During a concurrent observation and interview on 5/12/2026 at 9:31 AM with Licensed Vocational Nurse (LVN) 1, Resident 3's LALM was observed to be set at 180 lbs. LVN 1 stated that Resident 3's LALM was set at 180 lbs. During a concurrent interview and record review on 5/12/2026 at 9:35 AM with LVN 1, Resident 3's weight record dated 5/6/2026 and Resident 3's Medication Review Report (MRR) dated 4/30/2026 was reviewed. Resident 3's weight record indicated Resident 3 weighed 152 on 5/6/2026. Resident 3's MRR indicated Resident 3's LALM's setting were to be accurate based on manufacturer's guidelines. LVN 1 stated that Resident 3 weighs 152 lbs. so the LALM should be set at 150 to 160 lbs. LVN 1 stated the LALM has to be at the correct weight setting in order to properly prevent skin breakdown. LVN 1 stated the LALM will put too much pressure on a wound if it is set above the resident's weight and the resident's wound may get worse. During a concurrent interview and record review on 5/15/2026 at 10:42 AM with Registered Nurse Supervisor (RN) 1, the facility's LALM manufacture's guidelines manual (Brand 1 Manual) was reviewed. The Brand 1 Manual indicated:Brand 1 LALM is indicated for the prevention and treatment of any and all pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program.Determine the patient's weight and set the control knob to that weight setting on the control unit.RN 1 stated the Brand 1 Manual indicated the LALM must be set according to the resident's weight. RN 1 stated the LALM is used to prevent pressure ulcers from getting worse and to prevent any new pressure ulcers. RN 1 stated if a LALM is set at a weight that is higher than the resident's weight, it applies more pressure on a wound and might cause the wound to get worse and might create new pressure ulcers. During a concurrent interview and record review on 5/15/2026 at 10:49 AM with RN 1, the facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 5/26/2021 was reviewed. The P&P indicated:1. The purpose of this procedure is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds.2. The procedure is to develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated by determining the need for support surface for bed. RN 1 stated that the policy indicated pressure ulcers will be managed properly, and healing of pressure ulcers will be promoted. RN 1 stated that if a LALM is not set at the resident's weight, it will add more pressure to a resident's wound and not promote healing. During a concurrent interview and record review on 5/15/2026 at 11:12 AM with RN 1, Resident 3's Care Plan (CP) for LALM for wound management dated 4/30/2026 was reviewed. Resident 3's CP indicated in the interventions that Resident 3's LALM settings are to be monitored for accuracy based on manufacturer's guidelines every shift. RN 1 stated the CP is not followed if the weight settings are not set to the resident's weight on the LALM.

Based on observation, interview, and record review, the facility failed to ensure a safe environment by not properly disposing of a used insulin syringe (specialized, single-use medical device used to inject insulin directly into the fatty tissue just beneath the skin) when one used insulin syringe was observed protruding halfway out of one of four sharps container (a specialized, puncture-resistant, and leak-proof bin used to safely dispose of medical instruments that can cut or puncture the skin).This deficient practice resulted in accident hazard and exposed staff and residents to the risk of needle stick injuries and potential bloodborne pathogen transmission (infectious microorganisms present in human blood that can cause disease in humans). Findings: During a concurrent observation and interview on 5/13/2026 at 11:57 AM with the Licensed Vocational Nurse (LVN) 5 in the hallway, LVN 5 stated that the Station 1 medication cart had been observed with an insulin syringe not fully placed in the sharp container, with half of it poking out of the sharps' container. LVN 5 also stated that visitors, residents, and staff were passing in the hallway and can get the needle and use it for other purposes. During an interview on 5/15/2026 at 10:22 AM with the Registered Nurse (RN) 2, RN 2 stated the insulin syringe should have been disposed of properly to prevent accidents and ensure the safety of residents, staff, and visitors. RN also stated confused residents might pick up the syringe and play with it. During a concurrent interview and record review of the facility's Policy and Procedures (P&P) on 5/15/2026 at 10:25 AM with RN 2, the P&P titled Sharp Disposal, revised date 1/2012, was reviewed. RN 2 stated according to the P&P, it indicated the facility shall discard contaminated sharps into designated containers. The P&P also indicated that contaminated sharps must be discarded into containers that are closable, puncture-resistant, and leakproof on the sides and bottom. RN 2 also stated that the facility did not follow its P&P because the needle was not correctly disposed in the sharp's container.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for one (1) of 1 sampled resident (Resident 6) reviewed for oxygen, by failing to ensure Resident 6 who was on oxygen therapy had her head of bed (HOB) elevated in accordance with the physician's order. This deficient practice had the potential to result in respiratory distress and had the potential to negatively impact Resident 6's health and well-being. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified dementia (memory loss and impaired daily functioning), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and personal history of pneumonia (history of lung infection). During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 4/1/2026, the MDS indicated Resident 6 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 6 was dependent (helper does all of the effort) with eating, toileting/personal hygiene, upper body dressing, rolling left and right, and sit to lying. The MDS also indicated Resident 6 was on oxygen therapy. During a review of Resident 6's Order Summary Report, dated 5/14/2026, the Order Summary Report indicated a physician order, with a start date of 10/1/2025, for oxygen at three (3) liters per minute (LPM) via nasal cannula (n/c- device used to deliver supplemental oxygen placed directly on a resident's nostrils) as needed for shortness of breath. The Order Summary Report also indicated an order, with a start date of 1/18/2026, to keep head of bed elevated to facilitate lung expansion every shift. During a review of Resident 6's Care Plan, dated 1/16/2026, the Care Plan indicated Resident 6 was on oxygen therapy as needed for history of pneumonia, history of acute and chronic respiratory failure with hypoxia (a condition where there is a dangerously low oxygen in the blood with normal or low carbon dioxide levels). The Care Plan interventions included to keep head of bed elevated to facilitate lung expansion every shift and to promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated) head of bed at 45 degrees. During an observation on 5/12/2026, at 1:24 PM, in Resident 6's room, Resident 6 was awake in bed, receiving 3 LPM of oxygen via nasal cannula. Resident 6's HOB was not elevated, and Resident 6 was flat on her back. During a concurrent observation and interview with Licensed Vocational Nurse 3 (LVN 3) on 5/13/2026, at 10:09 AM, in Resident 6's room, Resident 6 was observed sleeping in bed, receiving 3 LPM of oxygen via nasal cannula. Resident 6 was lying on her back with the HOB in flat position. LVN 3 stated Resident 6's HOB was flat and not elevated to 45 degrees. During a follow-up interview on 5/13/2026, at 12:15 PM with LVN 3, LVN 3 stated Resident 6 was on oxygen therapy and should have her HOB elevated at least 45 degrees to help expand her lungs and help her breath better. LVN 3 stated if Resident 6 does not get enough oxygen, Resident 6 can have trouble breathing and experience shortness of breath. LVN 3 stated it was the responsibility of all Licensed Nurses and Certified Nursing Assistants to ensure Resident 6's HOB was elevated while on oxygen therapy. During an interview on 5/13/2026, at 4:09 PM with the Director of Nursing (DON), the DON stated it was standard practice for facility staff to elevate the HOB to promote lung expansion while receiving oxygen. The DON stated Resident 6's care plan to elevate the HOB was not followed. The DON stated not elevating the HOB can result in Resident 6 not receiving enough oxygen which could lead to complication and hospitalization. During a review of the facility's Policy and Procedure (P&P), titled, Oxygen Administration, dated 1/31/2023, the P&P indicated that the facility will review the physician's orders of facility protocol for oxygen administration and review the resident's care plan to assess for any special needs of the resident.

Based on interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 5) reviewed for dialysis (a lifesaving treatment for residents with a kidney failure), who was receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment was provided dialysis care according to the resident's care plan by failing to ensure post dialysis weight was obtained on 4/23/2026. This deficient practice had the potential for complications such as blood pressure drop for unnoticed excessive fluid removed during dialysis and/or fluid overload (occurs when the body retains too much water) if fluid is not properly removed.Findings: During a review of Resident 5's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnosis of end stage renal disease (ESRD, irreversible kidney failure), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and bradycardia (abnormally slow heart rate, typically defined as resting below 60 beats per minute). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 3/24/2026, indicated Resident 5's cognitive (ability to think and reason) skills for daily decision making was modified independence (some difficult in new situations only). The MDS indicated Resident 5 required setup or clean up assistance (helper sets up or cleans up, resident completes activity) with eating. The MDS indicated Resident 5 required supervision (helper provides verbal cues) with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 5 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS also indicated Resident 5 is on hemodialysis while a resident in the facility. During a review of Resident 5's Care Plan focused on the resident's renal function, risk for complications related to hemodialysis, and renal insufficiency, initiated on 12/22/2025, the Care Plan indicated staff intervention included were to request pre and post weights from dialysis center, send communication book to dialysis and review book upon return. During a review of Resident 5's Order Summary Report dated 5/15/2026, the Order Summary Report indicated hemodialysis, every Tuesday, Thursday, and Saturday, ordered on 1/20/2026. During a concurrent record review and interview on 5/15/2026 at 8:20 AM, with Registered Nurse 1 (RN 1), Resident 5's Hemodialysis Communication Record, dated 4/23/2026, was reviewed. RN 1 stated the Hemodialysis Communication Record dated 4/23/2026 did not reflect Resident 5's post dialysis weight. RN 1 stated the resident's weight should have been completed in the dialysis center. RN 1 added that the Hemodialysis Communication Record on 4/23/2026 was also missing the facility's licensed nurse's signature from the licensed nurse who received Resident 5 from dialysis center. RN 1 stated the licensed nurse who received Resident 5 from dialysis center on 4/23/2026 should have called the dialysis center on 4/23/2026 to request the post dialysis weight. RN 1 stated, it was important to properly assess the residents and complete the Hemodialysis Communication Record to ensure that residents will receive proper care. During a concurrent record review and interview on 5/15/2026 at 2:19 PM with Registered Nurse 2 (RN 2), Resident 5's Hemodialysis Communication Record, dated 4/23/2026, was reviewed. RN 2 stated the Hemodialysis Communication Record for Resident 5 should have been entirely completed by the charge nurse to include the resident's weight and licensed nurse's signature, upon the resident's return from dialysis on 4/23/2206 to know the status of the resident. RN 2 stated obtaining weight after dialysis was important to know how much fluid was removed during dialysis and to avoid complications such as hypotension if too much fluid was removed. During a review of facility's Policy and Procedure (P&P) titled, Dialysis Care, dated 8/25/2021, the P&P indicated the nursing staff, dialysis provider staff, and the attending physician will collaborate on a regular basis concerning the resident's care as follows:Nursing staff will communicate information in writing to the Dialysis staff.The Dialysis Provider will communicate in writing to the Facility ay problems encountered whole the resident was at the dialysis provider and any ongoing monitoring required.Nursing Staff may use Hemodialysis Communication Record.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one (1) of six (6) sampled residents (Resident 38) when Licensed Vocational Nurse 2 (LVN 2) failed to administer Resident 38's potassium tablet (medication to treat or prevent hypokalemia [low blood potassium levels]) with food or full glass of water on 5/14/2026 as indicated on the facility policy and physician's order. This deficient practice had the potential to result in damaging the esophagus (muscular tube that connects the throat to the stomach) and irritating the stomach lining which may cause nausea, cramps, vomiting, or diarrhea (condition of having loose, watery stool at least three or more times in a single day, or more frequently) to Resident 38.Findings: During a review of Resident 38's admission Record, the admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnosis of muscle weakness, heart failure (a condition where your heart muscle cannot pump enough blood and oxygen to meet the body's need) and acute kidney failure (a sudden and rapid decline in the kidneys' ability to filter waste). During a review of Resident 38's Minimum Data Set (MDS- a resident assessment tool), dated 5/5/2026, the MDS indicated Resident 50 had modified independence (some difficulty in new situations only) with cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 38 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, and personal hygiene. The MDS indicated Resident 38 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene. The MDS indicated Resident 38 required substantial/maximal assistance (helper does more than half the effort) with upper body dressing. The MDS indicated Resident 38 was dependent on toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. During a review of Resident 38's Order Summary Report, dated 5/13/2026, the Order Summary Report indicated a physician's order, dated 4/24/2026 for potassium oral tablet 10 milliequivalent (mEq, unit of measurement) by mouth, one time a day for supplement. It also indicated to administer with meals/food or full glass of water. During a medication administration observation in Resident 38's room on 5/14/2025 at 8:27 AM, LVN 2 administered Potassium 10 mEq oral tablet to Resident 38 without food or a full glass of water. During an interview on 5/14/2026 at 2:15 PM with LVN 2, LVN 2 stated that he did not administer Resident 38's potassium medication with food and he did not offer Resident 38 a full glass of water to drink with the potassium. LVN 2 stated it was important to administer medication as ordered to get the full benefit of the medication and to prevent stomach upset. During an interview on 5/15/2026 at 10:04 AM with Registered Nurse 1 (RN 1), RN 1 stated medications that were ordered to be given with food should be followed because these medications might cause stomach upset or medication might not be effective. RN 1 stated Resident 38's potassium medication order should have been given with breakfast meal at 8 AM. During a review of Facility's Policy and Procedure (P&P) titled, Administering Medications, revised on April 2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. The P&P indicated medications are administered in accordance with prescribe orders, including any required time frame. The P&P also indicated, medication administration times are determined by resident need and benefit, not staff convenience.

