Every finding on record at New Orange Hills

Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain an active care plan addressing the risk for skin impairment for one of three sampled residents (Resident 2). * The facility failed to ensure Resident 2 had a care plan to address the risk for skin breakdown related to history of anal future. This failure posed as a risk of not providing Resident 2 with individualized and person-centered care.Findings: Review of the facility's P&P titled Comprehensive Resident Centered Care Plan dated 1/2021 showed it is the policy of the facility that the interdisciplinary team shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the facility's P&P titled Skin and Wound Monitoring and Management dated 4/2025 showed the following Procedure under Resident Assessment includes the following:- identify risk factors which relate the possibility of skin breakdown and/or development of pressure injury which include but are not limited to impaired mobility and decreased functional ability, co-morbid conditions, cognitive impairment, exposure of skin to urinary and fecal incontinence, history of healed pressure injury,- risk factors identified on assessment should be documented in the resident's clinical record and when appropriate, be addressed through a care plan, - develop an individualized person-centered care plan based on the assessment and designed to minimize the possibility of a skin breakdown. In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, the nursing staff shall implement approaches as appropriate and consistent with the resident's care plan. On 7/29/26 at 0934 hours, an observation of Resident 2 and concurrent interview was conducted with Resident 2's responsible party at bedside as translated by the Maintenance Director. Resident 2 was non-verbal but opened her eyes when her name was called. Resident 2's responsible party was asked for permission to conduct an observation of Resident 2's skin; Resident 2's sacral and buttocks area were observed clean with no open area. Medical record review for Resident 2 was initiated on 7/29/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was coded as rarely or never understanding, indicating that the BIMS assessment should not be conducted. Review of Resident 2's H&P examination dated 4/16/26, showed Resident 2's acute care hospital course prior to admission to the facility was notable for constipation, perineal ulceration, and electrolyte imbalance. Review of Resident 2's Order Summary Report showed a physician order dated 7/10/26, showed the treatment plan for the resolved anal fissure was to monitor the area every shift and notify the PCP of any changes or any break in skin integrity. Review of Resident 2's TAR for July 2026 showed documented evidence the facility monitored Resident 2's resolved anal fissure for any changes or any break in skin integrity from 7/11 to 7/28/26. However, review of Resident 2's Care Plan Report showed the care plan to address Resident 2's potential and actual impairment to skin integrity related to a perianal wound was resolved on 7/24/26. Resident 2's care plan failed to show the revised or active care plan with interventions to address the ongoing risk for skin impairment related to Resident 2's history of an anal fissure. On 7/29/26 at 1441 hours, an interview and concurrent record review was conducted with the MDS Coordinator. The MDS Coordinator verified Resident 2's Care Plan addressing the potential and actual impairment of the skin integrity related to a perianal wound was discontinued, and Resident 2 had no active care plan addressing the ongoing risk for skin impairment related to Resident 2's history of an anal fissure. When asked whether the care plan should have been revised to monitor and prevent recurrence of skin impairment related to the resident's history of an anal fissure, the MDS Coordinator responded, Yes, it was discussed by the Interdisciplinary Team during the Skin and Wound Meeting. When asked what specifically was discussed, since no documentation was present in the care plan, the MDS Coordinator did not provide a response. The MDS Coordinator stated a review of the most recent quarterly meeting dated 7/20/26, showed the care plan was reviewed; however, there were no care plan to address the ongoing risk for Resident 2's skin impairment. On 7/29/26 at 1630 hours, an interview and concurrent record review for Resident 2 was conducted with the DON. The DON verified the care plan addressing the potential and actual impairment to skin integrity related to the perianal wound was discontinued and there was no revision made to address the ongoing risk for skin impairment related to Resident 2's history of anal fissure. The DON stated the care plan should have been revised to address the ongoing risk of skin impairment. On 7/29/26 at 1645 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to maintain the highest practicable well-being for one of five sampled residents (Resident 1). * The facility failed to ensure the licensed staff assessed, identified, and intervened in a timely manner when Resident 1 did not have a urinary output draining from the suprapubic catheter (a hollow flexible tube used to drain urine from the bladder, inserted into the bladder through a cut in the abdomen, a few inches below the belly button) into a collection bag on 5/25/26 from 0700 to 2300 hours. In addition, Resident 1's physician was not notified until 2345 hours on 5/25/26. These failures resulted in Resident 1 to be emergently (life-threatening or severe condition that requires immediate medical interventions to prevent death, permanent disability, or serious organ damage) transferred to the acute care hospital with chief complaint of altered mental status (an unexpected change in a person's brain function such as mild confusion, delirium, lethargy -mental sluggishness or severe lack of energy and motivation) and decreased oxygen level. * The facility failed to ensure Resident 1's suprapubic catheter was changed every 30 days as ordered by the physician. This failure posed a risk for Resident 1's suprapubic catheter to have encrustation (the formation of a hard crust, layer, or scale on a surface) and balloon malfunction, and for Resident 1 to have severe urinary tract infection.Findings: Closed medical record review for Resident 1 was initiated on 7/6/24. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's H&P (History and Physical) examination dated 2/6/26, showed Resident 1 had the capacity to understand and make medical decisions. The H&P examination also showed Resident 1 had diagnoses including paraplegia (paralysis of the lower half of the body) and neurogenic bladder (a bladder that does not function properly to hold and release urine) which required suprapubic catheter. Review of Resident 1's MDS (Minimum Data Set- a standardized assessment tool that measures health status in nursing home residents) dated 4/10/26, showed Resident 1 was cognitively intact. a. Review of the National Institute of Health (NIH) resource for Fluids and Electrolytes - Nursing Fundamentals (undated) showed the nurses should notify the healthcare provider if the urine output for a patient is less than 30 ml (milliliter - unit of measurement) per hour. Review of Resident 1's Care Plan Report showed a care plan problem dated 4/14/26, to address Resident 1's use of the suprapubic catheter. The interventions included to monitor/record/report to the physician if there was no urine output from the catheter (a thin, flexible tube made of medical-grade materials inserted into the body to drain urine). Review of Resident 1's Fluid Output task sheet dated 5/25/26, showed the urine output at 0700 to 1500 hours, and 1500 to 2300 hours, were both marked as 0 (zero). Review of Resident 1's Change in Condition Evaluation dated 5/25/26 at approximately 2330 hours, showed Resident 1 had no urine output from the suprapubic catheter drainage bag, his gown was wet, and his abdomen was distended. The Change in Condition Evaluation also showed the staff attempted to flush (a procedure used to help keep urine flowing) the suprapubic catheter but resistance was encountered. Additionally, the Change in Condition Evaluation showed a bladder scan (a quick, non-invasive imaging test that uses high-frequency sound waves to measures the volume of urine in the bladder) was performed which indicated there was only 14 ml of fluid in the bladder. The Change in Condition Evaluation also showed Resident 1 suddenly stopped responding, vomited, and his blood pressure (BP) dropped to 77/58 mmHg (milliliters of mercury, BP normal range = 90/60 to 120/80 mmHg), with a heart rate of 45 bpm (beats per minute). The Change in Condition Evaluation showed 911 (standard universal emergency phone number for medical services utilized during a life-or-threatening crisis) was called and Resident 1 was transferred to Hospital 1. Review of Resident 1's Hospital 1 Emergency Center report dated 5/26/26 at 1248 hours, showed Resident 1 presented to the ER with chief complaint of altered mental status (an unexpected change in a person's brain function such as mild confusion, delirium, lethargy -mental sluggishness or severe lack of energy and motivation) and decreased oxygen level. The section for the History of Present Illness showed the facility staff attempted to flush the suprapubic catheter due to not draining when Resident 1 suddenly vomited brown liquid and became minimally responsive. The report showed Resident 1's suprapubic catheter was found to have blood in the catheter bag. The emergency center report showed Resident 1's suprapubic catheter distal tip (the furthest point of an object or body part from its center of attachment) and balloon was located at the base of the penis, suggest repositioning. The emergency center report also showed Resident 1's mental status worsened and Resident 1 was intubated (a medical professional had inserted a flexible tube into a person's windpipe through the mouth or nose). Review of Resident 1's Hospital 2 H&P (History and Physical) examination dated 5/30/26, showed Resident 1 presented as an OURS (Outside Utilization Resource Service, a centralized 24/7/365 team that coordinates inpatient care and facility-to-facility medical transfers for members receiving care outside of the network) transfer. Resident 1 was transferred from outside acute care hospital (Hospital 1) for resolved septic shock (the most severe, life-threatening stage of infection when an extreme bodily reaction to an infection-typically bacterial- causes dangerously low blood pressure and widespread organ failure, requiring immediate medical intervention), respiratory failure status post intubation, and extubation (intubation is the lifesaving insertion of a tube into the windpipe to keep the airway open, while extubation is the removal of that tube), malpositioned suprapubic catheter which was repositioned.and acute renal failure (a sudden loss of kidney function that happens over a few hours or days). On 7/6/26 at 0930 hours, an interview was conducted with LVN (Licensed Vocational Nurse) 1. LVN 1 stated both the CNAs (Certified Nursing Assistants) and licensed nurses monitored Resident 1's urine output. LVN 1 stated, We observe the urine output when we do rounds at the beginning of our shift. LVN 1 stated the CNAs were expected to notify the licensed nurse if there were any concerns including if a catheter was not draining, or if a resident reported they were unable to urinate. On 7/6/26 at 1640 hours, an interview was conducted with LVN 5. LVN 5 stated during her medication pass, CNA 6 notified her that Resident 1's suprapubic catheter did not have any urine drainage. LVN 5 stated Resident 1 usually had a lot of urine output because he drank a lot of water. LVN 5 stated Resident 1's gown was wet, and it smelled like urine. On 7/7/26 at 1032 hours, an interview was conducted with the DSD (Director of Staff Development). The DSD stated the CNAs rounded (patient checks ensure patient comfort and prevent emergencies) at least every two hours to reposition Resident 1 and were expected to observe the urinary catheter. The DSD stated the CNAs should notify the charge nurse if something was abnormal such as no urine output. The DSD stated the charge nurse should have been notified if there was no urine output in Resident 1's suprapubic catheter On 7/7/26 at 1520 hours, a telephone interview was conducted with CNA 6. CNA 6 stated she worked the 1500 - 2300 shift on 5/25/26 and took care of Resident 1 that day. CNA 6 stated when she first checked on Resident 1, the suprapubic urinary catheter drainage bag was empty and urine was all over the bed. CNA 6 stated it was not normal for the suprapubic catheter to leak that much. CNA 6 stated no one had reported to her there was a problem with Resident 1's urine drainage. CNA 6 stated she reported it to the licensed nurse. On 7/7/26 at 1650 hours a telephone interview was conducted with RN (Registered Nurse) 1. RN 1 stated she was called to Resident 1's room by LVN 5 on 5/25/26 at approximately 2300 hours, due to low urine output or no urine output in Resident 1's suprapubic urinary catheter drainage bag. RN 1 stated she had not been informed of any urine output issues prior to that time. RN 1 stated she tried to flush the catheter but there was a lot of resistance. RN 1 stated, The CNAs should have let the licensed nurses know within three to four hours if there was no urine output. Eight hours was too long to wait. RN 1 further stated she expected to be notified if there was no urine output within four hours so they could respond to the situation quickly. RN 1 stated the urine output should be at least 30 - 40 ml. On 7/7/26 at 1700 hours an interview and concurrent closed medical record review for Resident 1 was conducted with the DON (Director of Nursing) and Administrator. The DON and Administrator confirmed the urine output on 5/25/26 for 0700 to 2300 hours was marked as 0 urine output. The DON stated the lack of urine output from the suprapubic catheter should have been reported to the treatment nurse, RN supervisor, and physician. The DON stated no urine output from a urinary catheter could indicate kidney failure (in which the kidneys stop working). On 7/8/26 at 1511 hours, an interview was conducted with the DON. The DON stated the licensed nurses were ultimately responsible for the catheters. The DON stated the licensed nurses should monitor the amount of output and characteristics of the urine. On 7/8/26 at 1720 hours, a follow-up interview was conducted with the DON. The DON was made aware and acknowledged the licensed nurses failed to assess, identify, and intervene in a timely manner when Resident 1 did not have a urinary output draining from the suprapubic catheter since 0700 hours on 5/25/26. b. Review of the CDC (Center for Disease Control) resource for Catheter-associated Urinary Tract Infection (CAUTI) Basics dated 6/27/25, showed catheter-associated urinary tract infection occurs when germs enter the urinary tract through a urinary catheter and cause infection. Additionally, according to the CDC catheter associated urinary tract infections are preventable and treatable. Review of the NIH (National Institute of Health) resource for Change of the Suprapubic Catheter dated 7/1/24, showed a suprapubic catheter should be changed every two to six weeks. Review of Resident 1's Order Summary Report showed a physician's order dated 2/20/26, for Resident 1's suprapubic catheter changed every 30 days. On 7/6/26 at 1450 hours an interview was conducted with the Administrator. The Administrator stated the wound doctor (physician) from Healthcare Company 1 would come to the facility and change the suprapubic for Resident 1. The wound doctor would also provide a report of the suprapubic catheter change procedure. On 7/7/26 at 1419 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 6. LVN 6 stated the last time Resident 1's suprapubic catheter was changed was on 3/22/26, when Resident 1 was in the acute care hospital. LVN 6 stated the suprapubic catheter changed was documented in the physician's progress note dated 4/16/26, when Resident 1 had reported to the physician the catheter had been changed in the morning of 4/16/26. However, LVN 6 verified there was no record of the procedure. LVN 6 stated Resident 1's suprapubic catheter was prone to clogging which was why there was an order to change the suprapubic every 30 days and to flush the suprapubic catheter daily. LVN 6 stated they were not keeping a record of when the suprapubic catheter was changed. On 7/8/26 at 1215 hours an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated the physician's order to change Resident 1's suprapubic catheter was not on the TAR (Treatment Authorization Record); therefore, there was nothing to flag the treatment nurse on when Resident 1's suprapubic catheter was due to be changed. The DON confirmed there was no record of the suprapubic catheter being changed in April or May 2026.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to implement the infection control surveillance program for the months of July 2025 through January 2026. The facility conducted surveillance of resident infections only when the residents were prescribed antimicrobial medications and/or if the residents were diagnosed with an infection. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications or had not been diagnosed with an infection, met the facility's criteria for infection utilizing McGeer's Criteria. The facility failed to include these residents in the facility's infection control surveillance program. * The facility failed to ensure the clean linen sorting counter was kept in a sanitary manner and free from personal belongings. In addition, the facility failed to ensure the clean linens in the linen cart were stored properly. * The facility failed to ensure the staff followed the infection control practices when passing out of the meal tray for Resident 15. * The facility failed to maintain infection control practices when Vendor Employee 1 was instructed to enter the kitchen without wearing the proper beard restraint. * The facility failed to ensure Resident 14's indwelling urinary catheter drainage bag was not touching the floor mat. * The facility failed to ensure Residents 21, 44, and 137's personal belongings were stored in a sanitary manner. These failures posed the risk of not identifying resident infections and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: 1. Review of the facility's P&P titled Infection Prevention and Control Program revised 2/11/26, showed an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program is coordinated and overseen by the IP. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. The information obtained from infection control surveillance activities is compared with acknowledged standards and used to assess effectiveness of established infection prevention and control practices. On 2/17/26 at 1332 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked to explain the facility's resident infection surveillance program. The IP stated when a resident was prescribed antimicrobial medications or was diagnosed with an infection, the facility would then initiate a McGeer's Criteria form. The IP stated the McGeer's Criteria was utilized to determine if a resident had a true infection. Review of the facility's Infection Prevention and Control Surveillance Logs showed the number of the residents who were classified for HAIs, CAIs, and the residents who did not meet McGeer's Criteria (DNMC). The infection surveillance data from July 2025 through January 2026 showed the following: - for 7/2025: HAI – 35, CAI – 22, and DNMC – 1 with prescribed antimicrobials; - for 8/2025: HAI – 33 , CAI – 18, and DNMC – 1 with prescribed antimicrobials; - for 9/2025: HAI – 32 , CAI – 17 , and DNMC – 2 with prescribed antimicrobials; - for 10/2025: HAI – 32, CAI – 14, and DNMC – 1 with prescribed antimicrobials; - for 11/2025: HAI - 30 , CAI – 14, and DNMC – 0; - for 12/2025: HAI - 28 , CAI – 13, and DNMC – 1 with prescribed antimicrobials; and - for 1/2026: HAI – 28, CAI – 13, and DNMC – 1 with prescribed antimicrobials. Further review of the facility's monthly Infection Prevention and Control Surveillance Logs from July 2025 through January 2026 showed all the residents included in the facility's infection surveillance program were determined to have either an HAI or CAI (with prescribed antimicrobial medications or having been diagnosed with an infection). The Infection Prevention and Control Surveillance logs failed to show any residents who did not meet McGeer's criteria and were not prescribed antimicrobials. The IP verified no residents in the facility were classified as having not met the McGeer's Criteria between the months of July 2025 through January 2026. The IP was asked if the facility's infection surveillance program included the residents who exhibited signs and/or symptoms of an infection and were not prescribed antimicrobial medications (or were not diagnosed with an infection) when the McGeer's criteria form was initiated. The IP stated the facility did not initiate the McGeer's criteria form for the residents who exhibited signs and/or symptoms of infection and were not prescribed antimicrobial medications (or were not diagnosed with an infection). The IP was asked how many residents had met the McGeer's criteria and were not prescribed antimicrobial medications from July 2025 through January 2026 (excluding residents who were diagnosed with an infection). The IP stated she was uncertain, as the facility did not initiate the McGeer's criteria form for those residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications (or had not been diagnosed with an infection). 