Based on observation, interview, and record review, the facility failed to ensure the call light device (a device used by a resident to signal his or her need for assistance) for one (1) of four (4) sampled residents (Resident 8) reviewed for environment was within reach in accordance with the facility's policy and care plan. This deficient practice had the potential to result in delayed provision of care and services for Resident 8.Findings: During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] with diagnoses that included hypotension (low blood pressure), dementia (progressive brain disorder that slowly destroys memory and thinking skills), muscle weakness. During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 3/5/2026, the MDS indicated Resident 8's cognitive skills (processes of thinking and reasoning) for daily decision making was moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 8 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral, toileting and personal hygiene. The MDS also indicated Resident 8 required partial/moderate assistance (helper does less than half the effort) with shower, upper and lower body dressing, and putting on/taking off footwear. During a review of Resident 8's Care Plan, initiated on 5/15/2025, revised on 3/13/2026, indicated Resident 8 is at nutritional risk related to muscle weakness, dementia, dysphagia (difficulty swallowing) and cognitive communication deficit (occurs when a person has difficulty with verbal or nonverbal communication). Resident 8's Care Plan indicated to place call light within reach at all times. During a concurrent observation in Resident 8's room and interview with Resident 8 on 5/12/2026, at 10:09 AM, Resident 8's call light string was observed away from the resident, call light was observed behind Resident 8's bed, and not within Resident 8's reach. Resident 8 stated he could not reach his call light. Resident 8 added that his call light is usually on the left side of the bed where he can easily reach when he needed help. During an interview on 5/14/2026 at 4:06 PM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 8 is able to use the call light, which is why it is important to ensure the call light is always within the resident's reach. During an interview on 5/14/2026 at 4:11 PM with the Director of Staff Development (DSD), the DSD stated the call light needs to be within the resident's reach at all times so the resident can call for assistance. The DSD added that if the call light is not within reach, the resident cannot call or ask staff for help. During a review of facility's Policy and Procedures titled Accommodation of Needs, revised on November 2025, the P&P indicated the resident has the right to reside and receive services in the facility with reasonable accommodation of their needs and preferences. The P&P also indicated staff are trained and expected to assist the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with resident's wishes. For example, arranging the call light and personal items so they are in easy reach of the resident.

Based on interview and record review, the facility failed to maintain an accurate and complete record for two (2) of 23 sampled residents (Residents 32 and 72) as indicated in the facility's policy and procedure when: Resident 32's memantine (Namenda, medication used to treat moderate to severe dementia [progressive state of decline in mental abilities] was incorrectly ordered for supplement instead of for dementia.Resident 72's 24-hour intake and output (I&O- the measurement of all fluids that enter and leave the body) was not tallied as ordered by the physician. This deficient practice had the potential to result in miscommunication, improper delivery of care, and inaccurate information of the care provided to Residents 32 and 72.Findings: 1. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 32's diagnoses included dementia, depressive disorder (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), and muscle weakness. During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 32 had moderately impaired (decisions poor, sues/supervision required) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 32 was independent (Resident completes the activity by themselves with no assistance from a helper) with eating. The MDS indicated Resident 32 required setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with oral and personal hygiene. The MDS indicated Resident 32 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene and upper body dressing. The MDS indicated Resident 32 required substantial/maximal assistance (helper does more than half the effort) with shower, lower body dressing and putting on/taking off footwear. The MDS also indicated Resident 32 has a diagnosis of dementia. During a review of Resident 32's Order Listing Report, dated 5/13/2026, timed 2:55 PM, the Order Listing Report indicated memantine hydrochloride extended release (ER) oral capsule 28 milligrams (mg, unit of measurement), give one (1) capsule by mouth one time a day for supplement, ordered on 5/6/2026. During a concurrent record review and interview on 5/13/2026 at 3 PM with Registered Nurse 2 (RN 2), Resident 32's Order Listing Report, dated 5/13/2026, was reviewed. RN 2 stated that Resident 32's current memantine order was not and should have been ordered for dementia. RN 2 stated Resident 32's memantine order for supplement was incorrect because memantine is a medication indicated for dementia. RN 2 stated that the licensed nurse who obtained the memantine hydrochloride ER order on 5/6/2026 documented supplement,' instead of dementia, which Resident 32's previous memantine order had been indicated for. RN 2 stated that this was a human error resulting in the incorrect documentation of the medication's indication. During a concurrent record review and interview on 5/14/2026 at 2:48 PM withident 32's Order Listing Report, dated 5/13/2026, was reviewed. RN 1 stated memantine is never a supplement. RN 1 stated the order was documented incorrectly when the licensed nurse obtained the order on 5/6/2026. RN 1 stated maintaining accurate medical records, including medication orders, is important to avoid confusion. RN 1 further stated that incorrect documentation can lead to wrong treatment, which might cause harm to any resident During a follow up interview on 5/15/2026 at 2:16 PM with RN 2, RN 2 stated accurate documentation of orders is important for the licensed nurse to be aware of the purpose of the medication. RN 2 stated that inaccurate documentation might lead to confusion in the delivery of care. During a review of Facility's Policy and Procedure (P&P) titled, Physician Orders, dated 3/22/2022, the P&P indicated the medical records department will verify that physician orders are compete, accurate and clarified as necessary. 2. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included acute kidney failure with tubular necrosis (renal failure- a kidney condition involving damage to the tubule cells of the kidneys which can lead to acute kidney failure), heart failure (when the heart muscle is weakened or stiff and cannot pump blood around the body as well as it should), and dependence on renal dialysis (HD-when a person relies on a medical machine or process to artificially clean their blood). During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72 was assessed having intact cognitive skills for daily decision making. The MDS indicated Resident 72 required setup or clean-up assistance with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 72 was dependent (helper does all of the effort, resident does none of the effort) with toileting hygiene, shower/bathe self, lower body dressing, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The MDS also indicated Resident 72 was on dialysis. During a review of Resident 72's Order Summary Report, dated 5/14/2026, the Order Summary Report indicated a physician order, with a start date of 4/13/2026 for: Fluid restriction: 1200 milliliters (ml- unit of measurement) per 24 hours Nursing: 600 ml (7AM to 3 PM =300 ml, 3 PM to 11 PM= 200 ml, 11PM to 7AM =100 ml) Dietary: 600 ml (breakfast= 360 ml, lunch= 120 ml, dinner 120 ml Every night shift monitoring I&O tally total intake and output for 24 hours During a review of Resident 72's Care Plan, dated, 1/19/2026, the Care Plan indicated Resident 72 exhibited or was at risk for fluid volume excess as evidenced by renal failure, end stage renal disease (ESRD- the final most severe stage of kidney failure where the kidney can no longer filter waste and excess fluid from the body) on HD. The Care Plan intervention indicated to monitor and tally total intake and output for 24 hours every night shift. During an interview on 5/15/2026, at 8:57 AM, with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 72 was on dialysis and was on fluid restriction. LVN 4 stated Resident 72's fluid intake was monitored every shift, and the night shift staff added the total fluid intake for the day and documented it in Resident 72's medical record. During a concurrent interview and record review on 5/15/2026, at 9:18 AM, with the Director of Nursing (DON), Resident 72's Medication Administration Record (MAR), from 5/1/2026 to 5/31/2026 was reviewed. The DON stated the MAR indicated Resident 72's total fluid intake on 5/3/2026, 5/4/2026, 5/9/2026, and 5/10/2026 were zero (0). The DON stated Resident 72's total fluid intake for 24 hours was not tallied and documented correctly because Resident 72's total fluid intake on 5/3/2026 = 580 ml, 5/4/2026 = 380 ml, 5/9/2026 = 580 ml, and 5/10/2026 = 620 ml. The DON stated Resident 72's physician order to tally Resident 72's total fluid intake was not followed. The DON stated it was important to follow and implement Resident 72's fluid restriction order to know how much fluid Resident 72 had in a 24 hour period and to prevent complications such as fluid volume deficit (when the body loses too much water and electrolytes which could lead to organ failure) to fluid overload (too much fluid in the body which could lead to shortness of breath or heart failure) which could result in hospitalization. During a review of the facility's P&P, titled, Charting and Documentation, revised on 7/2017, the P&P indicated: Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure that Resident 102's gastrostomy tube (G-tube a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) tip was not placed inside Resident 102's bedside drawer wrapped in tissue paper. This deficient practice had the potential to result in contamination of Resident 102's G-tube and increase the risk for infection.Findings: During a review of Resident 102's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach used for feeding or drainage), end stage renal disease (advanced stage kidney failure) and muscle weakness. During a review of Resident 102's History and Physical Examination (H&P), dated 5/13/2026, the H&P indicated that the resident does not have the capacity to make decisions. During a concurrent observation and interview on 5/12/2026 at 12:23 PM with the Licensed Vocational Nurse (LVN 5) in Room A, Resident 102's room, LVN 5 stated that Resident 102's G-tube tip was inside the bedside drawer and was wrapped with tissue paper. During a concurrent interview and record review on 5/13/2026 at 2:20 PM with the Director of Nursing (DON), Resident 102's Order Summary Report was reviewed. The DON stated that the order summary indicated an order dated 5/13/2026 for enteral feeding: Nephro 1.8 calories (high calorie nutrition formula) at 40 milliliters (mL - unit of fluid volume) via G-tube. During an interview on 5/13/2026 at 2:25 PM with the Director of Nursing (DON), the DON stated that as soon as the G-tube is disconnected from the resident, the tip must be recapped and stored properly for infection control (a practice used to prevent the spread of germs and infections in healthcare settings, schools, and the community). The DON stated that it was not specified in the facility's policy and procedure (P&P) for G-tubes, but it was the facility's practice to cap the G-tube tip for infection control. During an interview on 5/14/2026 at 3:59 PM with the Infection Prevention Nurse (IPN), the IPN stated that when the G-tube is not connected to the resident, it must be recapped. The IPN also stated that it should not be wrapped with tissue paper or placed inside the cabinet, as this can possibly cause sickness. During a record review of the G-Tube Protocol lesson plan dated 5/13/2016, the protocol indicated under general guidelines that when feeding equipment is not actively in use, it must be recapped and stored correctly. During a review of the facility's Policy and Procedure (P&P) titled Infection Prevention and Control Program, effective date 9/18/2024, the P&P indicated the infection prevention and control program was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (illnesses that can spread from one person, animal, or object to another through germs such as bacteria, viruses, fungi, or parasites) and infection.

Based on interview and record review the facility failed to provide supervision, safety measures and monitoring when one (1) of two sampled residents (Resident 1) eloped (exited the facility without the knowledge of facility staff) from the facility on 3/16/2026 around 8 PM and was not returned until 3/16/2026 around 8:45 PM by the police. This failure had the potential to lead to endangerment, accident and injury while outside the facility's premises without supervision from staff.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diverticulitis of the intestine (inflammation or infection of small, bulging pouches that form in the lining of the lower intestines), other abnormalities of gait (manner of walking) and mobility, and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a Resident assessment tool), dated 3/5/2026, the MDS indicated Resident 1 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, upper/lower body dressing, sit to lying, sit to stand, toilet transfer and walking 50 feet (ft.- unit of measurement for distance) with two turns. During a review of Resident 1's Progress Note, dated 3/16/2026, at 10:46 PM, the Progress Note indicated at approximately 8 PM, Resident 1 was not in her room nor around the station as observed by the Certified Nursing Assistant (CNA). A Code Pink (an emergency code for elopement) was called. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included essential hypertension (high blood pressure), muscle weakness, and lack of coordination (unsteady movements). During a review of Resident 3's History and Physical Examination (H&P), dated 2/10/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions. During an interview on 4/1/2026, at 11:16 AM, with Resident 3, Resident 3 stated Resident 1 left with her sister in the morning of 3/16/2026 for an appointment and had a taste of the outside. Resident 3 stated Resident 1 always said she wanted to go home. On the evening of 3/16/2026, after Resident 1's sister left, Resident 1 paced back and forth in the room and went to the bathroom that was shared with the next room and exited to the hallway through the other room. During an interview on 4/1/2026, at 1 PM with CNA 1, CNA 1 stated she was assigned to Resident 1 on 3/16/2026. CNA 1 stated she last saw Resident 1 in her room at around 6:10 PM before she went on her break. CNA 1 stated at approximately 8 PM, Resident 1's roommate asked for assistance to go to the bathroom and she observed Resident 1 not on her bed when she turned on the bathroom light. CNA 1 informed Licensed Vocational Nurse 1 and a Code Pink was called. During an interview on 4/1/2026, at 1:24 PM, with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had unsteady gait and was forgetful. RN 1 stated Resident 1 was noticed missing by CNA 1 after CNA 1 returned from her break. RN 1 stated Resident 1 could only have exited from the door in front of Nurse's Station 1. During an interview on 4/1/2026, at 1:40 PM with the Director of Nursing (DON), DON stated the main door was locked at 6 PM and does not open from the outside. The DON stated the main door could still be pushed open from the inside even if it was locked. The DON stated Resident 1 most likely exited the facility through the main door because it was closer to her room. The DON stated the main door was not supervised after 6 PM. The DON stated it was not safe for the main door to not be supervised. During a review of the facility's policy and procedure (P&P), titled, Safety of Residents, dated 6/27/2022, the P&P indicated the facility will provide a safe environment for residents and Facility Staff.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 6) received treatment and care in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) by failing to complete medication reconciliation (the process of verifying and updating a patient's medication list during the transition from hospital to home or another care setting) of Resident 6's Discharge Medication List from General Acute Care Hospital (GACH 2) to administer the resident's Terazosin (a medication used in men to treat symptoms of benign prostatic hyperplasia [BPH-also known as an enlarged prostate], which include difficulty urinating, painful urination, and urinary frequency and urgency) once a day to start on 1/28/2025 at 9 PM. This failure could lead to worsening of the Resident 6's BPH and hospitalization.Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 1/28/2025, with diagnoses including but not limited to urinary retention (the inability to completely or partially empty the bladder) and BPH. During a review of Resident 6's Minimum Data Set (MDS-a resident assessment tool), dated 1/31/2025, it indicated Resident 6 had intact cognitive skills (ability to think, understand and reason) for daily decision making. The MDS also indicated Resident 6 required set up or clean up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral and personal hygiene. The MDS indicated Resident 6 also required substantial or maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathing self and upper body dressing and dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene, lower body dressing, and putting on/taking off footwear. During a concurrent interview and record review on 7/17/2025 at 5:14 PM with the Director of Nursing (DON), the External Facility Discharge Medication List from General Acute Care Hospital (GACH 2) dated 1/26/2025, Resident 6's Medication Administration Record (MAR) from the facility dated January 2025, and Resident 6's Order Summary Report from the facility dated1/28/2025 to 4/30/2025 were reviewed. The External Facility Discharge Medication List from GACH 2 dated 1/26/2025 indicated terazosin 5 mg (milligram-a unit of mass or weight equal to one thousandth of a gram) orally once a day, next dose on 1/28/2025 at 9 PM. Resident 6's MAR and Order Summary Report for January 2025 to April 2025, did not indicate there was an order for terazosin nor it was given to Resident 6 from 1/28/2025 to 4/24/2025 The DON stated the terazosin order that was in Resident 6's External Facility Discharge Medication List from GACH 2 was not reconciled in the physician's order when the resident was admitted at the facility on 1/28/2025. The DON stated that since it was not reconciled, it would not be in the order summary and MAR and Resident 6 did not receive the terazosin during the resident's stay in the facility from 1/28/2025 to 4/24/2025. During an interview on 7/17/20265 at 5:25 PM with the DON, the DON stated, Resident 6's missing medication that was not reconciled from the discharge medication list was not acceptable as it will affect the residents' health and safety and residents are put at risk for experiencing complications for not having received the medications. Resident 6's BPH symptoms could end up getting worse and affect Resident 6's overall health. The DON stated RN 1 could not explain why the terazosin order was not reconciled in Resident 6's Order Summary. The DON stated there were 87 doses of Terazosin that was not given to Resident 6, from 1/28/2025 to 4/24/2025 because the resident's discharge medication list for GACH 2 was not reconciled correctly. During a concurrent interview and record review on 7/18/2025 at 10 AM with Resident 6's attending physician (MD), the External Facility Discharge Medication List from GACH 2 was reviewed. The discharge medication list from GACH 2 reflected order for terazosin to give once a day. The MD validated that terazosin was not reconciled and was not given to Resident 6 during the resident's stay in the facility from 1/28/2025 to 4/24/2025. The MD stated the terazosin was for Resident 6's BPH and resident did not receive this medication. During a review of the facility's Policy and Procedure (P&P), titled Reconciliation of Medication on Admission, revised 1/5/2025, the P&P indicated the purpose of the P&P is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The P&P also indicated, medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. In addition, the P&P indicated, medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. The P&P indicated steps includes: Verify and clarify medication list with the physician Transcribe verified orders to point click care (PCC-a cloud-based healthcare technology platform that focuses on connecting care providers, services, and financial operations within the senior care and long-term care sectors) under physician orders

Based on interview and record review, the facility failed to prevent accidents to one of four (Resident 1) sampled residents who was identified at risk for falls and had a history of falls in accordance with the facility's policy and procedure (P&P) titled, Fall Management by failing to:1. Ensure adequate supervision of Resident 1 was provided to prevent accidents and injury on 7/16/2025.2. Create a comprehensive resident - centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for Resident 1's long term care plan with focus on Resident 1's risk for fall/injury which includes intervention to supervise the resident every hour from 4/1/2025 to 7/16/2025. This deficient practice resulted in Resident 1 found on the floor near the Nurse's Station and the resident lying on her right side next to her on 7/16/2025 at 4:45 AM. Resident 1 was noted to have a small skin tear on the right temple (the area on the side of the head, just above the cheekbone and below the hairline) with minimal bleeding.Findings: During a review of Resident 1's admission Record, the admission Record, the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified dementia (a brain disorder that results in memory loss, poor judgment, and confusion), muscle weakness, and history of falling. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 1 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, oral/personal hygiene, and upper/lower body dressing. Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfer. During a review of Resident 1's Nursing Documentation Evaluation, dated 3/23/2025, the Nursing Documentation Evaluation form indicated Resident 1's Fall Risk factor included disorientation, confusion, and visual impairment. Resident 1's Nursing Documentation Evaluation form indicated fall risk indicators were identified for Resident 1. During a review of Resident 1's Interdisciplinary Care Conference (IDT- a meeting where healthcare professionals from different disciplines collaborate to develop or review a resident's care plan), dated 7/16/2025, the IDT indicated, on 7/16/2025 at 4:45 AM, Resident is observed on right side lying position next to her wheelchair. A small skin tear is noted to the right temple with minimal bleeding observed. During an interview, on 7/18/2025, at 11:27 AM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was at risk for falls because the resident always tried to jump and move out of bed. CNA 1 stated CNA 1 did not know if Resident 1 had a history of falls in the facility. During an interview, on 7/18/2025, at 12:04 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was assigned to Resident 1 the morning of 7/16/2025 when Resident 1 had a fall. LVN 1 stated Resident 1 was a fall risk and had a history of falls. LVN 1 stated, at around 4 AM, on 7/16/2025, Resident 1 woke up and was restless and anxious in bed. LVN 1 stated CNA 2 placed Resident 1 on the resident wheelchair and wheeled Resident 1 to the Nurse's Station. LVN 1 stated, at around 4:45 AM, LVN 1 was notified by Housekeeping 1 (HSK 1) that HSK 1 found Resident 1 on the floor in the Nurse's Station. LVN 1 stated Resident 1 was found lying on her right side in the Nurse's Station. LVN 1 stated Resident 1 had discoloration and skin tear on the resident's right temporal area. During an interview, on 7/18/2025, at 12:24 PM, with HSK 1, HSK 1 stated, on 7/16/2025 at around 4:30 AM, HSK 1 passed by the Nurse's Station to get the broom and saw Resident 1 sitting on her wheelchair with CNA 2 and when she returned back to the Nurse's Station, she observed Resident 1 leaning towards the right side of the resident wheelchair and did not see CNA 2 or other facility staff at the Nurse's Station. HSK 1 stated HSK 1 informed LVN 1 to check on Resident 1 because the resident could fall and when HSK1 returned to the Nurse's Station, HSK1 found Resident 1 on the floor. HSK 1 stated Resident 1 was alone in the Nurse's Station when HSK1 found Resident 1 on the floor. During a concurrent interview and record review, on 7/18/2025, at 1:01 PM, with the Director of Nursing (DON), Resident 1's long term care plan with focus on Resident 1's risk for falls with risk factors including the resident's physical behavior observed by staff of scooting (sliding in a sitting position) from her low bed onto the fall mat, revised on 3/23/2025, was reviewed. The DON stated Resident 1's care plan intervention for resident safety check every hour for proper positioning, and to address and anticipate resident's needs was cancelled on 3/23/2025. During the same concurrent interview and record review, on 7/18/2025, at 1:01 PM, with the DON, Resident 1's long term care plan with focus on Resident 1's risk for fall/injury dated 4/1/2025 was reviewed. The DON stated Resident 1 has fallen in the facility at least three times from 7/30/2024 to 1/28/2025 and that is the reason why Resident 1 cannot be left unsupervised especially when the resident is in the wheelchair. The DON stated Resident 1 had a behavior of scooting and swinging her legs. The DON stated, at approximately 4:30 AM, on 7/16/2025, HKS 1 walked by the Nurse's Station and observed Resident 1 leaning towards the right side while sitting in the wheelchair at the Nurse's Station. The DON stated CNA 2 should not have left Resident 1 unsupervised on 7/16/2025. The DON stated Resident 1 sustained a skin tear on the resident's right temple. The DON stated facility staff should monitor Resident 1's safety every hour due to the resident's history of falls. The DON stated Resident 1's long term care plan with a focus on Resident 1's risk for fall/injury, dated 4/1/2025, did not include monitoring Resident 1's safety every hour and it should be included. The DON also stated, monitoring of Resident 1's safety every hour was included in Resident 1's previous care plan for at risk for fall that was cancelled on 3/23/2025 and it should have been carried over/ added in Resident 1's care plan for risk for fall/injury. The DON stated there was no intervention in Resident 1's fall care plan for her scooting behavior. The DON stated Resident 1's care plan for risk for fall/injury was not and should have been resident-centered given Resident 1's history of falls and scooting behavior. During an interview, on 7/18/2025, at 2:36 PM, with Physical Therapist 1 (PT 1), PT 1 stated Resident 1 was not cognitively intact and had a history of restlessness. PT 1 stated Resident 1 was dependent with chair repositioning PT 1 stated supervision by facility staff was necessary for Resident 1 while she was on her wheelchair. During a review of the facility's P&P titled, Fall Management, dated 5/26/2021, the P&P indicated the purpose of the policy is to reduce risk for falls and minimize the actual occurrence of falls. The P&P indicated, under the procedure, the following:1. Identify patient's fall risk by reviewing the Nursing Documentation.2. Develop individualized plan of care.3. Review and revise care plan as indicated.4. If patient falls: update care plan to reflect new interventions. During a review of the facility's P&P, titled, Care Plan Comprehensive, dated 8/25/2021, the P&P indicated the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. Each resident's comprehensive care plan is designed to:o Build on the Resident's individualized needs, strengths, preferenceso Identify the professional services that are responsible for each element of careo Reflect currently recognized professional standards of practice for problem areas and conditions Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The Interdisciplinary Team is responsible for evaluation and updating care plans when there has been a significant change in the residents' condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish). Resident 2, who had behavioral issues, hit Resident 1 on the face and head on [DATE] in Resident 1 and 2's room. The facility did not identify, assess, and implement interventions to address Resident 2's behavior, mood, and cognitive (the ability to clearly think, learn, and remember) status prior to Resident 2 hitting Resident 1 on the face. In addition, the facility failed to protect Resident 1 when Resident 3 reported to Licensed Vocational Nurse 2 (LVN 2) about Resident 2's behavioral issues and requested for Resident 2 to be transferred to another room on several occasions prior to [DATE]. Residents 1, 2, and 3 remained in the same room up to [DATE]. These deficient practices resulted in Resident 1 to experience physical abuse. Resident 1 was found unconscious on [DATE] at 7 AM, 6.5 hours after the resident was hit on the face and head by Resident 2. Resident 1 was then transferred to the General Acute Care Hospital (GACH) via 911 (a number to contact emergency services) was called. According to GACH records, Resident 1 had a large right subdural hematoma (collection of blood outside the brain) measuring up to 3.7 centimeters (cm, unit of measurement) and was comatose (state of deep unconsciousness for a prolonged period) upon arrival to the GACH. Resident 1 died on [DATE] in the GACH with diagnoses that included large subdural hemorrhage (a pool of blood between the brain and its outermost covering), neurogenic shock (a life-threatening medical condition in which there is insufficient blood flow throughout the body), and brain death (permanent, irreversible, and complete loss of brain function). This deficient practice also placed Resident 3 and other resident in the facility at risk of being physically abused by Resident 2. On [DATE] at 8:03 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Assistant Administrator (AADM), Director of Nursing (DON), Director of Staff Development (DSD), and Medical Records Director (MRD) regarding the facility's failure to: 1. Protect Resident 1's rights to be free from physical abuse when Resident 2, who had behavioral issues, hit Resident 1 on the face and head during a resident-to-resident altercation (confrontation or aggression that may result in injury) that happened on [DATE] in Resident 1 and 2's room. 2. Prevent Resident 2 from physically abusing Resident 1, who was assessed as needing extensive assistance in bed mobility and unable to walk, when the facility did not identify, assess, and implement interventions to address Resident 2's behavior, mood, and cognitive status that could place other residents at risk for abuse. 