2. On 2/12/26 at 0829 hours, an observation of the facility's laundry room and concurrent interview was conducted with Housekeeping 1 and the Maintenance Director. The counter designated for clean laundry sorting was observed with three facility communication devices (walkie-talkies) with charger, a personal water bottle, and a personal cellphone. Additionally, a clean linen cart was observed adjacent to the clean laundry sorting counter. The top shelf of the clean linen cart contained clean linens. However, a portable speaker was observed on the top shelf of the clean linen cart. Housekeeping 1 verified the findings and stated the facility staff personal items should not be stored on the clean laundry sorting counter, for infection control purposes. The Maintenance Director was informed about the observation in the laundry area and verified the findings. On 2/18/2026 at 1016 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. On 2/12/26 at 1242 hours, an observation of the passing out of meal trays to the residents was conducted with the DSS. The Business Office Manager was observed holding the tray for Resident 15 close to her body and allowing her hair to hang over the milk cartons on the tray. The DSS stated the department managers usually would assist with passing out the meal trays during mealtimes. On 2/17/26 at 1401 hours, an interview was conducted with the Admissions Director. The Admissions Director stated a new program called Angel Rounds was initiated about four months ago. The program rotates the department managers to assist the staff with passing out of the meal trays. The Admissions Director stated he received an in-service during a stand-up meeting on how to pass out the meal trays. The Admissions Director stated they were trained on hand hygiene and to keep their hair pulled back and away from the trays. On 2/17/26 at 1409 hours, an interview was conducted with the Business Office Manager. The Business Office Manager acknowledge she did not have her hair properly pulled back and allowed her hair to hang over Resident 15's meal tray. The Business Office Manager verified she received training on how to wear her hair while passing out the meal trays but did not follow procedure that day. On 2/17/26 at 1418 hours, an interview was conducted with the DSD. The DSD verified that an in-service was provided on how to pass out the meal trays during the stand-up meeting. The DSD verified staff were trained on pulling their hair back when passing out meal trays to residents. 4. Review of the facility's P&P titled Dress Code (undated) showed the following: - Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department. - Hat for hair, if hair is short, which completely covers the hair. - If applicable, beards and mustaches (any facial hair) must wear beard restraint. On 2/12/26 at 1010 hours, a tray line observation and concurrent interview was conducted in the kitchen with the DSS. During the tray line observation, an individual wearing a hat and had no beard restraint was observed entering the kitchen and walked past the yellow food and safety line. The individual was identified to be a vendor employee. An interview was conducted with Vendor Employee 1. Vendor Employee 1 stated it was his first time at the facility, and the receptionist had told him to enter the kitchen to pick up the items. Vendor Employee 1 stated he was not aware and was not supposed to cross the yellow food and safety line in the kitchen without the proper hair coverings. The DSS verified Vendor Employee 1 entered the kitchen without the proper hair coverings. The DSS also verified there was no signage at the kitchen entry to notify the people entering the kitchen were required to wear the proper hair coverings. 5. Medical record review for Resident 14 was initiated on 2/11/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Order Summary Report showed a physician's order dated 10/6/25, for an indwelling urinary catheter size 16 Fr to gravity drainage bag for skin management. On 2/17/26 at 1322 hours, an observation was conducted for Resident 14. Resident 14 was observed lying in bed. Resident 14 was observed with an indwelling urinary catheter attached to a drainage bag which was inside the dignity bag (a bag used to cover and hold the catheter drainage bag so it was not visible). The drainage bag was observed hanging on the side of the bed; however, the drainage bag was touching the floor mat. On 2/17/26 at 1341 hours, an observation and concurrent interview for Resident 14 was conducted with CNA 1. CNA 1 verified Resident 14's indwelling urinary catheter drainage bag was touching the floor mat. On 2/17/26 at 1349 hours, another observation and concurrent interview for Resident 14 was conducted with LVN 2. LVN 2 verified Resident 14's indwelling urinary catheter drainage bag was touching the floor mat. On 2/18/26 at 1325 hours, an interview was conducted with the DON. The DON stated the urinary drainage bags should not touch the floor. The DON further stated she expected the staff members to place a basin under the urinary drainage bag to prevent the urinary drainage bag from having contact with the floor. The DON was informed and acknowledged the above findings. 6. Review of the facility's P&P titled Resident's Personal Property dated 5/2007 showed it is the property of the facility to provide space and safety for resident's personal property and to store all items in appropriate place, as space permits. a. On 2/11/2026 1048 hours, during the initial tour to the facility, three bags of clothing were observed in between two closets in Resident 21's room with one bag and clothing touching the floor. Medical record review for Resident 21 was initiated on 2/13/26. Resident 21 was admitted on [DATE]. Review of Resident 21's H&P examination dated 4/9/25, showed Resident 21 had the capacity to understand and make decisions. b. On 2/11/26 at 1100 hours, an observation was conducted for Resident 44. There were three paper brown bags observed on the floor against the wall on the left side of Resident 44's bed. The bags contained clothing and personal belongings covered by a white plastic bags which Resident 44 did not want to be touched. Medical review for Resident 44 was initiated on 2/ 18/25. Resident 44 was admitted to the facility on [DATE]. Review of Resident 44's H&P examination dated 7/23/25, showed Resident 44 can make her needs known. c. On 2/11/26 at 1115 hours, an observation and concurrent interview was conducted with Resident 137. Resident 137's personal belongings in a bag was observed on the floor. Resident 137 stated I do not have enough space in the closet. Medical review for Resident 137 was initiated on 2/18/26. Resident 137 was admitted to the facility on [DATE]. Review of Resident 137's H&P examination dated 2/11/26, showed Resident 137 had the capacity to understand and make decisions. On 2/11/26 at 1133 hours, an observation and concurrent interview was conducted with CNA 2 and LVN 3. CNA 2 and LVN 3 verified the observations of the personal belongings on the floor for Residents 21, 44 and 137. LVN 3 stated these personal belongings should not be on the floor, for infection control. On 2/12/26 at 1136 hours, an interview was conducted with the IP. The IP acknowledged the above findings and stated the CNAs were supposed to be putting the personal belongings away. On 2/18/26 at 1342 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the yellow cutting board used for cutting cooked meat, poultry, and fish was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the lid for the heavy-duty blenders used for pureed preparation was free from dust. * The facility failed to ensure the storage racks in the dry storage room were free from dust. * The facility failed to ensure the scoops used for food portioning and measuring cups were air dried prior to storing. * The facility failed to ensure the can opener was free from rust-like residue. * The facility failed to ensure the lids of the dry food storage containers were free from dust. * The facility failed to ensure the kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the floor drain for the three-compartment sink was clean and free from food particles. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Order Listing Report dated 2/11/26, showed 88 residents received food prepared from the facility's kitchen. 1. Review of the facility's P&P titled Sanitation dated 2023 showed:- The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order.- All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks, and chipped areas.- Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized.- The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures, and the hood over stove, which will be cleaned by the maintenance staff. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 2/11/26 at 0823 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed:- One yellow cutting board was observed without a cleanable surface;- The plastic lid for the heavy-duty blender was stored upside down on top of the blender and was coated in dust;- Multiple storage racks in the dry storage area were coated in dust;- The lid for the dry storage container for the sugar was observed coated in dust;- One stainless steel scoop was observed stored with dry watermarks and food residue;- One stainless steel measuring cup was observed stored with dry watermarks and food residue; and- The floor drain for the three-compartment sink had food particles in the drain, and dried brown water residue around the edges.The DSS acknowledged the above findings and stated the dirty items above would be washed again to prevent cross-contamination and the floor drain would be cleaned. 2. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 2/11/26 at 0823 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed:- One stainless steel pizza cutter with a melted black handle;- T wo stainless steel spatulas with melted cream handles; and- One hand-held can opener was observed stored with rust-like residue on the edges.The DSS verified the above findings and stated the damaged items would be disposed of. 3. Review of the facility's P&P titled Dishwashing (undated) showed:- All dishes will be properly sanitized through the dishwasher.- Dishes are to be air dried in racks before stacking and storing According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 2/11/26 at 0823 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed:- Three stainless steel scoops were observed stored with water inside the scoops.The DSS verified the above findings and stated the items above were supposed to be air-dried.

Based on observation, interview, and medical record review, the facility failed to develop and/or implement the comprehensive care plans for two of 27 sampled residents (Residents 4 and 99) and three nonsampled residents (Residents 35, 118, and 124). * The facility failed to develop a care plan for Resident 118's use of buspirone HCl (an anxiety medication) and include the specific targeted behaviors in the care plan interventions for Resident 118's use of psychotropic medications. * The facility failed to implement the care plan intervention for Resident 99's bladder incontinence. * The facility failed to develop a care plan interventions to address when Resident 4 and 124 have tremors or was moving while being shaved during showers. * The facility failed to develop a care plan to address Resident 35's toenails. These failures posed the risk of not providing the residents' individualized, person-centered care and not meeting the residents' needs. Findings: Review of the facility's P&P titled Care Planning revised 1/2021 showed the interdisciplinary team shall develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs. Review of the facility's P&P titled Psychotropic Drug Use revised 8/2017showed an individualized, person-centered care plan will be initiated. 1. Medical record review for Resident 118 was initiated on 2/11/26. Resident 118 was admitted to the facility on [DATE]. Review of Resident 118's Order Listing Report showed the following physician's orders:- dated 2/4/26, for Ativan (an anxiety medication) 1 mg every six hours PRN for 14 days for anxiety as manifested by increased agitation;- dated 12/5/25, for olanzapine (an antipsychotic medication) 5 mg at bedtime for psychosis as manifested by angry outbursts as evidenced by resisting care;- dated 9/10/25, for buspirone HCl (an anxiety medication) 5 mg three times a day for anxiety as manifested by increased physical restlessness;- dated 12/7/25, for bupropion HCl (an antidepressant) 75 mg daily for depression as manifested by verbalization of sadness; and-dated 12/7/25, for paroxetine HCl (an antidepression medication) 10 mg daily for depression as manifested by outbursts of crying. Review of Resident 118's Care Plan Report showed a care plan problem to address the following:- anti-anxiety medication PRN use revised 8/19/25, the interventions included the use of Ativan medication. However, the care plan failed to address the resident's specific targeted behaviors of increased agitation for PRN Ativan use;- psychotropic medications related to behavior management/yelling/screaming behavior and angry outbursts revised 11/19/25, the interventions included the use of olanzapine medication. However, the care plan failed to include olanzapine's targeted behavior of resisting cares; - anti-depression medication revised 3/3/24. The care plan failed to show the resident's use of bupropion HCl and paroxetine HCl medications. In addition, the care plan failed to address the resident's targeted behaviors of verbalization of sadness and outbursts of crying. Further review of Resident 118's care plan failed to show a focused problem for the resident's use of buspirone HCl and address the targeted behavior of increased physical restlessness. On 2/17/26 at 1317 hours, an interview and concurrent record review was conducted with the DON. The DON verified the resident's care plan did not address the specific psychotropic medications and the resident's targeted behaviors. The DON was made aware and acknowledged the above findings. 2. Medical record review for Resident 99 was initiated on 2/11/26. Resident 99 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 99's H&P examination dated 2/11/26, showed Resident 99 had recurrent urinary tract infection (UTI), left side hemiplegia and hemiparesis. Review of Resident 99's MDS assessment, Section GG dated 12/4/25, showed Resident 99 was dependent on the staff members for toileting hygiene care. Review of Resident 99's plan of care initiated 9/30/2025, showed a care plan problem addressing Resident 99's bowel and bladder incontinence related to her history of UTIs and impaired mobility due to hemiplegia. The interventions included to provide the use of disposable briefs and to change Resident 99's briefs every two hours and as needed. Review of Resident 99's Tasks – Bladder Continence for January 2026 failed to show Resident 99 was provided brief changes every two hours. On 2/12/26 at 1539 hours, an interview and concurrent medical record review for Resident 99 was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated staff members caring for Resident 99 were expected to follow the resident's plan of care. On 2/12/26 at 1554 hours, an interview and concurrent medical record review for Resident 99 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated staff members were expected to follow the resident's plan of care. On 2/18/26 at 1325 hours, an interview and concurrent medical record review for Resident 99 was conducted with the DON. The DON verified the above findings and stated staff members should have implemented the interventions in Resident 99's plan of care including the brief changes every two hours because the interventions were specific to the resident's needs. The DON was informed and acknowledged the above findings. 3. On 2/13/26 at 1013 hours, an observation was conducted for Resident 4. Resident 4 was observed with multiple surficial cuts to his chin. On 2/13/26 at 1030 hours, an observation and concurrent interview was conducted with LVN 14. When asked about the cuts to Resident 4's chin, LVN 14 verbalized the cuts occurred while the resident was being shaved. Medical record for Resident 4 was initiated on 2/13/26. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 12/13/25, showed Resident 4 did not have the capacity to understand or make decisions. Resident 4's diagnoses included cerebral palsy, seizure disorder, chronic respiratory failure with dependency on a ventilator, and post GT placement. On 2/18/26, at 1041 hours, an interview was conducted with CNA 7. CNA 7 verbalized she did shower Resident 4 on 2/13/26. CNA 7 verbalized she thought Resident 4's cuts were already present at that time. When asked if CNA 7 had reported to nursing staff, CNA 7 stated she assumed the cuts had already been reported. When asked how she would shave the residents that moved around a lot during showers, CNA 7 stated very carefully. Review of Resident 4's Plan of Care failed to show a care plan problem with interventions to address Resident 4's episodes of tremors when being shaved during showers. On 2/18/26 at 907 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified there was no care plan problem developed to address Resident 4's episodes of tremors when being shaved during showers. 4. On 02/17/2026 at 1344 hours, an observation for Resident 124 and concurrent interview was conducted with LVN 16 and CNA 8 at bedside. Resident 124 was observed in bed with a horizontal superficial cut measuring approximately 2.5 inches, running across the lower part of Resident 124's chin. The left corner of the cut was observed as a circular open wound with blood running down the left side of Resident 124's chin. When asked about Resident 124's cut, CNA 8 stated the cut occurred while CNA 8 was shaving Resident 124 in the shower. CNA 8 verbalized Resident 124 jumped while she was shaving his chin. LVN 16 and CNA 8 verified Resident 124 had an open cut that had blood flowing down the left side of Resident 124's chin. Medical record review for Resident 124 was initiated on 2/17/26. Resident 124 was admitted to the facility on [DATE]. Resident 124's diagnoses included diabetes, brain damage, and epilepsy. Review of Resident 4's' Plan of Care failed to show a care plan problem with interventions to address Resident 4's episodes of tremors/or moving when being shaved during showers. On 2/18/26 at 0914 hours, an interview and concurrent medical record review for Resident 124 was conducted with RN 3. RN 3 verified there was no care plan problem developed to address Resident 124's episodes of tremors and/or moving when being shaved during showers. 5. On 2/13/26 at 1533 hours, an observation was conducted for Resident 35. Resident 35 was observed in bed with Resident 35's responsible party at bedside. Responsible Party 1 verbalized concerns with Resident 35's toenails not being cared for. Resident 35's both first digit toenails were observed extended beyond the tip of the toes. Responsible Party 1 granted permission for a focused body check to be conducted for Resident 35 with the nursing staff. On 2/13/26 at 1545 hours, an observation for Resident 35 and concurrent interview was conducted with LVN 14 and CNA 6. A body check for Resident 35 was conducted by LVN 14 and CNA 6. Resident 35's toenails were observed with brown discoloration and his first digit toenails were long, approximately half of an inch beyond the tip of the resident's toes. LVN 14 verified the finding. LVN 14 stated she thought Resident 35 was visited by the podiatrist last month. Medical record review for Resident 35 was initiated on 2/13/26. Resident 36 was readmitted to the facility on [DATE]. Review of Resident 35's H&P examination dated 2/23/25, showed Resident 35's diagnoses included cerebral palsy with quadriplegia, post status tracheostomy placement, post status GT placement. Review of Resident 35's Podiatry Progress Note dated 12/18/25, showed Resident 35's diagnoses included nail dystrophy (abnormal changes in the shape, color, texture, or growth of fingernails or toenails, often causing thickened, brittle, or deformed nails), tinea unguium (common fungal infection of the fingernails or toenails caused by dermatophytes, resulting in thickened, discolored (yellow/brown), brittle, and crumbling nails) and toe pain. Review of Resident 35's plan of care failed to show a care plan problem was developed to address Resident 35's toe nails. On 2/18/26 at 852 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified there was no care plan problem developed to address Resident 35's toenails.