3. Identify and implement intervention when Resident 3 reported to LVN 2 about Resident 2's behavioral issues and request for Resident 2 to be transferred to another room, prior to [DATE]. In addition, Resident 1, 2, and 3 remained in the same room up to [DATE] that led to Resident 1 and 2's altercation on [DATE]. On [DATE] at 7:24 om, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the AADM, and DON. The acceptable IJ Removal Plan included the following: a. Resident 1 was discharged to acute hospital via 911 on [DATE] for further evaluation. b. The DON/Quality Assurance (QA) Educator initiated the following: - In-service and skills competency validation initiated on [DATE] by DON or designee to Licensed Nurses regarding timely neurological assessment (to check the mental status, reflexes [automatic action the body does in response to anything that can trigger a physical or behavioral change], and movement to evaluate the brain and nervous system [transmits signals between the brain and the rest of the body]) to include checking of patterns of speech, speech clarity, gag reflex (occurs in the back of the mouth and triggered when the body wants to protect itself from swallowing something), facial drooping (loss of motor control on one side of the face resulting in muscle weakness on one side of the mouth with inability to smile symmetrically [exact match]), and eye opening, verbal, and motor responses using Glasgow Coma scale (GCS, used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma residents). On [DATE], QA Educator initiated the skills competency validation of Licensed Nurses regarding timely neurological assessment and completion of Neurological evaluation flow sheet. - In-service on timely physician (MD) notification and documentation of reasons for refusals of neurological assessment and /or abnormal findings. c. The DON reviewed residents with change of condition (COC) necessitating neurological assessment such as unwitnessed fall and resident to resident altercation in the last 30 days. The DON and MRD identified seven (7) residents that were on neurological assessment status post fall incident with incomplete documentation/assessment. Identified Licensed Nurses who did not complete the neurologic assessment were given one to one (1:1) in-service regarding the importance of neurological assessment. The Licensed Nurses completed the COC documentation, updated the care plans, and placed residents on every shift monitoring for 72 hours. These residents have the potential to be affected by the deficient practice. There were no resident-to-resident altercations that have occurred in the last 30 days. d. The Interdisciplinary Team (IDT, means a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) will review any COC during the Clinical Meeting (team members review and discuss information and make recommendations that are relevant to the patient's needs) from Monday to Friday. e. Any COC requiring neurological assessment will be evaluated by the DON or designee for timeliness and compliance with facility's policy pertaining to neurological assessment. f. The MRD will complete a neurological assessment audit, COC audits for documentation of MD notification and reasons for resident refusals and report findings to DON /designee for immediate corrective action. daily, from Monday to Friday. g. Neurological assessment skills competency will be provided by the DON/designee during Licensed Nurses' orientation and will be validated annually and as needed. h. On [DATE], Neurological Evaluation Flowsheet was revised based on Neurological Assessment Policy provided during survey. The DON/QA Educator will initiate education, training, and skills competency on the revised Neurological Flow Sheet to Licensed Nurses starting on [DATE]. The DON/designee will complete the education, training, and skills validation of Licensed Nurses till 100 percent (%) completion is achieved. The DON/designee will evaluate the effectiveness of skills validation weekly through return demonstration for four (4) weeks. Newly hired Licensed Nurses will receive the same education, training, and skills validation and these will be included in the Licensed Nurses' annual skills competency. i. This process will be monitored by completing the following tasks: -The QA committee will continue to review the alleged deficient practice monthly or as often as deemed necessary based on observed trends and patterns of Neurological Evaluation Flowsheet completion, COC audits and compliance. - The QA committee will make recommendations to extend if deemed necessary based on patterns. j. Resident 1 was discharged to acute hospital on [DATE] via 911 for further evaluation. k. Resident 2 was discharged to acute hospital on [DATE] for further psychiatric (branch of medicine concerned with the study, diagnosis, and treatment of mental illness) evaluation. l. Resident 3 was interviewed by AADM and MRD on [DATE]. AADM and MRD conducted a Person Centered Interview and Rounding Worksheet. Resident 3 did not express any concerns at this time. m. Staff were in-serviced by DSD, QA Educator and /or DON on [DATE] and [DATE] regarding the following: m.1. Abuse reporting and investigation with an emphasis on roommate compatibility and a thorough investigation of alleged abuse. QA Educator will conduct a follow up education and training skills competency validation pertaining to Abuse reporting and investigation to staff. m.2. Roommate compatibility and timely response to residents' concerns and/or request for room change. m.3. Any change in residents' behavior will be addressed immediately by licensed nurse by initiating a change of condition, escalation of care plan interventions, involvement of psychiatrist, psychologist (person who specializes in the study of the mind and behavior), attending physician, appropriate room placement and medication regimen review. Any allegation of abuse will be investigated immediately and reported within two hours to California Department of Public Health (CDPH), Ombudsman (official who is usually appointed by the government to investigate complaints and attempt to resolve them) and law enforcement. n. Employees that are currently on vacation (17 employees identified) or on leave, will be educated by the DSD and/or Designee regarding the above topics prior to the start of their next shift. o. MD was notified by AADM on [DATE] regarding facility receiving an IJ. Medical Director stated to keep him informed regarding the facility's plan of correction. p. An emergency QAA Committee meeting was conducted on [DATE] with Medical Director, AADM, DON, Activities Director, Medical Records Director, RN Supervisor and Clinical Support. q. Person Centered Interview and Rounding Worksheets were conducted on [DATE] and [DATE] by Department Managers (Activity Director, Admission Director, Marketing, Dietary Manager, Business office assistant, Central Supply, Social Service Assistant) with 69 interviewable residents as identified based on Resident Responses Analyzer generated from the facility's computer system regarding roommate compatibility to ensure in house residents were compatible with one another in their current rooms. No concerns were identified during the Person-Centered Interview and Rounding Worksheets. Department Managers will continue to conduct Person Centered Interview and Rounding Worksheet daily from Monday through Friday to identify and address any issues related to roommate compatibility. On weekends, Activity Assistant, Manager of the Day, and Licensed Nurses will conduct Person Centered Interview and Rounding Worksheet. Licensed Nurses will observe and document residents' condition with recent room change every shift for 72 hours and will initiate a COC. Licensed Nurse will include COC on the progress note if indicated. If not indicated, Licensed Nurse will complete a Room Transfer/New Roommate Change form. r. An audit on the most recent room transfer/room change in the last seven (7) days was completed on [DATE] and there were no issues/concerns reported. s. On [DATE], all interviewable residents were queried (asked) by Social Services Assistant, Central Supply, and Dietary Supervisor regarding any recently witnessed or experienced altercations with other residents and no residents expressed any concerns at this time. t. On [DATE], IDT identified and reviewed residents with psychiatric diagnosis, including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Alzheimer's disease (type of dementia) and residents who were on monitoring for behavioral manifestations that may potentially affect others to ensure that appropriate care plan was implemented. IDT identified 10 residents that exhibited verbal and physical behaviors that may potentially affect others. IDT care conference was initiated on [DATE] to address behavioral problems and collaborate with psychiatrist, psychologist, and attending physician for further evaluation and treatment. Psychiatrist scheduled to conduct evaluation on [DATE] on the 10 residents identified. u. All allegations of abuse will be thoroughly investigated by the facility Abuse Coordinator. Room compatibility and any request for room change will be discussed by the IDT members Monday through Friday during stand-up meeting. Licensed Nurses will monitor, and document appropriateness of room change every shift for the next 72 hours. The DON/designee initiated an in-service to Licensed Nurses on [DATE] regarding the use of Person centered interview and Rounding Worksheet. The DON/designee will continue to in-service until completed. v. The AADM initiated an in-service on [DATE] regarding the use of Person Centered Interview and Rounding Worksheet to the department managers. w. Potential new admissions will be reviewed by the DON/Designee and will collaborate with IDT prior to admission for appropriate room placement and roommate compatibility. Department Managers will meet with assigned residents daily from Monday to Friday. Assigned Licensed Nurses, Manager of the day, and Activity assistant will conduct Person Centered Interview and Rounding Worksheet on weekends. Any signs of incompatibility will be addressed immediately for corrective action. x. This process will be monitored by completing the following tasks: The QA committee will continue to review the alleged deficient practice monthly and/or as deemed necessary for further recommendations and corrective actions until no issues are identified. The QA committee will make recommendations to extend if deemed necessary based on findings, patterns and trends reported. Findings: On [DATE], an unannounced abbreviated survey was conducted at the facility to conduct an investigation of a facility reported incident about resident- to- resident abuse. A review of Resident 1's Admission Record indicated an initial admission to the facility on [DATE] and readmission on [DATE]. Resident 1's diagnoses included end stage renal disease (a medical condition in which a resident's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life), dependence on renal dialysis, generalized muscle weakness and abnormalities of gait and mobility. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated [DATE], indicated Resident 1 was independent with cognitive (the ability to clearly think, learn, and remember) skills for daily decision making. Resident 1 was totally dependent (full staff performance) with one person for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 2's Admission Record indicated an initial admission to the facility on [DATE] and readmission on [DATE]. Resident 2's diagnoses included dementia, without behavioral disturbance, psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), mood disturbance (feelings of distress or sadness) and anxiety (feeling of fear, dread, and uneasiness). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was severely impaired with cognitive skills for daily decision making. Resident 2 was totally dependent with one- person assist for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 3's Admission Record indicated admission to the facility on [DATE]. Resident 3's diagnoses included right above knee amputation and muscle weakness. A review of Resident 3's MDS's dated [DATE], indicated Resident 3 had an intact cognitive skill for daily decision making. Resident 3 required limited assistance (staff provide guided maneuvering) with one-person assist for bed mobility, transfer, dressing, and toilet use and personal hygiene. A review of Resident 1's Nurses' Note, dated [DATE] at 1:30 AM, indicated Resident 1 was in bed when Resident 2 came up to him and tried to take his jacket. Resident 1 refused so Resident 2 hit him on the left side of his face. Licensed Vocational Nurse 1 (LVN 1) indicated neurological check (assess an individual's neurological functions, motor and sensory response, and level of consciousness) was started. A review of Resident 2's Nurses' Note, dated [DATE] entered at 4:06 AM, Resident 2 went up to Resident 1, and tried to take his jacket but Resident 1 resisted so Resident 2 hit him on the left side of his face. A review of Resident 1's Nurses' Note, dated [DATE], entered at 7 AM, Registered Nurse 1 (RN 1) indicated that Resident 1 was found unresponsive, respiration even and unlabored. Resident 1's oxygen saturation (amount of oxygen that's circulating in the blood) at 87% (normal level is between 95% and 100%), on room air. 911 was called and was transferred to GACH. During a concurrent interview with RN 2 and review of Resident 1's medical records on [DATE] at 5:20 PM, RN 2 verified that there was no behavior monitoring and interventions done to address Resident 2's behavior prior to the altercation between Resident 1 and 2 on [DATE]. RN 2 stated Resident 2 should have been moved out of the room and be placed in a single room after the altercation, to protect Resident 1 and prevent another resident- to- resident altercation. During an interview on [DATE], at 11:07 AM, the DSD stated, Resident 2 was very confused and would sometimes enter other residents' rooms and needs to be redirected back to his room. During an interview on [DATE], at 3:25 PM, LVN 1 stated on [DATE] at 1:30 AM one of the CNAs (unable to recall who) told him Resident 1 told CNA about the hitting. LVN 1 stated, she went into Resident 1's room and Resident 1 told her Resident 2 hit him on the head and face with Resident 2's right hand. During an interview on [DATE], at 3:29 PM, Resident 4 (witness of Resident 2's aggressive behavior) stated on [DATE] (five days prior to the altercation between Resident 1 and 2) Resident 2 had previously pushed Resident 3 with clenched hands. Resident 4 stated Resident 3 grabbed his grabber reacher (a tool that works as an extension of the arm) to block Resident 2. Resident 4 stated, he and Resident 3 were aware Resident 2 was unstable and could snap any time. Resident 4 stated Resident 3 notified the facility staff that Resident 2 was unstable, but facility staff did not listen and did not do anything. During an interview on [DATE], at 4:28 PM, Certified Nurse Assistant 1 (CNA 1) stated Resident 1 had redness on the left side of his face by the temple (located on the side of the head behind the eye between the forehead and the ear) area. CNA 1 stated on [DATE], approximately at 5:30 AM, CNA1 noticed something was off with Resident 1 and that Resident 1 was in a deep sleep. CNA1 stated she patted Resident 1 on his chest but was not arousable, so she called LVN1 who assessed Resident 1. CNA1 stated Resident 1 continued to have redness on the left side of his face. CNA1 stated LVN1 was aware of Resident 1's facial redness. During an interview on [DATE], at 6:08 PM, LVN3 stated Resident 2 was confused and required supervision. LVN3 stated Resident 2 would enter other residents' rooms and needed to be redirected back to his room. LVN3 stated on [DATE], two days prior to the altercation between Residents 1 and 2, Resident 2 entered an unnamed resident's room trying to take the residents wheelchair. LVN3 stated Resident 3 would complain about Resident 2 going through Resident 3's belongings. LVN3 stated she had informed the DON on more than one (1) occasion about Resident 2's behavior of wandering into another resident's room and going through other resident's belongings but the DON did not want to move Resident 2. A record review Resident 1's untitled GACH records, dated [DATE], indicated Resident 1 had a large right subdural hematoma measuring up to 3.7 cm and was comatose upon arrival to the GACH. A record review of Resident 1's untitled GACH records, dated [DATE], indicated Resident 1 died on [DATE] with diagnoses that included large subdural hemorrhage, neurogenic shock, and brain death. A review of the facility's policies and procedures titled, Abuse Prohibition and Procedure, dated [DATE], indicated if the suspected abuse is resident to resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. The policy also indicated the facility is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation.

Based on interview and record review, the facility failed to provide treatment and services for one of two sampled Residents (Resident 1), after being hit on the face and head, in accordance with current professional standard of practice by failing to: 1. Conduct a neurological assessment (to check the mental status, reflexes [automatic action the body does in response to anything that can trigger a physical or behavioral change], and movement to evaluate the brain and nervous system [transmits signals between the brain and the rest of the body]) to include checking of patterns of speech, speech clarity, gag reflex (occurs in the back of the mouth and triggered when the body wants to protect itself from swallowing something), facial drooping (loss of motor control on one side of the face resulting in muscle weakness on one side of the mouth with inability to smile symmetrically [exact match]), and eye opening, verbal, and motor responses using Glasgow Coma scale (GCS, used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma residents) on [DATE] in accordance with the facility's policy on Neurological Assessment. 2. Identify changes in Resident 1's neurological status. 3. Document Resident 1's reason/s for refusing Neurological assessment on [DATE] at 4:30 AM and 5AM and interventions taken by facility staff after refusal. These deficient practices resulted in Resident 1 being found unconscious on [DATE] at 7 AM, 6.5 hours after the resident was hit on the face and head by Resident 2, with an oxygen saturation (level of oxygen in the blood) of 87% (normal level ,d+[DATE]%). Resident 1 was then transferred to the General Acute Care Hospital (GACH) via 911 (a number to contact emergency services) was called. According to GACH records, Resident 1's pupils were fixed and pinpoint upon arrival to the GACH. Resident 1 had a large right subdural hematoma (collection of blood outside the brain) measuring up to 3.7 centimeters (cm, unit of measurement), and was comatose (state of deep unconsciousness for a prolonged period). Resident 1 expired on [DATE] in the GACH with diagnoses that included large subdural hemorrhage (a pool of blood between the brain and its outermost covering.), neurogenic shock (a life-threatening medical condition in which there is insufficient blood flow throughout the body), and brain death (permanent, irreversible, and complete loss of brain function). On [DATE] at 8:06 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Assistant Administrator (AADM), Director of Nursing (DON), Director of Staff Development (DSD), and Medical Records Director (MRD) regarding the facility's failure to: 1. Conduct Neurological assessment to include checking of patterns of speech, speech clarity, gag reflex, facial drooping, and eye opening, verbal, and motor responses using Glasgow Coma scale on [DATE] initiated at 1:30 AM in accordance with the facility's policy on Neurological Assessment. 2. Conduct neurological assessment on [DATE] from 5:30 AM to 7AM to identify changes in Resident 1's neurological status. 3. Document Resident 1's reason/s for refusing Neurological assessment on [DATE] at 4:30 AM and 5AM and interventions taken after refusal. On [DATE] at 7:24 PM, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the AADM, and DON. The acceptable IJ Removal Plan included the following: a. Resident 1 was discharged to acute hospital via 911 on [DATE] for further evaluation. b. DON/Quality Assurance (QA) Educator initiated the following: - In-service and skills competency validation initiated on [DATE] by DON or designee to Licensed Nurses regarding timely neurological assessment, to include checking of patterns of speech, speech clarity, gag reflux, facial drooping, and eye opening, verbal, and motor responses using Glasgow Coma scale. On [DATE], QA Educator initiated the skills competency validation of Licensed Nurses regarding timely neurological assessment and completion of Neurological Evaluation Flowsheet. - In-service on timely physician (MD) notification and documentation of reasons for refusals of neurological assessment and /or abnormal findings. c. The DON reviewed residents with change of condition (COC) necessitating neurological assessment such as unwitnessed fall and resident to resident altercation (confrontation or aggression that may result in injury) in the last 30 days. The DON and MRD identified seven (7) residents that were on neurological assessment status post fall incident with incomplete documentation/assessment. Identified Licensed Nurses who did not complete the neurologic assessment were given one to one (1:1) in-service regarding the importance of neurological assessment. The Licensed Nurses completed the COC documentation, updated the care plans, and placed residents on every shift monitoring for 72 hours. These residents have the potential to be affected by the deficient practice. There were no resident-to-resident altercations that have occurred in the last 30 days. d. The Interdisciplinary Team (IDT, a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a resident) will review any COC during the Clinical Meeting (team members review and discuss information and make recommendations that are relevant to the resident's needs) from Monday to Friday. e. Any COC requiring neurological assessment will be evaluated by the DON or designee for timeliness and compliance with facility's policy pertaining to neurological assessment. f. The MRD will complete a neurological assessment audit, COC audits for documentation of MD notification and reasons for resident refusals and report findings to DON /designee for immediate corrective action. daily, from Monday to Friday. g. Neurological assessment skills competency will be provided by the DON/designee during Licensed Nurses' orientation and will be validated annually and as needed. h. On [DATE], the Neurological Evaluation Flowsheet was revised based on Neurological Assessment Policy provided during survey. The DON/QA Educator will initiate education, training, and skills competency on the revised Neurological Evaluation Flowsheet to Licensed Nurses starting on [DATE]. The DON/designee will complete the education, training and skills validation of Licensed Nurses till 100 percent (%) completion is achieved. The DON/designee will evaluate the effectiveness of skills validation weekly through return demonstration for four (4) weeks. Newly hired Licensed Nurses will receive the same education, training and skills validation and these will be included in the Licensed Nurses' annual skills competency. i. This process will be monitored by completing the following tasks: -The QA committee will continue to review the alleged deficient practice monthly or as often as deemed necessary based on observed trends and patterns of neurological flowsheet completion, COC audits and compliance. - The QA committee will make recommendations to extend if deemed necessary based on patterns. Findings: A review of Resident 1's Admission Record indicated an initial admission to the facility on [DATE] and readmission on [DATE]. Resident 1's diagnoses included end stage renal disease (a medical condition in which a resident's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life), dependence on renal dialysis, generalized muscle weakness and abnormalities of gait and mobility. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated [DATE], indicated Resident 1 was independent with cognitive (the ability to clearly think, learn, and remember) skills for daily decision making. Resident 1 was totally dependent (full staff performance) with one person for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 1's Nurse's Note, dated [DATE], timed at 1:30 AM, indicated Resident 2 hit Resident 1's left side of the face. A neurological assessment was initiated by LVN 1. A review of Resident 1's Neurological Evaluation Flowsheet indicated a neurological assessment was completed for Resident 1 on [DATE] at 1:30 AM, 1:45 AM, 2AM, 2:15 AM, 2:30 AM, 2:45 AM, 3AM, 3:15 AM, 3:30 AM, and 4AM. At 4:30 AM and 5AM, it was documented that Resident 1 refused the neurological assessment. The Neurological Evaluation Flowsheets did not include an assessment for patterns of speech, speech clarity, gag reflex, facial drooping, and GCS, as indicated on the facility policy. A review of Resident 1's Nurses' Note, dated [DATE], timed at 8:55 AM, indicated Registered Nurse 1 (RN 1) found Resident 1 unresponsive with oxygen saturation at 87% at 7AM. 911 was called and Resident 1 was transferred to GACH. During a concurrent interview with Licensed Vocational Nurse 5 (LVN 5) and record review of the Neurological Evaluation Flowsheet on [DATE] at 3:15 PM, LVN 5 verified that the Neurological Evaluation Flowsheet for Resident 1 indicated that there was no neurological assessment conducted on [DATE] from 5:30 AM to 6:30 AM. LVN 5 stated that it should have been done every 30 mins as indicated on the flowsheet. LVN 5 added it was important to follow the instructions on the frequency of assessment as indicated on the Neurological Evaluation Flowsheet form to ensure whether the resident needs emergency medical treatment after a head injury. During a concurrent interview with RN1 and record review of Resident 1's Neurological Evaluation Flowsheet on [DATE] at 4:10 PM, RN 1 validated that Resident 1 did not have a neurological assessment at 5:30 AM to 6:30 AM. The last vital signs obtained for Resident 1 were at 4AM. RN 1 stated it was important to check and follow time intervals indicated in the Neurological Evaluation Flowsheet to assess if there was a change in Resident 1's condition. RN1 stated a neurological assessment must be conducted to monitor any head injury, bleeding, or swelling to the brain or any change in a resident's level of consciousness. During a concurrent interview with RN 2 and record review of Resident 1's Order Summary Report on [DATE] at 5:20 PM, RN 2 verified that there was no order for a neurological assessment to be conducted for Resident 1. RN 2 stated a physician order should have been obtained based on the facility policy on Neurological Assessment. RN 2 also verified that Resident 1 refused the neurological assessment on [DATE] at 4:30 AM and 5AM as indicated on the flowsheet. RN 2 stated LVN 1 should have notified MD when Resident 1 refused the assessment. During an interview with the DSD on [DATE], at 10:58 AM, the DSD stated neurological assessment or neuro check was conducted to assess if residents were alert and oriented after a head injury. The DSD stated neuro check should include assessing resident's pattern of speech, speech clarity, gag reflex, facial drooping, and use of GCS, which are in accordance with the facility policy. The DSD stated when a resident refuses a neuro check, intervention included was to call for another nurse to conduct the assessment. The DSD stated the reason for resident's refusal and any additional interventions taken by the staff should be documented on the Resident's clinical record. During an interview on [DATE], at 11:23 AM, LVN 4 stated on [DATE] at 7AM, LVN 4 found Resident 1 unresponsive. LVN 4 stated Resident 1 did not regain consciousness and was transported via 911 to GACH. LVN 4 stated when a resident refuses neuro check, the LN should document the refusal and implement other interventions such as explaining to the resident why the assessment needs to be conducted and to have another nurse assist and perform the neuro check. During a concurrent interview with RN 2 and record review of Resident 1's Neurological Evaluation Flowsheet on [DATE], at 1:14 PM, RN2 stated, Resident 1 was on neurocheck due to an abuse allegation of being hit on the face by Resident 2. RN2 stated a neuro check was done using the Neurological Evaluation Flowsheet to assess level of consciousness and orientation of the resident. RN2 stated there was no indication on the flowsheet to assess facial drooping. RN2 stated the neurological assessment performed was only based on the specific information on the flowsheet. RN2 stated the Neurological Evaluation Flowsheet did not indicate other assessments such as gag reflex and utilization of the GCS, so they were not done. During a concurrent interview with RN 2 and record review of Resident 1's Nurses Progress Notes on [DATE], at 1:29 PM, RN2 stated there were no interventions done and documented to address Resident 1's refusal for neuro check. During a telephone interview on [DATE], at 3:25 PM, LVN 1 stated that she started Resident 1's neuro check after it was reported that Resident 1 was hit on the face. LVN 1 stated, she checked Resident 1's pupil reaction, hand grip, and if able to respond to questions. LVN 1 further stated, Resident 1 refused neuro check because he asked me to stop and was getting tired and sleepy. A review of the facility's policy titled, Neurological assessment, revised ,d+[DATE] indicated the purpose of this procedure was to provide guidelines for a neurological assessment: General Guidelines included: 1. Neurological assessments are indicated: a. Upon physician order. b. Following an unwitnessed fall. c. Following a fall or other accident/injury involving head trauma. d. or when indicated by resident's condition. 2. When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures [represents the force that the heart generates each time it contracts]). This may be indicative of increasing intracranial pressure (ICP, growing pressure inside the skull when there is brain injury). 3. Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately. Steps in the Procedure 1. Perform neurological checks with the frequency as ordered or per falls protocol. 2. Determine resident's orientation to time, place and person. 3. Observe resident's patterns of speech and speech clarity. 4. Take temperature, pulse, respirations, blood pressure. 5. Check pupil reaction: 6. Determine motor ability: 7. Have resident move all extremities. 8. Ask resident to squeeze your fingers. Note strength bilaterally. 9. Have resident plantar and dorsiflex. Note strength bilaterally. Ask resident if he/she has any numbness or tingling in legs/feet/toes and document accordingly. 10. Determine sensation in extremities. Rub resident's arms at the same time to see if resident has decreased sensation in either arm. Check sensation in lower extremities also and document accordingly. 11. Check gag reflex with tongue depressor, if safe for resident. 12. Have the resident smile to determine if there is any facial drooping and document accordingly. 13. Check eye opening, verbal, and motor responses using the Glasgow Coma Scale. Record observations. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting 1. Notify the physician of any change in a resident's neurological status. 2. Notify the supervisor if the resident refuses the procedure. 3. Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was free from significant medication error (one or more observed or identified preparation or administration of medications ordered by a physician causing the resident discomfort or jeopardizes his or her health and safety). On 2/26/23, the licensed nurse (RN1) did not properly check and identify the resident prior to administering medications. RN1 erroneously administered eight (8) medications to Resident 1 belonging to Resident 2. This deficient practice resulted in Resident 1 to experience adverse effects that included nausea, vomiting, dizziness, and malaise (feeling of being unwell and feeling tired). Resident 1 was transferred to the General Acute Care Hospital (GACH) due to the adverse reactions to the medications. Findings: A review of Resident 1 ' s admission record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke, damage to the brain due to interruption of blood supply) affecting the left side and type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated 1/5/23, indicated resident was assessed to have severe impairment with cognitive skills (ability to understand and make decisions). The MDS also indicated Resident 1 required limited assistance from one facility staff when eating and extensive assistance from one facility staff during dressing and personal hygiene. A review of Resident 1 ' s eINTERACT Change in Condition Evaluation form (COC form) dated 2/26/23 entered at 2:01 PM, indicated, Resident 1 had change of condition of vomiting, body weakness and severe frontal lobe (forehead, front part of the brain. It controls high level cognitive skills and primary motor function [activity or movement of the body]) headache. A review of Resident 1 ' s progress notes (general) dated 2/26/23 entered at 2:48 PM, indicated, Resident 1 was taken to the GACH via 911 at 2:27 PM due to nausea, vomiting and chills. A review of Residents 1 ' s care plan (documentation of information that easily described the services, care and support being given to the patient), dated 2/26/23 indicated Resident 1 had episodes of vomiting, body malaise, and severe headache secondary to medication error. A review of Resident 1 ' s untitled GACH record dated 2/26/23, indicated the resident was seen by the GACH doctor on 2/26/23 at 2:31 PM. The GACH record indicated, the resident was sent to their Emergency Department (ED) from the facility due to dizziness with onset of 30 minutes prior to arrival. The GACH record also indicated, Resident 1 received her regular dose of medication for hypertension (elevated blood pressure) earlier that day, but then was accidentally given another resident ' s medication for hypertension. A review of Resident 1 ' s progress notes (IDT, interdisciplinary team [team consist of doctors, licensed nurses, social services and/ or dietary supervisor) dated 2/28/23 entered at 8:36 PM, indicated, Resident 1 received medications that belonged to another resident. A review of Resident 2 ' s admission record indicated the resident was readmitted at the facility on 11/18/22, with diagnoses that included type 2 DM, hydronephrosis (excess water in the kidney due to back up of urine) with renal (kidney) and ureteral calculous obstruction (blockage in one or both tubes that carry urine from kidneys to the bladder). A review or Resident 2 ' s medication review report dated 3/2/203, indicated the following medication order: 1. metformin hydrochloride (Metformin HCL, medication for DM) tablet give 500 (mg, unit of measurement) by mouth two (2) times a day with meals 2. sacubitril - valsartan (Entresto, medication for hypertension for patients with kidney disease) 24- 26 mg give 1 tablet by mouth two times a day for hypertension 3. metoprolol tartrate (medication