Based on observations, interviews, medical record reviews, and facility P&P review, the facility failed to provide the necessary respiratory care services for three sampled residents (Residents 23, 49, and 55) and two nonsampled resident (Residents 25 and 64) reviewed for respiratory care. * The facility failed to ensure Resident 23 was administered with oxygen as ordered by the physician. * The facility failed to notify the physician and hospice care when Resident 49 was not provided the BiPAP machine nightly as ordered due to a missing piece of the BiPAP mask. * The facility failed to ensure Resident 25's nasal cannula was stored in a sanitary condition when not in use. *The facility failed to ensure Resident 64's nasal cannula was stored in a sanitary condition. * The facility failed to ensure Resident 55 was not left unattended during administration of albuterol treatment (bronchodilator medication). These failures had the potential to affect the respiratory health and well-being of the residents in the facility.Findings: Review of the facility's P&P titled Oxygen Administration (Mask, Cannula, Catheter, Use of Humidifier) revised 12/2023 showed oxygen therapy is administered as ordered by the physician or as an emergency measure until the order can be obtained. 1. On [DATE] at 1432, an observation was conducted for Resident 23. Resident 23 was observed in bed in his room. Resident 23 was receiving oxygen at a rate of 2.5 liters per minute via nasal cannula. Medical record review for Resident 23 was initiated on [DATE]. Resident 23 was readmitted to the facility on [DATE]. Review of Resident 23's Order Summary Report showed a physician's order dated [DATE], to administer continuous oxygen at a rate of two liters per minute via nasal cannula. On [DATE] at 1554 hours, a follow-up observation, concurrent interview and medical record review for Resident 23 was conducted with RN 1. RN 1 verified Resident 23 was receiving 2.5 liters per minute rate of oxygen. RN 1 stated Resident 23 should only receive oxygen at a rate of two liters per minute as per the physician's order. On [DATE] at 0821 hours, another follow-up observation was conducted for Resident 23. Resident 23 was observed in bed in his room. Resident 23 was receiving oxygen at a rate of 2.5 liters per minute via nasal cannula. On [DATE] at 1325 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 49 was initiated on [DATE]. Resident 49 was readmitted to the facility on [DATE] and expired on [DATE]. Review of Resident 49's H&P examination dated [DATE], showed Resident 49 was receiving hospice care and had diagnoses of COPD and obstructive sleep apnea. Review of Resident 49's Order Summary Report showed the following physician's orders: -dated [DATE], to admit the resident to hospice care for her diagnosis of COPD, -dated [DATE], to call the hospice care for any changes in condition or for new orders, and -dated [DATE], to apply the BiPAP to the resident at bedtime with the following settings: IPAP =12 cmH2O, EPAP = 5 cmH2O, pressure support 4 cmH2O with 3 liters per minute of oxygen. Review of Resident 49's Progress Notes - Respiratory Therapy progress notes showed Resident 49 was not provided the BiPAP machine due to a missing piece of the BiPAP mask which provided comfort and complete seal for Resident 49. In addition, the progress notes showed the licensed nurses were made aware Resident 49 was not placed on the BiPAP machine on the following dates and times: - dated [DATE] at 2343 hours;- dated [DATE] at 2211 hours; - dated [DATE] at 0225 hours;- dated [DATE] at 0022 hours;- dated [DATE] at 0404 hours;- dated [DATE] at 0533 hours; - dated [DATE] at 0229 hours;- dated [DATE] at 0400 hours;- dated [DATE] at 0425 hours;- dated [DATE] at 0514 hours; and- dated [DATE] at 0040 hours. On [DATE] at 1554 hours, an interview and concurrent medical record review for Resident 49 was conducted with RN 1. RN 1 reviewed Resident 49's medical record and verified there was no documentation if a staff member followed up with the hospice care team or informed the physician when Resident 49 was not placed on the BiPAP machine due to a missing piece of the BiPAP mask. When asked who was responsible for informing the hospice care team or the physician, RN 1 stated the licensed nursing staff. On [DATE] at 1325 hours, an interview and concurrent medical record review for Resident 49 was conducted with the DON. The DON stated Resident 49 refused to wear the BiPAP mask because she was not comfortable. When asked if the physician was made aware of Resident 49's refusals, the DON stated no. The DON verified and acknowledged the above findings. The DON stated the expectation was to follow up with the hospice care team and physician regarding the missing piece of the BiPAP mask. 3. On [DATE] at 1008 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 25 at bedside. Resident 25 was observed in bed, awake with oxygen via nasal cannula from concentrator machine at a rate of 2 liters per minute. Resident 25 stated he would use oxygen at night and he could take it off anytime when he was awake during the day. Resident 25 was observed removing his nasal cannula attached to the oxygen tubing and placed the tubing on the hook attached to the over the bed table. Resident 25 stated the staff placed the hook on the table so it will not end up on the ground. Medical record review for Resident 25 was initiated on [DATE]. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's MDS assessment dated [DATE], showed a BIMS score of 15, meaning cognitively intact. Review of Resident 25's Order Summary Report dated [DATE] showed a physician order dated [DATE] to administer oxygen at a rate of 2 liters per minute via nasal cannula continuously every shift. On [DATE] at 1109 hours, an observation and concurrent interview was conducted with LVN 7 at Resident 25's bedside. Resident 25 was observed not using oxygen and the nasal cannula was hanging on the hook attached to the over the bed table. LVN 7 verified the nasal cannula was hanging on the hook attached to the over the bed table. On [DATE] at 0851 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 2. RN 2 stated the oxygen tubing should be placed in a clear plastic bag with label when not in use. RN 2 verified Resident 25 had a physician order for the use of oxygen therapy. RN 2 was informed of the above findings. 4. On [DATE] at 1223 hours, during the dining observation, Resident 64 was observed in bed eating her lunch meal. Resident 64's nasal cannula attached to the oxygen tubing was observed in the floor. On [DATE] at 1344 hours, a follow-up observation and concurrent interview was conducted with LVN 13 at Resident 64's bedside. Resident 64's nasal cannula attached to the oxygen tubing was observed on the floor. LVN 13 verified Resident 64's nasal cannula was on the floor. LVN 13 stated she will change the oxygen tubing. Medical record review for Resident 64 was initiated on [DATE]. Resident 64 was admitted to the facility on [DATE]. Review of Resident 64's MDS assessment dated [DATE], showed a BIMS score of 15, meaning cognitively intact. Review of Resident 64's Order Summary Report dated [DATE], showed a physician order dated [DATE], to administer oxygen at 2 liters per minute via nasal cannula as needed to keep oxygen saturation above 90%. On [DATE] at 0856 hours, an interview and concurrent medical record review for Resident 64 was conducted with RN 2. RN 2 verified Resident 64's used oxygen therapy as needed as per the physician's order. RN 2 was informed Resident 64's nasal cannula attached to the oxygen tubing was observed on the floor. RN 2 acknowledged the findings. On [DATE] at 1006 hours, an interview and concurrent medical record review for Residents 25 and 64 was conducted with the DON. The DON was informed and acknowledged the above findings. 5. Review of the facility's P&P titled Respiratory Medications (undated) showed RT and RN only who are administering respiratory medications shall assess and document side effects of and reaction to the medication given, and report to nursing and the resident's physician any reaction to the medication; and staff shall administer medications according to the policy above. On [DATE] at 1033 hours, an observation and concurrent interview was conducted with Resident 55. RT 2 was observed entering Resident 55's room to administer breathing treatment to Resident 55. RT 2 was observed exiting Resident 55's room and leaving Resident 55 with his breathing treatment on. When asked if the staff would leave the room with his breathing treatment on other occasions, Resident 55 whispered sometimes the staff would leave him while he receive his breathing treatment. RT 2 was observed pacing in the hallway outside Resident 55's room and then observed standing outside Room C. On [DATE] at 1047 hours, RT 2 was observed returning to Resident 55's room. Medical record review for Resident 55 was initiated on [DATE]. Resident 55 was readmitted to the facility on [DATE]. Review of Resident 55's H&P examination dated [DATE], showed Resident 55 had the capacity to understand and make decisions. Resident 55's diagnoses included ALS, chronic respiratory failure requiring tracheostomy and ventilator dependence, history of shortness of breath, history of pneumonia, and functional quadriplegia. Review of Resident 55's Order Summary Report showed the following physician's order for wheezing and shortness of breath: - dated [DATE], for albuterol solution 3 ml via Resident 55's ventilator every six hours; and - dated [DATE], for albuterol solution 3 ml via Resident 55's tracheostomy three times daily. On [DATE] at 1505 hours, an interview was conducted with RT 2. When asked about leaving Resident 55 unattended with his breathing treatment, RT 2 stated it was okay for RT 2 to exit Resident 55's room and leave Resident 55 with his albuterol treatment because Resident 55's visitor was inside the room with Resident 55. RT 2 stated as long as RT 2 was within earshot of Resident 55 he could exit Resident 55's room while Resident 55 was receiving his albuterol breathing treatment. RT 2 acknowledged he was outside Room C and was walking up and down in the hallway outside Resident 55's room. RT 2 further stated it was okay because Resident 55's family member could report any change in condition to RT 2. On [DATE] at 1430 hours, an interview was conducted with the DON. The DON was made aware of the findings.

Based on interview, medical record review, and facility P&P review, the facility failed to follow-up on the consultant pharmacist's recommendations for one of five final sampled residents (Resident 118) investigated for unnecessary medications.* The consultant pharmacist's report for December 2025 showed a recommendation to update Resident 118's behaviors for PRN Ativan (a medication for anxiety) to include specific and quantifiable behaviors targeted. This failure resulted in the continued deficient practice of inappropriate behavior being targeted by Resident 118's psychotropic medication use. Findings: Review of the facility's P&P titled Medication Regimen Review (MRR) revised 8/2027 showed the consultant pharmacist will review residents' medical records monthly, irregularities will be documented and provided to the facility within seven working days. The report will be acted upon, and nursing personnel will provide a written response. Review of the Consultant Pharmacist's Medication Regimen Review for December 2025, showed for Resident 118, agitation or restlessness is too subjective and should not be used as a diagnosis nor as a behavior. Please update the resident's PRN Ativan order with a specific and quantifiable behavior based on the resident's words or action such as striking out, resisting care, continuous yelling/screaming. Under the follow-through column for facility follow-up notes, a ? was handwritten. Medical record review for Resident 118 was initiated on 2/11/26. Resident 118 was admitted to the facility on [DATE]. Review of Resident 118's Order Listing Report showed the following physician's orders for Ativan:- dated 12/3/25, for Ativan 1 mg every six hours PRN for increased agitation. The order was discontinued on 12/7/25;- dated 12/8/25, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by increased agitation;- dated 1/1/26, for Ativan 1 mg every six hours PRN for 14 days, for increased agitation; - dated 1/20/26, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by increased agitation; and- dated 2/4/26, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by increased agitation. Review of Resident 118's medical record failed to show the facility followed up on the consultant pharmacist's recommendations and notified the physician to update the order with a specific and quantifiable behavior for anxiety. On 2/17/26 at 1317 hours, an interview and concurrent medical record review for Resident 118 was conducted with the DON. The DON verified the facility failed to follow up on the consultant pharmacist's recommendations to update the behaviors for the PRN Ativan use.

Based on observation, interview, and facility document review, the facility failed to maintain an effective pest control program to prevent the presence of an insect in Resident 132's room. * An insect was found crawling near Resident 132's bed. This failure had the potential for pests to multiply, and the presence of pest associated germs.Findings: Medical record review for Resident 132 was initiated on 2/11/26. Resident 132 was admitted to the facility on [DATE]. Review of Resident 132's MDS assessment dated [DATE], showed Resident 132 was severely impaired and never/rarely made decisions. On 2/11/26 at 1107 hours, during the initial tour of the facility, an observation was conducted with LVN 15 and Consultant 3 inside Resident 132's room. An insect was observed crawling near Resident 132's bed. The insect crawled under Resident 132's bed and LVN 15 and Consultant 1 were able to secure the insect and remove it from Resident 132's room. On 2/11/26 at 1233 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated there was a pest control company that came to the facility every two weeks, but the pest company did not spray inside the resident rooms due to the risks of the chemicals being used. The Maintenance Director added the pest control company sprayed the inside and outside perimeter of the facility. On 2/17/26 at 1130 hours, an interview was conducted with the DON. The DON verified Resident 132 was part of a vulnerable population and the facility should not have pests that could potentially jump into the residents' beds and possibly get into their mouths. On 2/17/26 at 1335 hours, an interview was conducted with the Administrator. The Administrator acknowledged Resident 132 was part of a vulnerable population and the facility should not have pests in the facility that could jump on the residents' who were not able to verbalize their needs. *Cross reference F584.

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure necessary care and services related to GT feeding were provided for two of two final sampled residents (Residents 2 and 144) and one nonsampled resident (Resident 30) reviewed for tube feedings. * The facility failed to ensure Resident 2 was administered the water flush via GT at the correct rate according to the physician's orders. * The facility failed to ensure Resident 30 was administered the enteral feeding via GT at the correct rate according to the physician's orders. * The facility failed to ensure Resident 144's HOB was elevated at least 30 degrees or greater during the enteral feeding to reduce the risk of aspiration. In addition, the failed to failed to ensure the GT residual monitoring was accurately documented. These failures posed the risk for complications related to use of the GT.Findings: 1. On 2/11/26 at 0930 hours, during the initial tour of the facility, Resident 2's GT feeding and water flush pump was connected to Resident 2. The water flush was set at 30 cc/hr. Medical record review for Resident 2 was initiated on 2/11/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 1/15/26, showed Resident 2 did not have the capacity to make needs known and or make medical decisions. Review of Resident 2's Order Summary Report showed a physician's order dated 8/3/25, to provide 500 cc water at 25 cc/hr x 20 hours via PEG-tube one time a day. Start at 1500 hours, run until total volume delivered. Change water bag every 24 hours. 2. On 2/11/26 at 1005 hours, during the initial tour of the facility, Resident 30's GT feeding and water flush pump was connected to Resident 30. The GT feeding was set at 65 cc/hr. Medical record review for Resident 30 was initiated on 2/11/26. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's H&P examination dated 8/6/25, showed Resident 30 did not have the capacity to understand and make decisions. Review of Resident 30's Order Summary Report showed a physician's order dated 1/16/26, to provide 1200 cc Diabetisource AC formula at 60 cc/hr x 20 hours, to provide 1440 kcal via PEG-tube. Start at 1500 hours, run until total volume delivered. On 2/11/26 at 1430 hours, an observation of Residents 2 and 30's GT feeding and water flush pump, interview and concurrent medical record review for Residents 2 and 30 was conducted with LVN 12. LVN 12 verified the water flush rate for Resident 2 was incorrect and should be set at 25 cc/hr. LVN 12 verified the GT feeding rate for Resident 30 was incorrect and should be set at 60 cc/hr. LVN 12 stated night shift nurses set up the GT feeding, but she should have verified the rates to the physician's orders when doing patient rounds. On 2/17/26 at 1130 hours, an interview and concurrent medical record review for Residents 2 and 30 was conducted with the DON. The DON verified the water flush rate set for Resident 2 did not match the physician's order. The DON also verified the GT feeding rate set for Resident 30 did not match the physician's order. On 2/18/26 at 1455 hours, a follow-up interview was conducted with the DON. The DON stated it was the responsibility of the charge nurse or the nurse supervisor to verify the water flush and GT feeding rates are set according to the physician's orders. 3. Medical record review for Resident 144 was initiated on 2/12/26. Resident 144 was admitted to the facility on [DATE]. Review of Resident 144's H&P examination dated 5/29/25, showed Resident 144 was GT feed dependent. Review of Resident 144's Order Summary Report dated 2/17/26, showed the following physician's orders: - dated 6/5/25, to administer Fibersource HN (enteral feeding formula) at 50 ml/hr via the GT; - dated 6/5/24, to elevate HOB 30 to 45 degrees during and one hour after feeding; and - dated 6/5/24, to check residuals and hold tube feeding if residuals above 150 ml, and to resume after two hour period. a. On 2/17/26 at 0842 hours and 0952 hours, Resident 144 was observed lying in bed asleep with Fibersource HN infusing at 50 ml/hr via GT. The HOB was slightly elevated and not at least 30 degrees. On 2/17/26 at 1003 hours, an observation of Resident 144 and concurrent interview was conducted with LVN 6 at Resident 144's bedside. LVN 6 stated when the enteral feeding was infusing, the HOB should be elevated at 30 degrees or more to prevent aspiration. LVN 6 verified Resident 144's GT feeing was infusing and the HOB was not at least 30 degrees. LVN 6 stated she determined the elevation of the HOB by looking at the bed to see if it was high enough. LVN 6 further stated she was uncertain on how high the HOB specific measurement was because there was no leveler device. LVN 6 verified the above findings. On 2/18/26 at 0903 hours, an interview and concurrent medical record review for Resident 144 was conducted with RN 2. RN 2 stated the licensed nurses should check the physician order for the GT feeding, check the placement of the GT and make sure the HOB was elevated to 30 to 45 degrees to prevent the risk of aspiration. RN 2 verified there was no specific device to measure the height of the HOB. RN 2 was informed of and verified the findings. RN 2 stated the HOB should have been elevated to at least more than 30 degrees when the GT feeding was infusing. b. Review of Resident 144's MAR for January and February 2026 showed to monitor the GT feeding residual every shift to be conducted by the licensed nurses. However, there was no specific amount of gastric residual documented. On 2/17/26 at 1003 hours, an interview and concurrent medical record review for Resident 144 was conducted with LVN 6. LVN 6 verified she checked Resident 144's GT residual on her shift before administering the medication and start of the GT feeding. LVN 6 stated she documented the residual in the MAR and in the progress note so the next nurse would know on how much residual the resident had. LVN 6 was informed and verified the monitoring of GT residual did not have the specific amount of gastric residual documented. On 2/18/26 at 0903 hours, an interview and concurrent medical record review for Resident 144 was conducted with RN 2. RN 2 stated the licensed nurses should check the GT residual before administering medication and starting the GT feeding, and document the result in the MAR. RN 2 reviewed Resident 144's MAR for the GT residual monitoring and verified the licensed nurses should have written the exact amount of the residual drawn from the GT when it was checked. On 2/18/2026 at 1022 hours, an interview and concurrent medical record review for Resident 144 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, and medical record review, the facility failed to provide foot care for one of non-sampled resident (Resident 35). * Resident 35's toenails were long and had brown discoloration. This failure posed the risk of further deterioration to Resident 35's toenails. Findings: On 2/13/26 at 1533 hours, Resident 35 was observed in bed with Resident 35's responsible party (Responsible Party 1) at bedside. Responsible Party 1 verbalized concerns with Resident 35's toenails not being cared for. Resident 35's first digit toenail was observed extended beyond the tip of the toes. Responsible Party 1 granted permission for a focused body check for Resident 35 to be conducted with the nursing staff. On 2/13/26 at 1545 hours, a body check for Resident 35 was conducted with LVN 14 and CNA 6. Resident 35's toenails were observed with brown discoloration and his first digit toenail was extended approximately one half inch beyond the resident's tip of the toe. LVN 14 verified the finding. LVN 14 stated she thought Resident 35 was visited by the podiatrist last month. Medical record review for Resident 25 was initiated on 2/13/26. Resident 36 was readmitted to the facility on [DATE]. Review of Resident 35's H&P examination dated 2/23/25, showed Resident 35's diagnoses included cerebral palsy with quadriplegia (permanent impairment of motor function in all four limbs, the neck, and the trunk due to brain damage), post status tracheostomy placement, post status GT placement. Review of Resident 36's Podiatry Progress Note dated 12/18/25, showed Resident 36's diagnoses included nail dystrophy (abnormal changes in the shape, color, texture, or growth of fingernails or toenails, often causing thickened, brittle, or deformed nails), tinea unguium (common fungal infection of the fingernails or toenails caused by dermatophytes, resulting in thickened, discolored (yellow/brown), brittle, and crumbling nails) and toe pain. On 2/17/26 at 1140 hours, an interview and concurrent medical record review for Resident 35 was conducted with the SSD. The SSD stated Resident 35's last podiatry visit was on 12/18/25. The SSD stated Resident 35's insurance covered podiatry visits every 90 days and as needed. The SSD stated no one informed her of the concern with Resident 35's toenails for her to arrange an appointment.

Based on observation and interview, the facility failed to provide a homelike environment for two of 27 sampled residents (Residents 55 and 132) and one nonsampled resident (Resident 79). * Stack of mattresses, boxes, and other miscellaneous items were stored outside; however, the items could be seen from Resident 55's window and were visible from the hallway. * Stack of wooden boards and orange traffic cones were stored outside; however, the items could be seen from Resident 79's window and were visible from the hallway. * Resident 132's room was not thoroughly cleaned. These failures had the potential for the residents to not have a home-like environment that could negatively affect the resident's well-being. Findings: 1. On 2/11/2026 1250 hours, anobservation was conducted in the hallway outside Resident 55's room. A stack of mattresses, boxes, and other miscellaneous items could be seen outside Resident 55's window and were visible from the hallway. Resident 55 was observed glancing outside the window facing the stack of mattresses, boxes, and miscellaneous items. An observation and concurrent interview was conducted with Resident 55. When asked about the stack of mattresses, boxes, and other miscellaneous items visible from his window, Resident 55 answered with a gesture which appeared to be a dislike to what he was seeing. When asked how long the items had been stored outside, Resident 55 whispered I did not know what that (the items) all was. On 02/11/2026 at 1258 hours, concurrent observation and interview was conducted with the Maintenance Director and Resource Maintenance. When asked about the items stored outside Resident 55's window, the Maintenance Director stated the area outside Resident 55's window was a storage area. The Maintenance Director stated there used to be a curtain to cover the area so the items stored were not visible from the resident's window. When asked about the stack of mattresses, the Maintenance Director stated the mattresses were to be thrown into the trash. When asked how long the stack of mattresses had been there, the Maintenance Director was unable to determine for how long. When asked how long the area had been without a curtain, the Maintenance Director stated about two weeks. Medical record review for Resident 55 was initiated on 2/11/26. Resident 55 was readmitted to the facility on [DATE]. Review of Resident 55's H&P examination dated 1/29/26, showed Resident 55's diagnoses included ALS, functional quadriplegia, chronic respiratory failure, post status tracheostomy placement with dependency on a ventilator. Resident 55 was bedbound. Further review of Resident 55's H&P examination showed his social preference included to remain in his room. 2. On 02/11/2026 at 1553 hours, an observation was conducted in the hallway outside Resident 79's room. A pile of wooden boards and orange traffic cones could be seen outside Resident 79's window and were visible from the hallway. Resident 79 was observed up on her wheelchair facing the window. An observation and concurrent interview was conducted with Resident 79. When asked about the visible items from her window, Resident 79 verbalized she did not like seeing the pile of wood boards and orange cones outside her window. When asked about her activities, Resident 79 verbalized she liked staying in her room and her activities included sketching inside her room. When asked how long the items had been there, Resident 79 stated maybe since she was admitted to the facility. On 02/11/2026 at 1605 hours, an observation and concurrent interview was conducted with RN 4. When asked about the pile of wood boards and orange traffic cones visible from Resident 79's window, RN 4 stated she did not know and would ask maintenance staff. On 02/11/2026 at 1620 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified the findings. When asked about the pile of wooden boards and orange traffic cones stored outside Resident 79's window, the Maintenance director stated he did not know for how long the items had been stored outside. On 2/11/26, medical record review for Resident 79 was initiated. Resident 79 was readmitted to the facility on [DATE]. Review of Resident 79's H&P examination dated 12/22/25, showed Resident 79's diagnoses included respiratory failure, asthma, and anxiety. Resident 79 did not have cognitive impairment. 3. On 2/11/26 at 1107 hours, during the initial tour of the facility, an observation was made of an insect crawling near Resident 132's bed. While attempting to secure the insect, the floor under and surrounding Resident 132's bed was observed to have a thick layer of dust under the bed and on the baseboard behind the bed. Additionally, there was crumpled trash and IV caps on the floor. LVN 15 and Consultant 3 verified the dust under the bed and on Resident 132's headboard and trash on the floor. Medical record review for Resident 132 was initiated on 2/11/26. Resident 132 was admitted to the facility on [DATE]. Review of Resident 132's MDS Section C assessment dated [DATE], showed Resident 132 was severely impaired and never/rarely made decisions. Review of the Daily Deep Cleaning to a Room Per Day Log for January 2026 showed Resident 132's room was deep cleaned on 1/26/26. Review of the facility's document titled Housekeeping Cleaning showed EVS (Environmental Services) were responsible for cleaning and disinfecting the baseboard and headboard and dusting and mopping the floor daily and as needed. On 2/17/26 at 1130 hours, an interview was conducted with the DON. The DON stated there was a standard of cleaning the housekeepers should be doing daily. The DON was made aware and acknowledged the amount of dust under Resident 132's bed was more than just one day of missed cleaning. On 2/18/26 at 1045 hours, an interview was conducted with Housekeeper 2. Housekeeper 2 verified it was their job responsibility to sweep and mop in the residents' room daily, including under the beds. *Cross Reference F925

Based on observation, interview, facility record review, and facility P&P review, the facility failed to provide privacy to two non- sampled residents (Resident 56 and 129). * The facility failed to ensure the privacy curtain was completely closed while providing care for Residents 56 and 129. These failures posed the risk of exposing the resident's body to other residents, staff and visitors, and had the potential to negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Resident Rights dated 11/2021 showed residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers- by. Review of the facility's undated P&P titled Suctioning Via Tracheostomy Tube Using an Inline (Closed System) Catheter (undated) showed to provide the resident privacy during the procedure. Review of the facility's undated P&P titled Tracheostomy Care (undated) showed to provide resident privacy during the procedure. 1. On 2/13/2026 at 0844 hours, a medication administration observation for Resident 129 was conducted with LVN 9. a. During the medication administration observation, LVN 9 was observed administering Resident 129's medications via GT with the privacy curtain not completely closed. The privacy curtain was closed only up to the left side of the foot board of the bed. Resident 129's abdominal area was exposed and a staff member walked by to go to Resident 129's roommate. When asked about the privacy curtain, LVN 9 stated the curtain should cover the resident completely. LVN 9 further stated I forgot. b. On 2/13/26 at 0920 hours, a medication preparation was conducted with LVN 2. While LVN 2 was preparing the medications outside Resident 129's room, RT 1 went in Resident 129's room and performed tracheostomy care and suctioning to Resident 129. RT 1 did not completely close the privacy curtain, and RT 1 could be seen outside the room performing the procedures. Medical record review for Resident 129 was initiated on 2/13/26. Resident 129 was admitted to the facility on [DATE]. Review of Resident 129's Progress Notes dated 2/12/26, showed Resident 129 was alert, oriented to time, place and persons, communicates verbally with clear speech and is able to understand and be understood when speaking. Review of Resident 129's Medication Review Report dated 2/13/26, showed the following physician's order:- dated 1/30/25, tracheostomy care every day and night shift; and- dated 11/9/25, to assess the need to suction the tracheostomy and/or oral secretions every two hours and PRN for pulmonary toilet management. On 2/13/26 at 0938 hours, an interview was conducted with RT 1. RT 1 was asked why the privacy curtain was not completely closed during the tracheostomy care and suctioning, RT 1 stated I did not know I have to fully close the curtain; I am not aware. 2. On 2/13/26 at 0934 hours, a medication administration observation for Resident 56 was conducted with LVN 9. When LVN 9 was in the process of administering Resident 56's GT medications, the privacy curtain was observed less than halfway closed and did not cover Resident 56 completely. LVN 9 was asked about the privacy curtain and LVN 9 stated I should have closed it completely to provide privacy. Medical record review for Resident 56 was initiated on 2/13/26. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's H&P examination dated 12/8/25, showed Resident 56 does not have the capacity to understand and make decisions. Review of LVN 9's New Employee Orientation Checklist dated 11/4/25, showed LVN 9 was educated on Resident's Rights which included personal privacy. Review of RT 1's Orientation Program completed on 4/2/25, showed RT 1 was educated on Patient's Rights; Resident Rights and Person-Centered Care. On 2/13/26 at 0945 hours, an interview was conducted with RN 5. RN 5 was informed of the above observations of LVN 9 and RT 1's failure to completely close the privacy curtain when providing care to Residents 129 and 56. RN 5 acknowledged the above findings and stated the privacy curtain should have been fully closed. On 2/18/26 at 1108 hours, an interview and facility record review was conducted with the DRT. The DRT stated he would educate the RTs upon employment and during meetings. The DRT stated for any respiratory care procedure being done, the curtains have to be closed at all times. The DRT was informed and acknowledged the above findings. On 2/18/26 at 1342 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one sampled resident (Resident 81) and two non-sampled residents (Resident 41 and 130) were assessed, had a care plan and a physician's order to self-administer the medications. * A ketoconazole (antifungal medication) cream was observed on top of Resident 81's bedside drawer. There were no assessment, care plan or physician's order to self-administer the medication. * A bottle of Hydrogen Peroxide (antiseptic solution ) topical solution and a jar of Desitin (anti rash medication) maximum strength was observed on top of Resident 41's night stand. There were no assessment, care plan or physician's order to self-administer the medication. * A Debrox earwax removal aid was observed on top of Resident 130's nightstand. There were no assessment, care plan or physician's order to self-administer the medication. These failures had the potential for the residents to administer the medication inaccurately and negatively impact the residents' physiological well-being.Findings: Review of the facility's P&P titled Self-Administration of Medication (undated) showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The P&P further showed the following: - Medications to be self-administered are specifically ordered and monitored by the facility nursing staff. - If a resident requests to self-administer drugs the IDT will determine if the practice is safe before the resident may exercise this right. - The IDT will determine who is responsible for the storage of the drugs and documentation of the administration of the drugs, as well as the location of drug administration. 1. On 2/11/26 at 0910 hours, during the initial tour of the facility, Resident 81 was observed asleep in bed. A tube of ketoconazole cream (anti-fungal medication) was observed on top of the bedside drawer. On 2/11/2026 at 1023 hours, a follow-up bedside observation and concurrent interview was conducted with LVN 13 for Resident 81. LVN 13 verified the ketoconazole medication was on top Resident 81's bedside drawer. LVN 13 stated Resident 81's parents were both doctors and wanted to treat their son on what they wanted, including applying the medication to the resident by themselves. Medical record review for Resident 81 was initiated on 2/12/26. Resident 81 was admitted to the facility on [DATE]. Review of Resident 81's Physician Progress Note dated 2/12/26, showed Resident 81 does not have the capacity to make medical decisions. Review of Resident 81's Order Summary Report dated 2/12/26, showed a physician's order dated 2/12/26, to administer Ketoconazole cream 2% to the perineal area topically every day. However, review of the Order Summary Report failed to show documented evidence for a physician order for the medication to be stored at bedside. Further review of the medical records failed to show documented evidence a self-administration assessment was conducted. On 2/18/2026 at 0859 hours, an interview and concurrent medical record review for Resident 81 was conducted with RN 2. RN 2 stated an assessment of the resident who wished to self-administer the medication should be conducted and a physician order should be obtained with special instruction for the self-administration of the medication. RN 2 was informed of the observation of Resident 81's topical medication at bedside. RN 2 verified and acknowledged Resident 81 have no physician order to self-administer or to leave the medication at bedside. In addition, RN 2 verified there was no assessment of self-administration of the medication conducted. On 2/18/26 at 1018 hours, an interview and concurrent medical record review for Resident 81 was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 2/11/26 at 0932 hours, during the initial tour of the facility, a bottle of Hydrogen Peroxide topical solution and a jar of Desitin maximum strength paste were observed on top of Resident 41's nightstand. When asked about the medication at bedside, Resident 41 was unable to respond to the questions. Medical record review for Resident 41 was initiated on 2/12/26. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's H&P examination dated 11/1/25, showed Resident 41 does not have full medical capacity to make decisions due to significant cognitive impairment secondary to traumatic brain injury. Review of Resident 41's Order Summary Report dated 2/12/26, failed to show the orders for the use of Desitin paste and Hydrogen Peroxide topical solution. On 2/11/25 at 1018 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified the Hydrogen Peroxide topical solution and Desitin paste was on top of Resident 41's nightstand. CNA 2 stated there should be no medications at bedside, and I am not assigned to this resident though. On 2/11/26 at 1043 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the Desitin paste and Hydrogen Peroxide bottle were on top of Resident 41's nightstand. LVN 2 stated the family would bring and use their own products. LVN 2 stated they would brush the resident's teeth using Hydrogen Peroxide and then would clean him and use the Desitin cream. LVN 2 further stated the family was aware there should be no medications at bedside, but they would continue to bring the medications. LVN 2 acknowledged the Desitin paste and Hydrogen Peroxide topical solution should have been locked, if kept at bedside it would need a physician's order. 3. On 2/11/26 at 1038 hours, during initial tour of the facility, a box of Debrox earwax removal aid was observed on top of Resident 130's nightstand. Resident 130 stated he bought it himself and would use it to remove the earwax. Resident 130 further stated the staff were aware that he would use the eardrops by himself and the last time he used them was this morning. On 2/11/26 at 1040 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified there was a box of Debrox earwax removal aid on top of Resident 130's nightstand. LVN 2 opened the box and there was a white bottle inside the box labeled Debrox earwax removal aid, 15 ml. LVN 2 stated there should be no medications at bedside. Medical record review for Resident 130 was initiated on 2/12/26. Resident 130 was admitted to the facility on [DATE]. Review of Resident 130's H&P examination dated 9/26/25, showed Resident 130 had full capacity to make his own healthcare decisions and provide informed consent. Review of Resident 130's Order Summary Report dated 2/12/26, failed to show a physician's order for the use of Debrox earwax removal aid. Further review of Resident 130's medical record failed to show an assessment and care plan to address Resident 130's use of Debrox earwax. On 2/11/2026 at 1054 hours, an interview was conducted with the ADON. The ADON was informed of the Debrox earwax removal aid at Resident 130's nightstand. The ADON acknowledged the observation and stated there should be no medication at bedside. On 2/18/26 at 1342 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Based on observation, interview, medical record, facility record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one of six nonsampled residents (Resident 56) observed for medication administration. * The facility failed to ensure Resident 56's baclofen (a muscle relaxant) was administered as per the physician's order. This failure posed a risk for the resident to experience muscle spasms and could negatively affect the resident's well-being.Findings: Review of facility's P&P titled Guidelines for Medication Administration (undated) showed routinely scheduled medications will be administered at the times specified in the Standard Times for Medication Doses. Review of facility's document titled Medication Administration Times showed twice a day schedule was to begiven at 0900 and 1700 hours. Review of the facility's P&P titled Obtaining and Refilling Medications Policy dated 2/2017 showed: - it is the policy of the facility to obtain medications from new physician orders and refill medications needed in a timely manner; and - it is the responsibility of each staff member who passes medications, to ensure each resident has an adequate amount of every prescribed medication at all times. On 2/13/26 at 0927 hours, a medication administration observation was conducted with LVN 9. During the medication preparation for Resident 56, LVN 9 stated she will not be able to administer the baclofen medication as scheduled at 0900 hours. LVN 9 further stated the baclofen medication was not available and should be delivered soon. Medical record review for Resident 56 was initiated on 2/13/26. Resident 56 was admitted to the facility on [DATE]. Review of Resident 56's H&P examination dated 12/18/25, showed Resident 56 does not have the capacity to understand and make decisions. Review of Resident 56's Order Summary Report dated 2/13/26 showed the following physician's orders:- dated 5/16/24, to give saccharomyces boulardii (a medication supporting gut health, boost immune system and aid digestion) oral capsule, one capsule via GT one time a day for probiotic;- dated 6/17/24, to give metoprolol tartrate (antihypertensive medication) 50 mg via GT two times a day for high blood pressure;- dated 9/8/24, to give carbidopa-levodopa (medication used to manage tremors, stiffness and slowness of movement) oral tablet 25-250 mg one tablet via GT five times a day for Parkinson's disease;- dated 5/19/25, to give hydroxyzine HCL (medication used to treat itching caused by allergic reaction) oral tablet, one tablet via GT two times a day for itching; and - dated 10/6/25, to give baclofen oral suspension 25mg/5 ml, two ml via GT two times a day. Review of Resident 56's MAR for February 2026 showed LVN 9's initial and a code 7 (other/see nurses notes) as the entry for the baclofen medication administration for 2/13/26 at 0900 hours. Review of Resident 56's Nurses Progress Notes dated 2/13/26, showed a documentation of the physician notification when the baclofen was not administered and pending pharmacy delivery. On 2/13/26 at 1439 hours, an interview was conducted with LVN 9. LVN 9 stated the baclofen was not delivered yet and the desk nurse LVN 11 had called the pharmacy and notified the physician. On 2/13/26 at 1457 hours, an interview and concurrent record review was conducted with LVN 11. LVN 11 was asked about the facility's usual practice for when the medication was unavailable medication. LVN stated as long as it gets delivered by the pharmacy for Resident 56, we could give the resident acetaminophen (pain medication) as an alternative for the meantime. LVN 11 was asked if the acetaminophen medication a muscle relaxant, LVN 11 stated no. LVN 11 acknowledged Resident 56's baclofen medication should have been refilled ahead of time.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary medications for one of five sampled residents (Resident 118) reviewed for unnecessary medications. * The facility failed to ensure Resident 118 had appropriate targeted behaviors and a documented clinical rationale for the continued use PRN Ativan use. In addition, monthly psychotropic medication behavior summaries were incomplete for bupropion HCl, olanzapine, paroxetine HCl, and not completed for Ativan and buspirone HCl. This failure had the potential for the resident to receive unnecessary medication, as well as an undesirable outcome.Findings: Review of the facility's P&P titled Psychotropic Drug Use revised August 2017 showed PRN psychotropic medication orders are limited to 14 days unless the prescriber documents a clinical rationale in the resident's medical record for continued use. Medical record review for Resident 118 was initiated on 2/11/26. Resident 118 was admitted to the facility on [DATE]. Review of Resident 118's Order Listing Report showed the following physician's orders:- dated 1/27/25, for Ativan 1 mg every 12 hours PRN for 14 days, for agitation;- dated 2/13/25, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by agitation;- dated 2/24/25, for Ativan 1 mg every six hours PRN for anxiety. The order was discontinued on 3/10/25;- dated 3/10/25, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by physical restlessness;- dated 4/1/25, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by physical restlessness;- dated 4/22/25, for Ativan 1 mg every six hours PRN for 90 days, for anxiety manifested by physical restlessness; - dated 7/22/25, for Ativan 1 mg every six hours PRN for 90 days, for anxiety manifested by agitation. The order was discontinued on 9/10/25;- dated 9/10/25, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by agitation;- dated 9/10/25, for buspirone HCl (an anxiety medication) 5 mg three times a day for anxiety, manifested by increased physical restlessness;- dated 10/5/25, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by agitation;- dated 11/21/25 to monitor for episode of anxiety as evidenced by increased physical restlessness (buspirone) every shift. The ordered behavior to monitor failed to match the behavior targeted by buspirone;- dated 12/3/25, for Ativan 1 mg every six hours PRN for increased agitation. The order was discontinued on 12/7/25;- dated 12/5/25, for olanzapine (an antipsychotic medication) 5 mg at bedtime for psychosis manifested by angry outbursts evinced by resisting care;- dated 12/7/25, for bupropion HCl (an antidepressant medication) 75 mg daily for depression manifested by verbalization of sadness;- dated 12/7/25, for paroxetine HCl (an antidepressant medication)10 mg daily for depression manifested by outbursts of crying;- dated 12/8/25, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by increased agitation;- dated 12/12/25 to monitor for episode of anxiety as evidenced by verbalization of anxiousness (Ativan) every shift. The ordered behavior to monitor failed to match the behavior targeted by Ativan;- dated 1/1/26, for Ativan 1 mg every six hours PRN for 14 days, for increased agitation;- dated 1/20/26, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by increased agitation;- dated 2/4/26, for Ativan (an anxiety medication) 1 mg every six hours PRN for 14 days, for anxiety manifested by increased agitation and- dated 2/4/26, for Ativan 1 mg every six hours PRN for 14 days, for anxiety manifested by increased agitation. Review of Resident 118's Behavior Data sheets for psychotropic medication monthly monitoring showed the following:- a data sheet for olanzapine initiated for February 2025, had no monthly data for January 2026;- a data sheet for bupropion HCl initiated for February 2025, had no monthly data for January 2026; and- a data sheet for paroxetine HCl initiated for February 2025, had no monthly data for January 2026. Furthermore, there were no monthly Behavior Data sheets for Resident 118's use of buspirone HCl and Ativan. Review of Resident 118's medical record failed to show the prescriber's documented rationale for continued use of the PRN Ativan. On 2/17/26 at 1139 hours, an interview and concurrent medical record review for Resident 118 was conducted with the DON. The DON reviewed Resident 118's medical record and verified the Behavior Data sheets for olanzapine, bupropion HCl, and paroxetine HCl were incomplete for January 2026. The DON stated the monthly behaviors were ideally completed by the end of the first week of the following month. The DON verified there were no Behavior Data sheets for Resident 118's buspirone HCl and Ativan, and should have been completed. On 2/17/26 at 1317 hours, a follow-up interview and concurrent medical record review for Resident 118 was conducted with the DON. The DON verified Resident 118's ordered behavior monitoring and verbalization of anxiousness for Ativan use did not match the behavior of increased agitation in the Ativan order. The DON also verified the targeted behavior of increased agitation was not an appropriate specific targeted behavior and should have been clarified to a more quantifiable behavior. In addition, the DON verified Resident 118's medical record failed to show the prescriber's rationale for the continued use of PRN Ativan.