for high blood pressure) tablet give 2.5 mg by mouth two times a day 4. aspirin (reduce risk of serious problems like heart attacks and strokes) oral tablet give 325 milligrams (mg, unit of measurement) one time a day 5. ascorbic acid (vital to body ' s healing process) oral tablet give 500 mg two times a day 6. calcium with vitamin D (supplement for bone, nervous system, musculoskeletal, and immune system) oral tablet 500 mg, give 1 tablet by mouth one time a day 7. docusate sodium (Colace, treats occasional constipation) tablet, give 100 mg by mouth two times a day 8. multi-vitamin (dietary supplement containing all or most of the vitamins that may not be readily available in the diet) oral tablet give one tablet by mouth During an interview with Resident 1 on 3/1/23 at 12:54 PM, the resident stated on 2/26/23 between 11:00 AM to 11:30 AM (unable to recall specific time), Registered Nurse 1 (RN 1) was giving medications that she did not know what medications to the resident. The resident stated she told RN 1 more than once that she was already given medications in the morning. Resident 1 stated, RN 1 did not respond to the resident ' s comment and continued to administer the crushed medications in her mouth. Resident 1 stated, on the same date (2/26/23) after a few minutes after RN 1 gave her the unknown medications, Resident 1 began to feel dizzy, shaky, vomiting, headache, eyes felt heavy, and cold. Resident 1 also stated, Licensed Vocational Nurse 1 (LVN 1) told her on the same day she would be transferred to the GACH. During an interview with certified nurse assistant (CNA 1) on 3/1/23 at 1:20 PM, CNA 1 stated on 2/26/23 sometime prior to 12:30 PM Resident 1 informed CNA 1 that the resident was feeling dizzy, had a headache, and that the resident ' s head felt heavy. CNA 1 stated, Resident 1 would not stop vomiting. During an interview with the Director of Nursing (DON) on 3/1/23 at 2:05 PM, the DON stated RN 1 did not identify Resident 1 by checking the resident ' s photo from the electronic medication administration record (eMar) and did not check the resident ' s wrist band to verify name, date of birth, and room number prior to administering all eight (8) medications that belonged to Resident 2. The DON stated the medication error was discovered when LVN 1 witnessed RN 1 giving Resident 1 medications with a spoon on 2/26/23, between 11AM to 11:10AM. During the same interview with the DON on 3/1/23 at 2:10 PM, the DON also stated the medications given to Resident 1 in error on 2/26/23 that included sacubitril - valsartan which can cause some stomach upset and metformin could have led the resident to experience vomiting, body weakness and headache due to hypoglycemia (low blood sugar level) requiring the resident to be transferred to the GACH on the same day. During a concurrent review of Resident 2 ' s eMAR for the month for February 2023 and interview with the DON, the DON stated RN 1 admitted to her that RN 1 administered the 8 medications of Resident 2 to Resident 1 on 2/26/23 in error. The DON stated, according to Resident 2 ' s eMAR, the 8 medications were: 1. Metformin HCL tablet 500 mg by mouth 2. sacubitril - valsartan 24- 26 mg by mouth 3. metoprolol tartrate tablet give 2.5 mg by mouth 4. aspirin oral tablet give 325 milligrams mg by mouth 5. ascorbic acid oral tablet give 500 mg by mouth 6. calcium with vitamin D oral tablet 500 mg tablet by mouth 7. docusate sodium 100 mg tablet by mouth 8. multi-vitamin oral tablet give one tablet by mouth During an interview with Registered Nurse Supervisor (RNS) on 3/1/23 at 2:50 PM, RNS stated on 2/26/23 (unable to recall time) RN 1 approached him and asked who Resident 2 was. RNS informed RN 1, the resident was the lady on my left. RNS stated shortly after, LVN 1 approached him questioning as to why RN1 gave medications to Resident 1. RNS stated he attempted to talk to RN 1 to verify medications given to the resident, but RN 1 walked away from him. RNS stated shortly after RN 1 allegedly administered Resident 1 medications, the resident started having adverse reactions (undesired effect of the drug). During a telephone interview with RN 1 on 3/1/23 at 3:12 PM, RN 1 stated, on 2/26/23 during the morning shift (unable to recall specific time) RN 1 stated, she asked RNS Who Resident 2 was and RN 2 replied, it was the resident on my left. RN 1 stated she thought RNS gestured pointing to Resident 1. RN 1 then stated she prepared 8 medications (metformin, sacubitril - valsartan, metoprolol, aspirin, ascorbic acid, calcium with vitamin D, Colace, and multivitamins) by crushing them and spoon fed them to Resident 1 around 11am-11:10am. RN1 stated RNS informed her she had administered the wrong medications to the wrong resident shortly after she administered Resident 2 ' s medications. RN 1 stated, she did not identify Resident 1 properly prior administering the resident medications by checking the resident ' s wrist band, by photo identification (ID), resident self-identification, or using other staff to verify and identify the actual resident. A review of the facility policy and procedure (P&P) titled, Resident Identification System, revised December 2007, indicated a resident identification system is used to help facility personnel provide medical and nursing care which include: 1. The facility has adopted a photo and/ or wristband identification system to help assure that medication and treatments are administered to the right resident. 2. The photo identification or wristband identification is used by nursing service personnel when administering medications and treatments. A review of the facility ' s P&P titled, California Long Term Care (LTC) Facility ' s Pharmacy Services and Procedures Manual, revised on 4/1/22, indicated prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. The P&P indicated during medication administration, facility staff should take all measures required by facility policy and applicable law including identify the resident per facility policy.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 44) with pressure ulcer (or injury (PI)/areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore) to the sacral (bone located at the bottom of the spine between the hip bones) region by failing to: 1. Notify the physician when Resident 44's Stage 3 PI increased in size on 11/27/18 as indicated in the facility policy. 2. Providewound treatment according to the physician's order when Resident 44 returned to the facility on [DATE]. 3. Ensure Resident 44 was monitored on 12/1/18, to ensure repositioning and relieving constant pressure on the affected area as indicated in the professional standards of practice. 4. Notify the physician of the presence of eschar (dry, thick, leathery dead tissue) and slough (yellowish dead tissue) as observed during the wound treatment on 12/2/18 as indicated in the facility policy. 5. Place Resident 44 on the appropriate level for the low air loss mattress ((LAL), provides airflow to help keep skin dry as well as to relieve pressure) based on Resident 44's weight as indicated in the physician's order. As a result of these deficient practices, Resident 44's Stage 3 PI (full thickness tissue loss, fat may be visible but bone, tendon, or muscle are not exposed) deteriorated to a Stage 4 PI (full thickness skin loss with extensive destruction, tissue death, or damage to muscle, bone, or supporting structures). Findings: A review of Resident 44's Face Sheet (admission record), undated, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 44's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 10/26/18, indicated the resident had no cognitive (the mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 44 required extensive assistance (staff provided support with bearing weight, at times full staff performance of activity) from staff with activities of daily living ((ADLs) such as dressing, toileting, personal hygiene, and bed mobility) and had a pressure reducing device while in bed. A review of Resident 44's physician's order (untitled) for the Stage 3 PI included the following: 1. 11/15/18, to cleanse coccyx (tail bone) with normal saline (salt solution), pat dry, apply [MEDICATION NAME] cream (cream used to prevent and treat infection) 1 percent (%), then cover with dry dressing every day. 2. 11/29/18, low air loss mattress for wound management every shift to adjust firmness level according to resident's weight per manufacturer's indication. 3. 12/3/18, to cleanse the wound with normal saline, pat dry, apply [MEDICATION NAME] cream and lightly pack with xeroform (wound dressing) then cover with dry dressing every day. During an observation on 12/6/18, at 8 a.m., Resident 44 was lying in bed. The low air loss mattress setting was by weight. The weight knob was placed at 200 pounds (lbs.). During a concurrent interview at 8:12 a.m., the Director of Nursing (DON) verified the air mattress setting was at 200 lbs. and stated Resident 44's weight was 100 lbs. The DON stated that when the air mattress setting is higher than the actual weight of the resident, it makes the mattress firmer applying more pressure. A review of Resident 44's monthly weights (untitled) indicated on 11/3/18, the resident's weight was 98 lbs. During a wound treatment observation for Resident 44 on 12/6/18, at 9:04 a.m., Licensed Vocational Nurse 1 (LVN 1) verified that Resident 44 was 98 lbs. on 11/3/18. LVN 1 then prepared normal saline, [MEDICATION NAME] cream 1%, silicon dressing (dressing designed to absorb exudate and maintain a moist wound bed to facilitate fast healing) and xeroform. The wound was observed with eschar and slough. LVN 1 stated Resident 44 went out on pass on 12/1/18, Saturday, and was on the chair all day on 12/1/18 and the wound worsen. A review of the facility's record titled, Location of Administration Report, dated 11/1/18 thru 11/30/18, and 12/1/18 thru 12/31/18, included Treatment Administration Record for Resident 44 that indicated the wound treatment to the resident's coccyx was provided on 11/30/18, at 1:02 p.m., then 12/2/18, at 2:09 p.m. During an interview on 12/6/18, at 2:25 p.m., LVN 1 stated the last time she changed Resident 44's wound dressing was on 11/29/18. LVN 1 stated on 12/3/18, was when she observed that the wound was unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar), with slough and eschar. LVN 1 verified the size of the wound increased from 0.3 centimeters (cm) on 11/20/18 to 1.5 cm on 11/27/18. LVN 1 stated she failed to document the change in condition and report the change in wound size to the physician, per facility procedures. During the same interview, LVN 1 reviewed Resident 44's medical record and verified there was no documentation Resident 44 went out on pass on 12/1/18. LVN 1 then reviewed the binder containing the form titled, Release of Responsibility for Leave Of Absence, undated, there was no entry for 12/1/18. The facility had no documentation of the dates and times when Resident 44 went out on pass and returned to the facility. During an interview on 12/6/18, at 3:05 p.m., LVN 2 stated Resident 44 was out all day Saturday, 12/1/18 and did not do the treatment. During review of Resident 44's Treatment Administration Record, LVN 2 stated no other licensed nurses documented that they did the wound treatment on 12/1/18. LVN 2 stated she did the treatment on 12/2/18, in the afternoon and observed slough with eschar. LVN 2 stated she failed to document or report the change in condition to the physician or charge nurse, per facility protocol. LVN 2 stated Resident 44 had a Stage 3 PI and now the wound was unstageable. A review of the Skin Integrity Report indicated the following wound measurements: 1. On 11/20/18, Stage 3, measuring 0.3 cm in length by 0.3 cm. in width. 2. On 11/27/18, Stage 3, measuring 1.5 cm in length by 1 cm in width. 3. On 12/3/18, Unstageable, measuring 3 cm in length by 3 cm in width and depth undetermined due to 50% eschar and 50% slough. During an interview on 12/6/18, at 3:21 p.m., the DON stated when there is a change in a pressure injury, the staff should document a change in condition, notify the physician and obtain treatment orders, notify family and monitor the wound. The DON verified Resident 44's physician assessed the resident on Monday 12/3/18, changed the treatment order and ordered a wound consult (wound specialist) because the wound was unstageable. During an interview on 12/07/18, at 12:18 p.m. Resident 44's Family Member 1 (FM1) stated on Saturday, 12/1/18, took Resident 44 out of the facility in the morning for three hours and brought her back. FM1 stated brought Resident 44 back because resident was not supposed to be in the wheelchair for a long time. FM1 verified Resident 44 was in the facility the rest of the day. A review of the wound consult progress note, dated 12/9/18, indicated Resident 44 had a Stage 4 sacral pressure wound measuring 3 cm in length by 2 cm in width by 1 cm in depth. A review of the facility policy and procedures titled, Support Surfaces: Utilization, dated 3/1/16, indicated the mattress will be provided at the preferred pressure for redistribution surfaces. A review of the facility policy and procedures titled, Change in Condition: Notification of, dated 11/28/16, indicated the facility staff must immediately inform and consult the resident's physician of a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment). A review of the Medical-Surgical Nursing, Ninth Edition, 2013, pages 186-187, Prevention remains the best treatment for [REDACTED]. Never position the patient directly on the pressure sore. A review of the National Pressure Ulcer Advisory Panel (NPUAP) handbook on Prevention and treatment of [REDACTED]. https://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf

Based on observation, interview and record review the facility failed to provide the necessary care and services for two of 18 sampled Residents (Residents 8 and 13), by failing to: a. For Resident 8, the facility failed to thoroughly review the clinical records from the general acute care hospital (GACH 1) upon admission on 11/5/17, which indicated Resident 8 had diabetes mellitus (a condition in which the pancreas fail to produce insulin resulting in having high Blood sugar) that was being treated with insulin, a hormone produced in the pancreas to help breakdown the blood sugar in the cells to be used as energy thus control the blood sugar level in the body. In addition, Resident 8 who had a recent history of urinary tract infection (UTI; an infection in the kidney, ureters, urethra and bladder) was not assessed for signs and symptoms of UTI. As a result of this deficient practice Resident 8 was not assessed for signs and symptoms of [MEDICAL CONDITION] (high blood sugar level), monitored for blood sugar levels, and receive insulin (medication to lower the blood sugar level given by injection to the skin) as needed for three days. Resident 8 was transferred to the hospital via 911 (an emergency call system) due to high blood sugar 566 mg/dl (milligrams per deciliter; normal range is 79 115 mg/dl) and UTI. b. For Resident 13, the facility failed to ensure that one of 18 sampled residents was assessed thoroughly for pain and the assessment documented in the medical record. This deficient practice had the potential to affect resident's pain management regimen. Findings: a. On 11/16/17 at 6:30 p.m. during a facility tour conducted with Licensed Vocational Nurse 6 (LVN 6), Resident 8 was observed sitting in a wheelchair at bedside watching television. In a concurrent interview, Resident 8 stated she was recently hospitalized due to recurrent UTI and high blood sugar. Resident 8 stated, she informed the staff that admitted her that she was diabetic and that she receives insulin, however, she stated she did not receive insulin for three days before she was transferred to the hospital. When asked what happened before she was transferred to the hospital on [DATE], Resident 8 explained, during an exercise her hand was shaking and the rehabilitation therapist noticed she was weaker than previous days, the therapist informed the nursing staff right away. Resident 8 stated, Before I knew it the paramedics arrived and took me to the hospital. A review of the admission record indicated Resident 8 was admitted at the facility on 11/5/17 and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 8's minimum data set (MDS), a resident assessment and care screening tool, dated 11/17/17, indicated resident had no cognitive impairment (diminished ability to think and reason), able to speak clearly, express ideas and wants, and was able to understand others. The MDS also indicated Resident 8 required limited assistance (resident highly involved in activity) with one person assistance from staff for eating and personal hygiene. A review of the Progress Notes, dated 11/8/17, timed at 7:46 a.m., indicated Resident 8 had a change of condition with oxygen saturation (blood oxygen level in the blood) decreased to 89% (normal range is 90 100%) and had elevated body temperature of 102.2 degrees Fahrenheit (°F) (normal range 98.6 to 99.8 °F) at 4:45 a.m. and at 7:51 a.m. Resident 8's temperature was 98.4 °F and oxygen saturation at 98%. A review of eINTERACT Transfer Form (a form used by the facility to document the resident's change of condition) dated 11/8/17 at 1:55 p.m., indicated Resident 8 had an unplanned transfer to the GACH due to abnormal blood sugar of 566 mg/dl. There was no documentation in the nursing progress notes related to Resident 8's change of condition. A review of the History and Physical from GACH 2, dated 11/8/17, indicated Resident 8 had a long standing history of diabetes and was transferred to GACH 2 on 11/8/17 for evaluation of right flank pain, radiating down her right leg associated with urinary frequency which had been going on for three days without significant relief. Resident 8 was observed with bandemia (elevated immature white blood cell count which indicates presence of an infection or inflammation) which was treated with [MEDICATION NAME] (medication given into the veins to treat infection), and had elevated blood sugar (543 mg/dL) which was treated with insulin and was admitted to the hospital to closely monitor blood sugar and was placed on insulin therapy. A review of the Patient Transfer Referral Record, dated 11/10/17 indicated, Resident 8 was discharged from the GACH 2 on 11/10/17 and readmitted back to the facility with [DIAGNOSES REDACTED]. According to the National Institute of Diabetes and Digestive and Kidney Diseases, [MEDICAL CONDITION] is a kidney type of UTI that commonly begins in the bladder and moves upstream to one or both of your kidneys with symptoms that included flank pain, chills, fever and painful urination, which could lead to a serious kidney damage if not treated quickly. https://www.niddk.nih.gov/health information/urologic diseases/kidney infection [MEDICAL CONDITION] On 11/16/17 at 10 p.m., in an interview with the Registered Nurse Supervisor (RN 1), she stated she and another registered nurse admitted Resident 8 on 11/5/17 from GACH 1. RN 1 explained, she and the other RN supervisor were supposed to review Resident 8's medical records from GACH 1 which they received at least two hours before Resident 8 was admitted at the facility, but they did not review the medical records thoroughly and failed to identify that Resident 8 was a diabetic and was receiving insulin. RN 1 stated, I just checked the Patient Medication List that the EMT (Emergency Medical Technician - health care provider of emergency medical services) gave me which did not include insulin. On 11/16/17 at 10:10 p.m., the clinical records for Resident 8 were reviewed with RN 1 and indicated the following: 1. Resident 8 was originally admitted at the facility on 11/5/17; 2. Resident 8's clinical record from GACH 1 that was sent to the facility prior to admission on 11/5/17, indicated Resident 8 was emergently admitted to GACH 1 from another skilled nursing facility, on 11/2/17, due to an altered mental status lost her balance, and was evaluated with UTI and diabetes. The Medication List from GACH 1, dated 11/3/17 to 11/5/17, indicated Resident 8 was monitored and received Insulin Human [MEDICATION NAME] (rapid acting insulin for diabetes) before meals and at bedtime as needed according to resident's blood sugar level, and was placed on Hypoglycemic (a condition with low blood sugar level) Clinical Protocol (guidelines to implement if the blood sugar was low). 