Based on observation, interview and facility P&P review, the facility failed to ensure proper storage and disposal of medications for one of two medication storage rooms and three of five medication and treatment carts inspected for medication storage and labeling. * The facility failed to ensure medication storage room and carts were in a clean and sanitary condition. * The facility failed to ensure orally administered medications were stored separate from externally used medications. * The facility failed to ensure all medications and biologicals were not expired. These failures had the potential to negatively impact the residents well- being, the potential for the medications to lose stability and effectiveness, and unsafe administration of the medications and treatment. Findings: Review of the facility's P&P titled Medication Storage and Labeling (undated) showed the following:- all drugs will be labeled and stored in a manner consistent with manufacturer's published specifications, federal and state regulations, and to enhance accurate and safe medication administration by the facility staff,- external used drugs in liquid, tablet, capsule, or powder form shall be stored separately from drugs for internal use,- drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use. 1.a. On [DATE] at 1035 hours, an inspection of Medication Storage Room A and concurrent interview was conducted with RN 2. The following was observed:- the front handles of the IV supplies storage drawers were dusty. Additionally, the bottom of the IV cabinet had light brownish sticky stains;- the over the counter cabinets were dusty with light brownish stains on the bottom of the cabinet;- an expired covid 19 testing kit dated [DATE];- oral medications were stored with non-oral medications: loperamide HCL (medication to treat diarrhea) tablets stored between fleet enema (medication to treat constipation) and Bisacodyl suppositories (medication to treat constipation), - yellowish stained label of vitamin C bottle and Naloxone spray (medication used to reverse opioid overdoses) package,- the cabinet door of the e-kit storage cabinet had dusty, sticky grayish stains;- the medication refrigerator exterior handle had dusty, sticky grayish stains; and- the treatment supplies storage closet had dark stains. RN 2 verified the above findings and stated the nurses and housekeeping staff clean this room. RN 2 stated the housekeeping staff could not come in unless a nurse stayed during the cleaning. b. Review of the [NAME] Metrix Pro System (glucometer) Comprehensive Resource Guide (undated) under System Storage instructions of the facility's glucometer in use, showed to store the meter, control solution, test strips in carrying case to protect from liquid, dust and dirt. On [DATE] at 1500 hours, an inspection of Medication Cart A and concurrent interview was conducted with LVN 17. The following was observed:- brownish blackish stains on bin inside the left top drawer used to store glucometer strips and lancets and on bin used to store syringes, and- used plastic-like oral syringes stored in a bin with unused syringes. LVN 17 verified the above findings and stated the medication cart storage bins should have been cleaned by the nurses from all shifts. On [DATE] at 1044 hours, an inspection of Medication Cart A and concurrent interview was conducted with the IP. The IP verified the above findings and stated the bin storing the glucometer, lancets and syringes should have been clean. The IP further stated the used syringes could not be stored with the unused syringes. The IP stated the ADON oversaw the medication storage. 2.a. On [DATE] at 1000 hours, an inspection of Treatment Cart A was conducted with LVN 4. The following was observed:- an opened, single use suture removal tray;- opened package of gauze; and- an culture set with an expiration date of [DATE]. LVN 4 verified the findings. LVN 4 stated the wound culture set was expired and should not be used. LVN 4 further stated the suture removal tray was used yesterday and should have been discarded. On [DATE] at 1030 hours, during an interview with RN 2, RN 2 verified the above findings. RN 2 stated culture sets should not be kept if expired, the suture removal tray should have been discarded once opened and the gauze should not have been opened until ready for the resident's use. b. On [DATE] at 1139 hours, an inspection of Treatment Cart B was conducted with RN 1. A covid 19 reagent was expired on [DATE]. RN 1 stated it should have been discarded. On [DATE] at 1342 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure the facility staff (CNAs 7 and 8) were competent in providing the necessary care and services to the residents who needed to be shaved. * The facility failed to ensure CNAs 7 and 8 had completed the skills competencies on how to shave the residents with episodes of spasms. This failure resulted in residents' to have cuts to their chins and posed the risk of further injury to the residents. Findings: 1. On 2/13/26 at 1013 hours, an observation was conducted for Resident 4. Resident 4 was observed with multiple surficial cuts to his chin. On 2/13/26 at 1030 hours, an observation and concurrent interview was conducted with LVN 14. When asked about the cuts to Resident 4's chin, LVN 14 verbalized the cuts occurred while the resident was being shaved. Medical record for Resident 4 was initiated on 2/13/26. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 12/13/25, showed Resident 4 did not have the capacity to understand or make decisions. Resident 4's diagnoses included cerebral palsy, seizure disorder, chronic respiratory failure with dependency on a ventilator, and post GT placement. Review of Resident 4's February 2026 MAR showed Resident 4 was being administered with baclofen (muscle relaxant) medication three times daily for his spasms. Review of Resident 4's Progress Notes dated 2/13/26, showed Resident 4 was observed with scabs post status shaving. On 2/18/26, at 1041 hours, an interview was conducted with CNA 7. CNA 7 verbalized she did shower Resident 4 on 2/13/26. CNA 7 verbalized she thought Resident 4's cuts were already present at that time. When asked if CNA 7 had reported to nursing staff, CNA 7 stated she assumed the cuts had already been reported. When asked how she would shave the residents that moved around a lot during showers, CNA 7 stated very carefully. Review of CNA 7's employee file was conducted and the file failed to show a skills check was conducted related to how to shave residents, including how to shave residents with episodes of moving around while shaving. 2. On 02/17/2026 at 1344 hours, an observation for Resident 124 and concurrent interview was conducted with LVN 16 and CNA 8 at bedside. Resident 124 was observed in bed with a horizontal superficial cut measuring approximately 2.5 inches, running across the lower part of Resident 124's chin. The left corner of the cut was observed as a circular open wound with blood running down the left side of Resident 124's chin. When asked about Resident 124's cut, CNA 8 stated the cut occurred while CNA 8 was shaving Resident 124 in the shower. CNA 8 verbalized Resident 124 jumped while she was shaving his chin. LVN 16 and CNA 8 verified Resident 124 had an open cut that had blood flowing down the left side of Resident 124's chin. Medical record review for Resident 124 was initiated on 2/17/26. Resident 124 was admitted to the facility on [DATE]. Resident 124's diagnoses included diabetes, brain damage, and epilepsy. Review of CNA 8's employee file was conducted and the file failed to show a skills check was conducted related to how to shave residents including residents with episodes of moving around while shaving. On 2/18/26 at 1000 hours, an interview was conducted with the DSD. When asked what devices were used to shave Residents 4 and 124, the DSD showed the razors and shaving cream being used to shave the residents. When asked about the skills competencies for CNAs 7 and 8, the DSD stated he would do a follow up. On 2/18/26 at 1019 hours, a follow-up interview and concurrent document review was conducted with the DSD. When asked what skills competency was conducted for staff to ensure they were competent in shaving the residents with episodes of moving around during shaving, the DSD showed a facility document titled Shaving. The document showed the steps on how to perform shaving and a section to indicate whether the staff satisfactory/unsatisfactory demonstrated the skill; however, the form did not show the process for shaving residents that move around (had spasms) during shaving. The DSD verified CNAs 7 and 8 had not completed a skills check on how to shave the residents including residents who had episodes of moving around while shaving. The DSD verified the document titled Shaving used for skills check competency did not address how to shave residents with episodes of spontaneous moving around (spasms) during shaving such as Resident 4 and 124.

Based on observation, interview, and facility document review, the facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for 88 of 88 residents who received food prepared in the kitchen. * The cole slaw for residents on regular and puree diets was observed with ice in it. This failure had the potential for decreased meal intake which could result in weight loss, decreased nutritive value, and negatively impact the residents' quality of life for all 88 residents who received food prepared in the kitchen. Findings: Review of the facility's Order Listing Report for February 2026 showed a total of 88 residents received meals prepared in the facility's kitchen. On 2/12/26 at 1028 hours, a resident council meeting was conducted with multiple residents. During this meeting, Residents 1 and 2 verbalized the food was served cold and did not taste good. On 2/12/26 at 1135 hours, an observation of the meal tray service was conducted with the Dietary Supervisor. The kitchen staff were preparing beef stew and corn cole slaw. On 2/12/26 at 1244 hours, two test trays (a regular diet and a pureed texture diet) were requested and observed with the Dietary Supervisor and the RD. The regular diet test tray containing the cole slaw had small pieces of ice in it. The pureed diet test tray containing the cole slaw had clumps of ice formation in it. The above findings were verified with the Dietary Supervisor and the RD.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of an indwelling urinary catheter for one of three final sampled residents (Resident 15) reviewed for indwelling urinary catheter care. * Resident 15's indwelling urinary catheter was observed to be cloudy and had a lot of sediments in the tubing. In addition, the indwelling urinary catheter had no label when the drainage bag was changed. This failure had the potential for the resident to develop complications associated with the use of indwelling urinary catheter.Findings: Review of the facility's P&P titled Indwelling Catheter Care revised 6/2025 showed the facility will provide each resident with indwelling catheter care daily and as needed. On 2/11/26 at 0937 hours, Resident 15 was observed to have an indwelling urinary catheter connected to a urinary drainage bag placed at the side of the bed. The indwelling urinary catheter was observed to be cloudy and had a lot of sediments in the tubing. In addition, the indwelling urinary catheter had no label of when the drainage bag was changed. Medical record review for Resident 15 was initiated on 2/11/26. Resident 15 was readmitted to the facility on [DATE]. Review of Resident 15's Order Summary Report dated 2/12/26, showed a physician's order dated 10/20/25, for indwelling urinary catheter care every day for maintenance, urinary drainage bag change as needed, and indwelling urinary catheter change as needed for soiled, clogged, leaking and comes out. Review of Resident 15's MDS assessment dated [DATE], showed Resident 15's use of indwelling urinary catheter. Review of Resident 15's plan of care showed a care plan problem to address the use of the indwelling urinary catheter initiated on 10/17/25. The interventions included to monitor the indwelling urinary catheter for the signs and symptoms of infections. Further review of Resident 15's medical record failed to show documented evidence on when the indwelling urinary catheter was changed. On 2/12/26 at 1100 hours, an observation and concurrent interview was conducted with LVN 7. LVN 7 was asked about the indwelling urinary catheter care for Resident 15. LVN 7 verified the indwelling urinary catheter tubing had whitish color streaks and the urine in the urinary drainage bag was brownish to dark brown in color with a lot of sediments, and cloudy. LVN 7 acknowledged the urinary drainage bag needed to be changed because the resident was prone to infection. LVN 7 was asked when the catheter drainage bag was changed, LVN 7 was uncertain. LVN 7 verified the urinary drainage bag had no label on when it was last changed. On 2/18/26 at 0901 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 2. RN 2 verified Resident 15 had an indwelling urinary catheter and a physician's order for the indwelling urinary catheter care and maintenance. RN 2 reviewed the medical record and verified there was no documentation on when the indwelling urinary catheter of Resident 15 was changed. RN 2 acknowledged the above findings. On 2/18/26 at 1006 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, and medical record review, the facility failed to ensure one of 27 final sampled residents (Resident 1) received services to prevent pressure ulcers. * Resident 1's LAL mattress settings were not set according to Resident 1's weight. This failure posed the risk of Resident 1's pressure ulcers not receiving full treatment to prevent further decline.Findings: On 2/11/26 at 1239 hours, Resident 1 was observed in bed on a LAL mattress. The mattress settings showed the weight setting was set to 15 pounds. Resident 1 appeared to weigh more than 15 pounds. Medical record review for Resident 1 was initiated on 2/11/26. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed an order dated 2/10/26, to use LAL mattress for wound management. Check placement and settings every shift. Review of Resident 1's Skin Check Progress Notes dated 2/11/26, showed Resident 1 had an arterial wound to her right foot, stage 2 pressure injury to her left buttock area and a state 2 pressure injury to her left gluteal fold. On 2/17/26 at 1047 hours, Resident 1 was observed in bed on her back. The mattress settings showed it was set to 150 pounds. Resident 1 did not appear to weigh 150 pounds. On 2/17/26 at 1619 hours, an observation, interview, and concurrent medical record review for Resident 1 was conducted with LVN 14. LVN 14 stated Resident 1 weighed 104 pounds. LVN 14 verified Resident 1's LAL mattress settings were set at 150 pounds. LVN 14 acknowledged the mattress should have been set to the correct settings according to Resident 1's weight.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of three sampled residents (Resident 1). * The facility failed to ensure Residents 1's bed was in a low position as per the resident's care plan. Resident 1 fell from the bed and sustained a fracture on left lower leg. This failure contributed in Resident 1 sustaining serious injuries from fall and suffering from pain.Findings: According to the National Institute of Health publication titled Biomechanical Evaluation of Injury Severity Associated with Patients Falls from Bed published on 11/15/2008, showed falling from a high bed is dangerous, with potential effects ranging from sprains to severe injuries like fractures, concussions, traumatic brain injuries, and spinal cord injuries. The risk and severity of injury increase with the height of the bed and the hardness of the landing surface. Risk factors included the height of the bed. Higher beds increase the risk of more severe injury. Preventing falls from high beds include using low beds to minimize fall height. Review of the facility's P&P titled Falls Prevention dated 02/2023 showed residents identified at risk for falls would have appropriate interventions. Each resident fall, the facility would implement actions to reduce the incidence of falls and minimize potential injury from fall. The CDPH, L&C Department received a Letter from the facility dated 11/3/25, to report an Unusual Occurrence (fall with fracture). The facility Letter showed on 10/31/25 at approximately 1500 hours, Resident 1 sustained an unwitnessed fall. The report showed Responsible Party 1 was present at the facility and observed Resident 1 fall from the bed. The Letter further showed Resident 1 was transferred to the acute care hospital and returned at 0045 hours with fracture to the left lower extremity. On 11/6/25 at 1015 hours, an observation of Resident 1 and concurrent interview was conducted with Family Member 1 at bedside. Resident 1 was observed in bed as awake, alert and able to respond by gestures. Resident 1 was observed with a cast on the left lower leg with skin discoloration above the cast. Family Member 1 stated on 10/31/25 at around 1500 hours, he visited Resident 1 in the facility. Family Member 1 stated he looked at Resident 1's bed but Resident 1 was not in bed, and he noticed the bed was elevated high. Family Member 1 stated he thought maybe the staff got Resident 1 up in the wheelchair to attend the holiday party in the activity room. Family Member 1 stated when he was about to go to the activity room, he heard someone was calling for help. Family Member 1 found Resident 1 on the floor, on the left side of the bed, lying on her left side in a curl-ball-like position, crying, and in a lot of pain. Family Member 1 stated he yelled for assistance from the staff. Family Member 1 stated he accompanied Resident 1 to the hospital and was informed Resident 1 had a fracture on her lower left leg in three different bones. Family member 1 further stated Resident 1 had fallen hard from the bed and suffered pain and broken bones. Medical record review for Resident 1 was initiated on 11/6/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/5/25, showed Resident 1 had a diagnosis of Alzheimer's Dementia and a history of fall, and had no capacity to understand and make decisions. Review of Resident 1's Fall Risk Evaluation dated 7/21/25, showed Resident 1 was at risk for falls and had a history of fall in the past three months. Review of Resident 1's Physician Order Summary showed the following physician's orders:- dated 7/21/25, for the use of bilateral bolster pillows while in bed for postural support and proper body alignment, and- 10/6/25, for the use of bilateral floor mats to minimize risk of injury. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had severe cognitive impairment, dependent on staff on all ADLs, and had a history of fall. Review of Resident 1's Care Plan Report showed a care plan problem initiated on 5/4/25, addressing the risk for falls related to late effects of nontraumatic intracerebral hemorrhage, generalized body weakness, left hemiplegia, seizure disorder, impaired vision, Alzheimer's disease and medication side effects. The interventions included were to place the floor mats to minimize risk of injury and place the bed in low position. Review of Resident 1's Progress Notes dated 10/31/25 at 1608 hours, showed at around 1515 hours, Responsible Party 1 informed the licensed nurse Resident 1 was on the floor. The note further showed during the assessment Resident 1 complained of pain to the left lower extremity, noted with bump on top of anterior (front) part of the ankle, and light blue discoloration to the left side of foot. Review of Resident 1's Change of Condition Evaluation showed the following:- dated 7/21/25, Resident 1 had a fall; and- dated 10/31/25, Resident 1 had a fall. The Review Findings And Provider Notification - Summary section showed the nurse was notified Resident 1 was on the floor, and Resident 1 was side lying on the left side of the bed. The documentation further showed bump on left ankle noted, Resident 1 expressed pain to Responsible Party 1, 911 protocols initiated. Review of Resident 1's After Visit Summary from the acute care hospital dated 10/31/25, showed Resident 1 was diagnosed to have tibia (lowed leg bone) , fibula (lower leg bone) and foot fractures. On 11/6/25 at 1400 hours, an interview for Resident 1 was conducted with CNA 1. CNA 1 stated Resident 1 was dependent to staff on ADLs. CNA 1 stated she heard Family Member 1 was yelling for help on 10/31/25. CNA 1 stated the nurses attended Resident 1 immediately and found the resident on the floor. CNA 1 verified and acknowledged she observed Resident 1's bed was elevated, hip high. On 11/6/25 at 1600 hours, an interview for Resident 1 was conducted with LVN 1. LVN 1 stated on 10/31/25, she immediately attended Resident 1 when summoned for help by Family Member 1. LVN 1 stated Resident 1 was found on the floor, curled up close to the dresser, crying and in distress. LVN 1 verified and acknowledged she observed Resident 1's bed was elevated, hip high when she assisted Resident 1 on the floor. On 11/10/25 at 1020 hours, an interview for Resident 1 was conducted with LVN 2. LVN 2 stated Resident 1 had a history of fall. LVN 2 verified Resident 1 had bolster pillow in bed, floor mat on both side of the bed and kept the bed in lowest position. LVN 2 stated she attended Resident 1 immediately when Family Member 1 was asking for assistance on 10/31/25. LVN 2 stated Resident 1 was found lying on the floor. LVN 2 stated during the transfer of Resident 1 back to bed, LVN 2 observed a bump on Resident 1's shin and ankle area of the left leg. LVN 2 verified and acknowledged she observed Resident 1's bed was elevated when she assisted Resident 1 on the floor. On 11/10/25 at 1050 hours, a telephone interview for Resident 1 was conducted with LVN 3. LVN 3 stated Resident 1 was found on the floor on 10/31/25. LVN 3 verified and acknowledged the bolster pillows in bed and floor mat was in place. However, LVN 3 observed Resident 1's bed was hip high when he assisted Resident 1 on the floor. On 11/10/25 at 1415 hours, an interview was conducted with the DON. The DON stated on 10/31/25 at around 1500 to 1515 hours, when Family Member 1 was asking for assistance, she attended right away and found Resident 1 on the floor. DON verified and acknowledged she noticed Resident 1's bed was elevated and was not aware why the bed was elevated. The DON further stated the bed should have been in lowest position when not providing care.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) was free from accident hazards. * The facility failed to identify Resident 1 as a high risk for falls when her name outside her door was marked with a star so the staff could easily identify she was at risk for falls. * Resident 1's plan of care failed to reflect the number of persons or assistance needed and the appropriate assistive device to be used when standing or ambulating as noted by the PT. * The facility failed to clarify Resident 1's need for a back brace with her physician. These failures resulted in Resident 1 sustaining a fall with an occipital skull fracture, contributing to Resident 1's death. Findings: According to a report received from the facility, Resident 1 fell on [DATE], and sustained an occipital skull fracture ([MEDICAL CONDITION] at the back of the head) and cerebral hemorrhage/hematoma (bleeding in the brain). Review of the facility's P&P titled Falling Star Program Fall Prevention Policy and Procedure revised 1/2/2020, showed the goal of the Falling Star Program is to prevent falls, reduce both the incidence of falls, and the injuries that may accompany falls. The process included identifying residents at risk for falling and establishing a common method of communication to remind the staff to monitor these residents for fall prevention. Falling stars will be used to identify residents on the Falling Star Program. One Gold Star will be placed on the resident's name plate or on the wall next to the name(s) outside the resident's room. If the Fall Risk Assessment is scored at 10 or greater on a change of condition, the RN Supervisor will initiate the Falling Star Program. Review of the facility's P&P titled Falls and Fall Risk, Managing (undated) showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Closed medical record review for Resident 1 was initiated on 2/6/2020. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Admission/Readmission Screener dated 1/15/2020, showed Resident 1 was admitted from the acute care hospital with low back pain. The assessment showed Resident 1 needed extensive assistance to walk in her room with a walker. The assessment failed to show the number of persons required to assist her. Resident 1 had dizziness, moderate difficulty with hearing, and was moderately impaired with her vision. a. Review of Resident 1's Safety Device/Mobility Device assessment dated [DATE], showed she had unsafe mobility due to poor balance and gait dysfunction, and was at risk for falls. Review of Resident 1's Fall Risk assessment dated [DATE], showed Resident 1 was a high risk for falls. Review of Resident 1's Order Summary Report showed the following physician's orders [REDACTED]. - Eliquis tablet 2.5 mg (anticoagulant medication) one tablet by mouth one time a day; and - Monitor resident for bleeding due to the anticoagulant therapy. Review of Resident 1's Medication Administration Record [REDACTED]. On 2/27/2020 at 0625 hours and 3/5/2020 at 0920 hours, an interview was conducted with CNA 2. CNA 2 stated she had not cared for Resident 1 prior to 1/20/2020. CNA 2 stated she usually received a report on the residents from the previous shift's CNA, but that night, the CNA left before she could get report from him. CNA 2 stated if she had any questions about her residents, she would have asked her charge nurse. CNA 2 stated when she made her rounds, she usually took the resident census sheet and compared it to the resident's name next to the resident's door. CNA 2 stated if a resident was a fall risk, there would be a star next to their name outside the door, but there was no star next to Resident 1's name. CNA 2 stated when she took Resident 1 to the bathroom in the morning, she ambulated without difficulty using her walker. CNA 2 stated Resident 1 wanted to wash her face and brush her dentures at the sink. CNA 2 stated she handed a towel and Resident 1's dentures to her. Resident 1 thanked her and asked her to step out of the bathroom. CNA 2 stated she told Resident 1 she would be right outside the bathroom, and CNA 2 left the door open about an inch so she could see Resident 1 and hear her as she did not want to leave her. CNA 2 stated she heard something and saw Resident 1 turned towards the door to leave the bathroom, so CNA 2 reached out to open the door, and in that moment, Resident 1 fell . CNA 2 stated she had not gotten report from her charge nurse at the beginning of the shift regarding Resident 1 on 1/20/2020. On 3/5/2020 at 0900 hours, an interview was conducted with LVN 6. LVN 6 stated a star placed next to the resident's name outside the door was used to identify a resident who was a high fall risk. On 3/5/2020 at 1105 hours, an interview was conducted with the DON. The DON stated staff would know a resident at risk for falls by a star near their name outside their door. On 3/8/2020 at 0651 hours, a telephone interview was conducted with LVN 8. LVN 8 stated the fall risk assessments were completed upon admission. If a resident was assessed as a high risk for falls, a star was placed on their door and a high fall risk band was put on their wrist to identify them as being at high risk for falls. LVN 8 stated CNAs received report about residents from the previous shift's CNAs as well as from the licensed nurses. When asked if she had explained to CNA 2 what Resident 1's care needs were on 1/20/2020, LVN 8 stated she told CNA 2 to make sure Resident 1 was assisted at all times, which meant a CNA was with her when she went to the restroom. LVN 8 stated she did not remember if Resident 1 could be by herself in the bathroom or not. b. Review of the facility's P&P titled Care Plans - Baseline revised December 2016 showed a baseline plan of care to meet the resident's immediate need shall be developed for each resident within 48 hours of admission. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Review of Resident 1's Physical Therapy Treatment Encounter Notes dated 1/20/2020, showed Resident 1 ambulated with the use of a two-wheeled walker and required contact guard assist (the person assisting the resident maintained contact with the resident either through a gait belt or a hand). Pain exacerbated by standing, reaching, prolonged activity. Review of Resident 1's Occupational Therapy Treatment Encounter Notes dated 1/19/2020, showed Resident 1 was a fall risk and used a back brace for out of bed activities. The documentation showed Resident 1's standing ability while performing ADL care was assessed as poor plus. Review of Resident 1's plan of care showed the following care plan problems to address: - Risk for falls or injury, required assistance or unable to transfer, chronic back pain with a created date of 1/16/20. The interventions included to assist with mobility as required and provide assistive device when indicated. The interventions did not specify what assistance Resident 1 required when ambulating or standing. - Decrease ADL functional activities related to chronic back pain with a created date of 1/16/2020. The care plan problem showed Resident 1 needed extensive assistance for toileting and grooming. Further review showed Resident 1's plan of care did not address the specific assistance or assistive devices she required when ambulating or standing as reflected by PT and OT's notes on 1/19 and 1/20/2020. On 2/6/2020 at 1240 and 1340 hours, an interview was conducted with PT 1. PT 1 stated the PT note dated 1/20/2020, showed Resident 1 required contact guard assist for walking. PT 1 explained contact guard assist meant Resident 1 could walk, but she needed to have the staff's hands on her while she was walking. PT 1 stated contact guard assist meant touching or guiding the resident as needed, and it may or may not require a gait belt on the resident. When asked how he relayed this information to the nursing staff, he stated he spoke to the assigned CNA, LVN, and desk nurse. PT 1 stated he communicated any pertinent resident needs or concerns he had. On 2/6/2020 at 1321 hours, an interview was conducted with OT 1. OT 1 stated the OT progress note for Resident 1 dated 1/19/2020, showed while Resident 1 walked, she helped Resident 1 navigate her walker. OT 1 stated if Resident 1 was standing at the sink and turned to walk out of the bathroom, she should be supervised or have stand by assistance. OT 1 stated Resident 1 could sit on a chair by herself, but she could not be left alone when standing in the bathroom. OT 1 stated due to Resident 1's injuries, her nerves were weak and both legs could give out or buckle at any time. On 3/5/2020 at 0810 hours, an interview was conducted with PTA 1. When asked how PTA 1 communicated a resident's ability, level of assistance required, or assistive device a resident needed to the nursing staff, PTA 1 stated he let the nursing staff know and the nursing staff should have access to the therapy notes. When asked to explain what two-wheeled walker with contact guard assist meant, PTA 1 stated it meant he was not confident in the resident's ability to walk and they needed the walker to stabilize themselves. PTA 1 stated he would not walk out of the room as he was not confident in Resident 1's ability to keep her balance more than two minutes as something might happen. PTA 1 stated when the resident started to move, he would personally be close enough to them to reach them and catch them if they fell . On 3/5/2020 at 0830 hours, an interview was conducted with OT 1. OT 1 explained the initial PT and OT evaluations were often done together and then either one would speak with a nursing staff. When asked to explain standing balance for ADLs is poor plus in her 1/19/2020, note, OT 1 stated it meant the resident needed to have support - literally right there holding on to her. Resident 1 could stand up and wash at the sink a little, then she got tired and would need to sit down as her endurance was poor. On 3/5/2020 at 1025 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DSD. The DSD stated if a resident was assessed as a high fall risk, the care plan problem for high fall risk would be initiated by the admitting nurse. The DSD stated each department in the facility should be adding care plan problems for their discipline for a resident. The DSD reviewed Resident 1's plan of care and stated the care plan was not specific enough for Resident 1's mobility or medical equipment needs, and she would like to see the care plan more tailored to Resident 1's specific needs. c. Review of Resident 1's Physical Therapy, PT Evaluation and Plan of Treatment dated 1/16/2020, showed Resident 1 had a back brace which Resident 1's family member took home. Resident 1 was advised by the therapist to have her family member bring the back brace in. The documentation showed Resident 1 felt unsteady when standing, when walking, and was worried about falling. Review of Resident 1's plan of care showed a care plan problem for decreased ADL functional activities related to chronic back pain with [MEDICAL CONDITION] dated 1/16/2020. The care plan problem showed the use of a brace was not marked. Review of Order Summary Report dated 1/15/2020, for Resident 1 did not show an order for [REDACTED].>Review of Resident 1's Physical Therapy Treatment Encounter Notes dated 1/18/2020, showed her back brace was donned for out of bed activities. Review of Resident 1's Occupational Therapy, Treatment Encounter Note dated 1/19/2020, showed she wore a back brace for out of bed activities. On 3/5/2020 at 0810 hours, an interview was conducted with PTA 1. PTA 1 stated when he worked with Resident 1 on 1/20/2020, she did not have her back brace on. PTA 1 stated he was not sure why Resident 1 didn't have the back brace on her that day. On 3/5/2020 at 0830 hours, an interview and concurrent medical record review was conducted with OT 1. OT 1 stated Resident 1's back brace had been brought from home. OT 1 then stated Resident 1 should have worn the back brace. OT 1 stated whenever she got Resident 1 up out of bed, she had Resident 1 wear her back brace. OT 1 stated she would have to check the physician's orders [REDACTED]. On 3/5/2020 at 0920 hours, a telephone interview was conducted with CNA 2. CNA 2 stated she did not see a back brace in Resident 1's room, so she did not put it on Resident 1 when she got her up to the bathroom. Review of Resident 1's SBAR Communication Form and progress note dated 1/21/2020 at 0742 hours, showed the CNA was at the doorway waiting for Resident 1 to finish washing her hands. Resident 1 turned to go to the door and fell , hit the back of her head, and had a small laceration on her scalp. On 3/4/2020 at 1044 hours, a telephone interview was conducted with Resident 1's family member. The family member stated when Resident 1 was at the facility, she was responsive and the family was looking forward to her going home in a week or two. The family member stated Resident 1 told them she was up in the bathroom washing up and lost her balance. The family member stated they were told by the facility staff someone was outside the door but not in the bathroom with her. The family member stated the facility was aware Resident 1 was a fall risk and she should not have been left alone. The family member stated if someone had been there, they could have caught Resident 1 or prevented her from hitting her head. On 3/10/2020 at 1110 hours, an interview was conducted with the DON. The DON verified Resident 1's use of a back brace should have been clarified with her physician, her care plan should have been updated to include the PT, and OT assessments or recommendations, and the Falling Star program should have been implemented. Review of the acute care hospital's ED notes dated 1/21/2020, showed Resident 1 was admitted from the emergency room to the intensive care unit with a right-sided occipital fracture with a trace subarachnoid hemorrhage (bleeding into the space surrounding the brain). It showed she had three staples over a 1.5 cm wound on the back of her left head. Review of the CT Angio Chest Trauma result dated 1/21/2020, showed acute-appearing buckle fracture deformities of the right six to eight ribs. Review of Resident 1's Certificate of Death dated 1/26/2020, showed the immediate cause of death was [MEDICATION NAME] force injuries and a fall same level.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a pressure ulcer for two of two sampled residents (Residents 1 and 2). Residents 1 and 2 were admitted to the facility without pressure ulcers but developed pressure ulcers after admission to the facility. * Resident 1 was admitted to the facility without a pressure ulcer. The facility failed to follow Resident 1's plan of care to turn the resident every 2 hours and administer a moisture barrier cream treatment as ordered by the physician. As a result, Resident 1 developed a Stage II pressure ulcer to his coccyx on 3/1/17, which deteriorated to a Stage IV pressure ulcer on 3/14/17. Resident 1 was confined to bed and his physical therapy was delayed as a result of the development of a Stage IV pressure ulcer while in the facility. Resident 1 stated he felt depressed as the wound was delaying his ability to be discharged home. * Resident 2 was admitted to the facility without a pressure ulcer. The facility failed to reposition Resident 2 and perform treatments as ordered for the skin redness to the coccyx discovered on 4/5/17. On 4/26/17, Resident 2's coccyx wound had worsened to a Stage II pressure ulcer. Findings: Review of the facility's P&P titled Wound Care Suggestions and Documentation dated September 2014, showed residents who are unable to independently turn will be repositioned at the minimum of every 2 hours. Preventative skin care program includes application of a moisture barrier ointment to protect the skin if indicated. All residents will have a complete skin assessment performed by licensed staff a minimum of weekly and charted on the weekly summary. The wounds should be measured and evaluated weekly for improvement or decline. 1. Medical record review for Resident 1 was initiated on 5/10/17. Resident 1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], showed Resident 1 had no cognitive impairment, could communicate his needs and required extensive assistance from two or more persons for bed mobility. Review of Resident 1's Resident Admission Skin Assessment Form dated 2/22/17, showed Resident 1's coccyx was within normal limits and without abnormalities (no skin breakdown or open areas). Review of Resident 1's care plan problem titled Skin Breakdown dated 2/22/17, showed a potential for skin breakdown related to decreased mobility. The care plan problem showed a goal for Resident 1 to be free from skin breakdown. Interventions included to turn Resident 1 every two hours while in bed. Review of the medical record showed no documented evidence the resident was consistently turned and repositioned every two hours as care planned to prevent the pressure ulcer development. Review of the Interdisciplinary Wound Care Committee record dated 3/1/17, showed Resident 1 had developed a new in-house pressure ulcer to his coccyx. Documentation showed the pressure ulcer on Resident 1's coccyx was first identified on 3/1/17, as a Stage II pressure ulcer. There was no documentation of the size of the pressure ulcer. Review of Resident 1's physician's orders [REDACTED]. Review of Resident 1's Treatment Administration Record (TAR) for March 2017, showed an entry to apply moisture barrier cream to the Stage II pressure ulcer on the coccyx. Further review of the TAR for the month of March 2017 showed no documented evidence the moisture barrier cream was applied from 3/1/17 through 3/10/17, during the 7 PM to 7 AM shifts and on 3/8 and 3/9/17, during the 7 AM to 7 PM shifts; all of these dates were blank and with no nurses' initials documented to show the treatments had been performed as ordered. Review of a physician's orders [REDACTED]. The treatment order was changed to apply Santyl ointment. Santyl ointment contains an enzyme which breaks up dead skin and tissue. A physician's orders [REDACTED]. However, review of the medical record showed no documented evidence the resident was consistently turned and repositioned every two hours as care planned and ordered to prevent further deterioration of the Stage II pressure ulcer on the coccyx. Review of Physician 1's progress note dated 3/14/17, showed Resident 1's Stage II pressure ulcer to his coccyx was first identified on 3/1/17, which was assessed to have deteriorated to a Stage IV on 3/14/17. Documentation showed the measurement of the Stage IV pressure ulcer on the coccyx was 3 cm (length) x 2.5 cm (width). Physician 1 documented the wound care nurse had notified her on 3/13/17, that Resident 1's Stage II coccyx pressure ulcer had deteriorated on 3/11/17, to an unstageable wound. Physician 1 documented it was unclear as to how the wound had rapidly deteriorate that quick, and was unfortunate set back as resident's therapy with slide board transfers was now delayed. The physician's progress note also showed Resident 1 had told Physician 1 he was not being turned every 2 hours and sometimes was sitting in stool. On 5/10/17 at 1629 hours, an interview and concurrent record review was conducted with the ADON (acting DON as of 4/1/17). The ADON was asked if Resident 1 reported to her that he was not being turned. The ADON stated Resident 1 informed her on 4/20/17, two CNAs on the night shift were giving Resident 1 an attitude about being turned. The ADON was asked if she had investigated Resident 1's concern. The ADON stated she conducted an interview with CNA 6 and CNA 7, as she felt based on the time frame provided to her by Resident 1. The ADON stated CNA 6 and CNA 7 told her they turned Resident 1 as per his turning schedule. The ADON stated she also spoke with six or seven additional CNAs, and they denied failing to turn the resident. The ADON was asked if she documented any of her interviews with these CNAs. The ADON stated, I wrote some notes on a census sheet. The ADON provided a copy of the census sheet notes. The census sheet dated 4/20/17, showed the following documentation, c/o turning PM shift (sometime day) CNA 6 and CNA 7 - attitude. The ADON stated there was no additional documentation in regards to this. Review of Resident 1's Nursing Assistant Daily Flow Sheets (used by the CNAs to document turning the residents every two hours) for the months of February, March, and April 2017 showed the following documentation for the bed mobility/position every two hours: a. Blank areas with no charting were noted on the following dates: - Night Shift: 2/24, 3/28, 3/29, 4/2, 4/4, 4/6, 4/16, 4/19, 4/21, 4/22, 4/23, and 4/26/17. - AM Shift: 3/29, 4/1, 4/5, 4/7, and 4/10/17. - PM Shift: 4/9, 4/15, and 4/16/17. b. N (No according to the charting code) on the following dates: - Night shift: 3/3 through 3/7/17 and 3/9 through 3/27/17. c. S (supervision/cueing according to the charting code) on the following dates: - AM Shift: 3/1 through 3/9/17. On 5/10/17 at 1629 hours, an interview and concurrent record review was conducted with the ADON. The ADON verified on 3/1 through 3/9/17 (the time frame in which the pressure ulcer deteriorated from a Stage II to a Stage IV), the AM shift documentation showed Resident 1 was given supervision/cueing with repositioning. The ADON acknowledged the resident could not reposition himself and required staff assistance with turning and repositioning. The ADON verified on 3/3/17 through 3/14/17 (the time frame in which the pressure ulcer deteriorated from a Stage II to a Stage IV) the night shift had documented Resident 1 was not being turned. The ADON stated N as per the document charting code indicated No, the resident was not being turned. The ADON stated she was unable to determine if Resident 1 was being turned on the dates and shifts listed above due to the the lack of documentation. On 5/11/17 at 0800 hours, an interview was conducted with Resident 1. Resident 1 stated he was admitted to the facility with no pressure ulcers. Resident 1 stated staff on all shifts failed to turn him, with an increased incidence on the night shift. Resident 1 stated he had told approximately six different facility licensed nurses and CNAs since his admission that he was not being turned. Resident 1 stated after the development of the coccyx pressure ulcer, he was confined to bed for several weeks. Resident 1 stated he felt depressed because the wound prevented him from attaining his goal of being discharged home. Resident 1 stated, I know I could have been home if was not for this wound. I can not even get onto my own chair. This has prevented me from being independent and caring for myself, instead of enjoying time out of bed and learning how to live and move after my accident. The resident was asked at what time barrier cream was applied to his coccyx. Resident 1 stated the barrier cream was applied during the day shift. An observation of Resident 1's pressure ulcer and interview was conducted with Treatment Nurse 1 on 5/11/17 at 0905 hours. Resident 1 was observed with full thickness tissue loss to his coccyx, measuring 4 cm (length) x 3 cm (width) x 3.5 cm (depth). Treatment Nurse 1 assessed the resident's pressure ulcer and stated the measurement of the tunneling was 4.8 cm at 9 o'clock. Treatment Nurse 1 stated Resident 1's coccyx area was clear and without skin breakdown or tissue injury on admission to the facility. Treatment Nurse 1 stated the redness on the resident's coccyx area developed and was treated with a moisture barrier cream. Treatment Nurse 1 stated Resident 1 had developed a Stage II pressure ulcer and was placed on a low air loss mattress. Resident 1's wound then deteriorated to a Stage IV pressure ulcer. Treatment Nurse 1 stated Resident 1 was bed bound for two weeks when he developed a Stage IV pressure ulcer. Treatment Nurse 1 stated the resident had told her he was very sick of being in bed. Treatment Nurse 1 stated before the Stage IV pressure ulcer was developed, Resident 1 spent approximately three hours a day in his wheel chair. On 5/16/17 at 0831 hours, an interview and concurrent record review was conducted with CNA 5. CNA 5 had cared for Resident 1 during the night shift on 3/3, 3/4, and 3/6/17 (the time frame the Stage II had deteriorated to Stage IV pressure ulcer). CNA 5 verified he charted N on these dates. CNA 5 stated N meant no, Resident 1 was not turned and he could not turn himself. CNA 5 was asked if Resident 1 had ever refused to be turned. CNA 5 stated Resident 1 refused to be turned a handful of days he worked. CNA 5 stated he was uncertain of the exact dates, stating sometime between the end of February 2017 and early March 2017. CNA 5 stated when a resident refused to be turned he circled his entry on the Bed Mobility/Position form and documented the refusal on the back of the page. CNA 5 stated he was also required to inform the LVN charge nurse of the refusal who would then then co-sign his documentation. CNA 5 stated he did not document Resident 1's refusals because he was told by the LVN charge nurse, the LVN would document the refusals on the MAR. CNA 5 stated he did not verify if the LVN charge nurse documented Resident 1's refusals. CNA 5 was asked if Resident 1 had reported to him that he (Resident 1) was not being turned. CNA 5 stated the resident told him the AM and PM shifts failed to turn him because they were too busy. CNA 5 stated he reported the resident's complaint about not being turned to his supervisor, LVN 3. Review of Resident 1's MARs for the months of February and March of 2017, did not show documentation Resident 1 was refusing to be turned. The MAR for March 2017, failed to show documentation Resident 1 was being turned and repositioned every two hours from 3/1/17 through 3/12/17 and 3/13/17 through 3/31/17. In addition, there were 23 times where there was nothing documented. On 5/22/17 at 0832 hours, an interview and concurrent record review was conducted with CNA 8. CNA 8 cared for Resident 1 during the night shift on 3/7, 3/12, 3/13 (time frame Stage II deteriorated to Stage IV) 3/24, and on 3/26/17. Review of the Nursing Assistant Daily Flow Sheet (bed mobility/position every 2 hours section) for March 2017, showed CNA 8 documented N (N indicated no, the resident was not turned every 2 hours) on 3/7, 3/12, 3/13, 3/24, and 3/26/17. CNA 8 stated, Y indicated yes, the resident was turned every 2 hours. CNA 8 stated Resident 1 did not refuse to be turned during the times she cared for him. Review of the Interdisciplinary Team Conference Record - Wound dated 5/24/17, showed Resident 1 