3. There was no documented evidence that Resident 8's blood sugar level was monitored. 4. There was no plan of care developed to assess, monitor and intervene if Resident 8's blood sugar levels were high or low due to diabetes. A review of the 24 Hour Laboratory Report from GACH 1 indicated Resident 8's elevated blood sugar levels on the following dates and times were as follows: 11/2/17 at 5:30 a.m. 278 mg/dl, 11/2/17 at 7:19 a.m. 233 mg/dl 11/2/17 at 11:57 a.m. 250, mg/dl 11/2/17 at 6:46 p.m. 198 mg/dl 11/3/17 at 8 a.m. 206 mg/dl 11/3/17 at 12:09 p.m. 254 mg/dl 11/4/17 at 7:39 a.m. 191 mg/dl 11/4/17 at 12:52 p.m. 236 mg/dl 11/4/17 at 6:19 p.m. 180 mg/dl 11/4/17 at 8:27 p.m. 195 mg/dl 11/5/17 at 7:30 a.m. 187 mg/dl. According to the facility's laboratory blood sugar reference range, a normal blood sugar lever was between 75 to 110 mg/dl. On 11/17/17 at 8:30 p.m. in an interview the director of nursing (DON) stated, the RN supervisors receives the inquiries or records from the hospital at least six hours prior to the arrival of the resident to the facility. The DON explained that the hospital records received from GACH, which indicated Resident 8 was diabetic and has been checked for elevated blood sugar and was receiving insulin, was given to the RN supervisors, so if the RN supervisors thoroughly reviewed Resident 8's GACH 1 record and noted high blood sugar levels, the RN supervisors should have asked the doctor why the resident was receiving medication for diabetes and why the blood sugar was not being checked. On 11/17/17 at 9:50 p.m. in an interview, the DON was asked to provide a policy and procedure to guide the staff with the admission process, the DON replied We do not have a policy and procedure for admitting residents. On 11/18/17 at 5 p.m. in an interview Family 1 (FAM1) stated, Resident 8 was recently discharged from GACH 1 due to UTI and she was surprised when she received a call that Resident 8 was being transferred to the hospital with high blood sugar because she communicated to staff that admitted Resident 8 on 11/5/17, that Resident 8 was diabetic and was receiving insulin. On 11/18/17 at 6 p.m., in an interview with the medical director for the facility (MD 1), MD 1 stated that when a resident was admitted to the facility, the physician relies on the report received from the RN who admitted the resident at the facility, then the physician must assess the resident physically and reviews the records from the acute hospital within seventy two hours after admission to the facility and order the necessary care and treatments the resident needed including an order to routinely monitor blood sugar to determine how much insulin the resident required. MD 1 also stated that the blood sugar of diabetic residents who required insulin can become elevated which put the residents at risk for dehydration, UTI and sometimes coma because the sugar in the body cannot be used as fuel when the body does not have insulin. On 11/18/17 at 7:30 p.m. a record review of Resident 8's clinical record conducted with the DON indicated; 1. A review of the PRN Pain Management Flow Sheet indicated Resident 8 had complained of generalized body pain, 7 8 out of 10 on the pain scale from 0 (No pain) to 10 (severe pain), from 11/5/17 to 11/8/17, and was given pain medications [MEDICATION NAME] 10 mg/325 mg or [MEDICATION NAME] 50 mg given alternately for complaint of generalized pain. On 11/8/17 at 10:40 a.m. Resident 8 was given [MEDICATION NAME] for right hip pain rated as 7 out of 10 on the pain scale 2. No record in the nursing progress notes or in the clinical records that indicated Resident 8 was assessed and had no signs and symptoms of UTI. 3. There was no plan of care to assess and monitor Resident 8 for UTI. In a concurrent interview, the DON stated, Resident 8 should have been assessed and monitored anddeveloped a plan of care for UTI because of the recent history of UTI. According to American Diabetes Association (ADA), [MEDICAL CONDITION] (high blood sugar level) happens when the body has too little insulin or when the body can't use insulin properly. The signs and symptoms include the following: · High blood glucose · High levels of sugar in the urine · Frequent urination · Increased thirst Part of managing your diabetes is checking blood glucose often, and treating high blood glucose early will help avoid problems associated with [MEDICAL CONDITION] such as diabetic coma. http://www.diabetes.org/ b. A review of Resident 13's Admission Record, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 13's Minimum Data Set (MDS; a care screening and assessment tool) dated 10/24/17, indicated the resident was cognitively intact. The MDS indicated Resident 13 required extensive assistance with two-person assistance during bed mobility and transfers. A review of Resident 13's Physical Examination, signed and dated by the physician on 10/20/17, indicated the resident was requiring pain management while in the facility. During a medication pass observation, on 11/18/17, at 9:25 a.m., Resident 14 was observed lying in bed in an upright position. Resident 13 asked Licensed Vocational Nurse (LVN) 4 for pain medication. LVN 4 stated that he had to check her blood pressure (BP) first. After checking the resident's BP, LVN 4 asked the the location and level of the resident's pain. Resident 13 stated that her level of pain was a 9 out of 10 and had a major headache and pounding at the back of her head. Resident 13 stated that her knees was also bothering her a lot. Resident 13 stated the level of her knee pain was 7 out of 10. LVN 4 administered one tablet of [MEDICATION NAME] 5-325 milligrams (mg) for pain and stated that he would be back in one hour to check her pain level. During the observation, LVN 4 continued administering the rest of Resident 13's medications. LVN 4 did not provide a thorough assessment of Resident 13's knee pain by asking to describe the pain as to the onset, characteristic, and duration. LVN 4 did not provide non-pharmacological interventions such as repositioning prior to administering the pain medication. During an interview, on 11/18/17, at 9:55 a.m., in the presence of the Nurse Practice Educator (NPE), Resident 13 stated both of her knees hurt because she had [MEDICAL CONDITION]. Resident 13 stated the pain was a sharp pain. Resident 13 also stated that she had a brain surgery prior to admission to the facility. A review of Resident 13's Pain Management Flow Sheet, dated 11/18/17, timed at 9:36 a.m., indicated LVN 4 documented Resident 13's pain evaluation and treatment. LVN 4 did not document the characteristic of Resident 13's headache (pounding). LVN 4 did not document Resident 13's complaint of 7 out of 10, knee pain. The pain management flow sheet indicated Resident 13 had frequent general body aches and occasional pain at the back of her head. A review of Resident 13's care plans did not indicated an individualized care plan was developed for Resident 13's complaints of pain at the back of her head. During an interview, on 11/18/17, at 4 p.m., LVN 4 stated he did not know Resident 13 had surgery to the head. LVN 4 stated he failed to document the resident's knee pain and did not assess resident's knee pain thoroughly. LVN 4 stated he should have documented the characteristic of Resident 13's headache. A review of the facility's policy titled Pain Management, revised on 11/28/16, indicated that resident's level of comfort would be maintained by providing a system to identify, assess, treat, and evaluate pain. The policy indicated that an individualized, interdisciplinary care plan would be developed and include pharmacological and non-pharmacological approaches.

Based on observation, interview, and record review the facility failed to ensure one of three sample residents (Resident 1)was provided adequate supervision to prevent accidents by failing to: 1. Ensure Resident 1 was not left in her room unattended while she was in her wheelchair in accordance with the facility's Action Plan. (Facility's plan to prevent Resident 1 from falling in response to Resident 1's Family's grievance.) 2. Provide a properly functioning alarm device(alarm pad - a pad placed on the resident's bed or wheelchair connected to a battery operated alarm which is activated when the resident attempts to get up, alerting the staff that the patient requires assistance)in accordance with the facility's Action Plan. These deficient practices resulted in Resident 1 falling and sustaining a head injury and a neck fracture. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set ((MDS) medical, mental, and psychosocial assessment of the resident), dated 10/6/16, indicated Resident 1 had severe cognitive deficits(significant memory loss that affects daily functions and decision making), decreased hearing, decreased vision, and decreased comprehension of others. Resident 1 required extensive assistance with one person physical assist with bed mobility, transferring, walking, toilet use, and bathing. The MDS also indicated Resident 1 was not steady and only able to stabilize self with staff assistance when moving from a seated to standing position, on and off the toilet, and surface to surface transfer (moving between bed and chair or wheelchair). Resident 1 required a wheelchair to get around the facility. A review of Resident 1's fall care plan interventions, last re-evaluated on June 2015 included: Increased visual checks by staff. Have call light within reach. Keep bed in lowest position and side rails used as an enabler. A review of Resident 1's annual Falls Risk Review dated 4/5/16, indicated Resident 1's conditions which placed the resident at risk for falls included: Poor safety awareness/judgement and memory deficits, sensory deficits in vision and hearing, unsteady gait/balance, medications(high blood pressure medications and laxatives). A review of Resident 1's family member(FM)1's grievance letter, dated 4/11/16, indicated the following: On two occasions FM 1 observed Resident 1 left unsupervised on 4/2/16 and 4/6/16. FM 1 expressed her concern for Resident 1's quality of care and safety as Resident 1 was physically weak, had poor judgement regarding personal safety and stressed by any attempts from her part to get up can result in fatal consequences. FM 1 requested a plan of action. A review of Resident 1's physician's orders [REDACTED]. A review of an email the facility sent to FM 1 included the facility's Action Plan for Resident 1 dated 4/14/16 to prevent the resident from falling in response to FM 1's grievance. The Action Plan included the following: 1. Ensure communication between nursing staff assigned to Resident 1 to maintain observation supervision while Resident 1 was in a wheelchair outside of her room and not to leave Resident 1 in her room unattended while she's in her wheelchair. 2. Provide Resident 1 an alarm pad for her wheelchair. 3. Continue to monitor Resident 1 per care plan. A review of Resident 1's Progress Notes, dated 1/3/17 at 6:19 p.m., indicated Resident 1 had an unwitnessed fall resulting in a laceration(open wound)to her forehead at 5:45 p.m., 9-1-1 was called, and Resident 1 was sent out to the hospital at 6:05 p.m. A review of the facility Event Summary Report, dated 1/5/17 at 6:20 p.m., indicated the staff heard someone calling for help from Resident 1's room. Resident 1 was found lying on the floor by licensed vocational nurse(LVN)1 with blood coming from her front head and complaining of pain in the head and neck. The Event Summary Report indicated Resident 1 had an alarm but the alarm did not sound, was not set up properly, did not have a battery in working order, and was not turned on. An interview was conducted on 1/19/17 at 3:55 p. m with LVN 1 who was Resident 1's nurse on the day Resident 1 fell . She said she was aware that Resident 1's alarm device was not working properly one hour into her shift. LVN 1 stated at 4:30 p.m., the registered nurse (RN) supervisor handed her a new alarm device for Resident 1. LVN 1 stated she wheeled Resident 1 into her room to place a new alarm device but then heard another resident asking for help and left Resident 1 in her room. LVN 1 returned when Resident 1's roommate was calling for someone to help her. LVN 1 verified Resident 1's fall occurred two hours after she was first aware of Resident 1's alarm not working properly. LVN 1 stated she was aware of the facility's action plan regarding the nursing interventions that were to be implemented to prevent Resident 1 from falling. LVN 1 stated a copy of the Action Plan was posted over Resident 1's bed head board, Resident 1 was not to be left alone in her room while in her wheelchair and that Resident 1's alarm device was not working. During an interview with the RN Nursing Educator on 1/24/17 at 10:33 a.m. she stated that the alarm device was supposed to be checked every shift by the licensed nurses and documented on the treatment administration record. If the alarm device was not working, the licensed nurses are to find out what the problem is to ensure the resident's alarm was working properly, such as replacing batteries, pressure pads, or the entire device. During an interview with the RN supervisor on 1/24/17 at 3:45 p.m., the RN supervisor stated on the day Resident 1 fell , as she made her rounds she noticed Resident 1's alarm device was not working properly. The RN supervisor got a new alarm from central supply at the beginning of the shift and gave it to LVN 1. During an interview with the Director of Nursing(DON), on 1/26/17 at 3:45 p.m., she stated the evening licensed nurses are supposed to start their shift at 3:00 p.m. and are supposed to make their rounds, and check on their assigned residents alarm devices. The maintenance of alarm devices are the licensed nurse's responsibility. A review of Resident 1's Fire Department EMS (Emergency Medical Services) Report, dated 1/3/17, indicated emergency medical services responded to a 9-1-1 call and found Resident 1 complaining of neck pain. Resident 1 had a Z shaped laceration to her forehead, and was transported to the general acute care hospital (GACH)emergency department. Resident 1's GACH Emergency Department Physician notes, dated 1/3/17, indicated the Fire Department EMS paramedics brought Resident 1 to the emergency department with c-spine precautions (cervical-spine precautions, where the neck is immobilized using a neck brace)complaining of neck pain. The Emergency Department Physician found Resident 1 to have a seven centimeter(cm)forehead laceration, pain to her neck and ordered Resident 1 have a CT scan (computerized tomography scan, combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images of the area). Resident 1 was found to have a cervical-spine fracture located at cervical 2 (C-2), which is the second top neck bone of the cervical spinal column and displacement (shifting)of the C-2 bone. The Emergency Department Physician identified Resident 1's condition as serious and ordered Resident 1 admitted to the GACH. Record review of the GACH Neurosurgeon (doctor who performs surgery on the brain and spinal column)consultation, dated 1/8/17, indicated Resident 1 had an acute C2 fracture (C-2 bone help to control the rotation of the head.)with a 2-3 mm (millimeter) displacement indicating she would be placed in an aspen collar (hard, stiff neck brace that restricts neck movement and decreases pain). During a concurrent interview and observation with Resident 1 on 1/11/17 at 3:35 p.m. at the GACH. She was observed to have a large, four inch Z - shaped scab from her hairline to the side of her eyebrow and a large bruise from the right side of her forehead along the side of right hair line and extending down her right neck. Resident 1 was wearing her aspen collar and looked visible uncomfortable. Resident 1 was observed with facial grimacing, frowning, and pointing to her neck and stated she was in pain. A review of the GACH Discharge Summary, dated 1/16/17, indicated Resident 1 was admitted on [DATE] and discharged on [DATE]. A review of Resident 1's GACH medication administration indicated from 1/3/17 to 1/16/17 indicated Resident 1 received Morphine Sulfate (narcotic medication for severe pain) two milligrams (mg)intravenously (IV, in the vein)eight times for complaints of pain and Codeine/APAP #2 (combination medication using a narcotic and an analgesic to treat moderate to severe pain)twelve times for complaints of pain. According to the facility's Falls Management policy, revised 3/15/16, those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury and develop individualized plan of care and review and revise care plan regularly.

Based on observation, staff interview, and clinical record and administrative document review, the facility failed to provide supervision and assistive devices to prevent an accident for 1 of 19 sampled residents (Resident 8). Resident 8 fell and sustained a right femur fracture (a break in the upper bone of the leg) as a result of staff's failure to implement "safe transfer techniques" and interventions to prevent falls, based on Resident 8's assessed risks and needs. The facility's failure to implement appropriate safe transfer interventions placed the resident at risk for life-threatening events such as falls and fractures. Findings: On 8/4/14 at 2:35 a.m., during the initial tour with the Assistant Director of Nurses (ADON), Resident 8 was observed asleep in bed. She wore an immobilizer splint on her right leg (a device used to prevent, restrict, or reduce normal movement in a limb). According to the ADON, Resident 8 was confused and disoriented and could not be interviewed. On 8/5/14 at 9:30 a.m., during a concurrent observation and interview with Certified Nursing Assistant (CNA) 2, Resident 8 was asleep in bed. CNA 2 stated she and a Hospice Aide (HA-outside agency staff who cares for the terminally ill) were at the resident's bedside to reposition the resident. When asked about the level of assistance needed by the resident, CNA 2 stated Resident 8 was totally dependent on staff for all activities of daily living, and required two staff members to assist her with repositioning and transfers. When asked why Resident 8 wore an immobilizer splint on her right leg, CNA 2 responded, "She fell in July during transfer and broke her leg." On 8/5/14 at 11:00 a.m., during an interview, the Director of Nurses (DON) stated Resident 8 fell on [DATE], when CNA 3 attempted to transfer the resident by herself from the resident's wheelchair to the bed. The DON stated Resident 8 became weak and slid down onto the floor, assisted by CNA 3. When requested to interview CNA 3, the DON stated CNA 3 was no longer employed at the facility. On 8/5/14 at 11:55 a.m., Resident 8's clinical record as well as administrative documents were reviewed with the DON as follows: Resident 8's "FACE SHEET" indicated she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE], reflected Resident 8 required "two + (plus) persons" physical assistance for bed mobility and transfer in and out of bed, and had impairment or limitations in range of motion (ROM) on both upper and lower extremities. The care plan for falls initiated on 1/14/14 reflected interventions as follows: "Increased visual checks, call light within reach, environment free of clutter, activities, and medication review." The care plan dated 1/14/14, did not include the number of staff assistance required to safely transfer the resident as identified in the MDS dated [DATE]. The annual "Falls Risk Review (FRR)" dated 4/2/14, reflected Resident 8 was a "high risk for falls" due to an unsteady gait/balance, use of antipsychotic medications, (medications primarily used to manage psychosis, delusions, hallucinations, or disordered thought, and other non-psychotic disorders) medication use, and vision deficit. The annual Minimum Data Set (MDS) assessment dated [DATE], reflected Resident 8 required "two + (plus) persons" physical assistance for bed mobility and to transfer in and out of bed, and had impairment/limitations in range of motion (ROM) on both upper and lower extremities. The care plan with an evaluation date of "4/14," did not include the number of staff assistance required to safely transfer the resident as identified in the MDS dated [DATE]. The quarterly FRR dated 7/8/14, reflected Resident 8 was a "high risk for falls" due to an unsteady gait/balance, antipsychotic medication use, and vision deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE], reflected Resident 8 required "two + (plus) persons" physical assistance for bed mobility and to transfer in and out of bed, and had impairment/limitations in range of motion (ROM) on both upper and lower extremities. The care plan with an evaluation date of "7/14," did not include the number of staff assistance required to safely transfer the resident as identified in the MDS dated [DATE]. The "Post Fall SBAR" (Situation, Background, Assessment, Request) dated 7/11/14, reflected, "On 7/11/14, Resident had assisted fall. Nurse aide attempted to lift the resident from wheelchair to bed. Resident's body became flaccid and began to slowly slip down. Resident's body ended in kneeling position with upper body on CNA and lower body touching floor..." The incident report dated 7/11/14, indicated, "Resident became weak during transfer and slid down..." Resident 8's x-ray report dated 7/16/14, reflected Resident 8 sustained "Acute distal femoral shaft fracture with slight medial displacement." The facility's policy titled, "Lifting and Transferring of Residents" dated 7/14, indicated, "Residents who require assistance in transferring are transferred using a gait/transfer belt... The designated method of transferring of a resident is indicated in the plan of care and MDS." On 8/5/14 at 12:30 p.m., during an interview, the DON stated; "CNA 3 did not follow safe transfer techniques. Resident 8 was weak and dead-weight, and CNA 3 attempted a one-person transfer without using a gait belt." On 8/5/14 at 3:35 p.m., the DON acknowledged Resident 8's fall with injury was due to facility's failure to implement safe transfer techniques and interventions to prevent falls based on the resident's assessed needs and identified risk factors.

Based on observation, interviews, review of the clinical record and facility policies and procedures (P&P), the facility failed to ensure that one of one sampled resident (Resident 1), who was assessed as requiring total assistance during transfers, was transferred by two staff members using a Hoyer lift (a mechanical hydraulic lift) in accordance with the facility's policy and procedure. This deficient practice resulted in Resident 1 sustaining a right arm fracture (broken bone). Findings: On [DATE] at 1:40 p.m., an investigation was conducted at the facility regarding a self- reported incident whereby Resident 1 sustained a right upper arm fracture. Review of the closed record revealed that Resident 1 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The annual MDS, dated [DATE], indicated that Resident 1 was severely impaired in cognitive (mental) skills for decision-making (never/rarely made decisions), was unable to walk, and was totally dependent (full staff performance) on staff for all of her daily living needs, including transfer. The MDS also indicated that the resident had functional limitation in range of motion (the distance and direction a joint can move to its full potential) to right upper extremity, as well as both lower extremities. The resident was assessed as "not being steady, only able to stabilize with staff assistance" for surface-to-surface transfer (transfer between bed and chair or wheelchair) under the section titled, "Balance During Transitions and Walking". A care plan titled, "ROM (range of motion) Program/ Ambulation/Splinting/Transfer", dated [DATE], which addressed RNA (restorative nursing assistant) passive and active ROM program, indicated that the resident was at risk for decline in range of motion, decreased muscle strength, and decreased functional use of extremity. A review of the ADL activity care plan dated [DATE], disclosed that the resident was totally dependent on staff in areas of bed mobility and transfer. The nursing intervention was that the staff will place the resident in wheelchair daily as tolerated. However, the interventions did not address how the resident would be transferred safely from one surface to another surface (i.e. transfer between bed and chair or wheelchair). During an interview on [DATE] at 1:40 p.m., the DON stated that on [DATE], CNA 1 was transferring the resident from the wheelchair to the bed when he noticed the resident's right arm dangling, and the resident started to slip from the Hoyer lift sling. After returning the resident to her bed, CNA 1 noted redness to the resident's right upper arm area. The charge nurse conducted an assessment, but determined there was no injury. On [DATE], the resident's right upper arm was noted with discoloration and swelling. The physician was notified, and ordered an x-ray of the right arm which revealed a fracture. The DON then stated that the resident expired on [DATE] of cardiac arrest (the heart stopped beating). Review of the Incident/Accident Investigation Report dated [DATE] indicated that a certified nursing assistant noted bruising and swelling on the resident's arm and reported it immediately to the charge nurse. The attending physician was immediately notified and ordered an x-ray to Resident 1's right arm. The x-ray result showed fracture of the right humeral (the long bone in the arm that runs from the shoulder to the elbow) neck with moderate medial displacement (bone not lined up straight) of distal fracture fragment and diffuse osteopenia (a condition where bone mineral density is lower than normal) is noted along with the humeral neck fracture. The physician was notified of the x-ray result and ordered to apply sling to the right arm and to give Tylenol 650 milligrams (mg) every six hours as needed for pain and Tylenol with Codeine (narcotic) #3 one tablet every six hours as needed for severe pain. The physician came and evaluated Resident 1 on [DATE] and ordered the resident to be transferred to the acute hospital emergency room for evaluation. Resident 1 returned to the facility on the same day with a right arm immobilizer (a device used to position the arm to keep it from moving) and pain medication order. During an interview on [DATE] at 2 p.m. CNA 1 stated that at approximately 1:30 p.m. that day ([DATE]), he was transferring Resident 1 from the wheelchair back to bed using the mechanical lift. The resident was placed in a standing position, and was holding onto the lift handle bars as CNA 1 manipulated the controls, to place the resident down onto the bed when the resident's right arm suddenly dropped downwards. CNA 1 further stated that as the resident started to fall; he grabbed the back of her pants, but was having difficulty steadying the resident in the sling, as she was heavy. He called out for assistance, and another CNA assisted him in getting the resident back to bed. After the resident was back in bed, he observed redness to the resident's right upper arm. CNA 1 then stated the resident was non-verbal and confused, but did not indicate any pain at the time. As the interview continued, CNA 1 stated the charge nurse assessed the resident, and then stated the resident was "okay", was not showing any signs of pain, and did not flinch when her arm was raised. When asked what was the usual procedure for transferring residents requiring total assistance, CNA 1 replied there should be two people. CNA 1 further stated the CNAs usually transfer the residents by themselves, because everyone else was busy. During the observation and demonstration on the use of the mechanical lift with CNA 1 and the DSD on [DATE] at 2:10 p.m., the DSD stated that while the resident was still in the wheelchair, a sling is placed around the resident's waist which was then attached to the lifting device. The resident held onto the handle bars of the lift, and the lift is then raised to bring the resident up over, then down onto the bed. While Resident 1 was being raised up, she released her hand from the handle bar causing her to slip in the sling, which then threw her off balance. When queried as to how many staff were required for the transfer, the DSD replied two people were required, and per instructions on the manufacturer's video. On [DATE] at 2:20 p.m., the DON further reiterated that there should have been two staff present to transfer Resident 1 for safety purposes. According to the undated facility's policy titled, "Lifting and Transferring of Residents", nurses were to assess and determine lifting and transferring requirements, and the procedure to be used, for each resident. Procedures included assessing resident in order to determine physical limitations, as well as the ability to follow directions. The policy further stipulated that at least two people were to be present while resident is being transferred with the mechanical lift.