had developed an avoidable pressure ulcer on his coccyx based on the National Pressure Ulcer Advisory Panel guidelines. On 5/24/17 at 1100 hours, an interview and concurrent record review was conducted with Physician 1. Physician 1 stated she informed the DON on 3/14/17, of Resident 1's complaint of facility staff not turning every two hours and that he was sometimes left sitting in stool. The DON had informed Physician 1 an action plan would be developed and the DON would speak to the nurses. Physician 1 stated she was not informed Resident 1's treatment was not administered on 3/1/17 through 3/10/17 during the 7 PM - 7 AM shifts, and 3/8 and 3/9/17 during the 7 AM - 7 PM shifts. Physician 1 stated failing to carry out the treatment order could have contributed to development/worsening of Resident 1's pressure ulcer on his coccyx. On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 was asked if Resident 1 reported to her that he was not being turned. Treatment Nurse 1 stated Resident 1 had told her a CNA on night shift, sometime last week, had failed to turn or reposition him and let him sleep. Treatment Nurse 1 stated she reported the resident's complaint to her supervisor, RN 1. Treatment Nurse 1 verified there was no documentation as to why the treatments were not done from 3/1/17 through 3/10/17 during the 7 PM to 7 AM shifts and on 3/8 and 3/9/17 during the 7 AM to 7 PM shifts. Treatment Nurse 1 unable to determine if the treatment was administered on these dates. On 5/24/17 at 1635 hours, an interview was conducted with RN 1. RN 1 stated Treatment Nurse 1 did not report to her last week or at any time Resident 1 was not being turned by a CNA on the night shift. RN 1 stated if it had been reported to her Resident 1 was not being turned, she would have conducted interviews with Resident 1, CNAs, nurses, and followed up with the Quality Assurance Committee inquiring as to any reports of residents failing to be turned. RN 1 stated she had not conduct interviews or follow up with Quality Assurance because Treatment Nurse 1 did not report to her Resident 1 was not being turned. On 5/25/17 at 1603 hours, an interview was conducted with LVN 3. LVN 3 was asked if Resident 1 or any staff had reported to her that Resident 1 was not being turned every two hours. LVN 3 stated Resident 1 told her that sometime during the month of March 2017, that the AM shift staff did not turn the resident every two hours while he was in bed. LVN 3 stated she reported the resident's complaint about not being turned to the AM shift nurse; however, she could not remember who the nurse was. LVN 3 stated aside from Resident 1, she was never informed by anyone else the resident was not being turned. Review of Resident 1's Pressure Skin Condition Record dated 3/1/17, showed Treatment Nurse 1 was the first to identify the Resident 1's coccyx pressure ulcer on 3/1/17. There was no documentation of the stage of the pressure ulcer. On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 confirmed she did not document the stage of Resident 1's coccyx pressure ulcer on 3/1/17. Review of Resident 1's Pressure Skin Condition Record dated 4/15/17, showed Resident 1 had a Stage IV pressure ulcer to his coccyx which measured 4.7 cm (length) x 4.0 cm (width) x 3.3 cm (depth) with tunneling of 4 cm at 9 o'clock. The Pressure Skin Condition Record dated 4/21/17, showed the Stage IV coccyx pressure ulcer was increasing in size, it now measured 5.0 cm (length) x 4.0 cm (width) x 3.3 cm (depth). The documentation did not show the measurement for tunneling. On 5/24/17 at 1232 hours, an interview and concurrent record review was conducted with Treatment Nurse 1. Treatment Nurse 1 stated she was unsure why she had not documented the measurement for tunneling. Treatment Nurse 1 stated documentation of tunneling was necessary to determine if wound was improving or worsening. On 5/24/17 at 1310 hours, an interview was conducted with Treatment Nurse. Treatment Nurse 1 stated photographs of Resident 1's coccyx pressure ulcer were taken on admission and when there was a change in the condition of his pressure ulcer. She said the photographs were taken when the Stage II pressure ulcer was identified, and when it deteriorated to a Stage IV. Treatment Nurse 1 stated she recalled taking the photographs of Resident 1's Stage II pressure ulcer as she was the first to identify the wound. The treatment nurse stated Resident 1's wound photographs were printed from the facility's camera, placed in the resident's medical record under the progress note section, and then the photographs were deleted from the camera. There were no photographs of Resident 1's wound in his medical record. The treatment nurse was unable to locate the photographs in the medical record or on the facility's camera. On 5/24/17 at 1310 hours, a request was made to the ADON to review any and all photographs of Resident 1's pressure ulcer. No photographs were ever provided. On 5/24/17 at 1350 hours, an interview was conducted with Resident 1. Resident 1 confirmed facility staff had photographed the wound to his coccyx on several occasions. On 5/24/17 at 1436 hours, an interview was conducted with the Administrator. The Administrator stated the facility does not have a P&P for taking photographs of resident wounds. The Administrator stated the facility practice was to take photographs on admission and when requested by a physician. 2. On 5/10/17 at 0830 hours, Resident 2 was observed on her back in bed with the head of bed elevated watching television. On 5/10/17, the additional observations were made and showed the following: - At 0945 hours, Resident 2 was observed in the standing frame in the physical therapy department. - At 1045 hours, Resident 2 was sitting in her room in a wheelchair. - At 1145 hours, Resident 2 was sitting in her room in a wheelchair. - At 1415 hours, Resident 2 was lying in bed on her back with a private caregiver at her bedside. - At 1525 hours, a concurrent observation was made with LVN 1; Resident 2 was lying in bed on her back. At no time during the above observations was Resident 2 observed to have spontaneous or purposeful movements to reposition herself. Medical record review for Resident 2 was initiated on 5/10/17. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Resident Admission Assessment form dated 4/4/17, showed the resident was alert but confused and was unable to move her extremities. The skin assessment section showed the skin was within normal limits other than a bruise on the left antecubital area. Review of Resident 2's Braden Scale (skin assessment form) dated 4/4/17, showed Resident 2 was confined to bed, had limited ability to respond to pressure-related discomfort, and was unable to make even slight changes in body or limb position without staffs' assistance. Resident 2's calculated Braden Scale score was 11. A score of 12 or less represented High Risk to develop a pressure ulcer. Review of Resident 2's physician's orders [REDACTED].= intact, O = open area, B = bruises. Another physician's orders [REDACTED].= left, R = right, B = back and to circle and document on the back of the form if the resident refused to be repositioned. Review of Resident 2's Body Assessment form dated 4/5/17, showed the resident had blanchable redness to the coccyx (no documented measurement). The redness to Resident 2's coccyx was documented on 4/9, 4/16, and 4/23/17. A physician's orders [REDACTED]. Review of Resident 2's MDS dated [DATE], showed the resident had short and long-term memory problems, severe cognitive impairment, and unable to speak. The resident required extensive physical assistance of two plus persons for bed mobility and total physical assistance of two plus persons to transfer to and from the bed. Review of Resident 2's Body Assessment form dated 4/26/17, showed the resident had a Stage II pressure ulcer on the coccyx, measuring 0.6 cm (length) by 1.2 cm (width) with superficial depth. A physician's orders [REDACTED]. Review of Resident 1's Treatment Administration Record for April 2017, showed the physician's orders [REDACTED]. However, this order was not carried out for the AM shift on 4/17, 4/18, 4/19 and 4/20/17, and not carried out on the PM shift for the entire month of April 2017. Review of the CNA notes for the month of April 2017, in the section for Bed mobility/Position every two hours for the AM and PM shifts, showed the resident was totally dependent/required full staff performance for bed mobility. The documentation from the night shift for the section Bed Mobility/Position every two hours showed 19 nights with entry N. According to the Codes at the bottom of the page of the CNA note, an N meant No. The dates between Resident 1's admission and 4/26/17, when the resident's Stage II pressure ulcer was identified, N was documented 15 times for Bed Mobility/Position every two hours on the night shift. On 5/10/17 at 1415 hours, an interview was conducted with Resident 2's Private Caregiver about the resident's activities for the day. The Private Caregiver stated the resident remained up in the wheelchair until 1330 hours after the resident had finished her lunch. The Private Caregiver stated the resident was then transferred back to bed by two CNAs using a mechanical lift, positioned on her back at the time. The Private Caregiver stated the resident was supposed to be repositioned every two hours because of her pressure ulcer. On 5/10/17 at 1515 hours, an interview and concurrent medical record review was conducted with LVN 1 regarding Resident 2's pressure ulcer. LVN 1 stated Resident 2 was unable to move or turn herself, and she was supposed to be repositioned every two hours. LVN 1 stated she documented on the MAR to identify the resident had been turned every two hours during her shift; however, LVN 1 stated she did not observe Resident 2 had been turned and did not document which position the resident was in every two hours. LVN 1 stated she asked the CNA to reposition the resident every two hours, and relied on the CNA to follow the instructions. LVN 1 verified the physician's orders [REDACTED]. On 5/10/17 at 1525 hours, a concurrent observation was made of Resident 2 with LVN 1. Resident 2 remained positioned on her back. It had been over two hours since Resident 2 had been returned to bed from sitting in her wheelchair and placed on her back. LVN 1 was informed Resident 2 had been observed throughout the day either sitting in a wheelchair or lying on her back without any off-loaded her coccyx area. LVN 1 stated she was unaware the resident had not been repositioned. A concurrent review of Resident 2's CNA Notes for April 2017 was made with LVN 1. LVN 1 verified for 19 of the 30 day, an N was documented for Bed mobility/Reposition every two hours on the night shift. LVN 1 stated an N meant No, and indicated the resident had not been turned. On 5/11/17 at 1145 hours, an interview was conducted with CNA 1 regarding Resident 2's pressure ulcer. CNA 1 stated during their initial rounds of Resident 2 on 4/16/17, the resident was on her back and soaking wet. CNA 1 stated it looked like the resident had not been changed or turned for a long time based on how soaked the resident's incontinent brief was with urine. CNA 1 stated when she wiped Resident 2's skin over the coccyx her skin appeared bright pink as though the top layer of skin had peeled off. CNA 1 said she immediately called the treatment nurse to assess the resident. On 5/19/17 at 1128 hours, an interview and concurrent medical record review was conducted with Treatment Nurse 2 regarding Resident 2's skin and the facility's pressure ulcer assessments. Treatment Nurse 2 stated a treatment nurse always assessed a resident's skin within 12 hours of admission if possible, though the facility's P&P was within 24 hours. If a skin problem was observed the treatment nurse notified the resident's case manager and DON or ADON, measured the area, obtained physician orders [REDACTED]. Treatment Nurse 2 stated the definition of a Stage I pressure ulcer was non-blanchable redness, or blanchable redness which did not refill within three seconds. She stated she would press the reddened area with two fingers and if the area turned white it was blanchable. If the reddened area did not resolve with relief of pressure to the area she would classify it as a Stage I pressure ulcer. Treatment Nurse 2 stated she assessed Resident 2's skin on 4/5/17. The treatment nurse stated the resident had blanchable redness to her coccyx which did not resolve with pressure relief to the area. Treatment Nurse 2 stated she did not measure the reddened area, or document how long the area stayed blanched, and did not classify the area as a Stage I pressure ulcer. Treatment Nurse 2 stated for a Stage I pressure ulcer she would usually obtain an order for [REDACTED]. Treatment Nurse 2 stated in retrospect, she should have classified and obtained treatment orders for Resident 2's reddened area as a Stage I pressure ulcer. According to the Northwest Regional Spinal Cord Injury System, Department of Medicine at the University of Washington, a pressure sore has begun if the pressure is removed from a reddened area for 10 to 30 minutes and the skin color does not return to normal. A person should stay off the area and treat the area as a Stage I pressure ulcer. To test for blanching, press a finger into the pink, red, or darkened area, the area should become white, when the pressure is removed the area should return to pink, red or darkened within a few seconds. If the area stays white, blood flow is impaired and damage has begun.

Based on observation, interview and closed clinical record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided sufficient supervision to prevent falls and a head injury. Resident 1 sustained five falls during the 16 days she resided in the facility. Resident 1 was a high risk for falls and injuries due to recent history of a brain aneurysm (weakness in a blood vessel wall, which causes the blood vessel to bulge and sometimes rupture) repair. The facility failed to move Resident 1's room closer to the nurses' station or provide 1:1 sitter/caregiver as recommended by the IDT as directed in her plan of care and physician's orders [REDACTED]. Failure to provide adequate supervision resulted in Resident 1 sustaining a fall on 5/29/13 at 0000 hours, which resulted in a subdural hematoma, requiring surgical intervention. Findings: Review of the facility's P&P titled "Fall Prevention," revised date 10/25/11, showed the facility is to provide a safe and secure environment for each resident, and protect residents from injury and/or harm. A fall can be defined when the resident is discovered on the floor. In the event of a fall, qualified staff is to assess the resident for injury, investigate the reason for the fall, and determines appropriate interventions to prevent future falls. On 6/4/13, closed clinical record review for Resident 1 was initiated. Resident 1 was admitted on [DATE], from the acute care hospital. The resident's recent hospitalization was due to status [REDACTED]. Resident 1 was admitted to the facility for rehabilitation. The goal was for her to return home with her family. Review of Resident 1's Minimum Data Set (MDS an assessment tool) completed on 5/23/13, showed Resident 1 was alert with cognitive impairment and poor memory recall. She was able to make simple needs known and required extensive assistance with transfers and activities of daily living. She was assessed to have poor balance and an unsteady gait, requiring staff's assistance. The MDS identified Resident 1 had fallen in the past 30 days, more than two times, with injuries fall-related. Review of a Fall Risk Assessments dated 5/14 and 5/17/13, showed Resident 1's fall risk score was 14 and 16. A score of 10 or higher identified the resident as a "HIGH RISK" for falls. Review of the resident's plan of care showed a care plan problem dated 5/14/13, was developed to address Resident 1's fall risk due to a history of falls. The approaches included to ambulate with a two person assist done for safety; respond promptly to all request for assistance, bed in the low position with a bed alarm and floor mats. Review of the licensed nurses' notes showed Resident 1 sustained five falls between 5/14/13 and 5/29/13. a. On 5/17/13 at 0320 hours, Resident 1 was "...found by CNA on floor pad next to bed after hearing alarm sound." She had "removed her trach (tube inserted into opening through the neck into the trachea) again." The resident denied any injury but complained. The trach was irritating her. Messages were left for the physician and family to notify them of the fall. A physician's orders [REDACTED]. A licensed nurse's note dated 5/17/13 at 1100 hours, showed a NP came in to see the resident. The NP was made aware of the resident's constant agitation manifested by pulling out trach more than 5 times since admission and climbing out of bed. The NP requested 1:1 sitter if approved and covered by the insurance. Review of the Observation and Care Record form dated 5/17/13 at 1400 hours, showed RN 1 received a call from Resident 1's health insurance, informing staff the 1:1 sitter request was denied. There was no documented evidence the resident's family was contacted to see if they were able to provide a sitter. Review of the fall investigation report dated 5/17/13, showed the IDT recommended a physical therapy assessment for Resident 1 and consider a unit/room change. A Neurological Assessment form was initiated after the fall on 5/17/13 at 0320 hours, and continued until 5/19/13 at 1805 hours. The assessments showed the resident's vital signs, pupil response, speech and level of consciousness were all within normal range. On 6/4/13 at 1100 hours, an interview with RN 1 was conducted. The RN stated she explained to the resident's health insurance Case Manager about Resident 1's need for close supervision, but the Case Manager said "it is not covered." When asked if she had brought the issue to the facility's Administrator and/or the resident's family member, RN 1 stated "No, because she heard the family was experiencing financial hardship." When RN 1 was asked if they considered moving the resident's room closer to the nurses' station, she stated a room closer to the nurses' station was not an option, because these rooms were designated for residents was are ventilator dependent. An observation on 6/4/13 at 1330 hours, showed Resident 1's room was located near the end of the hallway, six rooms away from the nurses' station. b. A licensed nurse's note dated 5/19/13 at 2230 hours, showed Resident 1 was found sitting on the floor mat, next to the bed. The resident stated she was trying to stand up. "I loss my balance and hit my head on something." The resident pointed to the left side of her forehead. The resident's left side of her forehead showed no bruising, redness or laceration. The resident denied pain or a headache. The physician and family were notified. A fall investigation report dated 5/19/13, showed the IDT recommended a physical therapy assessment and consider unit/room change. No other interventions/recommendations were documented. A Neurological Assessment form was initiated on 5/19/13 at 2145 hours and continued until 5/21/13 at 1230 hours. The assessment showed the resident's vital signs, pupil response, speech and level of consciousness were within normal range. The plan of care was revised to show the resident's actual fall on 5/19/13. The approaches included low bed, bed alarm, floor mats, neurological checks per protocol and concave mattress. There was no documented evidence the concave mattress was implemented. On 5/22/13, an IDT/Care Conference meeting was conducted with the resident's family member in attendance. Documentation showed staff discussed the resident's improvement with therapy. Documentation showed Resident 1 required moderate assistance to ambulate 100 feet; still required standby assistance with a walker and has balance issues and was easily distracted. On 6/19/13 at 1630 hours, an interview was conducted with LVN 2. LVN 2 stated it was the facility's policy to initiate neurological checks when a fall was witnessed. There was no evidence Resident 1's room was changed or a 1:1 sitter was provided after the second fall. c. On 5/20/13 at 2130 hours, Resident 1 was found sitting on the floor mat. She stated she fell when she tried to stand up. Resident 1 stated she had no pain and did not hit anything; however, she had pulled out her indwelling urinary drainage catheter. d. On 5/20/13 at 2230 hours, when staff entered the resident's room to reinsert the indwelling urinary drainage catheter, staff found Resident 1 on the floor again. The physician and the family were notified. Review of the fall investigation report dated 5/20/13, showed no IDT recommendations or care plan review. Review of a Post Fall Assessment form dated 5/20/13, showed Resident 1 had fallen on 5/17, 5/19 and 5/20/13, in the early morning hours. Staff documented Resident 1 was attempting to go to the bathroom alone. Resident 1 complained of severe headache during physical therapy and nursing was notified. Staff documented Resident 1 had poor safety judgement and required verbal cues. Under the section titled "Action taken immediately post-screening" were recommendations for a room change closer to the nurses' station, a low bed, and, if possible, a bedside commode for evening toileting, and a mat. There was no evidence the facility attempted other interventions such as a 1:1 sitter. In addition, there was no evidence the resident's room was moved closer to the nurses' station. e. Review of the licensed nurses' notes dated 5/29/13 at 0000 hours, showed LVN 1 heard a "loud thud" coming from Resident 1's room. LVN 1 found Resident 1 sitting on the floor, at the right side of her bed. The resident was alert, awake and stated she landed on her buttocks, but denied hitting her head. LVN 1 and a CNA assisted the resident to her wheelchair. Some time later, the resident asked to return to bed. The nurse documented staff would continue to observe the resident. The next licensed nurses' note entry was on 5/29/13 at 0645 hours. Resident 1 complained of pain and soreness on her buttocks. Staff noted bluish discoloration and administered Tylenol. Resident 1 then complained of a headache. Her blood pressure was 130/70 and her pulse was 87 beats per minute. At 0700 hours, the physician was paged and message left for resident's family member. At 0720 hours, the resident's family called and was informed of the resident's fall. At 0925 hours, Resident 1 was transported to the emergency department via paramedics. (Cross-refer to F309) A licensed nurse's note dated 6/1/13 at 1830 hours, showed it was a late entry for 5/29/13. Staff documented at 0100 hours, Resident 1 was in bed. When staff asked if she was okay, the resident answered "yes." At 0230 hours, Resident 1 was in bed with her eyes closed, breathing unlabored. At 0330 hours, the resident was in bed with her eyes closed. At 0505 hours, the resident was in bed, awake and responded to questions. A telephone interview with Resident 1's family member conducted on 6/5/13 at 1500 hours. The family member stated he visited the resident daily. He stated, he had observed the resident trying to get out of bed by herself. He said she was becoming stronger with physical therapy and seemed to be "coming along pretty well, but her memory was poor, and the "falls were a disaster." He stated the facility was aware of the resident's history of brain surgery to repair the aneurysm. He stated after the second fall, he was notified the physician ordered the resident to have constant supervision by a caregiver. He stated, he was told by RN 1 caregivers are not normally provided by the facility and the resident's health insurance had denied paying for a caregiver. The family member said no one ever discussed that he could have paid a caregiver to sit with her. He said, "I would have certainly paid...but that option was not given to me." When asked if staff ever discussed moving the resident's room closer to the nursing station, he stated staff had not talked to him about that. On 6/28/13 at 1000 hours, a follow-up telephone interview was conducted with Resident 1's family. He stated, if he'd known the resident was such a high fall risk and would have benefited from having someone sit with her, he would have ensured someone was with her at all times. He stated he visited her daily and no one asked him to sit with her. He stated the resident remains in ICU but is not doing well.

Based on interview and closed clinical record review, the facility failed to ensure appropriate care and services were provided to one of three sampled residents (Resident 1). Resident 1 sustained a fall on 5/29/13 at 0000 hours. Staff failed to initiate neurological assessment until 0700 hours, seven hours later. Resident 1 was experienced a significant and potentially life threatening change of condition (headache, change in pupil dilation, lethargy) after the fall on 5/29/13. When Nurse Practitioner 2 ordered Resident 1 transferred to the acute hospital ER, the facility contacted a basic life support (BLS) ambulance, not emergency (911) transportation. When the BLS ambulance EMT identified Resident 1's condition was too severe to be transported by BLS, 911 was called. This caused a delay in transporting Resident 1 to the ER. Upon arrival to the ER, the resident required an emergency craniotomy (surgical opening of a portion of the skull) for evacuation of a subdural hematoma (a collection of blood on the surface of the brain). Findings: Review of the facility's P&P titled Change of Condition Management dated 8/23/10, showed if a resident's condition changed, the attending physician must be notified immediately of the changes. If the change in condition progresses to an emergent nature, 911 will be called for immediate transfer to the nearest acute facility. Review of the facility's P&P titled "Neurological Assessment" (undated) showed the purpose of the policy is to provide guidelines for the assessment of any resident suspected to have sustained a head injury and/or have a change in their level of consciousness. The physician/family/legal representative is to be notified in the event of a suspected head injury and/or when their is a change in their level of consciousness. On 6/4/13, closed clinical record review for Resident 1 was initiated. Resident 1 was admitted on [DATE], from the acute care hospital with status [REDACTED]. Resident 1 was admitted to the facility for rehabilitation. The admitting physician's orders [REDACTED]. Review of Resident 1's Minimum Data Set (an assessment tool) completed on 5/23/13, showed Resident 1 was alert with severe cognitive impairment but was able to make simple needs known. She was assessed to have poor balance and an unsteady gait, requiring staff's assistance. Review of the plan of care showed a care plan problem dated 5/14/13, identified the resident was a fall risk due to a history of falls and cognitive impairment. The resident had fallen on 5/17, 5/19, 5/20 (twice) and 5/29/13 (Cross-refer to F323). Interventions included a low bed, bed alarm and a floor mat. On 5/19/13, a concave mattress was added as an intervention. However, there was no evidence this was implemented. Another care plan problem dated 5/14/13, to address potential for injury complications related to anticoagulant or antiplatelet medication. Staff identified the resident was receiving [MEDICATION NAME] (anticoagulant, slows blood clotting time). Review of the licensed nurse's note dated 5/29/13 at 0000 hours, showed LVN 1 heard a "loud thud" coming from Resident 1's room. LVN 1 found Resident 1 sitting on the floor. The resident was alert, awake and stated she landed on her buttocks but denied hitting her head. The LVN and a CNA assisted the resident to her wheelchair. Some time later, the resident asked to return to bed. The nurse documented staff would continue to observe the resident. On 5/29/13 at 0645 hours, Resident 1 complained of pain and soreness on her buttocks. Staff noted bluish discoloration and administered Tylenol. Resident 1 then complained of a headache. The resident's blood pressure was 130/70 and her pulse was 87 beats per minute. Staff documented relaxation techniques were provided and instructed the resident to relax and take deep breaths. At 0700 hours, the physician was paged. On 5/29/13 at 0730 hours, NP 2 called back and was given report. The NP was informed of Resident 1's fall during the night and she was now complaining of a headache, and there was a yellowish bruise to her forehead. When the resident was asked if she remembered hitting her head during her fall, the resident said, "I guess so." She also "complained of nausea. Her skin was cold and clammy." Her blood pressure was 134/86 and respirations 22. The NP ordered a STAT (immediate) x-ray and recommended a 1:1 sitter (someone who stays with the resident at all times). Review of the Neurological Assessment form showed an assessment was not initiated for Resident 1 until 5/29/13 at 0700 hours (seven hours after the fall). The neurological assessments showed a rapid change in the resident's condition. At 0700 hours, the resident's blood pressure was 128/72, her pulse was 88 beats per minute, and her pupils were equal, normal size and reactive to light. The resident was alert with clear speech. However, at 0745 hours, the resident's left pupil was nonreactive to light and unequal in size when compared to the right eye (changes in pupil size and/or unequal pupil size can occur with serious conditions such as head trauma). At 0830 hours, Resident 1 no longer had spontaneous speech. At 0900 hours, Resident 1 was no longer alert, she was lethargic, drowsy and unable to speak. Her blood pressure had increased to 160/82 (normal range 120/80) and her pulse was 56. A physician's orders [REDACTED]. Review of a licensed nurse's note dated 5/29/13 at 0840 hours, showed RN 1 spoke to Resident 1's health insurance Case Manager, regarding Resident 1's fall and change of condition and the resident was exhibiting signs and symptoms of "brain bleed vs concussion." Authorization for an ambulance was obtained. At 0845 hours, a call was placed to a private ambulance company (BLS). At 0858 hours, the BLS ambulance arrived and an EMT stated they were not comfortable in transporting the resident due to her altered mental status and change in pupil reactions. The paramedics (911) were called. At 0910 hours, paramedics arrived. The resident was not responding to verbal commands. Her blood pressure was 180/70. At 0925 hours, the resident was transported to the emergency department. This was an hour and 10 minutes after the physician ordered the resident be transferred to the ER. Review of a skull x-ray done on 5/29/13, showed there was "extensive postsurgical changes from the right frontal craniotomy." Review of the ER report dated 5/29/13, showed Resident 1's Glasgow Coma Scale (GCS - a scoring system used to describe the level of consciousness in a person following a [MEDICAL CONDITION]) score was 3 (GCS between 3-8 = Severe). The resident's blood pressure ranged between 180/100 to 230/100. Resident 1 was intubated (tube inserted into the mouth/throat to maintain an airway). Resident 1 was nonresponsive and emergently taken to the operating room for a craniotomy to evacuate the subdural hematoma. A CT scan dated 5/29/13 at 1018 hours, showed a large left subdural hematoma, measuring 20 mm in thickness. It also showed a stable post right front temporal craniotomy. On 6/3/13 at 1500 hours, Resident 1 was observed at the acute care hospital. The resident was in the Intensive Care Unit (ICU). She was unresponsive, intubated and on a mechanical ventilator (to assist with her breath). Her head was shaved and on the left side of her scalp was a fresh recent incision with sutures. During an interview with RN 1 on 6/4/13 at 1200 hours, she stated she called the resident's health insurance and asked for a regular (BLS) ambulance to transport the resident to the hospital. When asked why 911 was not called, she said because Resident 1 was not in a life threatening situation. However, Resident 1 was a full code, and was rapidly declining. On 6/19/13 at 1630 hours, an interview was conducted with LVN 2. LVN 2 stated she left a message for the physician regarding Resident 1's fall; however, the physician did not call back. LVN 2 stated it is the facility's policy to initiate neurological checks when a fall is witnessed. On 6/26/13 at 1500 hours, a telephone interview was conducted with LVN 1. LVN 1 stated she was caring for Resident 1 on the early morning of 5/29/13. She was asked about Resident 1's fall incident on 5/29/13 at 0000 hours. LVN 1 confirmed she did not notify the physician or initiate neurological checks. She stated the RN supervisor assessed the resident and there was no apparent serious injury. On 6/27/13 at 1015 hours, a telephone interview was attempted with Resident 1's physician. However, the physician declined to be interviewed. The physician only stated she would not permit her NP to be interviewed. When asked why she declined to be interviewed, she stated "Nothing I say will change the facts." On 7/3/13 at 0900 hours, a telephone interview was conducted with the facility's Medical Director. He stated, per the facility's P&P, the physician should be immediately notified of a resident's fall or change in condition. He stated, neurological checks should be initiated immediately after the fall; waiting has the potential in delay in identifying any changes in the residents condition.

Based on interview and closed clinical record review, the facility failed to routinely assess and/or evaluate one of two sampled residents (Resident 1) who was routinely receiving opioid medications. The facility failed to identify and/or address Resident 1's increased lethargy and decline in his cognition and overall weakness. On 12/27/12 at 2355 hours, Resident 1 was cyanotic (bluish discoloration of the skin and mucous membranes, resulting from inadequate oxygenation) and required manual oxygenation with an ambu bag (hand-held device used to provide positive pressure ventilation to a person who is not breathing, or breathing inadequately). Emergency medical services (911) was called. Paramedic (EMT) staff administered [MEDICATION NAME] (medication used to reverse respiratory depression caused by narcotics) intravenously (IV, into the vein). Resident 1 started to respond and was transferred to an acute hospital emergency department. The resident's [DIAGNOSES REDACTED]." The administration of narcotic medication and failure to assess his change of condition caused a delay in treatment, and a decline in Resident 1's medical condition. Findings: Lexi-Comp Online (web based Internet site) shows a warning for the administration of [MEDICATION NAME] (opioid/narcotic) to residents with pre-existing respiratory diseases. The medication may cause potentially life-threatening respiratory depression, even with therapeutic use. The elderly person may be particularly susceptible to the central nervous system depressant. The half-life (time required for half the quantity of a drug to be metabolized out of the body) of [MEDICATION NAME] is two to four hours. Lexi-Comp Online identifies [MEDICATION NAME] as an opioid pain medication, with a warning of a risk of respiratory depression in elderly persons. Geriatrics have been found to be twice as sensitive as younger persons to the effects of [MEDICATION NAME]. The half-life of a [MEDICATION NAME] is 17 hours. Closed clinical record review for Resident 1 was initiated on 1/28/13. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's admission MDS (an assessment tool) dated 12/18/12, shows he was alert, oriented and able to make his needs known. Review of the physician's admission orders [REDACTED]. In addition, the physician ordered a [MEDICATION NAME] 50 mcg/hr, to be changed every 72 hours. Resident 1 required the use of continuous oxygen therapy at 3 liters per minute via a nasal cannula, and use of a [MEDICAL CONDITION] (pressure controlled ventilation in a system allowing unrestricted spontaneous breathing at any moment of the ventilatory cycle) every night while sleeping. Review of Resident 1's Controlled Drug Record for [MEDICATION NAME] 10 mg tablets, showed staff was to administer one tablet every four hours, as needed for moderate pain; and two tablets every four hours, as needed for severe pain. Resident 1 was administered the following: a. On 12/12/12, [MEDICATION NAME] two tablets (20 mg) was given at 0530 hours and at 0900 hours. This was three and a half hours in between doses) b. On 12/13/12, [MEDICATION NAME] two tablets (20 mg) was given at 2100 hours and on 12/14/13 at 0015 hours. This was three and a quarter hours in between doses) c. On 12/24/12, [MEDICATION NAME] two tablets (20 mg) was given at 1730 hours and at 2030 hours. This was three hours in between doses. Further review showed Resident 1 received 116 doses of [MEDICATION NAME] 10 mg between 12/11/12 - 12/27/12. Review of the Controlled Drug Record for the administration of the [MEDICATION NAME] (50 mcg/hr every 72 hours) showed [MEDICATION NAME]es were administered on 12/13, 12/19, 12/22 and on 12/25/12. Review of Resident 1's Occupational Therapy Daily Treatment Notes showed the following: a. On 12/19/12, Resident 1 continued to be lethargic, kept his eyes closed during treatment, only briefly opening his eyes when asked to. b. On 12/20/12, did not participate in ADLs today. c. On 12/24/12, sleepy throughout treatment. d. On 12/26/12, not able to follow commands, required increased assistance, lethargic, unable to keep his eyes open. e. On 12/27/12, required maximum/dependent assistance to sit. The Occupational Therapist's analysis of functional outcome/clinical impression dated 12/28/12, showed Resident 1 was declining and requiring increased assistance with all ADLs and transfers. He had an increase in confusion and decrease in endurance. Review of Resident 1's Physical Therapy Daily Treatment Notes showed the following entries: a. On 12/24/12, Resident 1 refused (multiple times) to participate in physical therapy. The resident stated he is too sleepy and has pain. b. On 12/25/12, the resident had a difficult time participating, was confused and restless. He remained lethargic and unable to keep up with his physical therapy tasks. He only responded to verbal commands by momentarily opening his eyes. The Physical Therapist's analysis of functional outcome/clinical impression dated 12/28/12, showed Resident 1 had declined over the last week in functional activity, with poor participation and motivation. Review of the Nurse's Note dated 12/27/12 at 2325 hours, showed Resident 1 had his [MEDICAL CONDITION] mask in his hand, his facial color was blue and he was gasping for air. The LVN immediately summoned the RN; staff started "bagging" him (ambu bag to provide positive pressure ventilation), Once emergency services arrived, they administered [MEDICATION NAME] and the resident "started to respond." The resident was transferred to an acute hospital emergency department for further evaluation. Review of the Paramedic Report Sheet dated 12/27/12 at 2315 hours, showed Resident 1 was unresponsive with a heart rate between 115 to 120 beats per minute, and his oxygen saturation level was 57% (normal level 97% to 99%). Review of Hospital 1's documentation showed the following: * Emergency Physician Record dated 12/27/12, shows a clinical impression as "narcotic overdose." * The H&P dated 12/28/12, showed "the resident was found unresponsive, diaphoretic (sweating) and lethargic. The resident was "on a lot of narcotics and was given [MEDICATION NAME] with good response." The impression was listed as possible narcotic overdose. * On 5/7/13, review of Resident 1's urine drug screen dated 12/28/12 at 1100 hours, (approximately 11 and a half hours after the administration of [MEDICATION NAME]), showed his urine was positive for opiates. * Review of a physician's consultation report dated 12/28/12, showed the plan was to decrease the resident's narcotic use. On 1/4/13, Resident 1 was transferred to Hospital 2. Review of Hospital 2's admission H&P dated 1/4/13, showed on 12/28/12, the resident had been admitted to Hospital 1 for decreased responsiveness and diaphoresis and was thought to be overdosed on narcotics. On 1/28/13 at 1620 hours, an interview was conducted with the DON. She stated she was unaware of Resident 1 receiving the administration of [MEDICATION NAME] by the EMT staff on 12/27/12. She also stated she was unaware Resident 1 was receiving [MEDICATION NAME] more than the physician had ordered. During a telephone interview on 5/6/13 at 0855 hours, the SSD, stated when Resident 1 was admitted to Hospital 2 on 1/4/13. He remained lethargic but was alert. On 5/13/13 at 1505 hours, a telephone interview was conducted when the EMS Manager. The EMS Manager was asked the reason [MEDICATION NAME] was administered to Resident 1 on 12/27/12 at 2332 hours. She stated when the paramedics arrived at the skilled nursing facility, Resident 1 had a decrease in his level of consciousness, was unresponsive and had pinpoint pupils (the black area in the center of the eyeball). She stated, it is a standard of practice to administer [MEDICATION NAME] when a resident is assessed with [REDACTED]. She stated, one minute after the administration of [MEDICATION NAME], Resident 1 stared to move, and had spontaneous respirations, his pupil size increased to 3 mm and had a low blood pressure reading.